Opinion  

Clinicians and politicians - and even a significant proportion of the public - accept that the NHS requires a certain amount of rationing and control if it is to deliver optimal care. The question is how that rationing should be carried out and who should set the limits. A number of reports and other events in recent weeks have revealed just how much doubt there is over that process.

PCTs have been criticised in a King's Fund report for setting targets for GPs to cut referrals, without any clinical backing for these targets. One PCT is quoted as noting that cutting one referral per practice per week would save £1.25 million over three weeks - it did not say which referrals should be cut.

Meanwhile, NICE, which is attempting a scientific approach to these issues, is under fire from all directions. Health economists have claimed it sets its cost-effectiveness threshold too low and even though it won the High Court case over Alzheimer's drugs, its public reputation took another knock. Plus, according to our report on page 8, GPs remain in two minds about NICE decisions, choosing to follow the institute's guidance only when it agrees with their own clinical views.

Rationing decisions are hard to justify to patients when even the 'experts' don't agree.

What the NHS needs is a consistent, clinician-led, non-political process to set the standards not just for prescribing but for referral management and other resource issues. We need a transparent system that is trusted by health professionals and patients and that cannot be disrupted by arbitrary PCT-budget-saving decisions.

However, whether even an 'independent' NHS could drag that particular bunny out of its hat is open to question.