LETTER : Spending decisions for the NHS

Sir: Polly Toynbee may have got it wrong. She argues (25 March) it would cost pounds 20,000 per patient year to dialyse those 1,000 over 60 years of age who could benefit from dialysis. Let us assume the cost and survival data are correct. Is this the best way to spend pounds 20m?

This question can only be answered with comparative data which answers the question whether there other interventions which, if given an additional pounds 20m, would produce more health gains? By spending pounds 20m on dialysis, 1,000 renal failure patients would each get an additional year of life. By spending money on proven interventions such as improved cardiac services and GP advice to stop smoking, greater levels of health gain would be produced. Spending money on hip replacements and cataract removal would save no lives but would transform the quality of beneficiaries' lives. All spending decisions in the NHS result in less being available for other patients who could benefit from care. With resources scarce the challenge is to target resources at those patients who can benefit most.

The advocacy of sectional interests (eg, those with chronic renal failure) does not ensure that the NHS produces maximum health gains for the UK population from its pounds 40bn budget. Perhaps the NHS has got it right and denies benefits to these patients so it can benefit other patients more with the marginal pounds 20m? Perhaps the NHS should not pursue mere efficiency but give up achievable health gains by spending elsewhere in order to care for needy patients in need of dialysis?

Such questions need to be resolved in a rationing debate which is explicit. Just what weight do we as a society wish to give to efficiency and equity?

Professor Alan Maynard

Secretary

The Nuffield Provincial

Hospitals Trust

London W1