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The near hysterical reaction to calls for health rationing is not because people are interested in the health of the nation but because they are afraid of their own future, afraid of diseases such as cancer and afraid of old age. Who will be there to care for me when I am dying and alone?

Rationing has always been with us. I remember my first year as a house doctor, straight out of leaving medical school. One of my patients was a man dying of kidney failure. We only had a limited number of places on the dialysis programme. He was never offered the treatment because he was "too old and not intelligent enough". But how to you decide? One doctor commented that anyone who could start the last war in the army as a private, and still be a private at the end with so many losses, was clearly someone with limited abilities, who would be unlikely to be able to manage dialysis machinery at home and would "do badly".

I would not seek to justify his logic, but some kind of rationing is essential in any free system and to argue otherwise is foolish. All free offers of things worth having tend to be oversubscribed - which means that supplies run out, and then many people get nothing. The answer is to manage supply and demand. True, we could always boost taxation, until each of us is spending up to a third of all we earn, paying our health insurance premiums to the government in return for unlimited NHS treatment. However few people would chose to do that. But even if the health spending in Britain was trebled, there would still not be enough resources to meet every wish. For example, if there was unlimited access to counselling or psychotherapists or cosmetic surgeons or to infertility clinics.

So then, if it is true that whatever is free tends to be undervalued and abused, then demand has to be limited in some way, either by restricting supply on a priority basis, or by making life difficult for people wanting more care. Both these systems are operating. Doctors are vetting cases before treatment, especially in fund-holding practices and in specialities such as neurosurgery, and people are made to wait.

Waiting lists are the oldest and most subtle rationing device. It starts to operate the moment you crawl out of bed in the morning with a blinding headache and decide not to bother the doctor because it will take twenty minutes to get through the switchboard, and then half an hour to get dressed, park and walk in, and then another half an hour to an hour to be seen - if they will see you today at all.

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The waiting continues when your doctor writes to the hospital requesting an appointment. By the time the date is confirmed, many people feel better. The crisis is over and the thought of more time off work or more favours begged from friends for childcare is too daunting. And so it goes on. At every stage people melt away. Only a few make it to the clinic, and then land up on another waiting list for treatment.

However the latest revolution in the NHS has produced trusts which are now taking the opposite line: in the past they had no incentive to work hard, and indeed welcome the waiting list system. Now many are vying with each other for patients, and we are all bombarded with a subtle advertising campaign from the moment we enter a hospital site.

There has been a dramatic change in psychology. Clinics no longer keep people waiting. Casualty departments pride themselves on rapid case assessment. More people means more money - but from the same pot. This new welcoming face in hospital care has meant that GPs are now being pushed to make decisions themselves about rationing.

So what is the answer? The situation is made ever more difficult by astounding advances in medical technology, some of which save money, but most simply gobble up resources faster than ever. Once a treatment is available (and free) the pressures become almost irresistible to use is, especially where it is a matter of "life and death", or where children are involved. The slimmest hopes of cure drive doctors and patients alike to ever more exotic approaches. But high-tech medicine is often medicine gone stark raving mad, where those who are ill become dwarfed by tubes, wires and machines in a desperate fight against the inevitable in a culture that seems to see all death as failure.

Rationing has always been with us, and should continue to be. The only alternative is an arbitrary "first come, first served" handout of care packages that will leave the less articulate and most vulnerable at terrible risk of receiving nothing at all. Health care needs managing, and we will all be healthier for it.


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