Rationing

doi:10.1136/bmj.311.6999.264a

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P J Ayres

Senior registrar in public health medicine Nuffield Institute for Health, Leeds LS2 9PL

Local debate is needed

EDITOR,--Richard Smith is right to call for the reopening of the debate on rationing,1 but he misses the point in asserting that “Britain has not had the … prolonged debate on rationing that is needed” because the key level at which this debate is needed is the local one. In the past, decisions on rationing in the NHS have been influenced by institutional factors,2 but now commissioners must ration. It is an uphill struggle for two reasons.

Firstly, “the NHS is drowning in organisational tasks while the real work of planning …