necessary. A national waiting list policy that whether these policies are subject to review and current screening programme and that a lack of guarantees access according to agreed criteria, whether such criteria are explicit. staff would limit an immediate expansion.' rather than simply guaranteeing maximum wait- We have recently completed a cross sectional Age Concern England's view is that the funda- ing times, could facilitate contracts between pur- postal survey ofthe 106 new health authorities in mental issue of the equity of the NHS breast chasers and providers on the basis of agreed England and Wales, requesting details ofpolicies screening service should not depend on further criteria for the prioritisation of waiting lists. on in vitro fertilisation. The response rate was information. The question that needs to be Points could be assigned to patients by 94% (100/106). Of the 100 responders, 67 fund answered is why the programme of breast consultants to reflect, for example, current in vitro fertilisation and 16 do not. The remain- screening invitations excludes the age group of health status, assessed using the EuroQoL or ing 17 were in the throes of the policy making women in whom the largest number of cancers SF36 health status measures; expected gain in process and were unable to offer a clear might be detected. This reduces the potential quality of adjusted life years (QALY)3 from response. effectiveness of the breast screening programme treatment; or some combination of clinical All of the 67 who funded In vitro fertilisation and, more importantly, denies older women an factors such as rate of deterioration and social did so on a restricted basis. These restrictions important step towards the early detection of factors reflecting dysfunction in usual activities. varied in severity, with some constructed so as to breast cancer. This is being pursued by New Zealand's Health effectively deny access except under exceptional The inequity of this situation will become Commission4 and in the United Kingdom is circumstances. The restrictions were invariably increasingly difficult to reconcile as women aged being piloted at Salisbury District Hospital.5 explicit and were a mixture of medical reasons- 50-64 move through the breast screening Points schemes could help establish thresholds for example, woman's age, ranging from 34 to 42 programme and then ask, at age 65, why they for entry on to elective waiting lists and help years (where age is used as a marker for clinical cannot continue to receive invitations. The standardise general practitioners' referral prac- effectiveness)-and social factors such as marital current system, in which women aged 65 or over tice for routine procedures. status, heterosexuality, and marital stability. In can request a screening every three years, has If rationing in the NHS is inevitable, waiting all cases access was also controlled by consider- proved a resounding failure, with around 97% of list points schemes could help to ensure that ing only couples (not individual) presenting eligible women failing to be screened. patients with similar need, somehow reflected by themselves for referral. Women should be informed that breast their points allocation, could be assured of simi- It is clear that in vitro fertilisation continues to cancers do occur in older women and that it is a lar access to treatment, regardless of clinical spe- be overtly rationed within the NHS. What is of good precaution to report any breast symptoms cialty, geographical location, or general practi- concern is the use of criteria which are not promptly. A recent Gallup survey showed that tioner's status. Points schemes could provide a always related to clinical effectiveness but have a 65% of older women thought that their age redefinition of the principle on which the NHS sociological construct that may discriminate group was at little or no risk from breast cancer; was founded within the constraints of resource against some members ofsociety. It is not clear at 28% thought that there was no risk at all. limitation. present whether such criteria are acceptable to Many older women do not seek advice about RHIANNON TUDOR EDWARDS local populations. They seem to reflect the values breast symptoms, believing they cannot develop Lecturer in health economics of purchaser or provider clinicians, or both. the disease. In many cases, older women mention Department of Public Health, that the screening cut off age at 65 encourages University of Liverpool, LAIN SMrrH this belief. PO Box 147, Senior lecturer in health services research Liverpool L69 3BX Nuffield Institute for Health, In view of all these factors, Age Concern Eng- University of Leeds, land is calling on the government to urgently 1 New B on behalf of the Rationing Agenda Group. The ration- Leeds LS2 9PL address the shortage of radiologists, as any ing agenda in the NHS. BMJ 1996;312:1593-601. AURORA PLOMER further delay in extending the programme would (22 June.) Lecturer 2 Samuel 0. Fundholding practices get preferences. BMJ Law Department, be unacceptable. 1992;305:1497. University of Leeds 3 Gudex C, Williams A, Jourdans M, Mason B, Maynard J, SALLY GREENGROSS Director general O'Flynn P, et al. Prioritising health care. Health Trends 1 of Health. the national survey the 1990;22:103-8. College Report of of funding Age Concern England, and provision of infertility services. London: College of London SW16 4ER 4 National Advisory Committee on Core Health and Disability Health, 1993. Support Services. Core servicefor 1994/95. Wellington, New 2 College of Health. Report of the second national survey of the Zealand: NACCHDSS, 1994. funding andprovision ofinfertdity services. London: College of 1 Rubin G. Wrong comparison quoted for breast screening. 5 Edwards KT. An economic perspective of the Salisbury Health, 1995. BMJ 1996;312:1674. (29 June.) waiting list points scheme. In: Malek N, ed. Settngpriorities in health care. Chichester: Wiley, 1994. Don't confuse personal choice with Selection ofgroup members needs to be collective choice Ratio ofwaist circumference to clarified EDITOR,-MoSt of the problems we encounter height is strong predictor of EDrroR,-I think clinicians would take a little with rationing decisions' arise through collective intra-abdominal fat more notice of the Rationing Agenda Group if it choice in publicly funded systems. In other included more people who actually had to face words, decisions are taken by a collectivity that EDrrOR,-Waist circumference' and the ratio of binds individuals. In a privately financed system waist circumference to height' have been sick people and their families day by day over the proposed as better indicators of the need for years. It is difficult to identify any working clini- individuals are more able to make personal cians in the group.' choices (admittedly constrained by their management of weight than the classic body It would be interesting to know the method of income). Decisions are less likely to be taken by mass index. The relevance of the different proxy others on their behalf. Even in most privately measures is presumed to relate to their selection for members to sit in this group. King's prediction ofintra-abdominal fat, but a compari- Fund Policy Institute is presumably a registered funded systems third party decisions are charity-that is, receives a lot of money from the commonplace, but the distinction between son has not yet been reported. taxpayer-and its function should be more personal choice (making your own rationing Thirty one women and 16 men presenting for democratic. decisions) and collective choice (making deci- routine computed tomography had their weight, sions on behalf of others) is an important one. height, and waist circumference measured; all C J BURNS-COX but three men and three women also had their Consultant physician RAY ROBINSON hip circumference measured. The subjects were Frenchay Healthcare Trust, Director Frenchay Hospital, Institute for Health Policy Studies, aged 18-73, and the range of body mass index Bristol BS16 ILE Southampton SO17 1BJ (kg/m2) was 20.148.5. The cross sectional areas of both intra-abdominal and subcutaneous fat 1 New B on behalf of the Rationing Agenda Group. The ration- 1 New B on behalf of the Rationing Agenda Group. The ration- were calculated from images taken immediately ing agenda in the NHS. BMJ 1996;312:1593-601. ing agenda in the NHS. BMJ 1996;312:1593-601. (22 June.) (22 June.) cranial to the iliac crests, as previously described.3 Pearson product-moment correlations for the Purchasing policies for in vitro fertilisation logarithms of selected anthropometric variables vary considerably Breast screening has failed and ratios with estimates of total fat and the two older women fat compartments showed that the ratio of waist EDITOR,-The reports from the College of circumference to height had the highest correla- Health' 2 continue to confirm a considerable ED1TOR,-Gary Rubin, service director of the tion with intra-abdominal fat (r = 0.83, variation between health authorities in their pur- East Sussex Breast Screening Service, said that P<0.001). This was higher than the correlations chasing intentions for in vitro fertilisation. Some invitations to breast screening should not be of waist circumference (r = 0.75), body mass have also included sociomedical criteria for allo- extended to women aged 65 or over until more index (r = 0.69), and the ratio ofwaist to hip cir- cating these scarce resources. It is unclear as to information is available on the success rate ofthe cumference (r = 0.54) with intra-abdominal fat. BMJ vOLUmE 313 31 AUGUST 1996 559 2 Ashwell MA, Lejeune SRE, McPherson K. Ratio of waist cir- trust will be covered by a registration held by the cumference to height may be a better indicator of need for 250- Meno trust as data user (section 1(5) of the act).