Wednesday, October 14, 1998 Published at 11:01 GMT 12:01 UK
Who gets what?
Politicians may have difficulty uttering the word "rationing", but the National Health Service (NHS) is well aware of what it means and is getting to grips with its implications.
The debate over the anti-impotence drug Viagra has forced the government and the public to consider explicitly whether the NHS can still afford to offer all its treatments to all of the people.
The Health Secretary will soon announce the restrictions that will be placed on the release of the little diamond-shaped pills in the UK. But in truth, Viagra will be just the latest in a growing list of new drugs to face such limitations.
Robert and Julie Breckman are certainly aware of this new reality after they struggled to get hold of a drug called Aricept, used to treat Alzheimer's disease. When it was eventually prescribed for Julie, it helped her significantly.
"She became more stable," Robert says. "She was able to start dressing herself. She became more coherent and it certainly did prove a great benefit to her."
But the improvements eventually went away and Julie went into a downward spiral. Aricept is one of those drugs that does not work for everyone - only four out of 10 patients show any improvement at all.
For this reason, some health authorities will not pay for the drug, while others will only allow it to be prescribed in clearly defined circumstances.
Robert and Julie live in the area covered by the Kensington, Chelsea, and Westminster Health Authority in London.
It was these conditions that made it difficult for Julie to get the drug initially - especially when her diagnosis did not fit the guidance. Robert Breckman believes the decision to prescribe the drug should be left to the family doctor alone.
"If the local doctor prescribes a drug, the NHS should take it up. Otherwise, why employ staff if you're never going to take any notice of them?"
John James, the health authority's chief executive, does not accept the criticism.
As the person responsible for ensuring the efficient funding of the NHS locally, he says it is right to set up guidelines on expensive and unpredictable drugs.
"The difficulty with Aricept and with the other drugs that are coming in for dementia is that we don't know why some patients respond and others don't when they have apparently similar clinical conditions.
"That's why it's right to have a fairly careful system for ensuring that you continue the drug for those who are responding and to discontinue it for those who aren't."
One man's careful system is another's unreasonable restriction. Dr Sarah Eagger, a specialist in dementia, accepts the logic of the authority's position, but is concerned that such restrictions will limit the ability of doctors to evaluate the real worth of new treatments.
"Doctors have, historically, been used to trying out new medications and treatments and making their own decisions about whether a drug works or not and whether they should continue to prescribe it," she says.
"But it's a brave new world, and I think health authorities, clinicians and patients really do have to work in partnership to come up with what is ultimately some kind of equitable decision-making process where at least everyone across the country has an equal opportunity to try something.
"The problem at the moment, especially with this drug, is that it is very inequitable and that creates a lot of bad feeling."
Some of this ill feeling may disappear when the new National Institute for Clinical Effectiveness comes into being next year.
This new NHS body will assess new treatments and issue guidance on how the health service should respond to new and expensive drugs.
While the current furore over Viagra has brought politicians of all colours to the verge of accepting that the NHS may have to ration, you could argue the Health Service has already had the debate.
It just wants to know who should have the authority to decide who gets which drug or what treatment.