THE Scottish Medicines Consortium advice that Scottish NHS Boards should not provide two very expensive drugs for patients with cystic fibrosis ("Life-changing cystic fibrosis drugs rejected for use on NHS in Scotland", The Herald, August) because of a lack of evidence of cost-effectiveness, highlights again the need for difficult decisions to be made – and in all areas of health and health services. On current pricing, to treat even 100 patients with these drugs would cost the NHS rather more than £10 million per year. That is £10m which would not be available for other service provision.

BMA Scotland (of which I am a member) pointed to difficult decisions affecting frontline clinicians in its recent document offering a vision for secondary care. It sought a more mature approach to targets, an honest debate about funding and involving doctors in decision-making. It also seeks the end of the culture that sees doctors fear that they will be unfairly blamed for issues resulting from system-wide failings.

Treatment of the relatively small numbers of children with cystic fibrosis (about 750 in Scotland) is a tertiary out-patient responsibility, patients admitted when required to secondary care wards. Family doctors, health visitors, community physiotherapists and dieticians provide the primary care response over the patient’s lifetime, often limited beyond age 40. The stated BMA view of secondary care – doctors and teams being asked to work in services with neither enough staff nor money, can equally be levelled at primary and tertiary care. The balance between those three – and add in preventative work, social care and chronically underfunded mental health services – represents a complex broth to attempt to separate out the ingredients, assess them and prioritise.

Should we be concerned at the warning that we can no longer expect hospitals to provide the kind of comprehensive care we have always relied on them for? General practice and primary care teams already pressed will have even more patient and carer discontent voiced when referral to secondary care fails by wider margins to provide timely investigation, opinion and treatment. It is the same for quietly-rationed social care provided by cash-strapped local authorities, partners in health and social care partnerships.

Doing nothing does seem to be making a choice according to the BMA: “The inertia of recent years is a choice: a choice for reduced services, a choice for demotivated and fewer staff, a choice for less." As I have suggested before, an increase in income tax is the fairest way to fund what we want. As always if we stumble along “making savings” and with major underfunding, those in most need and least able to navigate the NHS will suffer most. That is many individuals in pain, experiencing new disability, anxiety and uncertainty. Decisions about care of the many and the few are complex but can be eased only when we achieve a financially stable position. Our Government and Parliament should recognise that and alter their language accordingly. We are listening.

Dr Philip Gaskell, Drymen.