It is well known that the NHS is struggling with vast mountains of debt - so is it time we should start measuring how its work actually affects a patient's quality of life? LUCY STEPHENS reports.

THE news that cash-strapped primary care trusts are limiting the procedures available on the NHS sparked a cry of "health rationing" from one GP.

But it also opened up again the age-old debate about our National Health Service: what can and can't it afford to pay for?

It is a question that has never been more relevant. The four primary care trusts (PCTs) across North Yorkshire alone - now to merge into a "super trust" this year - have a £51 million shortfall to make up over the next financial year. Nationally the level of debt is huge.

Health organisations must wrestle with paying the huge costs of drugs and hospital treatments, which means weighing up which treatments take priority and where they should be dealt with.

Included in new guidelines sent out to North Yorkshire GPs last week was a system of "thresholds" - ways of assessing patients with various conditions like arthritis hips and cataracts - and deciding which should be sent to hospital and which can be helped in other ways.

These are conditions which may not be life-threatening, but they have a huge impact on a patient's quality of life.

"If you've got arthritic hip pain... it's like having a constant toothache," says Dr John Iredale, chairman of the York and Selby GPs' committee.

"It's like having that for six months. Sometimes people end up having to take constant pain killers. They get depressed; there are all sorts of knock on effects.

"Having cancer is very serious. That can't wait because it's going to get worse. With an arthritic hip, you can wait a while - most people don't deteriorate. They will still be in a lot of discomfort.

"I think what's happening now is that people have a much higher expectation."

So how can the NHS assess how it is improving quality of life for hip replacement patients and others?

One way, says Professor Alan Maynard, health economics professor at the University of York and chairman of York Hospitals NHS Trust, is to ask them.

He thinks much more should be done to question patients after surgery to find out whether their lives have actually improved.

That way, the NHS will learn where it is making a real difference, and it might be surprised to find other areas where it isn't. And that, thinks Professor Maynard, will help it to target its cash more effectively.

"There's evidence that shows when you remove a cataract, from a minority of patients - ten per cent - there is not much improvement in visual acuity (sharpness)," he says.

"When you come in and we do your hip, do we really cure the pain and make you mobile? That shouldn't just be taken on trust.

"Elective treatments are mostly about quality of life. Let's measure it. Let's get a better handle on it. To what extent are we successful?

"I think we need a better system, by which we actually check what we're doing. Should we (the hospital and the PCT) be getting together and showing we're improving quality of life in a dramatic way?

"Isn't it about time doctors were more optimistic and tried to measure success?"

Dr David Geddes, a York GP and PCT medical director, says in these financially strapped times it is important to make sure limited funds are used in the right way.

"We need to keep on making sure that we're keeping the right patients getting the right surgery," he says. "We need to make sure we target people who have most to gain from it. We have identified people who would like to have a bunion or ganglion (removed) for a health need.

"If you keep on paying for those people, you're going to have fewer resources to pay for those areas where there's clear guidance where surgery can have an effect."

As for hip and knee patients, many of them would prefer not to undergo the trauma of a major operation and instead be cared for differently, he says.

Under new PCT guidelines, osteoarthritis patients will be measured under a special scoring system to assess how much pain they are in and how their quality of life is affected by their condition.

The PCT says the system gives GPs an extra guiding tool for their clinical judgement.

Patients scoring 70 out of 100 or over should be referred to hospital, those in the next category down can be looked at in the community.

"People have often opted for a conservative approach and gained from it," says Dr Geddes.

"What we are looking at in the guidance of this document is to make sure there's a consistent application, identifying those people who are least likely to have a benefit on their health or quality of life."