Elderly people have always been marginalised in NHS planning. But it's time to question what rationing and prioritising mean for older people, says Dorothy White

Any future system of long-term care for older people must be a combination of help to stay at home and the opportunity to go into a nursing home for the relatively few for whom this becomes necessary. The arrangements must be integrated and flexible, and the systems of payment must cover both.

Normal NHS planning is designed primarily for the younger population with healthier lives. We have never looked at what would be required to provide NHS care of equal value for older generations. The concept has been pushed out

of the way because it is overwhelming, and management words are being found to organise the task away.

What are these management words?

'Bottomless pits.' There will always be developments which seem bottomless. But these will always have compensating spin-offs. No pit need be bottomless just because at a particular moment one cannot see the bottom.

'Priorities and rationing.' Does this mean that younger people with longer chances of survival come first, that Viagra is more important than a year's survival for someone with terminal cancer? Look at the cost-benefits of hip operations, hitherto severely rationed and obtained after long delays, often in excruciating pain.

It is now considered virtuous for people to pay through BUPA or other schemes to make their own provision for early referrals. And to pay for their own minor operation outside the NHS. This is said to take pressure off the NHS. But look at the muddles which result and the effect on consultants' availability for working in hospitals, if extra sessions can be found. Yet middle England seems to think this is the pattern it should now follow.

Managing the NHS is one of the biggest managerial tasks in the country. Inevitably, there has to be experiment and change. But we seem to have reached a situation in which the language of priorities, rationing and the public-private partnership takes precedence. And behind all this is the concept of insurance.

The people doing this talking seem to be mostly those who have conveniently opted out in their 40s and 50s, always a bit sheepishly, by taking personal insurance. It means at this managerial level that they and their families can get swift care. It is easy for them to think impersonally, managerially. At a conference of health service administrators, I asked those who did not have access to private insurance to indicate. Very few did.

What does the language of priorities mean? Does it mean that having had cancer in 1966 followed by episodes treated by new techniques, it was not worth following up swiftly what turned out to be secondaries in my liver? My desperate daughters-in-law found the scan could be done immediately, albeit privately. But once in a private hospital more tests might be required and those could be prohibitively expensive. How ghastly for them to be put in this predicament.

But if prioritising and rationing is to be applied to older people, what should they know? The answer is everything. They should know what, why and how it operates. There should be no uncertainty, and the overall criteria should be national.

Who is to blame for the present situation? We are. We have allowed the NHS to become a closely guarded, almost non-virtuous public expenditure. As individuals, our top priority seems to be to keep taxes down, whatever the consequences. But I believe there is now a crucial opportunity to entirely review the ethics and structure of health services for older people. It is time to make a determined effort to get it right, and time for us all to reconsider our views about paying tax to do so.