Professor John Smyth is a man who is too clever for our own good. Assistant principal for cancer research development at Edinburgh University, editor-in-chief of the European Journal of Cancer and a former president of the Federation of European Cancer Societies, he is also a founder member of a world-famous choir, a keen fly-fisherman and a skilled pilot. But Smyth and a generation of the best medical minds have pushed the National Health Service to the brink of collapse.

“For the first time in history we have medicines and technologies that far exceed affordability,” he says, proffering coffee in the study of his elegant home on the edge of Edinburgh’s Botanic Gardens where literary biographies jostle with musical scores and medical texts. “We have a real dilemma in what to do with the resources we have. Nobody can afford it all. We have to face up to rationing. The politicians don’t like that word, but that is what it is.”

For the baby-boomer generation, skiing and partying its way to retirement in the belief that the NHS will deal with its excesses, Smyth’s message is a stark one.

“It means that healthcare isn’t free — it is that simple,” he says. “We’ve grown up in a system where we believe that if we are ill, somebody will look after us, that we can have a heart transplant for free if we need it. That is not the case in most places. We are going to have to make some very tough choices. My question is: who is going to make these decisions?”

Smyth, who was professor of medical oncology at Edinburgh for 30 years and oversaw the new £7m research centre at the city’s Western General Hospital, has been interested in the moral and ethical dilemmas of making tough decisions for years. Last week he went public with his concerns in a lecture to the Edinburgh International Science Festival. With the sort of timing more usually associated with his choral performances at La Scala or the Albert Hall, Audit Scotland subsequently revealed that the drugs budget in Scotland’s acute NHS hospitals has risen 76% in the past five years to £222m.

According to Smyth, we now face the very real prospect that we will not be able to afford the amazing advances in cancer treatments that we hear about on a near weekly basis. Worse, the services we take for granted just now may start to disappear as the malignant combination of an ageing population with greater health needs, the huge rise in the cost of ever more sophisticated treatments, and a drop in the number of taxpayers takes greater hold.

“I do not see the NHS as sustainable in its current form,” he says. “Ultimately we may simply have to stop doing the things we are currently doing. It would mean doing fewer operations, we’d prescribe less medicine and we would have fewer doctors. There would be longer waiting lists and people would die on waiting lists. On the way there, we would have ghastly open warfare. You would have all manner of grossly indecent arguments going on.”

How quickly is this likely to happen?

“If we haven’t already run out, we are close to the buffers of affordability.”

Smyth chooses his words as carefully as he prescribes his medicines. His intention, he says, is not to criticise but to encourage debate. A fan of the smoking ban, he believes treating the consequences of alcohol addiction, drug addiction and obesity will prove increasingly difficult to defend.

Refusal to treat patients with self-inflicted conditions is already happening in some branches of medicine, he says. “Cardiologists will say to somebody, ‘You need an operation on your heart but if you are not going to stop smoking, we won’t do it.’ I don’t know if orthopaedic surgeons have got to the stage of saying to people, ‘You need a new hip but you are 25 stone, we won’t put a new hip in until you get down to 20,’ but it is obvious we need to change the culture. We need parents telling their kids that if they are obese, one day somebody is going to deny them healthcare.”

Smyth, who has worked all his life in the NHS, is a supporter of the Westminster government’s latest reforms to deprive alcoholics of part of their benefits if they refuse treatment. Although his arguments are not influenced by the current recession, he believes that the economic downturn is making people question their acceptance of socially unacceptable behaviour.

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