Attempts to ration access to various treatments by NHS patients which have been made sporadically by local bodies since the 1990s are now becoming widespread and more wide-ranging.
The argument is that a significant number of hitherto routine treatments can be dismissed as “‘Procedures of Limited Clinical Value’, a term normally reserved for complementary therapies or cosmetic procedures where there is little evidence to prove their cost effectiveness or clinical benefit.
Last summer NHS England kicked off a new round of exclusions when it put pressure on local CCGs to cut funding for 17 procedures of allegedly limited effectiveness or clinical value – with an eye to making potential savings.
Four procedures for which there is a widely accepted lack of evidence (injections for non-specific low back pain without sciatica; knee arthroscopy for patients with osteoarthritis; dilatation and curettage for heavy menstrual bleeding in women; and surgery for snoring) were to be funded only in exceptional circumstances.
But a further 13 procedures, including breast reduction, varicose vein surgery, removal of benign skin lesions, and tonsillectomy – some of which have good evidence they can be effective, are to be performed on the NHS only when specific clinical criteria are met.
The NHS is aiming to more or less halve the number of these procedures, from 350,000 to 170,000 a year, and save almost half the current spend of £400m a year.
The list of treatments singled out for this has convinced many people that this as a further step towards introducing a two-tier system in which the better off are able to pay for non-NHS treatment, the poorer suffering in silence and private companies making a profit. Conspicuously as NHS bodies draw up longer lists of treatments they won’t pay for, private hospitals begin advertising a similar range of services for those willing and able to pay.
NHS England gives the impression that the proposals are fully in line with national clinical guidelines published by the National Institute for Health and Care Excellence (NICE), the recognised authority advising clinicians on the current state of research evidence, whose logo appears on the cover, and that NICE was a source for the proposals.
But in fact, as Keep Our NHS Public has revealed, NHS England’s proposals to withdraw 17 NHS clinical procedures contradict existing guidance from NICE. Instead KONP research found that:
“For nine of the 17 procedures, NHSE does not cite any evidence at all from NICE. For five procedures the NICE evidence cited does not support the NHSE proposal and for one, the NICE evidence cited gives only partial support. For only two out of seventeen withdrawn procedures does the cited NICE evidence back the NHSE proposal.”
However the initial list of 17 treatments was always seen as a first step, and some CCGs have gone far further and faster down the route of excluding services and effectively rationing care – leaving patients with the stark choice of going private or going without.
Bristol campaigners have been protesting over “Stolen Treatments” after the list of excluded treatments chiefs in the Bristol, North Somerset and South Gloucestershire (BNSSG) area reached a whopping 104. They complain that:
“GPs can no longer decide when to send patients to see a consultant at a hospital. Instead they must follow strict rules which mean they can only refer patients who are most severely affected.
“Some patients are being left with pain and disability and placed at increasing risk of severe complications. In addition, GPs’ professional opinions are being overridden by non-accountable panels and committees.”
In North Central London, the five CCGs have been corralled by the Joint Commissioning Committee into signing up for an extended list of 29 treatments, more than NHS England and the London Regional Directorate put together. One of the North Central CCGs, Enfield, began its deliberations by discussing an even longer list of 192 procedures.
Keep Our NHS campaigners are angry that the changes once agreed by Enfield were rolled out “across the other four boroughs was done without public consultation. It is arguable that this is another breach of CCGs’ statutory duty to consult the public before a significant change in services.”
The same process is taking place in many CCGs across England. In Milton Keynes the CCG has a list of 26 MusculoSkeletal (MSK) treatments which are either “restricted” or “not routinely funded” with a much more lengthy list under “general”.
Now research by the Medical Technology Group (“a coalition of patient groups, research charities and medical device manufacturers working to improve access to cost effective medical technologies for everyone who needs them”) has found that rationing of care through these measures is increasingly widespread.
CCGs are restricting patient access to proven treatment by including them on lists of treatments of ‘limited clinical value’. This includes patients being denied vital cataract surgery; over half of all CCGs (104 of the 195 CCGs in England) include this procedure in lists of treatments they deem to be of “limited clinical value”, despite being proven to be effective.
However national clinical guidelines published NICE in 2017 cite the cost effectiveness of cataract surgery, stating that it has ‘a high success rate in improving visual function, with low morbidity and mortality’.
The result of CCGs’ restrictions on cataract surgery is that patients across the country are being denied access to a procedure that they are entitled to, which could restore their eyesight and prevent accidents, such as trips and falls.
The research also suggests patients are being treated differently depending on where they live. For example, Basildon and Brentwood CCG restricts access to cataract treatment while nearby Barking and Dagenham CCG offers the procedure to all patients.
The MTG’s investigation, conducted in October 2018, reveals that CCGs across the country are also rationing access to other proven treatments which can make a significant difference to patients’ quality of life and deliver savings to the NHS in the long run.
The MTG study looked at three further treatments: surgical repair of hernias, glucose monitoring for diabetes patients, and hip and knee replacements. It found that:
Most CCGs commission hernia repair, but many apply onerous conditions. Almost half of CCGs (95) limit access and many take a ‘watchful waiting’ approach, where time is allowed to pass while further tests are carried out. The result can mean an increase in emergency cases and worse patient outcomes.
78 CCGs include hip and knee replacements on their list of restricted treatments, despite the procedures being proven to be effective in keeping people mobile.
12 CCGs refuse to provide patients with continuous glucose monitoring, a sensor that allows people with diabetes to monitor their glucose levels throughout the day. A further seven only provide it to patients after an Individual Funding Request, where they need to make a special case for the treatment.
Concerned that the treatment patients receive is being determined by where they live, not what they need, the MTG is launching Ration Watch, a campaign to highlight variation in local commissioning and call for changes to eradicate the postcode lottery.
Campaigners will want to use some of this research evidence, which is pressing for improvements in the NHS, even if they are not attracted to the MTG itself, which admits its membership “ranges from national charities to international companies.”
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