This is NHS Check report no 1 originally published by Labour’s Shadow Health Team in  June 2012

Crude, random rationing by health bodies goes far wider and deeper than first believed with 125 previously-free treatments restricted or even stopped altogether in last two years.

Labour uncovers new evidence to show:

  •           restrictions are linked to arbitrary caps and cost – despite  Ministers’ claims;
  •           restrictions are being introduced which diverge from NICE  guidelines;
  •           restrictions cover a number of serious treatments affecting patients’ levels of pain, mobility and quality of life;
  •           22 treatments or services stopped altogether by at least one  PCT/CCG;
  •           patients in parts of England left facing charges for essential  treatments such as cataracts, knee surgery and hip    replacements.

Labour calls on Ministers to initiate an immediate review of rationing in the NHS and to act immediately on new evidence showing treatment restriction on cost alone. 

We call for the immediate reversal of rationing decisions which leave patients in severe pain, restrict mobility, limit their ability to live independently or have a major psychological impact, pending the outcome of this review.

For all other treatments we believe the Government should initiate a public debate on whether or not they should be provided nationally by the NHS rather than allowing them to be restricted in a random fashion.

1.        Summary

A survey by Labour’s Shadow Health Team of all NHS Primary Care Trusts (PCTs) and shadow Clinical Commissioning Groups (CCGs) in England reveals that 125 separate treatments, previously provided free by the NHS, have been restricted or stopped altogether by NHS bodies in the last two years.  The crude, random rationing by health bodies goes far wider and deeper than first believed.

A number of treatment restrictions are based, directly or indirectly, on cost.  The nature of the restrictions varies between PCTs/CCGs, and includes: caps on the number of treatments provided; divergence from NICE guidelines; and more restrictive eligibility criteria.  These examples of cost-based restrictions also include serious treatments.

Health Minister Simon Burns, in response to the GP Magazine report showing that 90% of PCTs/CCGs are restricting procedures said:

Last year we made it clear that it is unacceptable for the NHS to impose blanket bans for treatment on the basis of costs. That is why we banned PCTs from putting caps on the number of people who could have certain operations.

“If local health bodies stop patients from having treatments on the basis of cost alone we will take action against them.”

Simon Burns statement 18th June 2012

This survey provides new evidence of direct and indirect cost-based restrictions for treatments, such as NHS South West Essex and NHS South East Essex which have placed a cap on their community diabetes services.

Other PCTs/CCGs have diverged from NICE guidelines and have placed restrictions on treatments by re-writing eligibility criteria, such as NHS Bassetlaw which has restricted Dupuytren’s contracture on the grounds of age, which is not included in NICE guidelines.

Many of the 125 treatments identified are major treatments that seriously affect levels of a patient’s pain, discomfort, mobility and quality of life.

A number of rationed or decommissioned treatments are common across several PCTs/CCGs, whilst others are specific to an individual PCT/CCG but serve to highlight the wide variation across the country.  Twenty-two treatments or services have been stopped altogether by at least one PCT/CCG.

The scale and pace of the treatments being restricted has dramatically increased in the last two years.  Restricted and decommissioned treatments cover the full spectrum of health care, from the cosmetic to the essential and all stages in between.

This survey provides clear evidence of random rationing across the NHS and of an accelerating postcode lottery which appears to be part of a coordinated drive to shrink the level of NHS free provision.

It is clear that many patients are facing difficulties in accessing routine treatments that were previously free and readily available, with some patients forced to consider private services in areas where the NHS has entirely stopped providing the treatment.

More worryingly, patients in parts of England have been left facing charges for essential treatments such as cataracts, knee surgery and hip replacements, as identified by this survey and the GP Magazine report yesterday (18th June 2012).

Labour is calling for the Government to order an immediate review of rationing in the NHS, and to act immediately on new evidence showing treatment restriction on cost alone.  The review needs to produce clear guidance on all of the treatments now being affected and to provide urgent advice on the commissioning of more serious treatments being targeted by PCTs/CCGs.

We are calling on the Government to reverse immediately rationing decisions that leave patients in severe pain, restrict mobility, limit their ability to live independently or have a major psychological impact, pending the outcome of the review.

We accept that some treatments are of borderline value and there is a legitimate debate to be had about whether they should be provided by the NHS.  We believe that debate needs to take place as part of a national review and before unilateral decisions to restrict or decommission treatments are made.

KEY FINDINGS

  • Two-thirds of all PCTs/CCGs responded to the survey – 100 of 151 (66%)
  • Of the PCTs/CCGs who responded, almost half (46 PCTs/CCGs) have restricted or decommissioned services in the years 2010-11 and 2011-12.
  • 125 different services have been rationed across the health service, with 22 being entirely stopped in some parts of the country.
  • The nature of the restrictions include: capping/limited budgets – a finite pot of money that runs out regardless of clinical need; age restrictions and the re-writing of eligibility criteria to restrict the numbers of patients who qualify for treatment.
  • Examples of treatments restricted directly or indirectly due to cost or divergence from NICE guidelines:
    • community diabetes service
    • carpal tunnel syndrome
    • cataract referrals
    • hip impingement/replacement/resurfacing
    • Dupuytren’s contracture
    • chlamydia screening programme
    • bariatric.
  • Most common treatments to be restricted by trusts across England include:
    • 24 PCTs/CCGs restricting tonsillectomy
    • 21 PCTs/CCGs restricting varicose veins treatment
    • 21 PCTs/CCGs restricting knee surgery/replacement
    • 18 PCTs/CCGs restricting hip impingement/replacement/resurfacing
    • 16 PCTs/CCGs restricting cataract referral
  • Most serious treatments (causing pain, discomfort, limiting mobility or ability to live independently for the patient) to be restricted or decommissioned include:
    • 24 PCTs/CCGs restricting tonsillectomy
    • 21 PCTs/CCGs restricting knee surgery/replacement
    • 18 PCTs/CCGs restricting hip impingement/replacement/resurfacing
    • 16 PCTs/CCGs restricting cataract referrals
    • 16 PCTs/CCGs restricting hysterectomy for Menorrhagia
    • 14 PCTs/CCGs restricting Dupuytren’s contracture
    • 14 PCTs/CCGs restricting surgery for carpal tunnel syndrome
    • 13 PCTs/CCGs restricting myringotomy with or without Grommets
    • 10 PCTs/CCGs restricting hand/wrist ganglion cyst treatment
    • 4  PCTs/CCGs restricting bunion removal
  • Examples of treatments completely stopped in some parts of the country:
    • 3 PCTs/CCGs – Chlamydia screening programme
    • 3 PCTs/CCGs – Benign skin lesions
    • 3 PCTs/CCGs – Osteopathy
    • 2 PCTs/CCGs – Toenail cutting service
    • 1 PCT/CCG – Removal of wrist ganglia
    • 1 PCT/CCG – Skin tags.

2.        Background

Earlier this year, the Shadow Health Team was alerted to a patient in Cheshire who had been charged by a GP practice for the removal of a wart – a procedure she had received free for many years.  We then came across a young boy from Merseyside who was refused treatment for grommets which was affecting his ability to concentrate at school.  Thirdly, we were contacted by a man from Nottinghamshire, who was refused treatment for a second cataract removal.   The new NHS Check website has also picked up similar examples.

These examples were surprising since Ministerial statements suggest this is not happening.  This was most recently articulated by the Secretary of State on BBC Radio 4s ‘File on Four’ programme:

“I don’t think it’s right in any sense that the NHS rations treatment… I have made it clear, my colleagues have made it clear, and the NHS people should be clear, that you cannot have blanket bans on treatment. You have to assess every patient on their merits.”

Health Secretary Andrew Lansley BBC Radio 4’s ‘File on Four’, Tuesday 12 June 2012

In order to establish the true picture, Labour’s Shadow Health team surveyed all 151 of England’s PCTs/CCGs.  Labour wanted to find out how widespread the problem has become in the two years since the last General Election and to get the full picture of the list of treatments being targeted by the NHS for decommissioning or restricting.

The information was secured by Freedom of Information requests, the questions being:

 

  1. To list all services or treatments that were previously commissioned by the PCT for residents in your area and have now been decommissioned or restricted, in the financial years 2010/11 or 11/12.
  2. If a service has been decommissioned or restricted:
  3. Provide the date from when the decision was applied.
  4. Specify whether the decision to decommission or restrict this service relates to new clinical guidelines.

 

 

 

 

 

 

 

 

 

This report presents the findings of the survey.

It exposes the gap between the rhetoric from Ministers in Westminster and the reality on the ground where patients are seeing NHS treatments restricted and removed.

It also explains why we are seeing widening public dissatisfaction with the NHS.  The recent British Social Attitudes (BSA) survey report showed that public satisfaction with the NHS has dropped from 70% to 58% – the biggest ever fall.   Ministers responded by pointing to the inpatient survey data, but it is clear that this is not telling the whole story of patient experience in the NHS, as many people are now not even getting in to the hospital.  This helps to explain and make sense of the BSA survey as people are being denied access to or charged for treatments previously available for free on the NHS.

This process underlines the importance of patients having a direct way of reporting incidents and their experiences in their local NHS.  In May, Labour launched the NHS Check website (www.yournhs.com) – a platform for patients, their families and NHS staff to share examples of what is happening on the ground in the NHS as it undergoes the biggest reorganisation since its creation.

NHS Check has received reports of how patients are being forced to pay privately for treatments that were previously provided free at the point of need by the NHS, alongside experiences of longer waiting lists, fewer nurses and low staff morale.

Within 48 hours of its launch, almost one thousand people had shared their experiences of Cameron’s Health Lottery on NHS Check.

The survey bears out Labour’s repeated warning of a distracting reorganisation being combined with the financial challenge.  It provides worrying evidence of random rationing in a crude efficiency drive with little direction or guidance from the centre.

NHS Check will now provide a report on separate issues each month until the next General Election – with a combination of fresh figures and human case studies to reveal the real picture of what is happening in the NHS.

3.        Detailed findings

125 treatments dropped or restricted in the last two years by at least one NHS body, covering the full spectrum of health care, from the cosmetic to the essential and all stages in between.

Stories emerge of patients having to pay charges to GPs for previously free services or facing agonising decisions about paying for operations.

The new figures unearth vast amounts of data on decisions taken by PCTs/CCGs to stop or restrict NHS treatments.

125 different services have been stopped by at least one PCT/CCG in the last two years by PCTs/CCGs facing financial difficulties, with 22 treatments no longer being offered to patients in certain areas.

There have previously been restrictions on some treatments, but the scale and pace of restricted treatments has dramatically increased in the last two years.  Axed or restricted services range through the full spectrum of healthcare from cosmetic treatments of little clinical value to serious services, which give greater cause for concern, and all stages in between.

The restriction of treatments which may be considered minor may still have physical health and psychological effects on the patient.

PCTs/CCGs have indicated a range of ways of restricting treatments.

Rationing of treatment varies from capping – the setting of a limited budget (eg NHS South West Essex and NHS South East Essex have placed a cap on their community diabetes services) to restricting treatment based on age or clinical need (eg NHS Warwickshire has produced new criteria that a patient must meet before being referred for knee replacement surgery).  The new criteria requires the patient to complain of intense or severe symptomatology and states that patients with a BMI > 40 should not be listed for surgery.

We have also uncovered evidence of PCTs/CCGs diverging from NICE guidelines.

In NHS Bassetlaw, needle fasciotomy for Dupuytren’s contracture is only considered if the patient is over the age of 45 and has loss of extension in one or more joints exceeding 25 degrees, or the patient is under the age of 45 with a greater than 10 degree loss of extension in 2 or more joints.  However, the referenced NICE guidelines (http://www.nice.org.uk/nicemedia/pdf/ip/IPG043guidance.pdf) for this treatment do not include any reference to degree of loss of extension or the above and below 45 years of age criteria.  Indeed, NICE guidelines indicate the procedure would be more appropriate in older people and other PCTs/CCGs restricting Dupuytren’s contracture make no reference to age.

The table at Annexe A below details the most common treatments being either restricted or decommissioned.

The table below details notable treatments which have been restricted due to direct or indirect cost implications or where they diverge from NICE guidance.

Treatment/

service

Nature of restriction/

decommissioning

Community Diabetes service NHS South West Essex and NHS South East Essex have capped (to within available resource) and restricted their community diabetes service. The PCT said “cost efficiency programmes [are] in place within all services.”
Clinical commentary and patient impact:   A robust Community Diabetes Service reduces emergency diabetic admissions considerably.  Capping such a service is nothing short of, “penny wise pound foolish”.

 

Carpal tunnel syndrome In April 2011, NHS Hull issued guidance to not routinely commission cases with moderate symptoms. Other PCTs have required the patient to have had a certain period of conservative therapy before treatment.Some PCTs will consider treatment if the patient is experiencing severe symptoms that interfere with activities of daily living
Clinical commentary and patient impact: Carpal tunnel syndrome is painful and disabling. There is still access to surgery but it is being made more difficult to obtain. It must be assumed that this is on grounds of cost rather than efficacy.

 

Cataract referrals Barking and Dagenham, Havering, Redbridge and Waltham Forest PCTs issued guidance in April 2011 to not refer patients for consideration of cataract surgery with a VA of 6/9 or better. NHS Bassetlaw introduced a policy for “value based procedures” in 2011/12 which imposed a threshold – meaning the PCT will only fund cataract surgery where there is a VA (visual acuity) of 6/12 (corrected) in the worst eye.
Clinical commentary and patient impact: Such absolute restrictions have no clinical imperatives.  There is now evidence that early cataract surgery is beneficial to patients, and the over reliance of VA as a measure is outdated.  Delaying surgery leads to more ophthalmic complications, making surgery more risky, and in the event proves costlier.

 

Hip impingement/replacement/

resurfacing

NHS Bury have imposed a threshold of an Oxford hip score below 20. However, an Oxford hip score above 20 “may indicate moderate to severe hip arthritis”. The advice is to “See your family physician for an assessment and x-ray. Consider a consult with an Orthopaedic Surgeon.”In 2011, NHS Warwickshire added new restrictions on hip joint replacement that included not normally listing patients for surgery if they have a BMI over 40.
Clinical commentary and patient impact: Orthopaedic operations such as knee and hip surgery can be due to a traumatic injury such as a sports injury or accidents, or a degenerative disease such as arthritis. Such rationing would aim to discriminate against the latter mainly, as these are chronic conditions. But the disability, pain, reduced social mobility, will cause a lot of suffering to these patients.Restrictions on hip replacement could well discriminate against older people, for whom hip surgery is not cosmetic but essential to relieve pain, further worsening of their condition and also major social handicaps if surgery did not happen.

 

Dupuytren’s contracture In NHS Bassetlaw, needle fasciotomy for Dupuytren’s contracture is only considered if the patient is over the age of 45 and has loss of extension in one or more joints exceeding 25 degrees, or the patient is under the age of 45 with a greater than 10 degree loss of extension in 2 or more joints.NICE guidelines do not include any reference to degree of loss of extensions or the above or below 45 years of age criteria. Other PCTs restricting Dupuytren’s contracture make no reference to age.
Clinical commentary and patient impact: This is a planned operation, but where the contractures are severe even undertaking basic tasks such as making a cup of tea or a meal are impaired. Surgery is indicated where other methods have failed; any delay will make the contractures get progressively worse, and it is likely then that at some stage surgery will no longer be possible.

 

Chlamydia screening Hammersmith and Fulham, Kensington and Chelsea and Westminster have decommissioned all outreach elements of the Chlamydia Screening Programme.
Clinical commentary and patient impact: Chlamydia screening is about control of an infectious disease. If some local areas stop their outreach screening and have an ineffective programme as a result this will undermine the programmes of neighbouring areas. The implication of cutbacks on sexual health programmes is serious in health terms particularly amongst young people.
Bariatric Patients generally have to be over 18 and have a BMI over a certain level to receive weight loss surgery. NICE guidance recommends a BMI over 40, however Kensington PCT will fund treatment for any patient with a BMI > 35 AND either stage 2 or 3 diabetes, airway complications, cardiovascular disease or sexual complications. NHS Bury will normally only fund treatment for patients with a BMI over 50.In NHS Bassetlaw, patients must have tried all available non-surgical measures to lose weight, including commercially provided weight loss support programmes.
Clinical commentary and patient impact: Access to Bariatric surgery by raising BMI threshold (as adopted by various PCTs), whilst being a perverse disincentive to help oneself, reduces economic effectiveness by not treating people until chronic ill health and co-morbidities make a return to employment unlikely & patient continues to suffer all the consequences of obesity like diabetes, hypertension and arthritis.

Patient case studies from the NHS Check website.

Examples are being received through the NHS Check website which evidence the results of the survey.  Many individuals wish to remain anonymous, but the context and quotes have been reproduced here:

To:  NHS CheckFrom:  Mr B, Nottinghamshire

“I went for a regular eye test in October, the optician told me I had a major Cataract on my left eye. I was then told that, because I had already had a Cataract operation on my right eye, 4 years ago, I would have a very long wait for an operation on my left eye or alternatively pay to have the operation carried out.  With the creation of the CCG in Nottinghamshire, the Lead Clinician of that Group, has informed the Council that both Cataract operations and Varicose Vein operations will not be carried out in Nottinghamshire anymore.

To:  NHS CheckFrom: Mrs A, Yorkshire

My daughter suffers from tonsillitis and constantly swollen tonsils. I have requested several times for her tonsils to be removed but the hospital informed me that tonsils do not get removed.

 

 

 

 

 

 

 

 

 

 

 

 

 

4.        Policy Implications

Labour believes this survey raises a number of urgent and important policy considerations for Ministers.

1.      We call on the Government to order an immediate review of rationing in the NHS, and to act immediately on new evidence showing treatment restriction on cost alone.  It should produce clear national guidelines for PCTs/CCGs;
2.      We call for the immediate reversal of rationing decisions which leave patients in severe pain, restrict mobility, limit their ability to live independently or have a major psychological impact, pending the outcome of this review;
3.      For all other treatments we believe the Government should initiate a public debate on whether or not they should be provided by the NHS rather than allowing them to be restricted in a random fashion;
4.      We call for urgent clarification of the Government’s policy on minimising potential  conflicts of interest and for reassurance that commissioners restricting or decommissioning services in the NHS are not opening up private markets from which they can benefit.  Failure to do so risks undermining public trust in the NHS.

The Government urgently needs to clarify its policy on the rationing of services in the NHS.  There are contradictory statements from Ministers with the Secretary of State appearing to rule out the NHS rationing treatment (BBC Radio 4 ‘File on Four’, 12 June 2012) whilst the HSC Act provides for localised decision-making and the opportunity for charging for treatment:

“The headquarters of the NHS will not be in the Department of Health or the new NHS Commissioning Board but instead, power will be given to the front-line clinicians and patients. The headquarters will be in the consulting room and clinic. The Government will liberate the NHS from excessive bureaucratic and political control, and make it easier for professionals to do the right things for and with patients, to innovate and improve outcomes.”

Equity and excellence: Liberating the NHS, Department of Health White Paper, July 2010

In response to the GP Magazine report that 90% of PCTs/CCGs are restricting procedures, the Health Minister Simon Burns said:

“It is quite unacceptable if this is going on in all those cases. As you’ll appreciate, it is a   complex issue. But the defining point is that people should be treated on clinical need, and not financial considerations.

                “We will come down on them like a ton of bricks. Ultimately, if they persist and refuse to accept the guidance, then we can remove the chairs of the PCTs.”

Simon Burns, News Channel, 19th June 2012

We are calling for the Government to order an immediate review of rationing in the NHS, and to act immediately on new evidence showing treatment restriction on cost alone.  The review needs to produce clear guidance on all of the treatments now being affected and to provide urgent advice on the commissioning of more serious treatments being targeted by PCTs/CCGs.

However, other treatments that have been restricted or decommissioned such as cataracts, knee surgery and hip replacements have an effect on the quality of life for patients causing pain and discomfort and should be subject to clinical decisions not random rationing.

We cannot allow a situation where patients, in pain or discomfort, are facing the choice of paying hundreds of pounds in charges or going without and continuing to suffer.

The survey responses show that there are areas where patients are now flatly denied treatment to remove non cancerous moles, scars and cysts and cataracts, and many others where they face fresh restrictions in accessing routine services.

We are calling on the Government to immediately reverse rationing decisions which leave patients in severe pain, restrict mobility, limit their ability to live independently or have a major psychological impact, pending the outcome of the review.

We accept that some treatments are of borderline value and there is a legitimate debate to be had about whether they should be provided by the NHS.  We believe that a debate needs to take place as part of a review and before unilateral decisions to restrict or decommission treatments are made.

The effect of the Government’s decision to place the headquarters of the NHS in the consulting room and clinic is that of random rationing.  The ‘national’ has been removed from the NHS.

In 2011 a surgery in Yorkshire informed patients waiting for treatments of cysts, skin lesions and in-growing toenails that their local NHS no longer offered these services.  Meanwhile the Haxby practice had established a private company to offer the same minor operations at a cost of £56.30 for the removal of a small cyst; £126 for larger cysts; £146.95 for the removal of an in-growing toenail and £243 for the removal of a non-cancerous mole (benign skin lesion).

The Government’s new system fails to guarantee patients are protected as GPs are handed control of the £80bn commissioning budget.  The move allows doctors to financially benefit from restricting local NHS services by offering the same treatments privately in their surgeries.  This early Haxby example is a worrying sign of things to come as the new arrangements take hold.

This is why we are calling on the Government to clarify the position on minimising potential conflicts of interest.  Public trust in the NHS will be further undermined if it is believed that those commissioning services in the NHS can up open up private markets for themselves.

5.        Conclusion

Labour’s survey uncovers worrying evidence about the direction of the NHS under the Coalition Government.  It contradicts Ministers’ statements that rationing isn’t taking place and it helps to explain why public satisfaction with the NHS has recently suffered its biggest ever fall (BSA survey). This survey bears out Labour’s concerns about the timing and ideology of the Government’s changes.  The NHS has been thrown into chaos by combining the biggest ever reorganisation with the financial challenge, and it is patients who are paying the price.

PCTs/CCGs, under instruction, have moved to cut services quickly and without debate in a crude efficiency drive.  Many of the PCTs/CCGs have restricted and/or decommissioned more than one service. The ideology of the HSC Act is also coming through, where there are no national standards and the creation of a postcode lottery is accelerating.

This random rationing marks the start of the end of a truly National Health Service.  Clinical Commissioning Groups will have full discretion to restrict and decommission services resulting in the differences between areas growing wider, with people in some areas paying for treatments that are free elsewhere.

Labour opposed the Bill because it was an attack on the ‘N’ in NHS.  We have been vindicated in this assertion as this survey reveals a postcode lottery running riot across health services in England.

The Government needs to be honest about the fact that patients are now facing charges for treatments previously provided for free on the NHS.

The British Social Attitudes survey shows that the rationing and decommissioning of treatments resulting in charges is having a direct impact on public satisfaction with the NHS.  It is a true reflection of people’s experiences of the NHS. It is clear that there is a yawning gap between what the Prime Minister and others are saying and the reality of what patients are experiencing on the ground.

During the General Election campaign, David Cameron said:

                “I’ll cut the deficit, not the NHS”                 David Cameron, 4th January 2010

It is now clear that 125 treatments have been cut on his watch – this is Cameron’s Health Lottery.

Annexe A

20 most common treatments affected:

Treatment/

service

Number of PCTs restricting or decommissioning

PCTs restricting

PCTs fully decommissioning

Nature of restriction/

decommissioning

Treatment of tonsillectomy 24 of 100 PCTs/CCGs Ashton, Leigh and Wigan; Blackpool; Bury; Tameside and Glossop; North Lancashire; Central Lancashire; East Lancashire; Blackburn with Darwen; Doncaster; East Riding of Yorkshire; Hull Teaching; Bassetlaw; Derbyshire County; Derby City; Walsall Teaching; Wolverhampton City; Dudley; Sandwell; Havering; Barking and Dagenham; Redbridge; Waltham Forest; Bath and North East Somerset; Cornwall and Isles of Scilly The restrictions on Tonsillectomy are often based upon the number of clinically significant sore throats in the preceding year or preceding 2 years. Normally 7 or more episodes in the last year, OR 5 or more episodes in each of the last2 years.

 

NHS Gloucestershire will also fund tonsillectomy where there have been 3 or more episodes in each of the last 3 years.

Clinical commentary and patient impact:  Accepting the de facto evidence that tonsillectomy abolishes attacks of tonsillitis, consider an adult having three attacks of tonsillitis per year, aged of 30, who elects to have a tonsillectomy.  The operation costs about £720.  The primary care consultation and prescription costs for antibiotics and painkillers are close to the index cost of the operation.

 

Varicose veins 21 of 100 PCTs/CCGs Ashton, Leigh and Wigan; Bury; Tameside and Glossop; Doncaster; Bassetlaw; Walsall Teaching; Wolverhampton City; Dudley; Sandwell; Havering; Bromley; Greenwich Teaching; Barking and Dagenham; Lambeth; Southwark; Lewisham; Redbridge; Waltham Forest; Bexley Care Trust; Plymouth Teaching; Bath and North East Somerset; Treatment of varicose veins is normally only be funded if certain clinical criteria are met including a varicose ulcer or a major episode of bleeding from the varicosity.

NHS Derbyshire will only be fund treatment if the patient is a non-smoker or has confirmed abstinence for at least 6 weeks prior to the procedure.

Clinical commentary and patient impact:  30% of adult population will develop varicose veins at some stage of their life. 5-10% of the population will develop complications or troublesome symptoms.  Eczema,ulcer and troublesome symptoms interfering with the life style are the ones recommended for treatment as they are classed as symptomatic varicose veins.

 

Knee surgery / replacement 21 of 100 PCTs/CCGs Bury; Warwickshire; Suffolk; Havering; Barking and Dagenham; Hammersmith and Fulham; Ealing; Brent; Hounslow; Hillingdon; Harrow; Kensington and Chelsea; Westminster; Redbridge; Waltham Forest; Milton Keynes; Buckinghamshire; Oxfordshire; Berkshire West; Berkshire East; Swindon; Knee replacement surgery is normally only offered where the patient complains of intense or severe symptomatology AND has radiological features of severe or moderate disease AND has demonstrated disease within all three compartments of the knee or localised to one compartment plus patellofemoral disease AND is troubled by limited mobility or stability of the knee joint.Patients who are morbidly obese (BMI > 40) are not normally listed for knee joint replacement surgery unless all reasonable attempts have been made to reduce weight.
Clinical commentary and patient impact: Orthopaedic operations such as knee and hip surgery might be usually due to a traumatic injury such as a sports injury or accidents, or a degenerative disease such as arthritis. Such rationing would aim to discriminate against the latter mainly, as these are chronic conditions. But the disability, pain, reduced social mobility, will cause a lot of suffering to these patients.

 

Hip impingement/ replacement/resurfacing 18 of 100 PCTs/CCGs Bury; Bassetlaw; Warwickshire; Hammersmith and Fulham; Ealing; Brent; Hounslow; Hillingdon; Harrow; Kensington and Chelsea; Westminster; Milton Keynes; Buckinghamshire; Oxfordshire; Berkshire West; Berkshire East; Swindon; Bristol; NHS Bury have imposed a threshold of an Oxford hip score below 20. However – an Oxford hip score above 20 “may indicate moderate to severe hip arthritis”. The advice is to “See your family physician for an assessment and x-ray. Consider a consult with an Orthopaedic Surgeon.”In 2011, NHS Warwickshire added new restrictions on hip joint replacement that included not normally listing patients for surgery if they have a BMI over 40.
Clinical commentary and patient impact: Restrictions on hip replacement could well discriminate against older people, for whom hip surgery is not cosmetic but essential to relieve pain, further worsening of their condition and also major social handicaps if surgery did not happen.

 

Cataract referral 16 of 100 PCTs/CCGs Bury; Bassetlaw; Havering; Barking and Dagenham; Hammersmith and Fulham; Ealing; Brent; Hounslow; Hillingdon; Harrow; Kensington and Chelsea; Westminster; Redbridge; Waltham Forest; Swindon; Bristol; NHS Bassetlaw introduced a policy for “value based procedures” in 2011/12 which imposed a threshold– meaning the PCT will only fund Cataract Surgery where there is a VA (visual acuity) of 6/12 (corrected) in the worst eye. Barking and Dagenham, Havering, Redbridge and Waltham Forest PCTs issued guidance in April 2011 to not refer patients for consideration of cataract surgery with a VA of 6/9 or better.
Clinical commentary and patient impact: Such absolute restrictions have no clinical imperatives.  There is now evidence that early cataract surgery is beneficial to patients, and the over reliance of VA as a measure is outdated.  Delaying surgery leads to more ophthalmic complications, making surgery more risky, and in the event proves costlier

 

Hysterectomy for Menorrhagia / Non-cancerous heavy menstrual bleeding / Dysmenorrhea 16 of 100 PCTs/CCGs Ashton, Leigh and Wigan; Bury; Tameside and Glossop; Doncaster;Hull Teaching; Bassetlaw;

Hammersmith and Fulham; Ealing;

Brent; Hounslow; Hillingdon; Harrow;

Kensington and Chelsea;

Westminster; Bristol;

Cornwall and Isles of Scilly;

Hysterectomy for heavy menstrual bleeding will usually only be funded by PCTs when other treatments have failed to relieve symptoms and a surgical treatment such as endometrial ablation, uterine artery embolisation or myomectomy has been offered and has failed to relieve symptoms.
Clinical commentary and patient impact:  Results of two new studies show that despite aggressive medical management most women with menorrhagia unrelated to pregnancy or malignancy will eventually need surgery and will undergo additional suffering by forestalling more definitive treatment.   The choice should be after proper informed discussion between patient and clinician & not at the discretion of managers on financial criteria.

 

Complementary therapies 15 of 100 PCTs/CCGs Blackpool; Bury; North Lancashire Teaching; Central Lancashire; East Lancashire Teaching; Blackburn with Darwen; Bassetlaw; Hammersmith and Fulham; Ealing; Brent; Hounslow; Hillingdon; Harrow;Kensington and Chelsea; Westminster; Many complementary medicine/alternative therapies are generally not funded on the NHS and have been restricted for lack of clinical evidence. The restriction tends to be that prior approval is required before the treatment can be funded on a case by case basis.Some PCTs still fund homeopathy and acupuncture (for pain relief) or osteopathy or chiropractic (for spine manipulation).

 

Bariatrics 15 of 100 PCTs/CCGs Ashton, Leigh and Wigan; Bury; Trafford; East Riding of Yorkshire; Wolverhampton City; South East Essex; South West Essex; Hammersmith and Fulham; Ealing; Brent; Hounslow; Hillingdon; Harrow;Kensington and Chelsea; Westminster; Patients generally have to be over 18 and have a BMI over a certain level to receive weight loss surgery. The patient must also have complied with weight management support. In NHS Bassetlaw, patients must have tried all available non-surgical measures to lose weight, including commercially provided weight loss support programmes.Kensington PCT will fund treatment for any patient with a BMI > 35 AND either stage 2 or 3 diabetes, airway complications, cardiovascular disease or sexual complications.

 

Treatment of benign skin lesions 14 of 100 PCTs/CCGs Ashton, Leigh and Wigan; Blackpool;Tameside and Glossop; North Lancashire Teaching;

Central Lancashire;

East Lancashire;

Blackburn with Darwen; Bassetlaw;

Walsall Teaching;

Wolverhampton City;

Dudley; Sandwell;

Suffolk;

Milton Keynes PCT; Buckinghamshire PCT; Oxfordshire PCT. Removal of skin lesions is being restricted largely for cosmetic purposes. Doncaster PCT will normally only approve interventions be for visible lesions (face and hands) of a significant size.

Removal will still be considered where malignant transformation is suspected, the skin lesion is causing pain, disability of physical discomfort or there is a high risk of the lesion becoming infected.

 

Clinical commentary and patient impact: The scale of rationing is worrying. If this many PCTs/CCGs have imposed restrictions or decommissioned this service then the risk is to the individual is likely to be underestimated.

 

Dupuytren’s contracture 14 of 100 PCTs/CCGs Tameside and Glossop;Bassetlaw;

Warwickshire;

Hammersmith and Fulham;

Ealing;

Brent;

Hounslow;

Hillingdon;

Harrow;

Kensington and Chelsea;

Westminster;

Plymouth Teaching;

Swindon;

Gloucestershire;

 

In NHS Bassetlaw, needle fasciotomy for Dupuytren’s contracture is only considered if the patient is over the age of 45 and has loss of extension in one or more joints exceeding 25 degrees, or the patient is under the age of 45 with a greater than 10 degree loss of extension in 2 or more joints. NICE guidelines indicate the procedure would be more appropriate in older people and other PCTs restricting Dupuytren’s contracture make no reference to age.
Clinical commentary and patient impact: This is a planned operation, but where the contractures are severe even undertaking basic tasks such as making a cup of tea or a meal are impaired. Surgery is indicated where other methods have failed; any delay will make the contractures get progressively worse, and it is likely then that at some stage surgery will no longer be possible.

 

Carpal Tunnel Syndrome 14 of 100 PCTs/CCGs Tameside and Glossop;Hull Teaching; Bassetlaw; Hammersmith and Fulham; Ealing; Brent;

Hounslow; Hillingdon;

Harrow; Kensington and Chelsea; Westminster;

Plymouth Teaching;

Swindon; Gloucestershire;

In April 2011, NHS Hull issued guidance to not routinely commission cases with moderate symptoms.

Other PCTs have required the patient to have had a certain period of conservative therapy before treatment.

 

Some PCTs will consider treatment if the patient is experiencing severe symptoms that interfere with activities of daily living

 

Clinical commentary and patient impact: Carpal tunnel syndrome is a painful and disabling, and is sometimes occupation related. There is still access to surgery but it is being made more difficult to obtain. It must be assumed that this is on grounds of cost rather than efficacy.

 

Caesarean section for planning / non-clinical reasons 14 of 100 PCTs/CCGs Blackpool; North Lancashire Teaching;Central Lancashire;

East Lancashire;

Blackburn with Darwen;

Bromley; Greenwich Teaching; Lambeth;

Southwark; Lewisham;

Bexley Care Trust;

Bath and North East Somerset; Bristol;

Cornwall and Isles of Scilly;

Planned caesarean section has been restricted to women with:

  • a term singleton breach (if external cephalic version is contraindicated or has failed)
  • a twin pregnancy with breech first twin
  • HIV
  • Both HIV and hepatitis C
  • Primary genital herpes in the third trimester
  • Grade 3 and 4 placenta praevia

 

Most PCTs do not offer planned caesarean section to women with:

  • twin pregnancy (first twin is cephalic at term)
  • Preterm birth
  • A “small for gestational age” baby
  • Hepatitis B virus
  • Hepatitis C virus
  • Recurrent genital herpes at term

 

 

Myringotomy with or without grommets 13 of 100 PCTs/CCGs Ashton, Leigh and Wigan; Blackpool;Bury; Tameside and Glossop; North Lancashire Teaching;

Central Lancashire;

East Lancashire Teaching; Blackburn with Darwen;

Doncaster; East Riding of Yorkshire; Bassetlaw;

Bath and North East Somerset; Cornwall and Isles of Scilly;

Myringotomy is normally only funded for children  over a certain age where otitis media with effusion (OME) persists after a period after a set period of time.

PCTs also require the child to have hearing loss of at least 25dB and evidence of a disability as a result of this hearing loss with either a delay in speech development, educational or behavioural problems attributable to the hearing loss.

 

Treatment is also considered if the child has a significant second disability that may itself lead to developmental problems.

 

PCTs will only fund grommets in adults with OME if there is significant negative middle ear pressure measured on two sequential appointments AND significant ongoing associated pain.

Clinical commentary and patient impact:   Any restriction of surgery on a child who has been deemed to require this procedure will undoubtedly affect their development, and cause longer term harm.

 

Hysteroscopy 13 of 100 PCTs/CCGs Blackpool; North Lancashire Teaching;Central Lancashire;

East Lancashire Teaching; Blackburn with Darwen; Hammersmith and Fulham; Ealing;

Brent; Hounslow;

Hillingdon; Harrow;

Kensington and Chelsea;

Westminster;

PCTs will only usually commission Hysteroscopy for Heavy MenstrualBleeding (HMB) if the following criteria are met:

  • As an investigation for structural and histological abnormalities where ultrasound has been used as a first line diagnostic tool and where the outcomes are inconclusive.

Where dilatation is required for non-hysteroscopic ablative procedures, hysteroscopy should be used immediately prior to the procedure to ensure correct placement of the device.

 

Trigger Finger 12 of 100 PCTs/CCGs Bury; Tameside and Glossop; Bassetlaw;Hammersmith and Fulham; Ealing;

Brent; Hounslow;

Hillingdon; Harrow;

Kensington and Chelsea;

Westminster; Swindon;

Trigger Finger procedures are normally only offered after failure to respond to conservative measures or fixed deformity non-correctable.

 

Dilation and curettage (for Menorrhagia) 12 of 100 PCTs/CCGs Ashton, Leigh and Wigan; Blackpool;Bury; Tameside and Glossop; North Lancashire Teaching;

Central Lancashire;

East Lancashire Teaching; Blackburn with Darwen; Doncaster; East Riding of Yorkshire; Bassetlaw;

Bath and North East Somerset;

 

PCTs will generally not fund D&C as a diagnostic tool or as a therapeutic treatment for menorrhagia.Some PCTs will still fund D&C as an investigation for structural and histological abnormalities where hysteroscopy and ultrasound has been used as a first line diagnostic tool and where the outcomes are inconclusive.

 

 

Treatment for erectile dysfunction (including penile implants) 11 of 100 PCTs/CCGs Salford; Hammersmith and Fulham; Ealing;Brent; Hounslow;

Hillingdon; Harrow;

Kensington and Chelsea;

Westminster; Berkshire West; Berkshire East;

 

Drug treatment for erectile dysfunction is normally only funded in exceptional circumstances.

PCTs restrict use of vacuum devices as they are less effective for orgasm and guidance is that they may block ejaculation.

 

Laser treatment or surgery for revision of scars 11 of 100 PCTs/CCGs Ashton, Leigh and Wigan; Doncaster;Bassetlaw; Hammersmith and Fulham; Ealing;

Brent; Hounslow;

Hillingdon; Harrow;

Kensington and Chelsea;

Westminster;

 

Revision surgery for scars is usually restricted unless there is significant deformity or to restore normal function.Some PCTs will commission scar revision for the face in exceptional circumstances.
Wrist ganglion 10 of 100 PCTs/CCGs East Riding of Yorkshire;Bassetlaw; Walsall Teaching; Wolverhampton City;

Dudley; Sandwell;

Plymouth Teaching;

Swindon; Cornwall and Isles of Scilly;

Hull Teaching; Treatment for wrist ganglion is normally only considered if the patient is in severe pain with restriction of activities of daily living. Cosmetic surgery for wrist ganglion is not normally funded.
Clinical commentary and patient impact:  Patients do not like these lesions and the commonest dorsal form (60-70%) most definitely causes pain & discomfort.

 

Spinal cord stimulation 10 of 100 PCTs/CCGs Bury PCT; Bassetlaw PCT; Hammersmith and Fulham PCT; Ealing PCT; Brent PCT; Hounslow PCT; Hillingdon PCT; Harrow PCT; Kensington and Chelsea PCT; Westminster PCT;  Spinal cord stimulation is restricted to those who meet certain criteria – including adults with chronic pain of neuropathic origin or where a patient is experiencing chronic pain for at least 6 months.
Clinical commentary and patient impact: 

 

 

 

 

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One Comment

  1. Mrs Anne Pizzey says:

    I was very interested to read this article. It is the first time I have come across it. Do you have a more up to date version as we are now in 2014? (Aug).
    I am an elderly lady of almost 75 who had a nickel free total knee replacement carried out 10 year’s ago.
    I now need my other knee replaced and am fighting to get my BMI down – due to the NHS guidelines – not easy when you have restricted mobility.
    A surgeon I have found who does carry out nickel free replacements has told me he can do my op on NHS as long as my BMI is less than 40 (it is around 43) and I am trying hard to lose the weight to meet NHS criteria.
    HOWEVER the same surgeon also told me that for around £10,000+ he would be able to do my operation privately even though my BMI is a little over 40!

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