This is NHS Check report no 4 originally published by Labour’s Shadow Health Team in  November 2012

Revealed:

  • An estimated 52,000 patients in England were denied treatment and kept off NHS waiting lists last  year due to cost-based restrictions
  • Official statistics show huge fall in operations in the eight treatments most commonly subject to new restrictions
  • Overall, 47 PCTs in England have restricted one or more of the eight treatments
  • Patients left in pain, discomfort, unable to work or paying to go private as cataract, varicose vein and carpal tunnel syndrome operations all affected
  • Evidence of accelerating postcode lottery across nhs in england undermines claims by ministers that rationing by cost is not happening

KEY FINDINGS

The table below shows the impact of restrictions imposed since the election:

ELECTIVE ADMISSIONS

YEAR

 

2008/09

2009/10

2010/11

2011/12

Real number change since change of Gov

Cataracts

305,946

323,167

325,204

319,860

-3307

Varicose Veins

34,687

34,554

31,674

25,712

-8842

Carpal Tunnel Syndrome

54,083

53,642

52,518

48,906

-4736

Tonsillectomy

47,942

48,169

45,007

44,581

-3588

Lesion of Skin

214,842

227,716

223,109

204,774

-22942

Dupuytren’s Contracture

9,609

9,231

8,899

8,477

-754

Myringotomy

34,162

33,571

31,882

29,748

-3823

Hysteroscopy

50,626

53,182

51,412

49,194

-3988

  • These figures for hospital episode statistics (HES) for patients admitted to hospital, analysed by the House of Commons Library, show a fall of 51,815 across all eight most commonly restricted treatments.
  • These are the first falls for many years in numbers of operations – against a background of growing demand.
  • Labour’s NHS rationing survey in June showed almost half of Primary Care Trusts or Clinical Commissioning Groups have restricted or decommissioned services in the years 2010-11 and 2011-12. It found 125 different services had been rationed across the NHS, with 22 being entirely stopped in some parts of the country.
  • Of the 100 respondents found to be restricting access to the above treatments in June:
    • 24 PCTs restricting tonsillectomy
    • 21 PCTs restricting varicose veins treatment
    • 16 PCTs restricting cataract referral
    • 14 PCTs restricting Dupuytren’s contracture
    • 14 PCTs restricting surgery for carpal tunnel syndrome
    • 14 PCTs restricting skin tag removal
    • 13 PCTs restricting myringotomy
    • 13 PCTs restricting hysteroscopy

Clinical commentary on restricted treatments:

Cataracts

Cataracts imply declining sight which can be an enormous problem for elderly people and is responsible for falls and injuries requiring hospital treatment.  Such absolute restrictions have no clinical imperatives.  There is now evidence that early cataract surgery is beneficial to patients, and the over reliance of Visual Acuity as a measure is outdated.  Delaying surgery leads to more ophthalmic complications, making surgery more risky, and in the event proves costlier.

Varicose veins

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 such as eczema or ulcers interfering with the life style.

Carpal tunnel syndrome

Carpal tunnel syndrome is a constriction of ligaments in the wrist affecting the nerves and can be 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.

Tonsillectomy

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.

Dupuytren’s contracture

Dupuytren’s contracture means a restriction on people’s normal use of their hand.  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.

Myringotomy

Myringotomy and grommet insertion is performed to allow air to circulate freely in the middle part of your ear. This is usually performed to help with hearing loss due to fluid in the middle ear or relieve pain due to poor air flow in the middle ear.  Any restriction of surgery on a child who has been deemed to require this procedure will undoubtedly affect their development and ability to concentrate in school, and cause long-term harm.

Hysteroscopy

A hysteroscopy can be used to help diagnosis cases where a woman’s symptoms suggest that there may be a problem with the womb. Symptoms might include:

A hysteroscopy can also be used to remove abnormal growths from the womb.

BACKGROUND

In June, Labour’s first NHS Check supplied the lists of bureaucratic restrictions that had been ushered in around the country – crude cost-cutting as the Government cut the NHS budget two years running. That report detailed the PCTs imposing restrictions and the nature of the treatments being restricted.  Today’s report shows the human impact that the rationing of these treatments is having.

In 2011 the then Health Secretary Andrew Lansley announced that he was banning Primary Care Trusts from rationing operations on grounds of cost.

“PCTs have to manage resources carefully but they must do so without restricting patient choice. That’s why I am taking firm action today and banning these unfair measures imposed on patients.”

Department of Health press release, 14 November 2011,

When presented with the evidence of rationing based on cost Ministers denied the existence of some of the restrictions and denied the impact of others.

The former Secretary of State, Andrew Lansley said:

“Time and again, he (Andy Burnham) says, ‘Oh, they are rationing.’  They are not.”

Andrew Lansley, Annual Report to Parliament on 4th July 2012, House of Commons Hansard, 4 July, c923

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

These new NHS figures provide evidence that people are facing difficulties in accessing routine treatments that were previously readily available, with some patients forced to consider private care where the NHS has entirely stopped the service.  Other independent voices have also expressed the same concerns for patients.

The RNIB found:

“Restrictions on access to cataract surgery by 57 per cent of PCTs in England are forcing thousands of people to live with serious and unnecessary sight loss according to new research carried out by the Royal National Institute of Blind People (RNIB).

“There is regional variation, for example, patients in North East England can have surgery as soon as the cataract affects their lives. In the South East some patients need to have a visual acuity as low as the third line down on an eye chart before they are able to access surgery.”

RNIB press release, 24 May 2012,

An investigation by GP Magazine found:

“GPs increasingly have to fight to obtain NHS treatment for their patients as managers raise the limits on access to care, a GP investigation has found.”

GP online, 19 November 2012,

This random rationing and accelerating postcode lottery is undermining a universal, comprehensive National Health Service.

Newly formed Clinical Commissioning Groups, taking control of primary care services from April 2013, will have full discretion to restrict and decommission treatments – resulting in the differences between areas growing wider.

Health Minister Earl Howe recently reiterated the Government’s belief that:

“GPs are the group of professionals who have the closest understanding of their patients and are able to take a measured and professional assessment of health needs in a particular geographic area […]. The rationing of services on the basis of cost alone is wrong. It compromises clinical values and patient care. […] By transferring commissioning powers to GPs we are empowering them to make these decisions and work with their local patients to ensure that they get the care that they need”.

Interview with GP Magazine, Thursday 22nd November 2012

Minister can no longer deny what is happening and must take urgent action before thousands more patients are left in pain and discomfort.

In light of the new evidence uncovered, Labour calls on the Government to:

  1. Honour commitments to end cost-based rationing by overruling PCTs imposing such restrictions and reversing any rationing decisions which leave patients in pain, restrict mobility, limit their ability to live independently or have a major psychological impact
  2. Stop decisions on rationing being taken without proper public consultation with patients and honour their claims to ensure full patient involvement and “no decision about me – without me”.

Annexe A – Corresponding restrictions and clinical explanation

Treatment/

service

Number of PCTs

Names of PCTs restricting/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 last 2 years.NHS Gloucestershire will also fund tonsillectomy where there have been 3 or more episodes in each of the last 3 years.
Clinical explanation:  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 explanation:  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.

 

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 explanation: 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.

 

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 explanation: 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 explanation: 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 explanation:  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.

 

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 explanation:   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.

 

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