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    In order to address the issue of where the NHS reforms may lead, and qualify the argument of the status quo of implicit priority setting of care combined with the Health and Social Care Act reforms, an increased integration with market mechanisms through greater use of private sector services, and the already existing financial pressure that the NHS is under will lead to care being rationed within the NHS, it is useful to use the example of the Oregon Health Plan, where prominence was given to the priority setting of care. Whilst the demographics are different, as is the political system, as a process of formulating healthcare policy, the Oregon Health Plan has many lessons that can be taken away, especially for the NHS.

    Whilst it has been argued that the Oregon Health Plan, created in 1994 to address the state’s Medicaid bill, was an attempt to explicitly prioritise care, and then use rationing processes for such care, it is important to consider that such rationing does not appear to have actually occurred. As will become clearer, this is a key example for the difference between priority setting and rationing, which does not appear to be widely discussed in the debate. There are two uses for the Oregon Health Plan in this discussion: firstly, a system in which priority setting was made public (with the theoretical end result being rationing of care); and secondly, the formation of a policy that had wide public involvement.

    What is the Oregon Health Plan? – Background

    The Oregon Health Plan (OHP) was the state of Oregon’s Medicaid programme pioneered by John Kitzhaber and approved by the Clinton administration to be implemented in 1994. The policy sparked a debate around healthcare both within the state and nationally, and preceded reform in other states. The explicit priority setting that occurred resulted in 10,000 medical procedures being categorized  and then each respective condition being ‘paired’ with a treatment, of which there were 709 ‘condition/treatment pairs’. Up to this stage, this is priority setting. Where the (explicit) rationing, in theory, took place was that the Oregon legislature placed a line on the list, where the state would cover all condition/treatments above the line, and not fund those below the line.

    Rankings of the 17 service categories in the Oregon Health Plan.

    Rankings of the 17 service categories in the Oregon Health Plan.

    The idea behind such a policy was to expand the number of people who were eligible for Medicaid, and therefore reduce the number of uninsured people, by reducing the number of services that would be covered; more people would be insured, but less services offered. The OHP brought coverage to an additional 100,000 people (an increase in the Medicaid population of 39%), as well as the existing 250,000 people who qualified for Medicaid.

    The formulation of the list incorporated a cost-benefit analysis, Quality of Well Being (QWB) scale, as well as taking into account public opinion on the value of healthcare. Such public consultations took place through “professionally conducted town hall meetings and public opinion surveys”, which, due to their popularity, received consistent media coverage. A wider debate also took place in an attempt to define what should be contained within healthcare provision for the state as a whole, as well as making public the rationing processes already used to prevent uninsured and underinsured people getting care.

    Given that most hospitals have a legal obligation to treat uninsured patients in an emergency, leading to instances where the provider does not receive payment, the OHP had the support of hospitals, as a way to reduce this financial burden, as well as attempting to prevent “inappropriate visits” to emergency facilities. Funding for the policy was continued in 1996 with a 30-cent rise in tobacco tax, allowing further expansion of the policy. The Health Evidence Review Commission is still responsible for maintaining the prioritized list of services.

    Analysis of Oregon Health Plan from literature – Did it work?

    The significant talk of rationing did not actually turn out to be the end result, as there was no widespread rationing of care, and it has been argued that the outcome was less than what the policy makers had envisioned. For instance, it has been stated that the current system has become more substantial than before the OHP, especially for mental health services, and dental care – which can be seen as more generous than private insurance. Additionally, transplant coverage – one alleged rationing target – was more generous after the rationing, than before.

    Interestingly, the original Bill that contained the OHP also stipulated for an employer mandate, similar to the Patient Protection and Affordable Care Act 2010, in a bid to reach universal coverage in the state, but this was not allowed under federal law and no exemption was made from the Employee Retirement Security Act (ERISA). Such inaction for an exemption led to 340,000 remaining uninsured in 1996.

    Although critics of the OHP highlighted the rationing element, many who were involved in the policy making process appear to have “championed” the process, as well as the positive outcome for the expansion of healthcare provision.  There are also wider economic lessons that can be taken, as the OHP policymakers initially looked at using cost per quality adjusted life years (QALYs), but did not find the data conclusive.

    Whilst people have questioned the fairness of focusing on Medicaid patients for the prioritisation of care, the OHP and its explicit list of care has been useful as a process of defining what healthcare is available, and due to the public involvement, was testament to such public debate.

    Politics of the Oregon Health Plan

    Although the OHP appeared to be controversial initially, the fact that the policy was able to remain in place is telling of the public involvement that was utilized throughout the development of the policy. It can be argued, therefore, that a significant aspect of the policy was its very existence, especially when considering the toxic political environment that surrounds healthcare policy within the US. In addition, although it received the title of a “policy experiment”, the OHP was able to carry with it political momentum through using priority setting as a basis.

    By sponsoring the original Bill, Kitzhaber took a calculated political risk, but he had a firm belief in increased coverage, as is telling in his response to being asked about the OHP appearing to ration healthcare for Medicaid patients, those with lower incomes (a claim that was dispelled within three years of the OHP), as he argued that the “‘Hippocratic Oath needs to be adapted to the 20th century’”, which has been interpreted to mean that a doctor is not simply there for the individual patient, but that there must be wider societal considerations taken into account also. The policy of combining health research and democratic participation was described as an “unusual marriage” between the two – continuing to highlight the innovativeness of the OHP.

    A wider commitment made by the OHP and its development as a policy was that healthcare was seen as a process by which investment can be made into the wider economy, based upon the principle that healthier people will lead to a more productive population and economy.

    Criticisms of the process

    An obvious criticism of the detail of the OHP is the content of the prioritized list itself; it does not take a qualified doctor to be able to appreciate the complexities within healthcare and the ensuing difficulties that would be apparent if a limited list of treatments were to be created. The argument has therefore been made that setting out to produce such a list in itself is defying “common sense”. Other criticisms have related to the morality of prioritizing healthcare treatments in such a way, as well as there being other areas of healthcare that could be rationed, such as administrative processes.

    cost-effectiveness process for the Oregon prioritised list

    Evidence based assessment, and cost-effectiveness process for the prioritised list

    Lessons for priority setting

    As the objective of the OHP was to utilize priority setting in a way to increase coverage, it is useful to consider any lessons for priority setting as a whole that can be offered. For example, as was found in the OHP, once the line had been imposed so that the services below the line were to be rationed, there was opportunity for the system to be “gamed”, by doctors using conditions that were above the line, even if the patient has an illness that is below. It was also found that the OHP did not take out the decision of the doctor, as in certain circumstances care was authorized, even if the particular treatment fell below the line.  The main lesson from the OHP, I would argue, in terms of the debate around priority setting is that making the choices explicit and using a systematic process can have, in theory at least, a more desired outcome than using an unsystematic, inconsistent, “ad-hoc” approach.

    Lessons for the NHS

    There are strong arguments that the experience and processes used are of relevance to a “universal system such as the NHS.” For instance, a comparison made at the time relates to the North East Thames Regional Health Authority, where a list of services to be excluded from NHS treatment was produced, but with very little information made public about the process of making such a list – in stark contrast to the OHP therefore where the process was as open and transparent as the final list was.

    Such a systematic process of understanding the priorities that society has for healthcare, as was followed in the OHP, has not yet led to a widespread debate in England, although there have been numerous attempts at increasing patient involvement within the NHS, with the latest being HealthWatch.

    The NHS has numerous challenges, and arguments can be made that it is a very different system in 2013 than it was when it was created in 1948. What has remained consistent however, and what will remain consistent after the implementation of the HSCA is that treatment will be provided free at the point of use. Patients will not be sent a bill following treatment that they have carried out, and patients will not be met with questions about insurance before they are asked about their medical requirements.

    National Health Service reforms and the Oregon Health Plan

    “The astonishing fact is that Bevan’s vision has stood both the test of time and the test of change unimaginable in his day. At the centre of his vision was a National Health Service, and sixty years on his NHS – by surviving, growing and adapting to technological and demographic change – remains at the centre of the life of our nation as a uniquely British creation, and still a uniquely powerful engine of social justice.”

    Gordon Brown

    Analysis of the Health and Social Care Act and the Oregon Health Plan

    The uniqueness of the NHS to England and the UK as a whole is an example of the relative difficulties associated with using lessons from healthcare systems that operate in one country, and applying them to another country. It is however useful to look at the OHP and take away any lessons, particularly in relation to priority setting that the NHS could benefit from.
    It is therefore necessary to look at the OHP in a theoretical manner, as opposed to looking at the policy with a view to replicating such a policy in England. The example of the OHP therefore, where priority setting was used to prioritize publicly funded healthcare, the way in which it was completed, and crucially the line that was drawn on the list, is of real value to the debate around healthcare reform.

    Had the results from the OHP turned out as was most feared, that those treatments under the line would be strictly rationed, this would have clearly been a negative outcome for some patients who have conditions on the lower end of the prioritised list, such as sexual dysfunction.

    A significant difference between the OHP and the approach taken by the NHS  is that priority setting and rationing in the OHP was completed in an explicit manner, and the NHS in a more implicit manner. In terms of transparency therefore, there is clearly a difference between the two processes and the way in which each were completed.

    rationing in the NHS

    I am going to use the lessons from the OHP, and bring them together with the NHS reforms, to argue that assuming that the NHS maintains the status quo of implicit priority setting of care; combined with the HSCA reforms of an increased integration with market mechanisms and competition through greater use of private sector services; and the already existing financial pressure that the NHS is under, will lead to greater rationing of care within the NHS.

    I will take each aspect in turn and assess why, when combined, these factors will lead to greater rationing within the NHS.

    Implicit priority setting

    The status quo of implicit priority setting within the NHS allows there also to be implicit rationing. If there is relatively little public awareness about the services that are rationed, then it is easier for such decisions to be made, out of the public domain. There are many priority setting policies in place within the NHS, but given the implicitness of these, there is very little awareness of what services are subject to rationing. Whilst there is an argument stating that currently within the NHS there is a mix of both priority setting, and rationing; it is the latter that creates the most cause for concern of healthcare provided within the NHS in England.

    Health and Social Care Act reforms

    Given the significant role of GPs on Clinical Commissioning Groups contained within the HSCA, a substantial concern is the lack of experience that GPs may have with the commissioning role within the NHS, and the potential that this has to negatively affect the commission of services.

    Considering the introduction of AQP, as well as the increased role of market mechanisms and a rise in private providers within the NHS, it is likely that there will be lower levels of public accountability within the NHS. This is due largely to the levels of public accountability that have typically been found within private sector services being less than public sector services.
    Whilst private involvement with the NHS is not inherently negative, in a controlled and regulated manner, having such an increase in the number of private providers will lead to less accountability. There is also a wider, deeper, issue here in relation to private companies and their involvement within healthcare. A public service such as the NHS is not the place for significant involvement of private companies that are susceptible to placing profit motivations, and shareholder interests, before public service.

    The increased local autonomy that is contained within the HSCA, primarily through the role of GP commissioning is another contributory factor to greater rationing within the NHS. This is especially so when considering the possibilities that this opens up for GPs and ultimately there being a case where GPs on a CCG choose to commission services from a provider which they run themselves, on a private basis.

    Nicholson Challenge / QIPP

    The existing financial pressures that the NHS is facing, even before the HSCA reforms were passed, could theoretically contribute to a rationing of care due to the lower levels of funding available to the NHS for services. There is however the potential that if the savings are made through decreases in administrative – non “front-line” – aspects of the NHS, then this could not impact rationing of care. The overall financial pressure upon the NHS is however likely to have a negative impact upon services, and such an impact will not just be felt in the administration side of the NHS.

    Why this means greater rationing within the NHS

    An obvious counterargument to the above argument and there being a rise of rationing is that, especially in relation to the Nicholson Challenge, such efficiency savings may indeed be made to parts of the NHS that are not “front-line”, and may not necessarily amount to the rationing of care that people receive. There are however, only so many efficiencies that can be made on so-called back-office administration. Given the relative importance of such aspects of the NHS, for example the storage of patient records, making efficiencies in one area of the NHS is likely to impact upon another.

    A counterargument in support of the HSCA reforms could be made on ideological grounds that the market will always prevail, and that the market knows best. Such a notion may indeed be the case within the motor industry, or the insurance industry for example. Whilst such a comparison might be useful in factors such as staff productivity, discussed earlier, there is very little comparison that can be made across different sectors. For example, if there is a decrease in the number of cars manufactured owing to efficiency savings within the supply chain, or within the factory; or less insurance products sold because of a reduction in sales staff, this will not have a detrimental impact upon the customer. In healthcare however, given its sensitivities, the impacts of rationing can lead to a decreased accessibility to healthcare, and therefore to a lower level of healthcare available to the customer; the patient.

    How the HSCA leads the NHS in the direction of the Oregon Health Plan.

    Following the argument that a maintenance of implicit priority setting, the HSCA reforms, and the Nicholson Challenge contributing to greater rationing within the NHS, it is useful at this point to relate such an argument to the OHP.
    Such an argument would therefore state, taking the outcome of the OHP in a theoretical sense – that is, the explicit priority setting leading to widespread explicit rationing of care – this is not too dissimilar to where the future of the NHS might lie if the implicit priority setting, HSCA reforms, and the Nicholson Challenge are maintained.

    Pressures leading to NHS rationing

    Schematic diagram of the relationship between priority setting, HSCA reforms, and the Nicholson Challenge within the NHS, the outcome of rationing within the NHS, and the relationship with the OHP.

    Such an argument is based upon factors – implicit priority setting, HSCA reforms, Nicholson Challenge – that are actually happening within the NHS. To offer a perhaps more optimistic outlook, however, it is useful to refer back to the OHP, and the lessons that can be taken away, and used within the NHS.

    Where the OHP values can help the NHS

    Taking the complete approach from the OHP and replicating it in England will not work, nor would the vast majority of the processes that were used, as has been previously discussed. There are however two main elements that are of significant use for the NHS: explicit priority setting, and widespread public debate.

    At present priority setting within the NHS is very much implicit with little information actually made public about the services that are provided by the NHS. Creating an explicit list of the services that the NHS funds could, therefore, be a step in the right direction for creating transparency within the NHS. Perhaps more importantly, such a list could also help to educate the public about what the NHS provides and would in theory make it more difficult for healthcare to be rationed because of the greater public accountability.

    It would be counterproductive for there to be a line placed on such a list, as in the OHP case, as this can create an incentive for the private sector to provide services that the NHS will not cover. Having a list at each CCG would be a starting point, with a view to there being a national explicit list of the services provided by the NHS in England. Having different lists for each individual CCG is what was discussed earlier as the disparities found across the nation in terms of the postcode lottery. Whilst this is not preferable, having an explicit priority setting process for healthcare provided by the NHS would be beneficial as this would make rationing of care clearer. Therefore, once such clarity has been reached, there is a greater chance of there being a less widespread postcode lottery.

    Following on from such an explicit list, as was an integral feature of the OHP, having a widespread public debate and consultation about the priorities that the public has for healthcare, and perhaps health in general, would benefit the NHS. Dependent upon the outcome of such a debate, this may place greater pressure on future governments to limit further reforms within the NHS.

    The public involvement with the healthcare reforms of the OHP, in appearance at least, seems to have sparked a debate within Oregon as to what it is the public demand for their healthcare. Whilst the OHP was addressing Medicaid, and not the whole population, it is interesting to note that such a debate does not appear to have ensued in the UK with the HSCA. The debate that has been associated with the HSCA has been relatively complex and confused given the relative difficulty in understanding the HSCA reforms and amendments in the passage of the Bill. Additionally, any debate that has ensued has largely been related to what service should be provided by a so-called National Illness Service, as opposed to a wider debate about the health priorities of the country. Whilst the debate around the OHP appears to have also focused upon the role of healthcare from a similar perspective, it is positive to note that the OHP provoked such a debate within the public.

    The future of the NHS

    The increased local autonomy contained within the HSCA reforms, and the further integration of market mechanisms and competition make up some of the most significant aspects of the HSCA. In order to use the lessons taken from the OHP, and apply them in a constructive manner to the NHS, there is a case that can be made for the NHS adopting a more explicit priority setting process. This is especially so when considering that CCGs will likely face similar priority-setting issues; having such a list of national principles would therefore be beneficial.

    Such a system could involve creating a list of principles that determines how money in the NHS is spent; or a list of treatments provided should be created, and prioritised, but – crucially – without the rationing line that the OHP had. The former appears more politically attractive given the public perception of the NHS, whilst the latter appears more radical, and therefore more politically challenging.

    Although creating an explicit list would not “necessarily increase the public knowledge of entitlements”, it could however lead to a greater public debate, which would certainly be a positive development. There are suggestions that a negative list – what the NHS should not provide – could be adopted using existing NICE guidelines. Whilst this may indeed lead to a widening of the debate, if this were to be introduced there would be a greater incentive for the role of private companies to fill the gap – on the assumption that such treatments would be profitable.

    An additional, perhaps more practical recommendation, is to use nudging to encourage providers and clinicians “towards clinical and cost-effective care” Such a dilemma can be described as politically paradoxical because of the potential progress that can be made, as was seen with the OHP, but also, and perhaps more relevant to the NHS, the clear political risk that creating an explicit list would require.

    Given the maintenance of implicit priority setting within the NHS, as has been discussed, this acts to amplify the impact of the HSCA reforms and the impacts of the Nicholson Challenge upon the NHS. Addressing the status quo of implicit priority setting could therefore lead to a wider public debate, as was seen in Oregon, with the potential to lead to an even stronger NHS. Taking the public with them, politicians and policymakers therefore have an opportunity in which to create a widespread public debate about the NHS – which has the potential to benefit an NHS that maintains to be for the people.

    Ian has been working with us for the last year and this is part of his undergraduate dissertation submitted to the University of Sheffield.

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    Labour Health Policy Consultation

    Response from Dr Kathy Teale and Councillor David Ellison, Members of SHA and Didsbury West Labour Party  Manchester Withington CLP


    Many studies have shown that the NHS is an extremely cost-effective health care system.   A recent Commonwealth Fund report from 2010 repeated this finding. This report compared health care systems in 6 developed countries including the UK, the US, Canadaand Germany.  They looked at 5 areas – Quality of care, Access, Efficiency,   Equity and population life expectancy.  The UK ranked 2nd overall, with a much lower cost per capita – $2454, as opposed to $US 7290. However it did badly on “long healthy lives” (many of the determinants of which are determined by social conditions and not a reflection the quality of health care) and “patient centred” care, (which reflects how convenient and pleasant the service is for patients, rather than looking at outcomes).

    The NHS is therefore not a “broken” system – and it’s high cost-effectiveness may be particularly relevant at a time of restricted government budgets.  However, there are elements which we need to improve, especially as the population ages and comorbidities such as obesity increase.  In particular, it needs to be more “patient-centred”.

    We currently, under the purchaser-provider split, have a system which has discouraged integration between primary and secondary care, and where rehabilitation services, community care and social care have been grossly and systematically under-resourced.  We have also inherited a network of acute hospitals which has not changed for the last 60 years, despite major changes in population distribution and needs.   Yet the recently-passed HSCA does nothing to address these problems, and in fact will lead to an increasingly fragmented and disparate service with differences in provision and access between regions becoming increasingly common.

    This paper looks at some of the ways we can improve on the current provision of health care in theUK– both in acute services and long term and social care.

    Response to Questions;

    1/ an integrated approach to Health and Social Care

    • Is whole person care the correct approach to healthcare in the 21st century?

    A    Yes, the consensus view is that that this is the way forward

    • How can whole person care be funded so that it becomes free at the point of use?

    A. Healthcare should be provided by the Public sector. The celebration of the humanity of the NHS was a key part of the Olympic Celebrations by Danny Boyle. Evidence from theUSAdemonstrates that costs of private provision are substantially higher due to administration, bureaucracy costs, excess provision to the wealthy, and still with inadequate provision to the poor and non-insured.  An extended state-backed insurance-based system for social care may need to be provided in theUKto fund care needs of the elderly in the future as costs of care and the number of elderly increases. Planning for this whole life care should start now.

    The principal of free Health services at the point of use must be maintained however. Up-front payments, as inFrance, disadvantage poorer patients and discourage access from the very patients that often most need to access services quickly.

    More emphasis should be placed on access to primary care, which evidence shows has become more restricted since the current government came into power. Easy and prompt access to primary care is essential for early diagnosis and reducing health inequalities especially in hard to reach groups.

    “Empowering primary acre is associated with better health outcomes and lower costs – primary care has been outmanoeuvred by a health industry intent on opening access to lucrative down stream services and resources “Brian Kiepper, US health commentator

    • How can we ensure a better experience of patient care?

    A    Ensure that service providers are responsive to patient requirements. That a complaints service continually responds to patients and that a system of continuous improvement is in place. Ensure that there is strong scrutiny of NHS services with an independent patient watchdog put in place.

    The emphasis on patient choice should be changed so that patients have choice over the treatment they have, and at which hospital, clinic, or care home. However, the expectation should be that the patient’s local provider is of high quality and most patients would want to go there

    • How can we better extend services to hard to reach families and communities?
    1. Make sure that people know about the services that are available, through public health promotion, use of community outreach services.  There must be a concerted drive to reduce health inequalities and differences in life expectancy that only began to close with injection of resources into the NHS by the last Labour government. Evidence is growing now that health inequalities are growing again.  Access must not be affected by wealth,  education, comorbidities, age , gender, or race .
    • How the health and social care service should be funded in the future?

    A     The most equitable way of providing healthcare is by population risk pooling i.e. funded by everyone through general taxation or state insurance system . Co-payment systems reduce access to those with low incomes and introduce a two tier service, reducing the impetus for service improvements for those on the lower tier. This will only serve to widen inequalities . Even a small charge to see the GP when trialled inWales, resulted in later presentation of morbidities .  Specific insurance systems introduce a smaller risk pool with the danger of cherrypicking .

    • How can services be made more accountable to patients , public and staff ?

    A   There needs to be democratic accountability for the Health service at the highest level to Parliament .  Democratic accountability at local level should be increased by strengthening the role of local authorities in the provision of public health and social care services . Authorities should have a role in driving down health inequalities . However to do this they will need sufficient resources.  The poorest parts of theUK, which are the areas of shortest life expectancy, have the highest health needs and therefore need appropriately increased funding to improve the health outcomes for these vulnerable populations.

    • How can we learn from the Dilnot Commissions about how we fund social care ?

    A   The Dilnot Commissions recommendations for social care need to be looked at. A state backed insurance system to meet the needs of an ageing population will be the fairest way of providing the increasing levels of social care required by a growing elderly population in the future .

    2/ Principles  of Health and Social Care

    • What would you list as the key principles for any health and social care service ?

    A  Health services should be funded  by the public sector through general taxation or insurance to provide general healthcare services for all citizens free at the point of use .

    There should be equality of access for all citizens.  However, in order to reduce health inequalities the service should positively seek out those in need of care and meet those needs.

    Treatments available should be evidence based and in accordance with best practice . Variability and idiosyncratic practice must be discouraged .

    Information about services and outcomes should be freely available to patients . There should be a continual process of public health education and promotion

    Healthcare provision should be planned and commissioned to ensure the changing health needs of the population are matched in line with advances in medical science and improved methods of care . Public Health services based on the needs of the population should drive change and improvement .

    Healthcare provision should be adequately funded and commissioned at a local level where possible to ensure that is  responsive to the needs of the population .

    Patients should have choice over the type of treatment they receive and where they receive it from . However it should be on the basis that the standards of service throughout  Health service are consistently high . Choice of provider alone does not drive up standards, as patients are unable to choose on the basis of any criteria reliably linked to quality of outcome.

    • How can we put the patient back at the heart of the NHS and re introduce cooperation rather than a market free for all ?

    A   What do we mean by patient at the heart of the NHS ?

    Patient centred – The commonwealth fund definition is “ care delivered with patient preference and need in mind, including good communication . continuity , feedback and engagement “  This does not involve outcomes, which are assumed.

    1/ Ease of access to primary care provision – 80% of healthcare contact is through primary care . Good communication , continuity of provider and emergency care when required are vital

    2/ Involve patients in decision making about their treatment

    3/ Emphasis on whole person care –not fragmented across different services especially for elderly and multiple co-morbidities

    4/ Abolish private sector competition which segments service and hives off profitable parts and introduces perverse incentives . Providers should not be “for profit “ , free flow of information and patient details between providers is vital . All centres to publish data, not just NHS providers.

    5/ Rigorous audit and monitoring against quality targets e.g. fractured NOF care – with payment attached to providers for fulfilment of targets .

    6/ rationalize secondary care services e.g. specialist care in a few big centres , less specialist in other and more local hospitals , balanced against access requirements

    7/ Conflict between efficiency and patient experience – e.g. theatre list efficiency – some patients have to wait and risk cancellation in high utilisation systems . Therefore improving patient experience may lead to greater costs

    8/ Improved communications once being treated , including with relatives

    9/ In turn patients have a duty to understand how the NHS works and is funded. Some patients are largely ignorant at the moment and don’t appreciate the service they receive. There is a social contract at the heart of the NHS

    3/ Tackling Health inequalities

    • How do you think the NHS can best work to reduce Health inequalities?

    A the Marmot report in 2010 identified 6 objectives to reduce Health inequality

    1/ Give every child the best starts in life.

    2/ Enable all children to maximise capabilities and have control over their lives

    3/Create fair employment for all

    4/Ensure Healthy standard of living for all

    5/ Create and develop healthy and sustainable places and communities

    6/ Strengthen the role of ill health prevention

    The NHS alone cannot solve the health inequalities in society alone; it is only part of the answer. Improving health prevention and promotion services will assist in driving social change to improve health. , tackling obesity, smoking drinking, drug taking and improving diets etc.

    One of the key ways of preventing premature morbity is ensuring that early intervention is available.  This will over time reduce costs as it reduces late presentations, improves care and reduces some of the need for expensive secondary care services

    • Which services need to work together to tackle health inequalities?

    A  Across each region of the country the NHS needs to work together to provide an integrated service to patients;

    1/    There needs to be an overall planning function  Matching the health needs of the population at a national , regional and local level with health care resources

    2/    Integration between primary and secondary care to create a seamless care pathway for patients.  The vertical integration of services can take places through a range of service providers in different areas, dependent on local circumstances

    3/ The Acute care services need to be arranged to continually drive up standards and bring the latest advances in medical science to the population. The model of Hub and spoke services is beginning to drive provision of specialist services.

    4/ Changes in future demographics especially the increasing numbers of elderly and  long term conditions need to be reviewed and planned . The balance between primary and secondary care needs to ensure the best use of resources.

    5/  If  rehabilitation, elderly and long term care is to move a hospital setting to the community, there needs to be massive investment in community care services to enable provision of 24/7 care, with the ability to provide intensive nursing care in the home .

    6/ There needs to be integration with social care functions currently proved by local authorities. Some of the most needy families are in receipt of large amounts of intervention and this needs to be brought together in a co-ordinated way


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    Bernie Creaven, executive director of  BMI Meriden Hospital, Coventry  ordered an immediate four-week postponement of operations on NHS patients referred to the hospital, which will be extended to a minimum of eight weeks by September.

    In a letter to the hospital’s consultants dated 13 July, seen by The Independent, Ms Creaven said the imposed delays were to discourage patients thinking of going private from opting for treatment on the NHS.

    Private hospitals receive taxpayer money for treating NHS cases, but can make larger fees if the patients go directly to them for treatment.

    “I believe time to access the system is the most critical factor for private patients converting to NHS patients,” she wrote. She added that “other aspects of differentiation” would be introduced over the next few weeks to make NHS treatment at the hospital relatively less attractive”.

    The 52-bed BMI Meriden Hospital in Coventry charges self-pay private patients from £8,500 for a hip replacement. The NHS cost is from £5,485.

    In her letter to consultants, Ms Creaven says: “Over the past few months I have had numerous discussions with consultants regarding the lack of differentiation between NHS and private patients and there is significant anecdotal evidence to suggest that the lack of differentiation has had a negative effect on our private patient referrals.

    “I now wish to implement with immediate effect a new rule which will mean that operations on NHS Choose and Book patients will not be able to take place until at least four weeks following their outpatient consultation. Also, in each subsequent month, I will extend this by another week until September and the time will be eight weeks from initial consultation. I believe that this time to access the system is probably the most critical factor for some private patients converting to NHS patients.”

    A spokesperson for BMI Healthcare said: “We treat both NHS and private patients to the same high standards of clinical quality.”

    I suppose this is what they call a free market in healthcare?  The patients are not the consumers.  They are the commodity from which profits are made.




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    I was recently questioned about the future of the NHS, during a live debate on the BBC Radio 4 programme Moral Maze, on 9 July 2014. One of the panelists took me to task for being a “bean counter”. I got side-tracked by this somewhat less-than-flattering characterisation of my professional role as a health economist, and so only managed to get across three of the six points I had planned to make. For what they are worth, this blog sets out all six points. And, as an added bonus, it then concludes by explaining why I am proud to be a ‘bean counter’.

    This blog sets out personal ethical views on a number of controversial matters of social value judgement. That is what the BBC programme makers asked me to do, and I hope my professional colleagues will not ‘tut tut’ too loudly when they see me doing it. Professional economists are supposed to help decision makers and stakeholders think through the implications of a range of alternative value judgements, rather than to impose their own particular personal or professional value judgements. However, this blog post merely voices my own value judgements – it does not impose them on anyone.

    Point number one is that the NHS performs rather well compared with other health systems across the world. It is relatively cheap, relatively good, and very fair. The UK currently spends about 9% of national income on health care, just under the OECD average, compared with 18% in the US. People in the UK are on average healthier than those in the US – even rich people with access to the best available health care in the US. And the UK regularly comes top of Commonwealth Fund surveys of fairness in high income health systems. The UK NHS is widely regarded as the fairest health system in the world, with the possible exception of Cuba.

    Point number two is that financial strain on the NHS will get worse in decades to come – potentially much worse. This is due to a fundamental clash between health economics and tax politics. The tax politics is obvious. Voters do not like high taxes, so there is a limit to how far taxes can be raised, even to pay for something as popular as health care. The health economics is less obvious, but surprisingly simple when you think about it. As countries get richer, they spend a higher percentage of national income on health care. There is a simple reason for this. As we get richer, which is more valuable – a third car, yet more electronic gadgets, or an extra year of life? (I am here paraphrasing Hall and Jones, who predicted that health spending in the US will rise to 30% of national income by 2050). In the technical economic jargon, health care is a ‘superior’ or ‘luxury’ good. Do not be misled by this jargon – it does not mean that health care is an unimportant frippery. Quite the opposite. Effective health care that extends life and improves quality of life is much more important than fripperies. That is why rich people want to spend such a large share of their incomes on it.

    Point three is that my own preferred solution to this problem – and here you will notice that personal ethical opinions are coming thick and fast – is gradually to ration NHS care more explicitly and extensively, within whatever budget the electorate are willing to vote for. That would enable the preservation of a tax-funded national health service that continues to provide a fairly comprehensive package of cost-effective health services to all citizens, that is nearly free at the point of delivery. (The NHS has never been 100% comprehensive or 100% free at the point of delivery). The rationing should be done through a transparent deliberative process, and based on a range of ethical principles, including cost-effectiveness, need, and compassion. Chief among these principles, however, should be cost-effectiveness – the principle that scarce NHS resources should be used to do as much good as possible in terms of extending people’s lives and improving their quality of life.

    Point four is that more extensive rationing is a better and fairer solution to the problem of preserving the NHS than more extensive user charges. User charges should not be imposed on cost-effective forms of health care, such as GP visits. Charges for GP visits deter people – especially poorer people – from seeking preventive and diagnostic care. Without effective prevention and diagnosis, health problems progress to become more harmful to the patient and more costly to the NHS. If health care is cost-effective it should be provided free on the NHS; and otherwise not. People can then pay for non-cost-effective care themselves, either out of pocket or via ‘top up’ private health insurance. The slogan “all necessary care should be free” should be re-interpreted as the slogan “all cost-effective care should be free”.

    Point five is that fervent ideological debates about ‘competition’ and ‘choice’ and ‘markets’ and ‘privatisation’ are largely red herrings. What matters is that the NHS provides a fairly comprehensive range of cost-effective care to all citizens, so that everyone receives the care they need at a cost they can afford. Who owns or manages health care provider organisations does not matter directly in and of itself. Ownership and management may matter indirectly, of course – but only insofar as they impact upon the cost, quality and social distribution of health care. The direction and size of such impacts in different contexts is a factual matter, to be settled in the court of evidence and experience, rather than a matter for fervent ideological debate.

    Point six is that a more extensively rationed NHS can still preserve the founding principles of the NHS. On the delivery side, it can preserve the principle of ‘equality of access’ to all necessary health care – where ‘necessary’ means ‘cost-effective’. And on the financing side, continued tax funding continues to preserves the principle of ‘solidarity’, that the strong should help the weak – the rich should help the poor, the young should help the old, and the healthy should help the sick. Finally, the NHS also preserves the benefit of financial risk protection. As was stated in the public information leaflet sent to all UK citizens at the founding of the NHS in 1948, one of the main benefits of the NHS is that “it will spare your family from money worries in time of ill health”.

    In conclusion, the best way to preserve the NHS is to engage in more explicit and extensive rationing. This in turn will require more of what my Moral Maze inquisitor called “bean counting”. More evidence will be needed to inform a suitably transparent and deliberative rationing process. In particular, more evidence will be needed about the impacts of different NHS services on cost, length and quality of life, patient experience, need, compassion and dignity, and other ethically important outcomes and processes. This form of ‘bean counting’ is not an ignoble exercise. The ‘beans’ in question here are people’s lives. People’s lives matter, and if seeking to improve the length and quality of people’s lives makes me a “bean counter” then I am proud to be one.

    Dr Richard Cookson, is Reader and NIHR Senior Research Fellow at University of York Centre for Health Economics

    This article was first published on the Academic Health Economists’ Blog

    The Academic Health Economists’ Blog

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    Over the next 40 minutes or so I will attempt to explore a serious problem of resource allocation and health rationing in the NHS and, I hope, show that this problem is far from unique to the NHS but also exists in healthcare systems throughout the world. And I will end with a call for those who are leading the NHS in our communities up and down the country to play their part in leading public debate on these difficult issues.

    First, a health warning. I am a practising lawyer who has spend time as an MP, government minister and over a decade acting for and against NHS bodies in a wide variety of challenging situations. My views are anecdotal not systematic. I hope they are emerge of my various experiences but they are not supported by volumes of academic research.

    It is a highly appropriate time to be considering the processes of managing change in the NHS for 3 reasons. First, because the NHS has just lost – by retirement – a significant figure in Sir David Nicholson and welcomes Simon Stevens – not yet Sir Simon – who takes over as Chief Executive of the NHS Commissioning Board, known as NHS England. A change of leadership gives a window of opportunity for an incoming leader to set a new agenda. However the importance of these issues is shown by the fact that Sir David, free of the chains of office, tweeted a link to an article I wrote for the Guardian sketching out these issues, hence inviting his 4000+ twitter followers to read it.

    Secondly, the NHS is also facing an unprecedented financial challenge in 2015/16. This is, “coincidentally”, the year immediately after the next General Election. As all politicians and senior civil servants know, nothing serious happens in the year before a General Election. Policy must be implanted in the first 18 months of a Parliament or the political vested interests will create political inertia and the chance for change has been lost.

    Thirdly, public expectations of some public services are very different to before the 2007 financial crash. At this time the public appears to accept that public sector financial constraints mean that tough decisions need to be taken in some areas of public service. My experience – as a somewhat electorally unsuccessful politician – suggests to me that this mood music will not last. It will not be long before strident voices will assert the need for completely comprehensive and perfectly functioning public services, paid for by someone else. I exaggerate for effect of course – but there is an element of truth in the caricature.

    I start by setting out the premise of this lecture: The NHS is not spending the money it gets from our taxes in a way that delivers cost effective and clinically effective healthcare for the population it serves. As a service, it has the tools to deliver effective change but key decision makers have too much timidity about using these tools to do their job properly.

    Why do I say the NHS is not spending our money effectively enough? First, some of the things our clinicians do – spending NHS money – are a complete waste of money; but identifying those “things” is fraught with difficulty. A senior clinical director told me that the most expensive thing in a hospital was a pen. Doctors use pens to order tests, sign off investigations and set out clinical requirements in clinical notes. The way that our hospitals and GP practices are organised means that doctors exercise their professional discretion to do things – all of which cost taxpayers money – with little or no enforceable financial accountability for their individual decisions. There are, for example, no legal restrictions on the drugs that a GP can prescribe for a registered patient of his or her practice, regardless of the cost or potential benefit (For the details see Professor Chris Newdick’s Chapter at paragraph 1.184ff in “Principles of Medical Law” (3rd Edition) (OUP)). That is not to suggest that our doctors are routinely acting in an irresponsible way; but I do suggest that there are no clear limits on the interventions that the NHS will finance – at least at GP level – for that individual patient sitting in front of the doctor. The duty of care to the patient implies a duty to do the best for that patient but there is no clear balancing duty to make effective use of scarce publicly funded resources.

    The Dartmouth Institute for Health Policy and Clinical Practice has estimated (note 2 of Bloche: New England Journal of Medicine 10.1056/NEJMp1203521) that 30% of spending on healthcare in the US is wholly ineffective. That means that money is spent on medical interventions which not only are not clinically effective but had no reasonable prospect of being clinically effective – all arising from clinical discretion. However that number must be treated with some caution because, as Lord Leverhulme once said, he knew half of his advertising was wasted, but didn’t know which half (This quotation has been ascribed to a number of people who have purchased advertising over the years).

    Secondly, with the growth of evidence based medicine, there is an increasing understanding of what works and what does not work in medicine – at least at the population level and the best way to organise services to deliver the best outcomes. That growing body of understanding does not, of course, mean that medical interventions delivered in accordance with the evidence will work for the patient at the individual patient level. One of joys of life – reflected in medicine – is that we are all different but we are increasingly understanding more about how to organise services so that, with pooled disciplines and clear protocols, outcomes will improve for a greater number of patients.   The improvements in outcomes for patients with strokes in London which centralised initial treatment at a limited number of hospitals is a well-known example of this working in practice.

    Reorganising the locations at which NHS services are delivered improves outcomes and saves lives in 2 ways. First, directly, lives are saved by the delivery of better organised services. Secondly, better use of NHS resources in one area of medical treatment frees up resources to be used in less glamorous areas, and thus delivers better outcomes for those patients.

    What are the principles that should drive decision making? At the policy level, it seems a statement of the obvious to say that, outside proper research studies, the NHS should only invest its resources in medical treatment that is both cost effective and has proven clinical effectiveness. The NHS has developed many statements to that effect but – to pick one – this is the relevant paragraph from the NHS England Ethical framework (Principle 6 of NHS England Ethical Framework):

    “The NHS Commissioning Board should only invest in treatments and services which are of proven cost-effectiveness unless it does so in the context of well-designed and properly conducted clinical trials that will enable the NHS to assess the effectiveness and/or value for money of a treatment or other healthcare intervention”

    The justification for this approach is that, in an NHS where demand far outstrip supply, every decision to invest resources in treatment of one patient means fewer resources to treat other patients. The opportunity cost of treating each patient can only be justified if there are proper grounds for believing that the treatment is both clinically effective and cost effective. That may sound harsh because it proposes denying clinically effective medical treatment to someone who may be able to benefit from that treatment. However that approach is a consequence of an important principle that the NHS should value all lives equally. That means valuing the life of the patient who is not immediately in front of a doctor on an equal basis to the patient who is seeking treatment.

    But this type of resource based decision making rarely happens in the NHS. The NHS continues to spend our money in ways that deliver less healthcare benefit than it could.

    Let me explain by way of some examples. There has been a wide professional consensus for at least a decade that the NHS is spending too much on too many hospital buildings that the NHS cannot afford. There is an urgent need to transfer funding to community based services. However in England, 10.55% of the NHS budget was spent on general practice in 2004-2005. By 2011-2012, this had fallen to 8.5% and last year dropped to 8.39%  even though this represents 92% of patient encounters within the NHS. So policy says one thing but the “payment by results” system we have for funding NHS hospitals does not deliver the policy outcomes.

    Secondly, as Dr Ben Goldacre has demonstrated by his brilliant writing which is both informed and readable (See for example the text on Midodrine at pages 138ff of Bad Pharma by Dr Ben Goldacre (2012) Harper Collins), healthcare systems around the world, including the NHS, are failing to reduce spending on drug treatments that do not work due to a combination of commercial interests. Despite that the pressure to spend more on drugs of dubious efficacy grows each year and investment in hospital buildings is forever increasing, even though the inevitable result is a reduction in the level of resources available to the community.

    For this evening, I am not so much interested in whether the NHS fails to make change where the evidence suggests that better use of NHS resources could deliver better outcomes for patients but why the NHS fails to take these decisions.

    The “why” is – I would suggest – much more interesting than the “whether”.   Any analysis of the mechanisms for change in the NHS must start with asking “who are the decision makers” for these key decisions?

    The NHS has been divided into commissioners and providers for over 20 years (Since the NHS and Community Care Act 1990 was brought into force in April 1993). With a few exceptions, such as drugs which have a NICE Technology Appraisal Guidance for patients within defined clinical cohorts (Regulation 4(2) of the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012), NHS commissioners have a wide area of discretion to decide what services to commission on behalf of NHS patients. Local Clinical Commissioning Groups and, for specialised services and primary care, NHS England have a wide discretion to decide what services should be commissioned for patients as part of NHS funded healthcare. They have extensive duties to involve patients in their decision making but, subject to that, they are the bodies that decide who gets what medical drugs. They decide whether to commission – i.e. pay for – an A & E at the local hospital, how community services should be organised and how nearly all of the local NHS is to be set up. However the GP contract has not historically placed limits on the drugs GPs can prescribe for their patients.

    Subject to this constraint, the legal position in the NHS is reasonably clear. The fact that a medical intervention is likely to be clinically effective for a patient or even safe the patient’s life places no duty on the commissioners to fund that treatment for a patient (R (On the Application Of Condliff) v North Staffordshire Primary Care Trust [2011] EWCA Civ 910). CCGs are entitled to work out where their priorities lie and how the NHS funds will be spent.

    But my experience is that local NHS commissioners remain very timid about making changes to the services they commission. It would be easy to say that changes to NHS services are delayed for fear of upsetting politicians who fear not being re-elected. But actually there is a more serious problem.

    The real problem – I suggest – is that the concept that the “NHS is free at the point of use” is translated by the public into “NHS care should not be constrained by money”.

    Despite the recognition in other areas of public services that the “cloth must be cut”, when it comes to the NHS there remains a measure of disconnect between the money that people pay in their taxes to support the NHS and the quality of service that taxpayers expect to receive. This feeling that “we cannot say it’s about the money” makes it very difficult for those concerned with NHS reform to have a sensible dialogue with the public.

    I cannot count the number of times that I have read NHS consultation documents which try to pretend that proposed changes to NHS services are only all about improving the quality of services as if the issue of money and resources was irrelevant. In contrast the internal documents leading to the proposals make it abundantly clear that the drivers for change are a desire to deliver the best quality of services within the financial and human resources available.

    But NHS managers are not alone because this disconnect does not just exist in the UK. Professor (and Doctor) Greg Bloche has accurately said that “withholding beneficial care to control costs is a radioactive proposition in American politics”.   Tea party darling Congresswoman Michelle Bauchmann said the proposition that doctors should take account of the cost of treatment was “an horrific notion to our nation’s doctors [and] to each American”.

    However if – in my anecdotal experience – NHS managers are asked “why” they are colluding with the idea that changes to NHS services are not about making the best use of available resources, legal problems are often cited as a reason. In fact, I would suggest that the opposite is the case. The approach of the courts actively recognises and supports the need to ration health along with other public services.

    In contrast to the political rhetoric, the courts in both the UK and in the United States have accepted that rationing is part of the healthcare delivery business in both the public and private sector. The Supreme Court has approved healthcare rationing and supported paying doctors to ration care. In Pegram v Herdrich the US Supreme Court said “.. no HMO organisation could survive without some incentive connecting physician reward with treatment rationing”. The Court of Appeal in this country has repeatedly held that it is lawful for the NHS to ration access to healthcare. As long ago as 1997 Lord Bingham said in R v Cambridge Health Authority ex parte B ([1995] 1 WLR 898):

    “I have no doubt that in a perfect world any treatment which a patient, or a patient’s family, sought would be provided if doctors were willing to give it, no matter how much it costs, particularly when a life was potentially at stake. It would however, in my view, be shutting one’s eyes to the real world if the court were to proceed on the basis that we do live in such a world. It is common knowledge that health authorities of all kinds are constantly pressed to make ends meet…. Difficult and agonising judgments have to be made as to how a limited budget is best allocated to the maximum advantage of the maximum number of patients. That is not a judgment which the court can make. In my judgment, it is not something that a health authority such as this authority can be fairly criticised for not advancing before the court.”

    That approach has recently been approved in a series of recent decisions, including R (Condliff) v North Staffordshire PCT  ([2011] HRLR 38, a case in which I appeared for the NHS body.)which decided that the human rights of the patient under article 8 of the ECHR were rarely if ever engaged in medical rationing treatment decisions.

    Further commissioning decisions are public law decisions. The House of Lords has held that, save in a case where it is misfeasance in public office with its incredibly high hurdles including showing malice, NHS commissioners cannot be sued for damages for public law decisions (O’Rourke v Camden LBC [1988] AC 188). Hence, at least in the UK, it is not legal constraints that hold back NHS reform.

    So I return to the central problem which – as a non-doctor I diagnose as – there has been a fear amongst NHS leaders that the NHS is a public service where the public do not have an appetite for reform. Those who make decisions about public services rightly feel themselves to be accountable to the public for these decisions and, at present, fear the public have no mood to accept the types of reform that are essential if the NHS is to achieve its twin objectives of (a) delivering the best care it reasonably can to vulnerable patients and (b) remaining within a largely static budget. The losers from this state of affairs are vulnerable patients who don’t get the treatment they need because it is spent on treatment that does not work, on hospitals that are not justifiable or services of marginal benefit.

    But perhaps we are at a tipping point. The in-coming NHS England Chief Executive, Simon Stevens, said last week that NHS England wanted local CCGs to come up with sustainable and future proofed local health systems, and then tellingly said:

    “If you’re going to get a sustainable and future proofed local health system, what are the longstanding assumptions and constraints we’d need to say goodbye to?”

    The second reason we might be at a tipping point is finance. The NHS is facing a funding gap in the next few years up to 2021 of between £30Bn and £12Bn depending on whose estimate you accept. As the Kings Fund said in their impressive interim report “A new settlement for health and social care” published in the last few weeks:

    “.. the NHS faces a severe and continued financial challenge …. there are some intense short-term pressures to be dealt with and some long hard term and unavoidable choices ahead”

    The NHS has had an expanding budget for almost all of its life, but that luxury is no longer going to be available.

    The third reason that changes need to be made is demographic. Everyone knows that we are getting older as a nation, and our services need to be organised to deliver care for the next generation rather than the last generation. But we also have far more people with long term conditions surviving into adulthood. Barely half social care spending is spent on people over the age of 65 (Kings Fund Report at page 12)  and there are more people under the age of 65 with 2 or more serious long term medical conditions than those over the age of 65. The Better Care Fund will kick in in 2015 to tie resources to better integration of health and social care, leaving much less in the NHS kitty for traditional acute care.

    So why when there is an impeccable health economics case for change in NHS services, is there no public appetite for that change? That is not a straightforward question. Nigel Lawson observed that “the NHS is the closest thing the English have to a religion”. Yet, as with all religions, informed debate is clouded by myths.

    The first myth is that the problems of the NHS could be solved with more money. Spending on the NHS rose 7 fold between 1949 and 2002 (allowing for inflation) and has continued to rise since then. More money might delay difficult decisions or cushion the fall, but more money of itself is not the answer. A high proportion of NHS acute care is provided to the frail elderly and, with an aging population, we need maybe 4/5% additional resources each year to carry on delivering the same level of services to our population. Although numbers of patients attending A & E are not rising dramatically, an NHS England report noted:

    “There were 10.6% more emergency admissions in 2012/13 than in 2009/10. There is general consensus (though it is hard to identify the evidence) that patients presenting are more ill and hence more likely to need admission and have longer stays”

    New, expensive drugs are coming off the pharmaceutical production line every year, offering marginal improvements on existing drugs but at a much higher cost. I could go on but please be assured that we can never spend “enough” on healthcare because the more we spend, the more demand there will be for state funded healthcare.

    The second myth is that investment in the NHS is the best way to improve the nation’s health. Sorry but this is just not true. According to the WHO, around 80% of deaths from the major diseases, such as cancer, are attributable to lifestyle risk factors such as excess alcohol, smoking, lack of physical activity and poor diet.   Extra spending on medical treatment for people with preventable diseases is not top of the list of effective interventions. So if we care about the health of our people, extra spending on the NHS is not necessarily the right answer. It may be on rare occasions but prevention is better than cure.

    The third myth is that the NHS equates to hospitals, and that the NHS delivers most of its care in hospitals. This is also simply not true. 92% of NHS care is delivered by GPs or in the community.   A significant proportion of NHS money is spent on managing people with long term conditions. However most of this case is or should be delivered outside a hospital setting. And the paradox is that the better that long term conditions such as COPD or diabetes are managed in the community, the less unplanned care has to be provided in hospitals.

    But the NHS only really makes savings if it closes or substantially scales back hospital buildings. Removing one service from the acute sector but leaving the building and staff in place will simply result in those staff delivering care in those buildings to other groups of patients, with little if any overall saving.

    These “myths” have made it virtually impossible to have a sensible discussion about what drugs or medical treatments the NHS should fund and how we should change the footprint of NHS buildings to get better value for money. We have NICE in the UK and US has the Patient Centred Outcomes Research Institute. But they are underfunded, dominated by supplier interests and can only scratch the surface of the rationing debate.

    A nationally set list of drugs and treatments that are funded and not funded across the whole of the NHS is probably an expensive paperchase that will get nowhere apart from endless legal challenges. As the Kings Fund Report noted:

    “Experiences from New Zealand, Chile, the US state of Oregon, Spain, Israel and Germany are not encouraging. There have been problems over enforcement and perverse outcomes in some cases. One of the best-known attempts to ration care was the Oregon approach that ranked treatments by priority and then set a cut off decided by the budget available. It led to treatable cancer being excluded from the benefits package”

    That approach is, in any event, a non-starter in a system where politicians are the ultimate decision makers. The line “this was a locally made decision” has been seen as essential to insulate our politicians from disappointed patients.

    It is an uncomfortable truth that, in a modern democracy, politicians are only able to “do politics” in the space in which public opinion allows them to operate. Politicians rarely lead public debate outside that legitimate area of public opinion and then they are described by the Sir Humphreys as being “brave, Minister”, with all its connotations of a lack of electability.

    So who can move the space for public debate about change in the NHS? The answer is that there are many candidates and some are stepping up to the plate. This is the classic area where NHS England have the chance to lead – and their independence from government precisely creates the space that allows them to flourish. Special credit must go to NHS England’s medical director, Sir Bruce Keogh, for his work on the future shape of Accident and Emergency services even though NHS England is, of course, not the primary decision maker for commissioning these services. I may have disagreed with him about Lewisham but overall he has been brave on the future shape of A & E care.

    The Medical Royal Colleges have a key role to play, as to academics those who work with the NHS on a daily basis in fora such as this.

    And now – ladies and gentleman – I get on my soapbox and make no apologies for it.  This essential debate is most important at the local level because, in a federated service like the NHS, delivering change is a bottom up process. That means the local NHS leaders – which primarily after the Health and Social Care Act 2012 means the GPs who sit on the local Clinical Commissioning Groups – have to make the case for change locally.

    And that cannot happen unless those who make NHS decisions locally invest far more time, energy and resources in educating the public about the choices that need to be made and actively lead local debate.

    Local NHS leaders need to explain some home truths as opposed to colluding in the myth that health is too important to be about money. If my treatment, my A & E unit or my maternity unit is allowed to be seen to be too important to allow money to be mentioned, it is someone else’s elderly care services, mental health services or respite care that will pay the price.   Taking on the role of being a local commissioner means that these GPs have to shout loudly that not every cancer drug can be financed, not every small A & E unit should remain open and many community hospitals are totally uneconomic.   It is their job to drive local public debate in order to counter the myths of objectors waving shrouds.

    To date the role of being the “big bad wolf” who cuts A & E or maternity units has been left to faceless NHS managers and the occasional brave public health doctor, or even worse accountants within the Trust Special Administrator process. But the financial challenges facing the NHS are now so vast and so close that the NHS has an urgent need to move services into the community in order to support the growing elderly population. These challenges are urgent and the NHS needs unprecedented levels of structural change.

    As a lawyer you would expect me to end with the law. The legal duties on commissioners under the NHS Act require every part of the NHS to engage with patients but in particular local CCGs. NHS managers have, by and large, been rubbish at genuine patient engagement, often because it is an afterthought. The traditional NHS way is to make reconfiguration or drug rationing decisions first and then consult the public afterwards. Not only is this now unlawful due to the wide duties under section 14Z2 of the NHS Act 2006, it shows a short-sighted approach to the local politics and leads terrible decision making because supplier interests dominate the decision making process.

    The public will only believe change is needed if they are trusted with all the data, and all of the options are openly debated at an early stage. But they also need to be repeatedly told as part of that consultation process that “we can only spend the money once”. To give credit, NHS England is trying hard to lead debate but the real debate needs to be led at a local level. The job of GP commissioners is to be community leaders for change. It means facing the local press and the radio, and crucially getting into the debate ring with the vested interests, including aspirant politicians, who are well-financed and will fight dirty. NHS commissioners need to fight back, holding on to the moral high ground at all costs and exposing the real costs of the choices that need to be made.

    If the local NHS does not invest in and lead public debate, political “space” will never be created to give politicians the opportunity to do the right thing. It’s a public service and commissioners must engage with the public – the great unwashed as they were referred to in previous generations.

    If local commissioners do not lead the debate on the reasons for NHS changes, elected politicians will have to oppose clinically required change. That will slow the change process or even prevent change happening.   And the losers will be those with mental health conditions, those suffering from chronic conditions and the frail elderly patients who don’t get the services they need because they are still being wasted on too drugs of marginal benefit and too many hospital buildings.



    [8] See Regulation 4(2) of the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012.


    This article was first published on David Lock’s blog


    This is  Labour Party  NHS Check 12  originally published by Labour’s Shadow Health Team in October 2013

    • Survey Reveals NHS On Road To Us-Style Healthcare
    • New Evidence Of NHS Hospitals Charging For Essential Treatments That Were Previously Free And Still Free Elsewhere
    • Thousands Of People Missing Out On Essential Treatment As David Cameron’s Postcode Lottery Grows
    • Labour Calls On The Government To Order An Immediate Review Of Rationing In The NHS And To Intervene To Stop Rationing On Grounds Of Cost

    This report shows that hospitals are beginning to charge patients for some treatments which were previously free on the NHS and continue to be freely available in other parts of the country.

    A Labour survey has revealed the details of punitive new restrictions put in place by Clinical Commissioning Groups. This follows an investigation by the British Medical Journal which found that as many as 1-in-7 of the new bodies have increased the rationing of treatments.

    Last year, Labour found that almost half of Primary Care Trusts were restricting routine treatments. Despite warnings from Labour and professional bodies, the problem has worsened – leaving patients facing an agonising decision of going without treatment or paying for private care.

    Increases in rationing are leading to a growing postcode lottery

    Labour’s Shadow Health Team surveyed all Clinical Commissioning Groups following reports that increasing numbers of patients were being denied GP referrals for treatment previously accessible on the NHS.

    An investigation by the BMJ in summer 2013 revealed that in the last six months, since they took control of the new NHS in April, 27 CCGs of 195 CCGs responding to the survey – close to 1 in 7 – had introduced new treatment restrictions. These included 8 CCGs restricting treatment for Foramen Ovale for recurrent migraines, 3 CCGs restricting hip or knee replacement surgery, 2 CCGs restricting cataract surgery, 4 CCGs restricting Caesarean for non-medical reasons, 2 CCGs restricting treatment for carpal tunnel syndrome, and 8 CCGs restricting therapeutic use of ultrasound. The full list of restrictions is listed in the table below.

    • Asymptomatic gall Stones 9
    • Foramen Ovale Closures for recurrent Migraines 8
    • Therapeutic use of ultrasound 8
    • Ganglions 7
    • Hallux Valgus 6
    • Skin Lesions 5
    • Caesarean for non medical reasons 4
    • Tonsilitis 3
    • Knee Surgery/replacements /hip 3
    • Varicose Veins 2
    • Cataracts 2
    • Carpal Tunnel Syndrome 2
    • IVF 1
    • Dupuytrens Contracture 1
    • Myringotomy 1
    • Hysteroscopy 1
    • Trigger Finger 1
    • Dilation and Curettage 1

    Labour’s Freedom of Information survey enabled investigation of the consequences of increasing rationing for access to treatment. It revealed wide variation across the country for the same treatment, with some NHS bodies setting down extra conditions before they fund the treatment. For example:

    • Patients in South Reading are required to lose more of their eyesight before they receive cataract surgery than patients in South Kent who qualify sooner.
    • Patients in the Black Country are forced to prove greater levels of pain and attempted weight loss before qualifying for knee replacement surgery, whilst South West London will fund patients in lower levels of pain.
    • Likewise for hip surgery, South West London and Stoke on Trent and North Staffordshire have different pain criteria.

    There is a legitimate debate to be had about the effectiveness of particular treatments or their use in particular contexts. But Labour FOIs have added to the growing evidence that some patients are being unfairly denied access to vital treatments.

    And as the next section shows, it seems that some hospital trusts are now introducing new private care options for treatments that are being rationed in the local area.

    Postcode lottery in cataract surgery


    In the 1990s, it was not uncommon for patients to wait up to two years for a cataract operation. The previous Labour Government took action to address this delay. It included issuing good practice guidance which established eligibility criteria and ensured patients should have access to surgery.

    The guidance stated that patients should be referred for surgery by their GP if a cataract leaves them with reduced vision or if it negatively impacts their quality of life.

    The guidance did not establish visual acuity thresholds – the measure of vision relating to how far a person can read down an eye chart – before a patient qualifies for treatment.

    The Royal College of Ophthalmologists cataract guidelines published in 2010 reinforced this guidance.

    Hospital Episode Statistics

    The latest figures show that the number of elective admissions for cataract surgery declined between 2010/11 and 2011/12 by over 5,000.

    These figures are precisely the opposite of what experts would expect. The RNIB have said “We would expect to see both the number of operations and spells to increase as the population ages and demand for surgery rises.”

    The figures suggest that since 2009/10, PCTs and CCGs have been introducing restrictions to cataract surgery.

    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 Visual Acuity as a measure is outdated. Delaying surgery leads to more ophthalmic complications, making surgery more risky, and in the event proves costlier”

    CCG referral policies – the variations

    Labour has uncovered evidence of CCGs who have implemented new restrictions on cataract operations in the last year. Earlier this year, the RNIB found widespread evidence of CCGs implementing restrictive commissioning policies that are not in line with either Department of Health guidance or Royal College guidance.

    South Reading CCG’s commissioning policy states: “cataract surgery is only routinely commissioned for patients who, after correction (eg, with glasses), have a visual acuity of 6/12 or worse in their cataract-affected eye.”

    However, Brighton and Hove CCG have no arbitrary restrictions on cataract operations and surgery is based on clinical need.

    Postcode lottery in knee replacement surgery

    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.”

    CCG referral policies – the variations

    NHS Black Country Cluster will only operate on patients with a BMI of 40 or over if they have documented proof that they have participated in a “comprehensive weight management programme” of at least 6 months duration prior to surgery.

    All other patients (ie those with a BMI of less than 40) are now required to meet a range of other criteria before they become eligible which include:

    • Conservative means (e.g. Analgesics, NSAIDS, physiotherapy, advice on walking aids, home adaptations , curtailment of inappropriate activities and general counselling as regards to the potential benefits of joint replacement) have failed to alleviate the patients pain and disability
    • AND Pain and disability should be sufficiently significant to interfere with the patients’ daily life and or ability to sleep/patients whose pain is so severe
    • AND Underlying medical conditions should have been investigated and the patient’s condition optimised before referral

    In contrast, Kingston CCG will fund elective surgery on any patient who has an Oxford Knee score – the questionnaire on function and pain – of less than 20 on the 0 to 48 system or greater than 40 on the 60 to 12 system.

    Postcode lottery in hip replacement

    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.”

    CCG referral policies – the variations

    Stoke on Trent CCG will only commission hip surgery if a patient scores 20 or under on the Oxford Hip Score (the equivalent questionnaire).

    Merton CCG will fund surgery for patients with a score of 26 or under.

    However, Hammersmith and Fulham CCG’s referral policy makes no reference to the Oxford Hip Score.

    NHS hospitals charge for rationed treatment

    In October 2012, the Government gave NHS Foundation Trusts the freedom to generate up to 49% of their income from private patients. A Labour Freedom of Information request to hospital trusts, on the income generated from private work in the first year of the new arrangements, reveals a significant increase. In 2012/13, hospitals generated £434 million – an additional £47 million on 2010/11. Meanwhile, trusts’ projections show that they envisage this will increase by a further £45 million to £479 million this year.

    Labour’s research has uncovered examples of treatments that are now rationed by the GP-led bodies and charged-for by hospitals– so-called ‘self-funding’ patients. This is where NHS hospitals offer to treat people as private patients but charge “NHS rates”.

    • In the last six months, James Paget University Hospitals NHS Foundation Trust has started offering self-funding options for Ophthalmology. Meanwhile, the local CCG NHS Great Yarmouth and Waveney has a restrictive commissioning policy for cataract operations – out of line with Department of Health and Royal College guidance.
    • Earlier this year, Southampton CCG was “red rated” by the RNIB – labelling its policy on cataract operations “very restrictive”. The local trust, Southampton University Hospitals, has a self-funding option in place for treatment in Ophthalmology services. Private patients can choose to benefit from high quality eye care by local NHS consultants at Southampton General Hospital. The hospital trusts website boasts: “Fewer non-urgent services can be paid for by the NHS but we know that patients still want to see our expert staff and be treated within the advanced care environment of a specialist teaching hospital. We offer the full range of consultations, investigations and treatments that you would expect from a specialist hospital […].”1 Also adding: “Our premier cataract service offers a new option, between the traditional private sector and the NHS, bringing private healthcare within the reach of many more people. This service offers you the option of cataract surgery even if your vision is better than the current level required for NHS surgery. We offer surgery when you feel you need it.”
    • Warrington and Halton Hospitals NHS Foundation Trust now offers a self funding option for removal of varicose veins. Their website states: “There are some treatments provided in the past that may no longer be accessible through local NHS funding… However, we know that many patients still want to have these procedures with us. In order to give our patients choice around their care, we have developed the MyChoice service. This allows you to pay (self-fund) to have these procedures with us at the standard NHS price. Private health insurance may also cover the cost of these procedures with us.”
    • Chelsea and Westminster hospital offer self funding options on “All medical and surgical specialities.” NHS North West London have tightened their criteria on a number of treatments in the last year. In June 2013, they updated their policies on removal of benign skin lesions, dupuytren’s contracture, carpal tunnel syndrome and cataract surgery.

    The late 1960s was a time of ideological confusion when the idea of social progress generally lost the association with science it had in the 1930s. The medical age of optimism began to seem an age of credulity. In 1971 Cochrane (Cochrane,  A.L., Effectiveness and efficiency,  London:  Nuffield Provincial Hospitals Trust, 1971.)  was the first of a series of authors presenting fundamental criticisms of the theory, practice and profession of contem­porary medicine in Britain and North America (Powles,  J.,   ‘On  the  limitations  of modern  medicine’, Science,Medicine and Man 1973; 1:1-30;  Fuchs, V.R., Who shall live?, New York: Basic Books, 1974;  Cochrane,   A.L.,   ‘1931-1971:   a  critical  review  with  particular reference to the medical profession’. In, Medicines for the year 2000, pp. 1-11. London: Office of Health Economics, 1979.) which were rapidly accepted by an unusually wide range of opinion-formers from both ‘Left’ and ‘Right’ traditions. In its most popular form, and with an irresponsible use of evidence setting it apart from the medical pioneers of this trend, it was presented by Ivan Illich in his book Medical nemesis, (Illich, I., Medical nemesis:  limits to  medicine, London: Marion Boyars, 1976.) which sold over 3 million copies worldwide. He accused doctors of expropriating the personal right of patients to control their own health, from a combination of greed and intellectual arrogance. He accused the medical profession of being the main danger to public health, as he had pilloried teachers as the main enemies of education in his previous book Deschooling society. Illich went to extraordinary lengths in pursuit of his medical enemy; here is a sample:

    Medical civilisation tends to turn pain into a technical matter and thereby deprives suffering of its inherent personal meaning. . . Culture makes pain tolerable by interpreting its necessity; only pain perceived as curable is intolerable.

    Like  any  intellectual fashion  achieving wide influence, Illich’s argument used some elements of truth, though nearly all his evidence was derived from medical sources, suggesting that medical science was more self-critical than his theory allowed. It still seems extraordinary that so weak an argument was taken so seriously, even in authoritative medical journals like  the  British   Medical Journal  and  the  Lancet, which devoted pages of self-doubt to an assault which would once have been brushed aside as a trivial impertinence. Ten years later, the Lancet still has space for random reflections of Chairman Illich, of a banality too complex and pretentious for analysis either as prose or scientific argument. (Illich, I., ‘Body history’, Lancet 1986; ii:1325-7.)

    The most credible explanation for this seems to be that many intellectual leaders of the profession were already looking for ways to justify their own retreat from the full social   implications of  making all important advances  in medical science available as a human right to the whole population. Assured of sponsorship, doctors still wanted to provide effective skills whatever the cost; but as the State set limits on its sponsorship for innovative medical science, the profession discovered new doubts about its mass applica­tion, though medical science itself was unquestionably in better shape than ever before.

    Common to all these intellectual critics were the following beliefs:

    1. That medical care has contributed little to improvements in health or expectation of life compared with nutrition, education, and conditions of life and work.
    2. That doctors and their public have expected too much from attempts to  restore  health by  surgical or bio­chemical  excision   or  substitution,  which  now incur increasing and eventually prohibitive costs for diminish­ing returns.
    3.  That personal medical care should therefore retreat to a more modest role in curing seldom, relieving often, and comforting always.

    This currently dominant set of ideas I shall refer to as the Liberal Critique, since it has all the historic qualities of Liberalism: scholarly backing, humane intentions, appeal to both Left and Right intellectual radicals without embarrass­ment to either, and ability to interpret defeat as victory. This is a savage description, but anger is justified; not because these three conclusions are untrue, but because of the increasingly obvious social and political context in which only these truths have been proclaimed, while others, less convenient to this scoundrel time, have been forgotten. The Liberal Critique has disarmed professional resistance first to revision, then to destruction of the post-war social settlement of which the NHS was an important part.

    Does Medical Care Matter?

    The view that medical care contributes less to health than nutrition, education and conditions of life and work is not new or original. It is difficult to think of any important innovator in medical thought who has not held this opinion. If you take a thousand people and lock them up, their first thoughts are of food, not doctors. The more primitive life is, the more important food and shelter become, but a society that is becoming more rather than less civilized gives more not less priority to education and health services, in that order. Even in specialized hospital medicine, outstanding innova­tors like Paget,  Osier, Albutt, Pickering and Platt always conceded the pre-eminent role of nutrition, education, and living and working conditions, compared with the salvage work they performed. Like pioneers in any field, they may sometimes have expected too much from attempts to restore health by surgical or biochemical excision or substitution, but again this is not new, and the general public, encouraged by press entertainers, has been far more credulous than its doctors. In Britain more than most countries there has been a vigorous tradition of medical scepticism ever since the Second World War, probably because until recently nearly all doctors were in a free public service rather than trade, and therefore had fewer incentives to deceive either themselves or their customers.

    The novel feature of the Liberal Critique is not this re­discovery of the dominant importance of environment for health, and our still limited ability to cure illness, but its emphasis on a diminishing role for medical care; not only the alleged pettiness of its actual contribution, but of its potential contribution in the future. The question would have been easier to understand around 1905, when the only major diseases in which medication influenced outcome were syphilis and heart failure, and effective surgery was limited to injuries and a few abdominal and obstetric emergencies. The rate of successful clinical innovation, far from levelling out or diminishing, is increasing every year. Seeds of a vast expansion of innovation in applied medical science were sown with the discovery of the structure of DNA in 1953, ‘a revolution in the biological sciences comparable to that in physics earlier this century’. (Weatherall,  D.,  ‘Molecular  and cell biology in clinical medicine: introduction’, British Medical Journal 1987; 295:587-9.) Medicine is applied human biology. It took about 40 years for nuclear physics to find a practical application; 34 years after Crick and Watson we are already beginning to see evidence that ‘medical sciences are about to enter the most exciting period of their development’.

    Undeniably, basic medical science is advancing with accelerating speed. Practical applications in teaching hospitals, though most of them still depend on basic medical sciences of the pre-molecular era, are already arriving faster than we can assimilate them within present staff resources.

    There is no real doubt that these new techniques are increasingly effective. Coronary artery bypass grafts (CABG) are a good example. When they began to be widely used in the United States in the early 1970s, thoughtful doctors had mixed feelings. On the one hand, CABG relieved the symptoms of chest pain from coronary heart disease (angina) almost completely in about 70% of cases, and increased survival by about 50% over the first seven years following operation for the minority of patients with angina who have left main coronary artery disease (about 13% of cases), with less than 3% mortality from the operation itself.

    CABGs may appear to support the view that effective medical care now incurs increasing and eventually prohibitive costs for diminishing returns, but this is so only if the technique is applied without an overall policy for control of coronary disease. Once-for-all surgical costs for CABG are £2,500-£4,500 at 1983-4 prices, not all that much more than the cost of modern medical care for the expected life­time of angina patients. (Williams, A.,  ‘Economics   of  coronary  artery  bypass  grafting’, British Medical Journal 1985; 291:326-9)  The difference in cost, around £2,500, is about the same as the cost of one total hip replace­ment operation. Surgical costs are more than twice as high in marketed, fee-paid care systems such as that in the USA, so in terms of cost-effectiveness, the case for CABG is stronger in a free public service, where surgeons are paid by salary. Like all new surgical treatments for common conditions, the technique becomes cheaper as it becomes perfected and standardized; the more advanced centres are now well into the next generation of surgical procedures for coronary salvage, coronary angioplasty, an essentially simpler pro­cedure which provides a rebore of the original vessel instead of replacing it, an even safer and much cheaper procedure. These techniques are effective and should be generally available without delay to those who need them, a policy which in no way contradicts the need simultaneously to step up health promotion, prevention and anticipatory care.

    One of the saddest recent developments in the NHS is the attempt to supplement inadequately funded NHS heart surgery by getting coronary surgery done privately under contract to the NHS, as my own Health Authority in West Glamorgan has recently decided to do. NHS units are still the sole source of training for the very specialized surgical teams which perform these operations, whether they ultimately work in the NHS or the private sector. Farming the work out to private contractors working for profit accelerates the destruction of the training, research and development facilities on which all progress depends.

    Though coronary death rates have fallen in USA, Australia, and New Zealand by about one-third over the same period that CABG has been in wide use in these countries, heart surgery has been estimated to contribute only 4-5% of this reduction. ( Goldman, L., Cook, E.F., ‘The decline in ischemic heart disease mortality rates: an analysis of the comparative effects of medical interventions and changes in lifestyle’, Annals of Internal Medicine 1984; 101:825-36.) It is still not clear why these big falls in coronary mortality have occurred, nor why they appeared first in the USA and Australia, and have hardly occurred at all in Britain and Sweden; on the whole, the most convincing evidence is for a reduction in average blood total cholesterol because of changes in the composition of quantity of fat in common foods, which have occurred in some countries and not others. There is no doubt at all that they do reflect changes in the way people live more than changes in medical care, except insofar as medical advice may accelerate changes in personal behaviour, on a scale sufficient to affect fashion. There has certainly been a stark contrast between the active advocacy of coronary prevention as well as surgical salvage by doctors in the USA, and the passivity of British doctors. (Beaglehole, R., ‘Medical management and the decline in mortality from coronary heart disease’, British Medical Journal 1986; 292: 33-5.) There is still much that is unexplained about coronary disease. Big reductions in coronary atheroma in young men preceded any big shifts in adult eating patterns, exercise, smoking or heart surgery by about ten years. They may at least in part have been caused by contrasts between childhood and adult nutrition in the entire cohort of men born between about 1910 and 1940. ( Marmot, M.G., Shipley, M.J., Rose, G.A., ‘Inequalities in death: specific explanations of a general pattern?’, Lancet 1 984; i:10003-6.; Forsdahl,   A.,   ‘Are  poor  living  conditions  in  childhood  and adolescence   an  important  risk   factor  for  arteriosclerotic  heart disease?’, British Journal of Preventive & Social Medicine 1977; 31:91-5.)  These questions are important, because molecular biology is going to give us weapons that act upon causal mechanisms in very large numbers of people, rather than the primitive strategy of salvaging advanced disease.

    There is no longer any doubt that CABG is a real advantage to patients carefully selected on clinical grounds, or that surgical salvage should have a useful, though relatively small and eventually diminishing part to play in any overall strategy for dealing with coronary disease. This was exactly the (unplanned) sequence followed for rheumatic valvular damage, the principal cause of early death from heart disease before coronary disease began to be common in the 1930s; a rapid but incomplete decline because of changed living conditions, accelerated and completed by surgical salvage. The difference between surgical valve repair or replacement in the 1950s and ’60s, and CABG today, is that free access to surgery on the basis of need alone is no longer expanding for the whole population.

    Studies in Sweden suggest that the justifiable annual demand for CABG would be around 300 per million popula­tion, if all suitable cases were accepted in the age-range 45-54. Reviewing the provision of CABG in Wales in 1983, the Royal College of General Practitioners found the opera­tion was being offered at 7% of this ideal rate in Wales, and 80% of it in the London (SE Thames) region, after subtracting cases ‘imported’ from other regions, ( Report   of  a Working Party. ‘Stitches in time’, Welsh Council, Royal College of General Practitioners, 1983.)  although male death rates in middle age from coronary disease in the South Wales valleys are about one-third higher than in England and Wales as a whole, and nearly twice as high as in the South East. ( Hart,   J.T.,  ‘The  marriage of primary  care  and  epidemiology”, Journal  of the  Royal  College  of Physicians  of London 1974; 8:299-314.)  Unlike facilities for open heart surgery for rheumatic valvular disease, regional availability of CABG is unrelated to need. In the absence of an active policy for preferential development in areas of high coronary mortality, there is a large element of social selection because of the lower expectations and therefore lower effective demand of poorer and less well-informed people, even in a system of free care. There is no evidence that any such policy is currently pursued or planned.

    Even if coronary surgery were available in proportion to regional need, no matter how successful it might be tactically, it could not be an effective mass strategy. Without organiza­tion of anticipatory care and prevention it only offers a personal short-term technological fix to a small high-risk minority, instead of tackling what is essentially a long-term behavioural problem for the whole population. Though molecular biology may give us alternative solutions, even these will probably have to be applied to whole populations at risk rather than to a few with advanced damage.

    The truth is that until we have successful prevention, we must have salvage; if we want to remain a civilized country, both strategies must be pursued, and for everyone. I have yet to meet any well-informed person who, having developed angina uncontrollable by stopping smoking, by medication and by minor restrictions in exercise, does not want a skilled surgical opinion. Whatever their views on grand social strategy, the experts all seem to make intelligent and dis­criminating use of high technology salvage for themselves and their families, and they still do this through the National Health Service whenever they can. In practice, even within the NHS we already have a two-tier system, in which a minority of well-informed people, and those with unusually energetic GPs, gain access to the best high-technology salvage, while the majority go by default.

    In an under-funded public service, as more people rightly make more sophisticated demands, waiting lists lengthen, and more people have to seek treatment privately. This is only beginning with CABGs, of which only 0.1% were done privately in 1981, but it is well established for hip replace­ment, 26% of which were done in the private sector in the same year. New techniques are either introduced reluctantly and inadequately, as with CABG, or in some regions abandoned almost completely to the private sector, as with vasectomy and termination of pregnancy. Using available data from various years from 1981 to 1984, private market penetration had reached 1% for obstetric care, 1.5% for mental handicap, 2% for chronic mental illness, 4% for acute mental illness, 13% for all elective surgery, 35% for long-stay institutional care of the elderly, and 47% for terminations of pregnancy.

    Paying More and More for Less and Less

    Of course, believers in the Liberal Critique deplore all this. They would like everyone to enjoy the same quality of care as themselves, but (they argue), Britain in its post-imperial state is becoming a poor country, in which painful choices have to be made;  to them it is obvious that with limited resources, the first things to go from a shorn public service should be luxury items like high technology medical care. The argument has even influenced people who consider them­selves Marxists. Writing in Marxism Today, Dr Steve Iliffe (Iliffe,   S.,   ‘The  painful  path   to   health’, Marxism Today  1986; 30:34-8)  has come to believe that:

    the guiding principles of the National Health Service are no longer workable. . . overall staffing levels should be kept constant. . . budget restraints on health authorities should be maintained. . . principled objections to charges for services should be overruled. . . Medicine is steadily becoming less cost-effective. . . money will come from different directions in different places, ending the pretence of a tidy monolithic institution. If this happens, we will be in debt to the Conservatives for the instability they once inflicted on the biggest institution in Europe outside the Red Army, and also on the traditions of the British Left.

    Iliffe gives CABG and total hip replacement as examples of rising costs with diminishing effectiveness. He can hardly deny that these procedures are effective in making thousands of lives enjoyable   rather than miserable.  As techniques become   standardized,   costs   fall, particularly if they are organized in a non-profit public service. The proportion of our Gross National Product spent on medical care has risen only from 4% in 1949 to 6% in 1981, is still less than any other country in Europe, and almost half that in the USA. The rate of fall of age-specific mortality has, of course, declined as more people reach a healthy old age, and more deaths result from natural senescence, but effectiveness of medical care in improving the quality of life has enormously improved.   There is no evidence that this tendency will diminish; on the contrary, the immense potential benefits of advances in basic biological science have hardly been tapped. It has been estimated that 25-30% of hospital beds, and probably an even higher proportion of all NHS spending, goes on care during the last year of life, ( Cartwright,  A., Hockey, L., Anderson, J.L., Life before death, p. 79. London: Routledge & Kegan Paul, 1973.)  either terminal care or more less unsuccessful salvage. In the light of current medical knowledge, this proportion is too high, but that means an increased investment in care in the community at earlier stages of disease, rather than a reduction in care of advanced disease and terminal illness.

    Social Causes of Disease

    Believers in the Liberal Critique nevertheless maintain that because in an ideal world each pound spent on better food, housing or education in deprived sections of the population would yield greater health benefits than each pound spent on medical care, public spending should follow the same order of priorities. Granted the unlikely premise (an ideal world), this would be true, and the argument is important.

    Although death rates at all ages have been falling ever since 1870, the difference between death rates for the rich and the poor has been widening since the 1930s (Fig. 2.1). Mortality differences for women follow the same trends, but are more difficult to interpret because women are classified by their husbands’ occupations.

    Fig. 2.1 Standardized Mortality Ratios (100 = average mortality across all classes) by social class, 1931-81, men 15-64, England and Wales.

    Class 1931 1951 1961 1971


    I professional



    76 (75) 77(75)


    11 managerial



    81 81


    III skilled manual and non-manual



    100 104


    IV semi-skilled



    103 114


    V unskilled



    143 (127) 137(121)


    *   Figures have been adjusted to classification of occupations used in 1951. ** Men 20-64 years, Great Britain.

    Source: Wilkinson, R.G., ‘Socio-economic differences in mortality: interpreting the data on their size and trends’. In Wilkinson, E.G.. (edA Class and health: research and longitudinal data, London: Tavistock Publications, 1986.

    Fig 2.2 Mortality of men  aged   15-64  by social class, 1971-75 and 1986-81.

    Mortality of men aged 15-64 by social class, 1971-75 and 1986-81.

    Fig. 2.2 shows data from follow-up of a 1% sample of the population of England and Wales, occupationally classified in the 1971 census, for the periods 1971-5 and 1976-81. (Fox,   A.J.,   Goldblatt, P.O.,  Jones,  D.R., ‘Social class mortality differentials:     artefact,    selection,    or   life    circumstances?’    In Wilkinson, R.G. (ed.), Class and health: research and longitudinal data, London: Tavistock Publications, 1986.)  It includes two further social groups, the ‘inadequately described’ (including many chronic sick with a high mortality) and the ‘unoccupied’ (including long-term unemployed whether or not they are able to claim unemployment benefit). Clearly there are even higher death rates for these groups than for Social Class V, the unskilled manual workers. Social class differences increased for all groups except the ‘unoccupied’, which fell from an SMR of 299 in the first period to 213 in the second. The authors of this study interpret this fall as an effect of ageing; men selected out of occupational classifica­tion by ill-health and who did not die in the first period, were less unlike those who remained classifiable in the second.

    Fig 2-3 Standardized mortality ratios for coronary heart disease in men aged 20-64, Wales, 1979-83.

    Standardized mortality ratios for coronary heart disease in men aged 20-64, Wales, 1979-83.

    Social and regional distributions of deaths from all causes differ little from social and regional distributions of death-rates from major specific causes, particularly premature deaths from coronary heart disease. Social class differences in coronary death rates for men in Wales aged 20-64 are shown in Fig. 2.3.

    Fig. 2 4 Percentages of Welshmen aged 45-64 who 1) thought it was impossible to reduce the risk of heart attacks; and 2) smoked cigarettes every day; by sex and social class, 1985.

    Welshmen- heart attacks and smoking

    Data from a recent survey of coronary risk factors in Wales based on a random sample of the whole population, (Nutbeam,  D., Catford, J.,  ‘Pulse of Wales: social survey supplement’, Heartbeat report no. 7, Cardiff: Heartbeat Wales, 1987.)  set out in Fig. 2.4, confirm that in Wales at least, with very high rates of unemployment, both fatalism about the possibility of preventing heart attacks, and the proportion who smoke the cigarettes responsible for many of the deaths, increase with descending social class, worst of all in those out of work. This picture of inequalities in distribution of actual disease, of informed confidence that disease can be prevented, and of avoidable precursors of potential disease, is true not only of coronary heart disease, but of all the main causes of pre­mature death and chronic disability. Worst of all, these inequalities are increasing. The available evidence was presented in the Report of Sir Douglas Black’s Committee on Inequalities in Health in 1980, powerfully reinforced by a wide range of subsequent research reviewed by Wilkinson, Marmot, Blaxter, Wadsworth and others. (Wilkinson, R.G. (ed.), Class and health: research and longitudinal data, London: Tavistock Publications, 1986.)

    Social inequalities in health are neither just nor inevitable. They are the result of social and economic policies adopted by governments, which clearly reveal the priorities of the social groups they represent. Fig. 2.5 shows the relation between inequalities of income and expectation of life for 11 developed countries.

    Fig. 2.5  Life expectancy  (male  and  female)  and gini coefficients of post-tax income inequality (standardized for household size).

    Life expectancy (male and female) and gini coefficients of post-tax income inequality (standardized for household size).

    The countries grouped on the upper left with relatively high life expectancy and minimal inequality of income, the Netherlands, Norway and Sweden, have strong egalitarian traditions which they still uphold. The countries grouped on the bottom right, with relatively low life expectancy and maximal inequality of incomes, the USA, Germany, Spain and France, have long been strongholds of social Darwinism. The war of every man against every man may be good for business, but certainly not for health.

    Paradoxically, the most rapid improvements in life-expectancy this century in Britain were concentrated in the war periods 1911-21 and 1940-51. (Winter, J.M. Quoted in Wilkinson, R.G., Class and health: research and longitudinal data, London: Tavistock Publications, 1986. , p. 110.)  Though these were years of relative austerity for the middle class, they were years of full employment and full bellies for the poor, with government policies of planned social intervention to create what was later called the ‘social wage’; free school meals, maternity and child benefits, sickness benefits, free access to museums, libraries, and parks, cheap municipal housing and public transport, and finally a free and comprehensive health service; the working model for the NHS hospital service in 1948 was the Emergency Medical Service scheme which effectively nationalized hospital resources during the war.

    Investment in a shared infrastructure of free services is a political choice, of proven effectiveness. Before the Second World War, infant mortality in Stockholm varied according to socio-economic group from 14 to 49 per 1,000 live births; today it is below 7 per 1,000 live births, with virtually no difference between socio-economic groups. (Dahlgren,   G.,   Diderichsen,  F., ‘Strategies for equity in health:report   from  Sweden’,  International Journal  of Health Services 1986; 16:517-37.) Governments, like our own in 1945 or in Scandinavia today, can choose to increase the social wage relative to personal incomes, or they can revert to sale and purchase of these elements of civiliza­tion, piece by piece, every man for himself, as Thatcher Conservatism does today.

    Fig. 2.6 Cross-sectional   relationship   between   occupational   earnings and standardized mortality ratios, England and Wales.

     Cross-sectional relationship between occupational earnings and standardized mortality ratios

    Redistributive    income   policies   are   another   way   of improving health selectively for least healthy social groups. Fig. 2.6 shows the relation between income and one indicator of health, the standardized mortality ratio. Wilkinson ( Wilkinson,   R.G.,   ‘Income  and mortality’,  p.   109 in Wilkinson,  R.G.   (ed.),   Class   and   health:   research   and  longitudinal data London: Tavistock Publications, 1986.)  explains the significance of this curve:

    successive increases in income bring diminishing health returns. The shape of the curve suggests that income transfers from the rich to the poor might be expected to bring substantial health benefits to the poor while having little effect on the health of the rich. Every pound transferred from people earning (in 1970) £60-70 a week to people earning £10-20 would reduce the death rates of recipients by five times as much as it increased those of the donors.

    The Black Report was commissioned by the last Labour government, but was completed and published in the early months of Margaret Thatcher’s first term as prime minister. In a foretaste of authoritarianism to come, everything administratively possible was done to smother the report at birth, but it quickly achieved the widest sales and press attention given to any similar document since the Beveridge Report. The Black Report is now being implemented in reverse; that is to say, government policies are, virtually without exception, the opposite of those recommended by the Black working party. By every measure of income, education, housing, availability of employment, nutrition, participative sport facilities, nicotine and alcohol depend­ence, and increasingly by access to sophisticated medical care (curative or preventive), Britain is becoming a more divided and unequal society.

    A Strategy for Advance

    The first step in devising strategies for more effective, and cost-effective, health services must be to oppose this policy of de-civilization. Scholars seeking solutions within limits set by the de-civilizers deceive themselves, and disarm and confuse what should be, and will become, a previously unimaginable social alliance of professional and public opinion for resumed social progress. Some advocates of the Liberal Critique have had useful things to say, and progressives can learn from them, but the essence of their strategy is retreat; an inglorious abdication from previous beliefs about the potential effectiveness of medical care, the potential value of medical science, the dignity and independence from the market of Medical Professionalism, and the feasibility of real social advance.

    Our health services have developed not in an ideal, painless world of armchair social strategies, but in the real, bitter world of injustice consciously and deliberately maintained by real, powerful people who gain from things as they are, in which the distribution of wealth and power is never changed without struggle. Priority investment in social infrastructure, redistributive personal income policies, and higher priority for health service spending rather than preparation for war or reduction in personal income tax, are not rival alternatives. None of them will be pursued by a government which assumes that what is good for the Stock Exchange is good for the nation; all of them would be pursued by a government concerned with the health and happiness of all of the people.

    On the other hand, realistic strategies for renewed advance must start from where we are, with the people we have. We cannot devise ideal solutions on a blank page, without regard to where we have come from, or where medical science is going. The content of potentially effective medical care has changed, both because of changes in public health, and because of advances in medical science, requiring big changes in the structure and staffing of care, most of all at primary care level.

    We have to consider a set of historical choices, in a way that has not faced doctors since they first began to define their professionalism in the early 19th Century. (Loudon, I.S.L.,  Medical care and the general practitioner 1750, Oxford: Clarendon Press, 1986. Together with Rosemary Stevens’ book, this is the best detailed account of the rise of British medical professionalism.)  If we wish to continue the association of Medical Professionalism with Medical Science, we must prepare to accept solutions outside the limits of professionalism as then defined.

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    The excellent Clare Gerada, Chair of the Royal College of GPs is calling for a brave and honest debate about rationing medicine.  According to GP magasine two thirds of GPs think that the NHS should stop providing free prescriptions for drugs that are available over the counter.  Generally stuff like Calpol which you can buy without a prescription is cheap, less than the £7.65 prescription charge we have to pay in England.  So it seems unlikely that requests for this stuff are coming from the people who have to pay charges.  Only a small minority of prescriptions attract a charge  – and none at all in Scotland, Wales or Northern Ireland.  So some of these requests may be coming from people who really have trouble finding small sums for medication.

    Honest debate about rationing medicine

    Child taking medicine

    Gordon Brown was talking about abolishing prescription charges in England in 2008, and we investigated the options.  Prescription charges were imposed in 1952 as a rather primitive form of rationing.  Apart from the free prescriptions for the poor, the old and the young there is a list of medical conditions which entitle a patient to free prescriptions – because in 1968 when prescriptions were reintroduced by the Wilson government there was life saving long term medication for those conditions.  The list hasn’t been revised since.   As the charges tend to deter people just above the level which qualifies them for free prescriptions from taking all their medication there is a downside.  Some of those people will end up in hospital because they don’t take their medication.

    Rationing healthcare is universal and inevitable.  The only question is how it should be done. Asking people to pay at the time they need treatment is agreed to be the worst possible way of doing it.

    Dr Gerada has often called for decisions about rationing to be made by politicians, not doctors.  We haven’t seen a rush of politicians stepping up to make proposals about what should be rationed or how.  The NHS reforms introduced by this government are designed to insulate politicians as far as possible from unpleasant decisions of this kind.  In reality it’s probably better for most of these decisions to be made in the consulting room than in Whitehall.  The introduction of Clinical Commissioning Groups does seem to have had beneficial effects in many areas, because it’s forcing GPs to look at each other’s practise and see where money could be saved.

    Perhaps the price doctors should ask in return for taking responsibility for rationing decision is that prescription charges should be abolished in England. Then the discussions in the consulting room need not be complicated by considerations about charges.

    Tagged , , | Comments Off on An honest debate about rationing medicine?, a professional networking site, found that 593 (54%) of the 1,096 doctors who took part in the self-selecting survey answered yes when asked: “Should the NHS be allowed to refuse non-emergency treatments to patients unless they lose weight or stop smoking?”

    One doctor said that denying in-vitro fertilisation to childless women who smoked was justified because it was only half as successful for them. Another said the NHS was right to expect an obese patient or alcoholic to change their behaviour before they underwent liver transplant surgery.

    Dr Tim Ringrose,’s chief executive, said the findings represented a significant shift in doctors’ thinking brought on by the NHS in England’s need to save £20bn by 2015. “This might appear to be only a slim majority of doctors in favour of limiting treatment to some patients who fail to look after themselves, but it represents a tectonic shift for a profession that has always sought to provide free healthcare from the cradle to the grave,” he said.

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    What is rationing / priority setting?

    Rationing and priority setting are referred to somewhat interchangeably within the literature, with little focus on the actual terminology, and more upon the outcome of priority setting and its impact upon healthcare.  Priority setting, “a more or less systematic approach to distributing the available resources among demands”, can lead to rationing of care, defined as “a failure to offer care, or the denial of care, from which patients would benefit”. Rationing can also be defined as any form, either implicitly or explicitly, of allowing people to “go without beneficial services” due to constrained costs.

    A more identifiable form of rationing involves denial of treatment due to cost-ineffectiveness –although not adequate in the eyes of the public – as opposed to rationing where there is a shortage of medical staff at a particular moment in time.  There is also rationing by waiting or delays in treatment, which appears as less visible than complete denial of treatment. Whilst all forms of rationing might not impact care, there is an issue of transparency of the healthcare service provided. Only if there is acknowledgment of rationing therefore, can “fair and reasonable priorities and standards be established”.

    The role of priority setting and rationing within the NHS

    Published in 2009, the NHS Constitution defines the NHS as providing a “comprehensive service”, but has not actually set out what the NHS does and does not provide. Given that the NHS in England is publicly funded with a multibillion-pound budget, it is inevitable that some form of priority setting based on economic grounds will be made, which, although largely denied by the Department of Health, is highlighted to a greater extent during times of fiscal pressure. Whilst the Department of Health is accused of being in “official denial that cost-motivated rationing is taking place”, there is ample evidence to suggest otherwise. For instance, the NHS has often “rationed with waiting lists”.

    The National Institute for Health and Care Excellence (NICE) is the Non Departmental Public Body responsible for providing guidelines for the use of new medicine and treatments. For the purpose of this paper, NICE is arguably the most important aspect of healthcare in England due to both the praise and criticism that the organization receives, and can be described as a “finely tuned machine”. NICE’s influence within the NHS can be demonstrated by the list of “do not do” clinical interventions, ranging from only using major surgery as a last resort, to the use of vitamins in reducing cardiovascular risks. Additionally NICE can be described as “doing the Oregon for the NHS on a day-to-day basis”.

    The current service, or “package of benefits”, funded by the NHS is “arrived at implicitly through the decisions of…politicians, regulators, commissioners, clinicians and patients” on a local level across the NHS, through PCTs. Such a process has the potential to lead to a variation in the service that is provided across England, and contributes to the notion of a postcode lottery, or “rationing by postcode.”

    Such a postcode lottery therefore does appear to show a need for standardisation of priority setting from a PCT perspective, which could theoretically allow a more balanced level of healthcare to be provided. The most notable political response to the notion of a postcode lottery is the establishing of NICE itself by the Blair government “to develop national service frameworks” to deplete such a variation in care.

    Whilst the postcode lottery can be attributed to the autonomy that each PCT has, one not entirely negative aspect of the disparity is that the NHS services in poorer areas do not appear to be disproportionately affected.

    Regardless of whether such a lottery actually exists or not, it is necessary to look at the issue of priority setting further within the NHS. For instance, a report in 2007 found that 53% of doctors knew of cases where patients had suffered due to rationing of their healthcare. Additionally, 85% of GPs believe that “in the next 5 years the NHS will have to set out …what is – and what is not – available to patients” in the NHS.

    The public will often show strong support for the NHS, but given some of the reaction to NICE decisions, there is not necessarily a connection made by the public to the limits of the NHS budget. One survey did however find that 61% of people surveyed believed that the “NHS will have to stop providing some treatments and services in the future due to rising costs and increased demand”. The same percentage also said it was “right that some hospitals stop providing certain services in order for the NHS to save money”.

    Whilst there is little evidence of complete consensus on whether priority setting and rationing is occurring within the NHS, the use of terminology is varied within PCTs, perhaps making it difficult for national surveys to have full validity. For example, terms such as “Procedures of Low/Limited Clinical Value” and “Interventions Not Normally Funded” are used in an apparent attempt to avoid the association of priority setting or rationing.

    An example of priority setting within the NHS is found at Croydon PCT where “34 low-priority procedures of ‘limited clinical value’” have been earmarked under four categories, from relatively ineffective to effective interventions. An important point to consider here is that priority setting processes adopted by other PCTs appear to have focussed upon new funding and developments, rather than existing funding too. Such a focus is also a criticism of NICE, and as will be discussed in Chapter 2, is in direct contradiction to the other approaches taken.

    An argument can be made that the public should have as much information as possible about the way in which funds are spent in the NHS. Given the importance of healthcare to one’s own life, it is of utmost importance that any priority setting made in the NHS is explicit.

    Discussing the role of priority setting is important because it can lead to variations in the level of care available, especially if left up to the PCTs to decide, as was shown with eligibility of IVF treatment. Given that a survey of PCTs found that 45% made public the criteria used by priority setting panels, and 44% made such decisions public, there is visible reluctance from some PCTs to engage with the public about priority setting and rationing.

    The processes the NHS uses for determining what services to provide can be regarded as “obscure and lacking in accountability” to patients. An argument in support of a more transparent decision-making process for priority setting is that if “decision makers were encouraged to make their decision-making processes and decisions public, it would help to guard against inconsistency, unjust preferences and groundless exceptions”, and therefore theoretically leading to a more transparent NHS.  Whether this necessarily leads to more accessible care – arguably more important than the transparency of the PCT – remains to be seen, however.

    The politics of rationing/priority setting

    Whilst the argument can be made that rationing is an “inherent feature” of the NHS, political leaders do not choose to talk about the NHS in such terms, due to the political sensitivity of the NHS and the political consequences that talking negatively about a well-respected public institution can have. It is common for ministers to occasionally “define what should be provided (for which they can claim credit) but will almost never explicitly decide what should not be provided (which might attract blame)”. The consequences for such an approach is discussed  in the analysis and lessons for the NHS that can be taken away from the Oregon Health Plan.

    Projections of UK health expenditure, 1960-2059

    Projections of UK health expenditure, 1960-2059

    In addition, as the NHS budget comes under more pressure, the “willingness” of political leaders to engage with priority setting may diminish, particularly if this leads to unpopular decisions. The existence of NICE has however led to some distance “from decisions that risked attracting criticism” between policymakers and healthcare provided.

    Ian has been working with us for the last year and this is part of his undergraduate dissertation submitted to the University of Sheffield.

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    Care UK sees an opportunity to make money out of NHS rationing decisions

    Care UK GP Newsletter

    Care UK GP Newsletter

    Charges advertised to doctors for people not eligible for NHS treatment:

    Care UK Tariff

    Richard Blogger’s articles about NHS hospitals doing private work

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


    • 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 Continue reading »
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