Best medical practice or justification for NHS rationing?
On 4 July 2018, the NHS England Board launched a consultation on stopping patients undergoing certain treatments:
Four procedures will only not be routinely provided on the NHS (Category 1 procedures):
- Snoring surgery
- Dilation and curettage for heavy menstrual bleeding
- Knee arthroscopies for osteoarthritis
- Injections for non-specific back pain
A further 13 treatments will only be offered when certain conditions are met (Category 2 procedures):
- Breast reduction
- Removal of benign skin lesions
- Grommets for glue ear
- Haemorrhoid surgery
- Hysterectomy for heavy menstrual bleeding
- Removal of lesions on eyelids
- Removal of bone spurs for shoulder pain
- Carpal tunnel syndrome release
- Dupuytren’s contracture release
- Excision of small, non cancerous lumps on the wrist called ganglia
- Trigger finger release
- Varicose vein surgery
As the news spread, a number of private healthcare providers were quick to take to social media and suggest that they would be happy to step in and fill the gap.
But would patients be wise to go down this route?
As both providers of private healthcare and firm champions of the NHS, we think the answer is check and take the advice of your doctor. This is rationing, but taking aim at those procedures where medical evidence suggests the potential benefits are poor or only good in certain circumstances. The Daily Mail suggested, the NHS ‘axing minor operations to save money’. Many of the procedures mentioned are fairly minor, and the purpose is to save money—but that is not really the point.
Instead, it would not be unreasonable to see this as the Medical Director for NHS England taking the NHS by the scruff of the neck and starting to enforce evidence-based medicine. For the Category 1 procedures it is claimed there is little evidence or none at all that suggests the procedures should be performed. For the Category 2 procedures there is evidence of benefit but should be only provided to patients who reach more strict criteria. For example it is suggested removal of skin tags on the NHS should not be for cosmetic reasons or grommets should only being considered in children with symptoms in both ears with prolonged persistent hearing loss. Other solutions are also being encouraged – such as providing hearing aids rather than surgery.
Reducing waste and improving services
The NHS Board and the Department of Health have been trying to reduce waste in the NHS for many years. The National Institute for Health and Clinical Excellence was established to review treatments and decide whether they represented value for money. Many people have complained about its methods of assessment—quality-adjusted life-years, or QALYs, are seen as a bit of a blunt instrument, and it is always easy to come up with individual ‘hard cases’ where patients have been refused drugs or other treatment that might have helped them. Few, however, doubt the importance of NICE’s work, or of ensuring that treatments are clinically effective.
But despite NICE, and despite many years of publication of best practice guidelines and Cochrane Reviews, plenty of doctors still carry out ineffective procedures. NHS England estimates that there may be as many as 100,000 ineffective procedures carried out each year, at a total cost of more than £200m.
That means 100,000 people who underwent the risk and pain of a procedure that probably will not help them.
It also means £200m that was not available to provide effective treatment to someone else.
We all understand that the NHS has finite resources. We also know that it is not really about money—or at least not completely. It is also about having enough qualified and high quality staff to provide the right care, and the theatre and ward time for operations and recovery. We cannot simply continue to recruit staff from abroad. We can and must learn to live within our own resources, both financial and human.
Access to treatment
What, though, if your doctor, whether NHS or private, says that you need one of these procedures?
Well, in the first place, the NHS is not banning the procedures completely, just making sure that they are only used where there is clear evidence that they will benefit that particular patient. If your doctor thinks that you need a procedure, then you are should to be able to get it. It would, however, be worth asking questions to make sure that this evidence is really there in your case. Getting a second opinion might also be a good idea.
Rationing in the NHS
Unfortunately the financial strains of provision of care are leading to greater and greater rationing of care. This is increasingly done under the guise of evidence based medicine and muddies the waters with regards to whats in your best interest or rather what the NHS is willing to pay for.
Increasing numbers of patients are finding they can’t have their operations on the NHS. Following freedom of information requests the BMJ revealed that in 2017-18 1700 requests by doctors for their patients to undergo hip or knee surgeries were rejected by the NHS. Ian Eardley, senior vice president of the Royal College of Surgeons, said, “Hip and knee surgery has long been shown to be a clinically and cost effective treatment for patients. We are therefore appalled that a number of commissioning groups are now effectively requiring thousands of patients to beg for treatment.”
“The money has in effect run out, and Clinical Commissioning Groups (CCGs) have got to find ways of delivering greater efficiencies.”
Julie Wood, chief executive of NHS Clinical Commissioners
Graham Jackson, co-chair of NHS Clinical Commissioners, also admitted to the BMJ that “It was right to follow clinical evidence to try to bring thresholds for surgery to a consistent and appropriate level. But he acknowledged that some CCGs may be overzealous in imposing criteria that make some patients ineligible for surgery because of financial pressures.”
A matter of ethics?
The bottom line is that patients should probably be wary of anyone who encourages them to have a procedure that the NHS will not provide, especially if there is a financial incentive involved. While few providers—and certainly few practitioners—are genuinely unethical, this is a difficult area for many practitioners, especially if they have seen real benefits in the past from some of these procedures.
We suggest that a little caution is probably advisable, for both practitioners and patients. Seeking the best independent advice about your healthcare can be invaluable. Medstars health concierge can be just the place to start.
This blog has been co-created by Melissa Lefler and Medstars co-founder Barry Lambert.
If you genuinely do need a procedure, it is worth doing your homework. Whether NHS or private, you need to find the right specialist for you.