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Denying surgery flies in face of choice

NHS plans to ration 'unnecessary' operations might save cash, but the basis of its decision is shaky and the move makes a mockery of the choice agenda

NHS plans to ration 'unnecessary' operations might save cash, but the basis of its decision is shaky and the move makes a mockery of the choice agenda



The Government's choice agenda has always had one fairly glaring flaw. Patients were expected to pick their preferred hospital, but without any real information about local health services on which to base their choices. It was a bit like a group of novices on a trip to the greyhounds, except patients who accidentally backed a winner got paid out in improved quality of life rather than in pound coins.

Patient-reported outcome measures, or PROMs, were supposed to change all that. The idea was that every hospital in the country would assess, by detailed questionnaire, a sample of patients before and after undergoing specialist procedures. The bigger the jump in quality of life, the better the hospital – arming GPs for the first time with hard information to discuss with patients during the offer of choice.

So far, so good – at least if you accept choice and information have some worth. But the NHS is littered with examples of good ideas being turned into bad ones, as the potential of a policy to improve care is overlooked in favour of its potential to save money or meet Government targets. Think the QOF, and its move from being an evidence-based clinical initiative to a vehicle for driving Government priorities, such as access.

So it is with PROMs, which are no longer to be used purely to help patients choose the hospital offering the biggest benefits for quality of life. In pilots of the questionnaires, managers noticed some of the procedures evaluated apparently offered no improvement in quality of life at all. In the straightforward balance-sheet world of the NHS accountant, that meant money was being paid out for no gain, and that the operations should be stopped. The NHS Confederation is already on the case, advising trusts to start blocking or delaying GP referrals for cataract, hernia and varicose vein operations.

Now of course the NHS has to ration, and some operations probably don't do a great deal of good. Varicose vein surgery is already unavailable on the NHS in many areas because of its lack of evidence for benefit. If there is good evidence that early cataract operations are also unnecessary, then guidance and referral criteria should be changed.

But there are multiple problems with using PROMs as the evidence base for what could be fairly dramatic changes in NHS policy.

First, a patient's current quality of life is only one factor when a GP decides to refer. Future quality of life, and the need to prevent problems further down the line, is an equally important part of the equation. Second, PROMs were developed as comparative tools, not absolute assessments of benefit.

And finally, the PROMs pilots assessed quality of life just 12 weeks after procedures were carried out – far too soon to measure longer-term benefits, and probably statistically invalid, given the questionnaires were mainly developed to assess differences over a six-month period.

Here is a policy that was intended to improve patient choices about their care, but that looks set to have precisely the opposite effect.

Where GPs were to have been given extra information to discuss with their patients, now they may be left to break the news that referral is no longer an option.

Editorial

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