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GPs go forth

How rationing of treatments has been rising for years – even before coronavirus

Léa Legraien and Anviksha Patel look at how policies to restrict procedures viewed as less effective barred patients from treatment even before the Covid-19 outbreak

It is likely that, for the foreseeable future, all procedures not considered urgent will be cancelled as the NHS battles against its biggest-ever challenge.

But a Pulse investigation reveals that even before this, an increasing number of procedures were considered of low clinical value, and were being rationed by CCGs.

When plans were put forward in 2018 to stop routine commissioning of four treatments and set specific criteria for 13 others, policymakers said the move would free up £200m for more beneficial procedures. The BMA called the restrictions ‘a tough pill to swallow’.

A year on since the changes were added to the 2019/20 NHS standard contract and the repercussions are being felt by both GPs and patients.

The guidance obliges GPs to argue why their patient should be considered for any of the 17 treatments – which include breast reduction, tonsillectomy, and haemorrhoid surgery.

One GP says ‘prior approval’ processes effectively see patients blocked from both treatments and consultant opinions.

It can be a bit of a fight to refer cases...Even if you meet the criteria, they want documentary evidence

Dr Fatema Jamil 

 

Brighton-based GP Dr Duncan Shrewsbury says: ‘One of my patients was not only unable to get a referral for a procedure that I felt would be of clinical benefit, we couldn’t even access the specialist opinion that would either confirm that, or suggest an alternative.’

 

But the restrictions go beyond national guidance. Locally, commissioners have been taking this approach for years – and are allowed to restrict a host of extra procedures in their area.

Exclusive figures collated by Pulse indicate increasing numbers of GPs’ patients are being put through this process.

Using data obtained through freedom of information (FOI) requests, it is estimated that almost 17,000 referrals were rejected across 57 CCGs last year, compared with just under 9,000 in 2015.

But the figures also show that the number of approvals has gone up, from 37,000 in 2015 to nearly 92,000 in 2019.

 

NHS Nottingham City CCG saw one of the biggest jumps in rejections. It said it rejected 128 applications for restricted procedures in 2015, but extrapolated figures show it was due to reject 662 in 2019. The number of treatments the CCG restricts has soared from 45 in 2015, to 154 now.

NHS Nene CCG rejected the most referrals for restricted procedures in 2019 – 4,104 according to extrapolated figures, up from 442 in the last nine months of 2015 when the commissioning body was established.

Northampton GP Dr Fatema Jamil says: ‘It can be a bit of a fight to refer cases. For example, for tonsillitis you have to have seven episodes in one year, 10 episodes in two consecutive years, or nine within the last three years. That’s a vast number and a lot of patients get it frequently and try to self-manage. Even if you meet the criteria, they want documentary evidence.’

For its part, NHS Nene CCG says the scheme has grown to include NHS England’s evidence-based interventions, with some local guidance. It adds: ‘All, however, go through a strict process before they [are authorised], and part of this includes going out to clinicians.’

The Royal College of Surgeons has long warned about local commissioners ‘rationing by stealth’ in the NHS in a bid to save money.

In a briefing note published in 2011, it said: ‘The Royal College of Surgeons is gravely concerned that the current financial climate is leading to surgical procedures which are not of limited clinical value – often procedures which are essential and of substantial clinical value – being stopped in some trusts or across the NHS and also a fundamental lack of transparency in the decision-making process.’

It is a simple matter of “computer says no” – the right hoop had not been jumped through

Dr Duncan Shrewsbury

In 2018, when NHS England set out its proposals to curb the 17 treatments it considered ‘ineffective’ or ‘risky’, it said this would stop 100,000 procedures a year and avoid spending £200m in 2019/20.

But GPs argue programmes aimed at rationing do not save money overall and instead prevent patients from accessing procedures they need.

Dr Shrewsbury, who is also a senior lecturer in general practice at Brighton and Sussex Medical School and a former RCGP trainees committee chair, says: ‘Research into referral-management systems has failed to show they are effective at either reducing cost within the healthcare system, or – more importantly to us – improving care and outcomes.’

Applying for approval for a restricted procedure is time-consuming for GPs.

Dr Jeremy Newman, a GP in Kent who also works with grassroots group GP Survival, says: ‘You have to apply for special funding, which is not very straightforward. Some of this requires circuitous routes and a very detailed case to define your patient as unique.

‘It requires us to do a fair amount of bureaucratic work. Ultimately, although we’re expected to advocate for patients, that comes at a high opportunity cost if we’re [to fill out] five pages of application for money that may or may not arrive.’

The whole process often seems futile, says Dr Newman: ‘It always feels quite frankly almost a bit depressing to do these things because you have a poor chance of success.’

It always feels a bit depressing to do these things because you have a poor chance of success

Dr Jeremy Newman

And the process sees rejected patients sent back to their GPs.

Dr Shrewsbury says: ‘It is a simple matter of “computer says no” – the right form had not been done, the right hoop had not been jumped through, the prior-approval process had not been satisfied, so no further thought or consideration would be given to that patient or their needs, and they are to be redirected back to me.’

Despite this, in some regions a large proportion of referrals for particular surgical procedures are approved.

Pulse’s figures show that between 2015 and 2019, across some 30 CCGs, around 94% of cataract procedures were authorised, as were 94% of knee replacements and 96% of hip replacement referrals.

While this might appear to be an argument for removing certain treatments from local rationing protocols, GPs suggest commissioners are reluctant to do this because any way of delaying procedures can help with budget controls.

Dr Newman says: ‘The NHS is under budgetary constraints and one of the problems is, of course, that the constraints vary according to region.

‘In Dorset, or other places with an elderly population, you have to configure services and spend more money on their needs – for example, joint replacement.’

He says rejection may be used as a way to manage demand: ‘An example of the things that commonly happen here in Kent is if you don’t write the BMI in the referral letter for a knee procedure, then that will automatically be rejected.

‘Some of this is probably a deferring or delaying tactic to slow demand down.’

Ultimately, GPs are concerned for their patients who are kept waiting – and how that impacts on their relationship with their GP.

Of course, in this new world, it is likely no patients needing these procedures will be seen while we continue to fight Covid-19. But once the NHS has got through this, GPs and their patients will hope for a review of this rationing policy.

NHS England’s rationed procedures

Four no longer routinely commissioned:

  • Intervention for snoring
  • Dilatation and curettage for heavy menstrual bleeding
  • Knee arthroscopies in osteoarthritis
  • Injections for non-specific low back pain without sciatica

 

13 only to be offered only when specific criteria are met:

  • Breast reduction
  • Removal of benign skin lesions
  • Grommets for glue ear
  • Tonsillectomy
  • Haemorrhoid surgery
  • Hysterectomy for heavy bleeding
  • Chalazia removal
  • Shoulder decompression
  • Carpal tunnel syndrome release
  • Dupuytren’s contracture release
  • Ganglion excision
  • Trigger finger release
  • Varicose vein surgery

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