10.08.2017
Not a commodity
The growing trend towards rationing treatment is a disgrace, writes James Linney
In July, the British Medical Journal (BMJ) carried an article relating to an increase in the number of appeals made by doctors on behalf of their patients, known as individual funding requests (IFRs), to gain funding for a range of different treatments.1
The BMJ had sent freedom of information requests to all the clinical commissioning groups (CCGs) in England, asking for a breakdown of the number and outcomes all IFRs recorded for the years 2015-17. I will forgive you if the story passed you by: it only registered a small ripple in the media at the time. In this article I am going to look in more detail at this information and its consequences, which I feel is much more significant than the media coverage it was given. If we scratch at the surface of this data, we reveal the startling reality of a whole new level of Tory-sponsored undercutting of the NHS.
The BMJ’s investigation found that in the past year there had been a 47% increase in the total number of doctor-led IFRs (50,200 requests, increasing to 73,900). In itself these numbers are not huge, but, as we will see, they are just the beginning. Yet, more than the quantity, it is in the qualitative change of the type of IFRs that we make our most ominous discovery.
The IFR procedure was introduced in the early 2000s, and they have traditionally been made by doctors on behalf of patients for treatments that would not routinely be funded by the NHS, where the doctor feels an exception should be made. For example, despite what the rightwing media would have us believe, cosmetic breast surgery is not routinely carried out by the NHS; but if a patient requires a breast reduction due to having chronic back pain as a result of a large breast size, then the funding would need to be applied for by either the patient’s GP or surgeon via the IFR procedure. A panel would then assess the case and decide if funding should be granted.
It is worth pointing out that the composition of the panel is not, as common sense would dictate, made up of people best placed to make these decisions: ie, doctors. Most panels require input from just one doctor, who will have never met the patient and who does not even have to attend the appeal hearing personally. The other panel members - the ones who actually make the final decision - include an “IFR lead manager” and an “IFR business manager”. In other words, the panel has cost-saving as its priority - the reason why about half of the IFR appeals in the last 12 months were refused. So, since the introduction of these IFRs, as one Guardian headline put it, “Doctors [are] forced to plead with NHS for treatments for their patients”.2
The number and type of treatments which doctors had to take through the IFR process has historically been limited. However, what we have seen over the past 12 months is an introduction by the vast majority of CCGs of an unprecedented widening of the type of treatments that are no longer available routinely on the NHS. These treatments, varying slightly from area to area, come with restricting conditions (termed “clinical thresholds”). The only option then is for the doctor to make an IFR request. These new (long) lists of treatments are not the rare and exceptional, like the plastic surgery example I mentioned above, but include very common treatments, the withholding of which potentially leads to people having to live with devastating disabilities and chronic pain. The CCGs defend this introduction by claiming that they have picked certain treatments that are of “limited clinical benefit”, and so in the name of saving the NHS money they will no longer be available routinely. Treatments included in most CCG lists are: cataract surgery, certain mental health services, excision of benign skin lesions, hernia operations, varicose vein operations, gallstone removal, fertility treatments, knee and hip joint replacements … I could go on: as I say, the list is extensive. If you want to see which treatments are being limited in your area, they will available on your local CCG website.
What these new CCG-dictated clinical thresholds mean is that the provision of all the listed treatments are now no longer considered on an individual, case-by-case basis. Instead, if the arbitrary conditions, as stipulated by the CCG, are not met, the treatment is automatically refused - irrespective of how beneficial the GP or hospital consultant feels it would be for their patient. This is rationing the likes of which we have not seen before.
Two examples
Before I look in more detail at the consequences of these changes I would point out that I am not against all ‘rationing’. For example, this year the NHS banned the use of homeopathy on the NHS - good! Not a minute too soon. Even if the NHS had significantly more resources available to it, to offer a treatment that has absolutely no proven benefit is a waste and a disservice to its users. However, by looking in more detail at two examples from the list, we will see that these new restrictions are not driven by what is or is not clinically proven to be beneficial, but by the implementation of further ‘efficiency savings’. I will be referring to the criteria as defined by the CCG from the area where I work, but broadly they are similar in CCGs across the country.
Firstly, the provision of knee and hip joint replacements. These are some of the most common elective operations performed by the NHS - about 160,000 annually.3 As we age, our large joints degenerate as a consequence of supporting our body weight; for some people this degeneration (called osteoarthritis) can lead to significant pain and disability. Non-surgical treatments, such as analgesic medications and physiotherapy, can help to reduce symptoms and delay deterioration, but for many people these treatments fail and the only definitive option is to remove the diseased joint and replace it with an artificial one. This is a big operation and not one that any competent doctor would offer without first considering less invasive options or taking the patient’s overall health into consideration.
However, two new CCG-defined criteria state that no hip or knee operation will be carried out unless the patient has a body mass index (BMI) of less than 35. If it is over 35 they are forced to complete six months of documented weight management intervention and if afterwards they still have a BMI above 35, the operation will not be funded, but their GP can use the IFR to appeal. On the face of it this does not sound completely unreasonable: if someone is overweight they should obviously be helped to lose weight - this can help reduce their symptoms, slow down disease progression and help aid recovery. Of course, we must keep in mind that people in this situation are facing a cruel catch 22: their chances of losing weight are significantly decreased if every time they take a step they are in terrible pain. And, yes, generally the more overweight the patient is, the greater the risks of surgery. However, there is no supporting clinical evidence that a BMI above 35 equals worse surgical outcomes and my CCG does not attempt to offer any. In addition, the National Institute of Clinical Evidence (NICE) states in its guidelines that “patient-specific factors (including age, sex, smoking, obesity and comorbidities) should not be barriers to referral for joint surgery”.4
What we are seeing is the use of an arbitrary numerical cut-off chosen to deny treatment. And it gets worse. In their wisdom, my CCG has also decided that only people suffering intense pain and severe functional limitations will get the operation they need. This is defined as being in “almost continuous pain” and are “largely or wholly incapacitated”. In other words, unless you have end-stage joint disease you are out of luck. This is in opposition to most clinical evidence - there have been several extensive studies, which have found that offering joint replacements at a late stage of disease leads to worse outcomes.5 Again NICE agrees, recommending that we should “refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain”.6
Then there is cataract surgery. Cataracts are an age-related disease of the eye, which with time loses its transparency. As the lens becomes cloudier, it leads to poor vision - initially only causing mild impairment, but untreated it leads to profound visual loss, usually affecting both eyes. This is another very common condition and represents the leading cause of visual impairment worldwide. Surgery (removing the diseased lens and replacing it) is the only proven treatment. The new CCG criterion introduces a scoring system for operating: the first eye with a cataract will be operated on only if it is having a significant impact on someone’s daily activities. The second eye will only be operated on if the visual acuity is ‘6/18’ or worse: ie, if the patient can only see at six metres what someone with normal vision would be able to see at 18 metres. Again this contradicts NICE’s guidelines, which states cataract surgery should not be restricted in either the first or second eye on the basis of visual acuity, but on the impact the condition has on the person’s life.7
So the new reality is that being able to walk without pain and having two working eyes can be considered of “limited clinical value”. I have used the above two examples to demonstrate how these new CCG clinical thresholds for treatments represent a fundamental new stage in the withdrawal of NHS services. The human cost of these new restrictions are profound. Withholding joint replacements results in horrendous pain and disability, leading to the inability to work, and the loss of mobility and independence. Similarly, the denial of cataract surgery leads to social isolation, the risk of increased falls and the inability to perform basic functions, such as reading. It is obvious that in both these examples the greatest burden of harm falls on those who are already the most vulnerable: ie, those who are less likely to have social support, those who cannot afford private treatment and those who are more likely to have other comorbidities. In other words, the poorer you are, the more you suffer: the consequence of not having a comprehensive health service that is free at the point of need.
And this is just the start - the list is due to be extended and a second wave of restrictions is going to be rolled out in the coming year. The CCGs are performing just as the Tories hoped they would: as local, isolated vehicles for the implementation of cuts. By driving the NHS to the point where it can no longer provide what people need, and no longer cope with the demand for treatment despite the best efforts of its hard-working staff, the Tories hope to reach their real ideological prize - full privatisation. Just this week we have also had news about maternity wards being forced to close, severe hospital staff shortages and the lack mental health placements for the most needy.
Our immediate goals must be to halt these savage funding cuts. The gains made by Corbyn’s Labour Party in June’s election and the weakness of the current government’s position hopefully represents the start of this fight. But to win the battle we need to do much more than argue for a fairer distribution of resources under capitalism: we need to reject the entire rotten system. Only then can the idea of human suffering as a commodity go to where it belongs - in the waste bin of history.
Notes
1. G Iacobucci,‘Exceptional requests for care surge as rationing deepens’: www.bmj.com/content/358/bmj.j3188.
2. www.theguardian.com/society/2017/jul/05/doctors-forced-to-plead-with-nhs-for-treatments-for-patients-bmj-finds#img-1.
3. www.njrcentre.org.uk/njrcentre/Patients/Jointreplacementstatistics/tabid/99/Default.aspx.
4. https://pathways.nice.org.uk/pathways/osteoarthritis#path=view%3A/pathways/osteoarthritis/management-of-osteoarthritis.xml&content=view-node%3Anodes-referral-for-consideration-of-joint-surgery.
5. PR Forin et al, ‘Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee Arthritis Rheum Vol 46, 2002; R Roder et al, ‘Influence of preoperative functional status on outcome after total hip arthroplasty’ Journal of Bone and Joint Surgery Vol 89, 2007.
6. www.nice.org.uk/guidance/gid-cgwave0741/documents/short-version-of-draft-guideline-4.
7. Ibid.