Rationing is a dirty word among those who have to balance the books in today’s NHS. They prefer to talk about rationalisation. To the patient, however, the result is often much the same — it is increasingly difficult to get services and treatment that were once widely available.
My local clinical commissioning group (CCG) — which buys care for patients across Gloucestershire from local hospitals and other providers — has written to GPs reminding us that “not all procedures are funded by the CCG”. The list of conditions and treatments currently subject to restrictions runs to more than 40 pages and some might surprise you.
Few would be shocked to discover that a CCG will not pay for breast augmentation in women with “small but normal breasts”. The NHS isn’t in the business of doing boob jobs and nor should it be. But what about piles or hernias? Surely you can still have your piles operated on or your hernia repaired? Not necessarily — such surgery is no longer an automatic right.
Patients must fulfil certain criteria (such as a groin hernia that gets bigger month by month or piles that stick out permanently) and each case be approved by the CCG before it picks up the tab for onward referral. And don’t even think about asking for varicose veins to be removed — unless they prevent “vital activities” or you have developed complications such as ulceration or haemorrhage.
None of this is new. Restrictions have been around much longer than CCGs (introduced in England in 2012), but the list of conditions and treatments they apply to has grown. And not just in my part of the world — “rationalisation” is in force in every CCG in England, with similar restrictions across the rest of the UK.
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A combination of rising demand, innovation and medical inflation (which far outstrips normal inflation) means that the NHS has to cut costs and one of the simplest ways is to restrict what it offers. Yet there is more to this than savings; lists like the one used by my CCG also reflect changes in our knowledge.
I did a brief stint in gynaecology in the late 1980s and most of the women I booked in for the morning operating list were there to have their womb “scraped” (dilation and curettage, or D&C) or removed (hysterectomy) because they were troubled by heavy periods. We no longer carry out D&Cs for this indication because they don’t work, and hysterectomy is only funded as a last resort for women with heavy periods because there are better, less invasive alternatives.
The very fact that a treatment or procedure is included on the restricted list means that my CCG deems there is “insufficient evidence of clinical and cost effectiveness to warrant [it] being available to all patients in all circumstances”.
So what does this mean for the patient? If you are asking your GP to do something about a child’s large tonsils or your grumbling wisdom teeth and unsightly varicose veins you’re likely to be told there is nothing the NHS can offer. If, however, you meet the criteria for a restricted treatment, GPs will highlight this in their referral. And if you don’t they can still lobby on your behalf if they believe you qualify because of exceptional circumstances.
If you are still refused, please don’t shoot the messenger — it is the CCG’s decision not the GP’s. And get used to the idea because whether you call them rationing or rationalisation, restrictions are here to stay.
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Restrictions on certain treatments and procedures vary across the country but in Gloucestershire they can broadly be divided into three categories:
■ Interventions not normally funded These are procedures that the CCG funds only in exceptional circumstances, eg, liposuction or fixing sticking-out ears.
■ Criteria-based access These are funded subject to the patient meeting certain thresholds. Examples include hip replacement and circumcision.
■ Criteria-based access with prior approval As above, but funding must be approved in each case by the CCG. Examples include hernia, varicose vein and bunion surgery.
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Q&A
Q: I have had a troublesome cough for the past six weeks so went to see my doctor. I was somewhat surprised to be told it might be whooping cough. I thought vaccination meant this was a thing of the past.
A: Whooping cough (pertussis) is more common than people think. Routine childhood immunisation offers protection but wears off by the early teens so most of us are susceptible — although it tends to be a much milder condition in people who have been vaccinated previously.
The classic story is of a persistent cough (it can last up to three months) that comes in paroxysms — you may be fine for an hour or two then spend five to ten minutes coughing uncontrollably. Generally you don’t feel ill and there shouldn’t be any significant shortness of breath.
Pertussis is a bacterial infection and antibiotics don’t do much except to reduce the likelihood of spread, if given in the first few weeks after the cough starts. This is important if you come into contact with babies who have not yet been vaccinated since it is a much more serious infection in this group.
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If you have a health problem email drmark@thetimes.co.uk