Two-thirds of NHS Trusts are rationing operations in accordance with the Audit Commission’s recommendations, reducing access to hip replacement, cataract, varicose vein and tonsil surgery to the most severe cases.
Most Trusts are restricting bariatric surgery to the worst cases – a policy that a surgeon has described as encouraging obese people to gain weight.
The denial of common operations to ‘non-urgent’ cases is part of a national drive to reduce the NHS budget by £20bn over the next four years.
A survey of 111 PCTs by the health service magazine GP found that the controversial ‘Croydon list’ of procedures to be rationed has become prevalent in the NHS, despite protests from industry, clinicians and patient groups.
The prevalent cuts in surgery provision include:
• No hip and knee replacements unless the patient is in severe pain.
• No cataract operations until sight loss ‘substantially’ affects the patient’s ability to work.
• No varicose vein surgery unless the patient is suffering ‘chronic continuous pain’, ulceration or bleeding.
• No tonsillectomy unless the child has suffered from tonsillitis seven or more times in the previous year.
Two-thirds of NHS Trusts are either not providing bariatric surgery or restricting it to patients with a BMI of 50 or even 60. NICE guidelines say it should be available to patients with a BMI over 40 (or over 35 where there is a co-morbidity). The recommendation followed studies showing that weight loss surgery reduced the overall cost of healthcare for these patients.
Professor Mike Larvin, a bariatric surgeon and Director of Education at the Royal College of Surgeons, commented: “In many regions the threshold criteria are being raised to save money in the short term, meaning patients are being denied life-saving and cost-effective treatments and effectively encouraged to eat more in order to gain a more risky operation further down the line.”
Chris Naylor, a senior researcher at the King's Fund, criticised the use of rationing to save short-term costs without regard to patients’ needs and the overall cost of their care: “Blunt approaches like seeking an overall reduction in local referral rates may backfire, by reducing necessary referrals – which is not good for patients and may fail to save money in the long run.”
Chaand Nagpaul of the BMA’s GPs committee argued that Trusts rationing access to treatments on the basis of local policies meant a return to the ‘postcode lottery’. “Patients and the public recognise that with limited resources we need to make the maximum health gains and so there needs to be prioritisation,” he said. “What is inequitable is that different PCTs are applying different thresholds and criteria.”
However, a DH spokesman defended the principle of local control: “Decisions on the appropriate treatments should be made by clinicians in the local NHS in line with the best available clinical evidence and NICE guidance. What is suitable for one patient may not be suitable for another.”