NHS rationing is affecting the relationship between doctors and their patients, a new survey has found.

The survey by Pulse Magazine revealed that three quarters of GPs believe the doctor-patient relationship has been tainted by cut backs to certain treatments.

Dr Clare Gerada, Royal College of General Practitioners, said the problems of the Health and Social Care Act have resulted in patients holding GPs responsible.

Typical treatments which have been affected by a rationing include GP referrals for bariatric, hip and knee and cataract surgery.

Out of the 237 doctors questioned, nine out of 10 reported pressure to ration treatments or services over the past twelve months. Two-thirds of respondents admitted local rationing was adversely affecting standards of patient care.

More than 40% of doctors said they had changed the therapy of patients to less effective options due to rationing guidelines in the past twelve months. A third also raised issues with getting patients to guideline-directed targets.

GPs also exposed other forms of rationing with 89% finding patients had been referred back to them after missed hospital appointments and 31% claimed hospitals were overemphasising the risks of surgery in an attempt to off put individuals.

A spokesperson for the Department of Health said they would be writing to the NHS to remind them that rationing on the grounds of cost was wrong.

Tighter medical device regulation could not have prevented the PIP breast implant scandal, according to a UK regulatory lawyer.

Regulatory processes cannot defeat a deliberate violation of the law, such as the French company PIP’s use of industrial rather than medical grade silicone, Dev Kumar of law firm Bristows commented.

Meanwhile, a Commons Health Select Committee has challenged the NHS decision to provide only PIP implant removals but not replacements, on the grounds that it forces patients to undergo an avoidable follow-up operation.

The PIP implant scandal has rocked the European medical device industry and led to calls for tighter regulatory controls and better surveillance.

This coincides with changes to the European regulatory framework for medical devices arising from other scandals, including the high failure rate of metal-on-metal hip implants.

“The House of Commons’ Health Select Committee’s report on the PIP breast implants has once again brought the medical device regulatory system to the forefront of everyone’s attention,” said Dev Kumar.

“The report, which also mentions the safety concerns of metal-on-metal hip implants, suggests that the CE mark requirements and regulatory framework are strengthened.

“The timing of the PIP case and Select Committee report are all the more relevant as they have surfaced at a time when the European Commission is drawing up proposals to revise the regulatory system for medical devices. Currently, these include plans to improve and strengthen the regulatory framework through the introduction of measures for more pre-market testing and post-marketing surveillance.

“However, the PIP case concerns a company that intentionally chose to use an industrial, as opposed to a medical grade, silicone filler. No regulatory system, however robust, can guarantee against a further incident of this nature occurring if there is deliberate intent to circumvent the law.”

The question of how the NHS should assist patients who received PIP implants from private clinics remains contentious. Current NHS policy is that such patients can have the implants removed, but not replaced, on the NHS if the clinic will not help.

However, a Commons Health Select Committee argued that to save patients from being operated on twice, the NHS should remove and replace the implants but impose a charge of about £1,500 for the latter procedure.

The DH responded by saying that requiring patients to pay for an NHS treatment would set a dangerous precedent.

Final NICE diagnostic guidance on the EOS 2D/3D X-ray imaging system calls for the system’s health benefits to be further investigated in clinical research settings.

The new system (pictured) from US company EOS Imaging uses low-dose radiation imaging to produce 2D X-ray images and 3D reconstructions for bones.

Its innovative slot-scan technology, scanning a line at a time rather than taking the entire image at once, enables it to produce upright and weight-bearing whole-body images.

By showing relationships between the spine, hip, pelvis and knees, the EOS system could particularly benefit the monitoring and treatment of patients with spinal deformities or alignment problems.

The system’s reduced dose also offers potential safety advantages in the repeated imaging of patients with spinal deformities, especially children.

The new guidance encourages the use of the 2D/3D imaging system in specialist research settings to collect evidence about clinical benefits associated with weight-bearing whole-body imaging and 3D reconstruction.

Professor Carole Longson, Director of the NICE Health Technology Evaluation Centre, said: “The EOS 2D/3D imaging system was identified by the Diagnostics Advisory Committee as an important emerging technology. There is evidence showing comparable or better images and radiation dose reduction associated with using the EOS system to image patients with spinal deformities.”

However, she said, there is currently no evidence that compares the diagnostic accuracy of the EOS system with that of conventional radiological examinations. “NICE will follow up the Diagnostics Advisory Committee’s research recommendations on the EOS 2D/3D system and will assess the feasibility of this research with a view to facilitating the development of further relevant evidence.”

Full data sets evaluating the system’s benefits will trace the outcome of its use from planning through to complex surgeries such as hip replacements.

Marie Meynadier, CEO of EOS Imaging, said: “The EOS 2D/3D imaging system is subject to an extensive programme of research associating radiologists and orthopaedic surgeons. We will provide data to NICE as they are established to determine when a cost-effectiveness review based on this evidence would be appropriate.”

The new external assessment centres recently announced by NICE will help to develop and facilitate research products to assist suppliers when NICE medical technology or diagnostics guidance recommends it.

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.”