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Editorial Tuesday 19 June 2012: Rationing and rationalising - thoughts on the GP survey of low-value procedures

GP magazine's Tom Moberly has carried out a FOI study of PCTs' policies of limiting access to non-urgent care.


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The questions asked were:

"What measures does the PCT plan to put in place to restrict GP referrals for non-urgent procedures in 2012/13?

Please confirm or deny whether the PCT’s policy on ‘non-urgent’ procedures (or procedures of ‘limited / low clinical value’) for 2012/13 will include restrictions on referrals for each of the following:
(i) joint replacements operations
(ii) cataract surgery
(iii) tonsillectomies
(iv) bariatric surgery"

Now this is timely stuff, on the eve of the NHS Confederation's annual conference, when serious issues of NHS resource use may leak out into the national media.

It also comes on the heels of the latest instalment of the Kings Fund's quarterly survey of finance directors, which found that although "the national financial position is positive and has been assisted by a pay freeze and control of tariff, many organisations have not delivered their cost improvement programmes (CIPs) but have still achieved a surplus or broken even ... (and) finance directors foresee increasing challenges in continuing to deliver CIPs at the level required".

And the recent BBC Radio 4 File On Four programme found that NHS waiting lists were being re-categorised: a new euphemism for fiddled.

The GP study is a bit of a classic example of Things That Are Not Surprising. Obviously, part of it is definitional: the clue is in the use of "non-urgent" or "limited / low clinical value" procedures.

Now these definitions may well be wrong. Because joint replacement, bariatric surgery and cataract surgery all seem to be silly places to make rationing - or perhaps rationalising - decisions.

Why is this? Because in the case of both joint replacement and cataract surgery, the work is going to have to be done at some point in the future.

And in the case of bariatric surgery, while many people might well prefer to see the NHS spend much more effort getting interventionist with people's diets and exercise regimes, we know that bariatric surgery can be effective for some people - and we also know that the health risks of remaining seriously overweight are considerable.

(Putting tonsillectomy into the same category as these other three seems to be a curious decision, as this article and this article show. In most cases, tonsillectomy seems to be about as effective as Royalty touching for scrofula. I wonder how many PCTs commission that?)

Clinical judgment
What the survey doesn't make totally clear is what processes the PCTs used to decide on the clinical thresholds.

In the case of obesity surgery, while NICE recommends it for a BMI over 40, some PCTs restrict it to those whose BMI is above 50: a pretty clear perverse incentive.

One of the fascinating by-products of the lengthy and heated debate over the Health And Social Care Bill was a much more widespread agreement that clinicians must lead commissioning and resource use decisions.

From that point of view, the level of involvement of local clinicians in the threshold-setting by PCTs is the fascinating but as-yet-unasked question. If the local clinical leaders who will be involved in running CCGs have been no part of this, that would be very surprising.

A clinically-led (not to say liberated) NHS would not do this sort of thing.

How much difference explicit thresholds make
It is also possible that PCTs set these explicit thresholds, and then local clinicians ignore or work around them. I'm not sure this is happening, but would point to a couple of things.

Research on the 'Oregon Project' in the USA demonstrated (among other things) that explicit threshold-setting of approved and un-approved procedures has unforeseen consequences and probably doesn't do what it says on the tin.

Also, as  you will perhaps have noticed, doctors are currently just a little bit pissed off with the Government for making them pay more for their pensions and get them later. This being the case, it just might be that if PCTs were rationing very effectively in this way, we would have heard an awful lot more about this than we have.

Our old friend outcomes
We need, of course, to look at outcomes. The latest data from the NHS Information Centre suggests that "96.1% of hip replacement respondents and 91.8% of knee replacement respondents recorded joint related improvements following their operation as measured by their response to a series of questions about their condition (Oxford Hip and Knee Scores). These values were 95.7% and 91.4% respectively in the finalised data for 2009-10.

"87.5% of hip replacement respondents and 79.2% of knee replacement respondents recorded an increase in their general health following their operation, based on a combination of five key criteria concerning their general health (EQ-5D Index score)".

PROMs also measures groin hernia and varicose vein surgery, and the PROMs data finds that "63.3% of hip replacement respondents and 54.0% of knee replacement recorded an increase in their EQ-VAS score (current state of the patients general health marked on a visual analogue scale) compared to 41.6% for varicose veins and 39.0% for groin hernias".

Rationing or rationalising?
If commissioners can successfully identify genuinely low-value healthcare (in Muir Gray's splendid phrase), then they should take action to stop it going ahead.

Low-value care encompasses much, from drugs prescribed and dispensed but not taken to interventions that do not make a significant difference to a patient's quality of life and have more drawbacks than advantages.

The problem that we face is that low-value is a value judgment. In the GP article, GPC chair Dr Richard Vautrey is quoted calling for a national list of low-value clinical procedures, to ensure patients are treated fairly.

A national list won't achieve that. We know that PCTs had different policies about ICE advice; the NHS Atlas of Variation again shows it.

Money is finite. Until we discover The Magical Money Tree Where Cash Grows For Free, clinicians are going to have to make decisions that involve trade-offs. There are many tools: programme budgeting and marginal analysis from health economics being the obvious one.

There are, of course, consequences and externalities to these choices. But these are choices the NHS has to make.