Doctors forced to plead with NHS for treatments for patients, BMJ finds
Growing rationing of healthcare is forcing more doctors to plead with the NHS to fund treatments patients need, including cataract removals, new hips and knees, and removal of varicose veins.
GPs and hospital consultants in England submitted 73,927 exceptional requests on behalf of patients in 2016-17 in a bid to persuade the NHS to fund drugs or surgery they were initially denied, an investigation by the BMJ has found.
That was almost 50% more than the 50,188 individual funding requests (IFRs) doctors put in to clinical commissioning groups (CCGs), the bodies that hold the NHS budget in local areas, in 2013-14.
The revelations have prompted fresh concern among doctors and health experts that the cash-strapped NHS is increasingly denying patients treatments that were routinely available until recently. The sick “have misguidedly become soft targets for NHS savings”, the Royal College of Surgeons (RCS) has said.
The BMJ’s findings are based on freedom of information requests sent to England’s 207 CCGs, of which 192 responded. Just over 50,000 IFRs were submitted in both 2013-14 and 2014-15. But that suddently rose by almost 20% to 60,425 in 2015-16 and then by about a fifth yet again to last year’s total of 73,927.
The commonest reason for an IFR last year was for surgery to remove unsightly skin, such as skin tags. Doctors did that on behalf of 6,079 patients.
The next most common after that were: cosmetic and aesthetic surgery (4,426 IFRs), plastic surgery (1,889) and fertility treatment (1,151).
Mental health conditions were the sixth commonest reason for a request. Despite the NHS’s pledge to improve access to care, doctors still had to submit an IFR to try to get 1,150 patients what they judged to be the care they needed.
Wakefield CCG last year processed 122 requests involving mental health treatment, such as diagnosis of autism, treatment for attention deficit hyperactivity disorder, psychiatry and counselling. But it approved just eight of them. A CCG spokeswoman said that patients nevertheless received “timely and necessary access” to psychological therapies.
The other procedures making up the top 10 commonest reasons for an IFR last year were: cataract removal (1,034), carpal tunnel surgery (952), hip and knee surgery (899) and breast surgery (786).
The true scale of denial of care last year will be larger as the magazine only obtained full responses from 169 CCGs.
It discovered that Aylesbury Vale and Chiltern CCGs in Buckinghamshire recently decided that all requests for a replacement hip or knee should be done by an IFR. The number of IFRs for such procedures across England as a whole soared from 49 in 2013-14 to 899 last year.
“Hip and knee replacements are some of the most clinically effective and economical treatments available on the NHS. Unfortunately, patients needing hip and knee surgery have misguidedly become soft targets for NHS savings,” said Stephen Cannon, vice-president of the RCS.
The three CCGs in south Staffordshire now require requests to pay for procedures it deems of “low clinical value” to be accompanied by an IFR. As a result, the number of IFRs it receives has shot up from 416 in 2014-15 to 7,000 last year.
Richard Vautrey, a GP in Leeds who is also deputy chairman of the British Medical Association’s GPs committee, said NHS bosses needed to have “an open and honest discussion” on rationing of care, given that different CCGs have different rules on what treatments patients can access.
“It’s clearly unfair for patients to be subjected to this postcode rationing, and it also adds further to GPs’ workload as they are called on to provide more and more evidence to support each application,” he told the BMJ.
Ruth Robertson, a fellow in health policy at The King’s Fund, said: “With financial pressures growing, we can only expect to see more of this. It is unrealistic to expect the NHS to maintain the current level of services within the current budget, and so the government needs to either find more money for the NHS or be honest with the public about what sort of healthcare it can expect in the future.”
Some CCGs grant many IFR requests, but others very few. Southern Derbyshire CCG received 14 requests last year for procedures such as cataract surgery, but approved none. In contrast, Stafford and Surrounds CCG processed 2,123 requests, including 764 for skin excision, 232 for cataracts, and 163 for hip or knee replacement, but approved them all.
Jonathan Ashworth, Labour’s shadow health secretary, said: “Underfunding and neglect of the health service is causing misery for patients and making it harder to access routine treatments on the NHS. Behind every one of these statistics is a patient and their family waiting longer in pain and suffering.”
Julie Wood, the chief executive of NHS Clinical Commissioners, which represents CCGs, said: “Unfortunately the NHS does not have unlimited resources, and ensuring that patients get high-quality care against a backdrop of spiralling demand and increasing financial pressures is one of the biggest issues CCGs face.”