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Clare Marx: Is a postcode lottery in health justified?
1. Is a ‘postcode lottery’ in health
justified?
• Twitter hashtag: #NHSrationing
2. Opening remarks and welcome
Chair: Clare Marx, President, Royal College of Surgeons
3. Is a ‘postcode lottery’ in
health justified?
#NHSrationingWiFi: RCS-Public
4. Outline of the afternoon
16:40: Public attitudes towards rationing of NHS treatments and services.
Ben Page, Chief Executive, Ipsos Mori
17:00: What can the NHS afford to provide: how do you make decisions about
rationing and who is best placed to make these decisions?
Chair: Sarah Neville, Public Policy Editor, Financial Times
Nigel Edwards, Chief Executive, Nuffield Trust
Dr David Jenner, Chair, Eastern Locality, NEW Devon CCG
Dr Karol Sikora, Dean of Medicine, University of Buckingham
Lord Warner, Labour Peer, ex health minister
17:55: Closing remarks
Clare Marx, President, Royal College of Surgeons
18:00: Drinks reception (in the Council room down the corridor) 4
5. Context of this debate
• The NHS faces significant financial pressures
• £30bn funding gap by 2020/21, according to NHS England
• £5.3bn integrated care fund is a good initiative but may cause pressure on
acute budgets in short-term
• The need to tackle inefficiency and waste
• Tariff uncertainty
• Meanwhile demand continues to increase
• Latest HES data shows 2.5% increase in number of episodes of care from
previous year
• Historically the NHS has sought short-term savings by arbitrarily cutting
services
• The RCS has monitored these decisions
5
6. Rationing of specific procedures
• In 2014 we collected commissioning policies for 5
procedures from 54 CCGs
• Tonsillectomy
• Cholecystectomy
• Hip replacement
• Hernia repair
• Surgical treatment of otitis media with effusion
• We compared these policies with available NICE
guidance and clinical guidance from the RCS and
Surgical Specialty Associations (SSAs)
6
7. Key findings from our report
• 73% of CCGs reviewed do not follow NICE
guidance on referral for hip replacement or have
no policy in place
• 44% of CCGs had imposed different pain
thresholds (Oxford Score) for hip replacement
contrary to NICE and clinical guidance
• Only 27% of CCGs complied with NICE or
surgical guidance on inguinal hernia repair
• 77% of CCGs did not follow clinical guidance on
the commissioning of treatment for glue ear
• Two CCGs had minimum “watchful waiting”
periods meaning some patients may not access
tonsillectomies for a year and a half
7
8. The case of NEW Devon
• CCG facing cumulative deficit
of £43.7m
• CCG said “urgent and necessary”
measures were required to
redress the situation.
• BMI (35) threshold for elective
activity
• Patients over threshold required
to undergo 6 month weight loss
programme funded by the CCG
• Smokers to quit 6 weeks prior to
surgery
8
9. CCG under intense scrutiny
• Pressure from the RCS
• “It is unacceptable for any CCG to have a blanket
ban on elective surgery for people above a certain
weight”
• Pressure from NHS England
• Simon Stevens, appearing at the Health
Committee, said: “frankly, we do have some
reservations about the particular approach that is
being proposed there”
• Pressure from the Government?
• At a parliamentary debate on events at NEW
Devon Jane Ellison said: “Today I had a telephone
discussion with some of the key people involved,
including the chief officer of the CCG...”
• The proposals were dropped shortly after
that phone conversation…
9
Jane Ellison, the Public
Health Minister
10. NEW Devon as the canary in the
NHS coalmine?
• The case of NEW Devon is representative of the real
challenges commissioners are facing
• Are the CCG’s actions not just a reaction to the realities
of their situation?
• They are not alone:
• FDS research shows that some commissioners are
refusing to provide dental implants, including to cancer
patients
• There is on going debate over which drugs to fund on the
NHS (eg in Cancer)
10
11. What does this mean for patients?
• Delayed treatment can result in poorer
outcomes and is distressing for
patients.
• In rare cases it may also expose the
patient to greater risk of medical
emergency
• E.g. strangulated hernia
• Conservative measures don’t
necessarily fix the underlying problem
• Pain relief doesn’t overcome the need
for a new hip due to osteoarthritis
• But isn’t there a need to allocate
resources fairly?
11
12. Questions for today
• If local commissioners choose different levels of service
provision should there be:
• A safety net of care provided?
• A process for dialogue between commissioners, patients and
clinicians?
• The role of NICE
• Should its guidance be mandatory?
• Should it be above political influence?
• Should we abdicate all responsibility and leave it all to the
politicians?
12
13. Public attitudes towards rationing of NHS treatments
and services
Ben Page, Chief Executive, Ipsos MORI
14. What can the NHS afford to provide: How do you make decisions about
rationing and who is best placed to make these decisions?
Chair: Sarah Neville, Public Policy Editor, Financial Times
Nigel Edwards, Chief Executive, Nuffield Trust
Dr David Jenner, Chair, Eastern Locality and Mid Devon sub-locality,
NHS Northern, Eastern and Western Devon Clinical Commissioning Group
Professor Karol Sikora, Dean of Medicine, University of Buckingham
The Rt Hon. the Lord Warner, Peer, House of Lords
