GPs and clinical specialists are worried about patients being turned away because of local NHS policies.
Tim* went to his GP because the deformity in his feet had worsened and stopped him walking. If he’d have taken sick leave, he would have lost his job, so he carried on working and wasn’t deemed impaired enough to have surgery. His debilitating health problem went untreated.
Tim is one of the patients who has been denied treatment because of the policy to restrict access to certain interventions by local NHS bosses, Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (BNSSG CCG).
The number of restricted treatments has grown to more than 100, and the Cable can reveal that clinical specialists have criticised policies for some treatments for being too restrictive and not meeting national guidelines.
While these policies are intended to deny cosmetic or ineffective treatments, some more important interventions are also affected. These include hip replacements, knee surgery and hernia repair – meaning people who genuinely need treatment to improve their quality of life risk being turned away.
The system requires patients to meet certain criteria in order to be eligible for treatment, such as the level of impairment, as power is shifted from GPs to funding panels. GPs have told the Cable about patients unable to meet unfair criteria, being lumbered with more bureaucracy and having to deal with patients growing increasingly frustrated with rejections.
In November 2018, NHS England issued new guidance to CCGs to restrict 17 surgical procedures deemed to be “ineffective or risky”. According to BNSSG CCG policy documents, 104 treatments are restricted as of April 2019. This is the subject of the ‘Stolen Treatments’ campaign by local group Protect Our NHS, who are collecting experiences of patients and GPs in order to hold the CCG to account.
We showed the CCG’s policies for some affected treatments to a number of medical associations, three of which expressed concern that they were too strict and did not meet national guidelines.
The British Orthopaedic Association (BOA) criticised the policies for hip and knee replacement and foot surgery, telling the Cable “Hip and knee replacements are highly effective procedures known to benefit patients suffering pain and poor mobility due to osteoarthritis. We consider that the policies from Bristol, North Somerset and South Gloucestershire CCG are too restrictive and could prevent or delay patients in accessing surgery that would benefit them.”
This is a problem nationally. A British Medical Journal investigation found that 1,700 applications for knee and hip surgery were rejected in 2017-18 in England – an increase of 45% from the previous year.
The BOA was also concerned about the policy for foot and ankle surgery: “The requirement for the patient to be experiencing ‘severe pain which is causing significant functional impairment’ is particularly stark. We are concerned that patients with lesser amounts of pain or impairment, but who are still significantly affected by their condition, will be denied treatment that will be effective for them.” This is what happened to Tim.
Similar issues were raised about the CCG’s policy for hernias – an operation that The Royal College of Surgeons revealed was being withheld from thousands of patients in 2018.
David Sanders, scientific secretary to the British Hernia Society (BHS) told the Cable “It is not acceptable to justify restrictive criteria as best practice. This denies patients access to a procedure that potentially limits pain and improves quality of life.
“The NHS has to be very clear about what it offers. Does it want a value for money service with quality and safety as a priority, or a rationed service that will inevitably put some patients at risk?”
How is it affecting GPs and patients
Dr David Porteous, who has been a GP in Bristol for 20 years, told the Cable “Restricting treatments that don’t provide benefits for patients overall is one thing, but when you come up with an arbitrary set of criteria where there’s no evidence involved, then that’s just not right.
“It’s growing and they are able to keep adding other treatments on to the list and change the criteria, making them more wide ranging. It’s getting worse,” he said.
“The fact that it’s not particularly well known about means people get quite a shock when I tell them they can’t have that. When that happens, I have to put up with a tirade of abuse because I’m the person delivering the cuts. I hate that because I don’t want there to be any cuts. I’m just trying to do my job.”
Porteous gave the recent example of treating nasal polyps – growths in your nose that stop you breathing and make you sneeze a lot. The criteria say there needs to be ‘significant impairment of functioning’. His patient couldn’t breathe through their nose so couldn’t sleep or eat properly, but this was deemed not serious enough for surgery.
ENT UK, the medical association for ear, nose and throat specialists, told the Cable the CCG’s policies were out of step with their commissioning guidelines. Professor Carl Philpott, head of the Rhinology & ENT research group at Norwich Medical School said “There should be no restriction placed on patients accessing treatment for a significant inflammatory disorder associated with poor quality of life.” He added that it was “outrageous” that patients may not even be entitled to getting a diagnosis, let alone treatment.
In addition, Claire Hopkins, the president of the British Rhinological Society (BRS), sent a letter to BNSSG CCG in November 2018 to express her concern about restricting access to treatment for chronic rhinosinusitis and other nasal problems. The Cable understands that six months later, the CCG has not responded.
Another GP who wished to remain anonymous told the Cable that these policies were putting them under greater pressure. “Every day GPs are having to navigate their way through an increasingly complex system to access help for the patients they care for,”he said.
“The criteria are often very hard to meet and if they are not met we have to apply for exceptional funding. This involves lengthy forms and applications which are almost always initially rejected. GP time would be better spent dealing with other problems.”
He added that the system meant getting advice from specialists was becoming “increasingly difficult”, because even referring the patient on to get a second opinion can require approval from the CCG.
Almost half of the restricted treatments (43) must be applied for via an exceptional funding request (EFR), which are almost always rejected. A freedom of information request revealed that there were 1,162 such funding requests to the CCG in the year to August 2018. Only 46 were approved – a success rate of 4%.
Another treatment restricted by BNSSG CCG since 2017 is the removal of ganglion cysts, a fluid-filled swelling that usually develops near a joint or tendon. The Cable spoke to a patient, who wanted to remain anonymous, about how he was denied treatment for one on their wrist. As a musician, he said the problem was stopping them play the piano, but he was denied surgery because their need wasn’t considered “exceptional” enough.
However, Professor Grey Giddins, of the British Society for Surgery of the Hand (BSSH) told the Cable the CCG’s policies for wrist ganglion and other hand problems (carpal tunnel syndrome, trigger finger and Dupuytren’s contracture) were “reasonable”.
Giddins was critical of NHS England’s recent inclusion of treatments for these conditions on the list of procedures with limited clinical effectiveness, but said the BSSH’s concerns had been addressed in the guidelines.
Despite approving of BNSSG CCG’s policies on hand surgery, he described CCG’s having individual policies as “a bonkers system” that could cause a postcode lottery. “It should be done centrally. You should ask the experts. Why try and reinvent the wheel?” In March, the Medical Technology Group (MTG) published a report calling for a national body to make sure access to treatments is consistent across the country.
A BNSSG CCG spokesperson said “Commissioning policies play an important role in enabling us to address our responsibility to meet the health needs of our local population using NHS funds, while ensuring patients receive treatment when there is clear evidence that the benefits outweigh the risks.
“All our commissioning policies are regularly reviewed in line with NHS England guidelines and NICE Technology Appraisal Guidance. We have recently undertaken a review of its commissioning policy process and extensively engaged with our member GPs, other clinicians and patient representatives to improve the transparency and efficiency of our approach.
“In line with our aim to continually improve our service, policies remain under review and the we welcome additional feedback on specific policies or on how our process could be improved.”
This investigation was in collaboration with Protect Our NHS, who are running a campaign called ‘Stolen Treatments’.
*Names have been changed.