Clare Marx, President of The Royal College of Surgeons, gives her response to The King's Fund's report, Understanding NHS financial pressures: how are they affecting patient care?
This presentation was recorded at our breakfast event, How are financial pressures affecting patient care?, on 14 March 2017.
So good morning. Actually a lot of the messages in this report really resonated just a year and a half ago I had a parent dying at home and there was no community support at that stage, so I think that actually what’s happening is we probably started from quite a low base and it’s now getting worse and that may be something for us all to reflect on, but I really wanted to pick up obviously on the access to surgical care.
I’ve just got a few slides to show you this morning because I wanted you to understand that we’re not naïve and we know that actually there is no system in the world that doesn’t have some form of rationing and I know it’s an R word and perhaps we should or shouldn’t speak about it this morning, but what we’re seeing at the moment is that we’re seeing decisions being made which are not necessarily being based on good evidence and are very arbitrary and are very diverse.
Now surgery is obviously a very easy place to start, because as you’ve heard it’s funded through commissioning and the providers are doing it, for the most part, on a tariff system and so it’s a high volume activity and we are interested that this report shows us that we started to see a very small decrease in the number of hip replacements being done over this last year, which is very surprising given the demography of the population, and also the fact that hip replacement is an incredibly successful operation for the most part. So, we would have expected this to be an operation which we would continue to see increasing in terms of its numbers, but this year it is lower than last year.
And we’ve identified as a college, there are three types of rationing being applied across the piece. One is purely financial, I’ll give you some examples of these in a minute. The other is what we call lifestyle restrictions so if you’re overweight or you’re a smoker, and the third, this is probably the most worrying, is the pain and disability threshold, but in both the second and third types of rationing, these are often explicitly linked to the fact that there is a lack of money.
So, if we just have a look at the purely financial, this is the West Kent study and the CCG in West Kent basically announced that it was going to ban all non-urgent surgery from December 20th till the 1st April and they reckon that would affect about 1700 people, they were trying to save £3.2 million. They did also say that it was going to affect obese patients and smokers, but there was one sort of light of positivity here which was they said that patients were still able to see consultants so that if somebody really was urgent at least, that they could still have that decision made on grounds of urgency, but nonetheless this is a blanket ban.
So, the next thing is lifestyles; last year we did a report from the college which was called Smokers Overweight Patients and Soft Target for NHS savings and here we found that about 34% of CCGs were delaying or refusing surgery based on BMI, body mass index, or smoking. CCGs were targeting hip and knee replacement and we found 22% of those CCGs had mandatory weight thresholds. We’d seen that in the place but it had certainly gone up. And then we also noticed from these studies that basically where, at the same time they were suggesting people should lose weight and stop smoking, 40% of local authorities were actually going to be spending less on smoking cessation or weight management, so it was a real catch 22 for the poor patients.
So, we’ve got more examples since then, and here’s one, the Vale of York, here basically they said they got a £24 million deficit and so in November they said they were going to stop most forms of elective surgery for smokers and patients with a BMI over 30 and that was going to be for a standard period of either six months if you’re a smoker or twelve months if you’re overweight unless the patient could lose 10% of their weight. Now, we don’t know whether that would have meant it’s still going to be twelve months or six months, there was no clear rules for the patients what they did if they managed to stop smoking or lose weight, how they got back into the system but we have to realise that we’re looking at a population where about more than a quarter of them have BMIs over 30. So, this is going to impact on a lot of people and unhelpfully this was an example of a patient who at 37 was overweight, she also had polycystic kidneys, also had depression but she got a letter saying that she couldn’t be referred for a hip replacement but the letter gave no help at all about how she could lose weight but it did actually offer some advice and some general sort of comments about the amount of money it costs the health people to be overweight which is not particularly helpful if you’re trying to actually lose weight.
So the last one is about arbitrary pain thresholds and here this would be Rotherham CCG which basically said unless you were in desperate straits you really couldn’t have a hip replacement and they suggested that you had to have intense and severe persistent pain and this would lead to severe functional limitations and of course there was also the BMI in there, and just at the bottom there, this was their actual, what they said severe pain was, which was that it occurred 75 to 100% of the day, they could only walk about 20 feet or they could stand for less than half an hour. Daily activities were significantly limited, unable to maintain a home, cook, dress and that of course means that they would probably be trying to access social services and then there was continuous use of NSAIDs and narcotics for treatment and they required walking sticks.
Now I just really want to explain why that is wrong. There is no clinical basis for that policy whatsoever. Patients who have sticks and walking disability who have pain that is so severe that they are struggling around using furniture often are greater risk of falls and certainly being restricted to your home environment and not being able to take regular exercise can cause depression. Also causes stasis in the veins, all these sort of things that are likely to lead to things like DVTs and so on, and we do know that in a lot of circumstances where a patient has struggled with their pain control and their function, actually their benefit from surgery is less so that when you actually get to the surgical environment the outcome is going to be less good.
And of course it doesn’t actually save any money in the long term because we’re just kicking the can up the street because this is just simply delaying the inevitable, and I put this up for those of you who don’t know but NICE have actually set out very clearly the guidance which says this has to be a conversation between the clinician and the patient, and that joint replacements should be considered before you get to established functional limitation or severe pain and that smoking and obesity should not be actually barriers for joint replacement.
So, what’s happening? Well we have to thank, and I see Celia here today, in NHS England and Right Care for a letter which explained to CCGs all the issues around TNO surgery and that has gone out and some of you will be aware about that, but basically treatment decisions have to be based on the conversation between clinician and the patient, and we think that really that clinical prioritisation is really essential, but here’s a question for all of us; should we actually be thinking about how we change clinical prioritisation rather than simply having groups of people giving arbitrary policies, because these arbitrary policies are restrictive and they are different and so it depends where you live in the country as to your access to surgery and secondly, or lastly really, do we need a much broader debate about what NHS can and can’t provide given the amount of money that’s going to be available to surgery in the future?