Rationing of Surgery

Eleanor Laing Excerpts

Tuesday 28th February 2017 Commons Chamber

[Rachael Maskell (York Central) (Lab/Co-op)]

I am grateful for the opportunity to debate the rationing of surgery. The reason this is such an urgent issue is threefold: first, it is causing detriment to the health of the people of York; secondly, it is discriminatory; and, thirdly, the policy now reaches beyond York.

I am sure the Minister will set out how, under the Health and Social Care Act 2012, matters of clinical decision making were devolved to clinical commissioning groups to make decisions about local need, but this matter is so serious that I urge him to take action, as the Secretary of State said he would. I have exhausted all routes to getting the policy reviewed, so I am now appealing, through this debate, for a complete review. NHS England has previously been clear that even time-limited bans on particular groups of patients receiving treatment is inconsistent with the NHS constitution. In the light of that, I trust it will commit to withdrawing its support for rationing now that evidence of its detriment is coming through.

The Vale of York CCG determined to delay surgery to patients who smoked or had a body mass index of more than 30. The policy came into force on 1 February 2017. It was first proposed in September last year, but then withdrawn and reintroduced in November. The reason: to delay immediate spend on surgery. However, it is a totally false economy, and although it may delay CCG spend now, in order to meet imposed spending restrictions, the Royal College of Surgeons says that it may actually increase NHS costs if patients develop complications while waiting for surgery. The college has been clear that rationing policies, such as those implemented by the Vale of York CCG, are unacceptable.

The York CCG’s ability to make rationing decisions comes direct from the 2012 Act. The duty on the Secretary of State for Health to “provide or secure” the health service was removed from section 1 of the National Health Service Act 2006, thereby removing his responsibility, and replaced by a duty to make provision for the health service. The list of services that the NHS had to provide—a principle that had been embedded in the NHS since its inception—was also removed, meaning there no longer had to be a universal list of service provision, and that each CCG could determine its own. In other words, it became a complete postcode lottery: where someone lives determines the healthcare they can access.

Nevertheless, I was encouraged by the Secretary of State’s response to a question on rationing from the Health Committee on 18 October 2016. He said:

“When we hear evidence of rationing happening, we do something about it…we are absolutely determined to give people the clinical care that they need.”

In response to the Chair of the Committee, he said:

“When we hear of occasions when we think the wrong choices have been made, when an efficiency saving is proposed that we think would negatively impact on patient care, we step in, because, challenging though it is, our responsibility to the public is to make sure that we continue to make the NHS safer and higher quality and that it offers a higher standard of care”.

Minister, it is time to step in.

Early on, the Vale of York CCG hit the headlines and became unstuck when it rationed interventions such as in vitro fertilisation treatments—a decision that was reversed—so this CCG has form. As we saw from yesterday’s health and social care debate, the NHS financial model has failed. Not only does the funding formula fall short of real need, but the NHS now has the wrong financial drivers in place, resulting in a demand- led approach to health provision and uncontrollable spend.

I could talk more on that, but the Vale of York CCG introduced a delay on surgery as a direct result of its failure to contain its spend within budget; it now has special measures bearing down on it. The CCG receives around £1,150 per patient, when demand seriously exceeds that. CCGs just down the road are receiving 50%-plus more. York has an ageing population demographic and areas of serious deprivation. I urge the Minister to look again at NHS funding, because it simply is not working and our CCG is being penalised for that.

The Vale of York CCG took the decision to ration surgery for up to a year for those overweight and up to six months for smokers. Having worked in the NHS as a clinician—I was a senior physiotherapist—I am all too aware of the risk factors created by people smoking and being overweight, not least when it comes to surgery, and I do not need the Minister, as a non-clinician, to spell them out to me today. I would see patients pre-operatively to provide advice, and would also treat them post-operatively to address the risks through respiratory therapy and mobilisation. All clinicians understand the risk factors, which is why it is so important that money is invested in public health services—something that the Government have failed to do.

A child receives, on average, 12 minutes a year of school nursing, which includes child protection work. That means that they get only a few minutes a year of advice on diet, exercise, smoking and sex education. Clearly, that is not enough, especially as PE has also been cut. Yesterday, I met local school nurses who set out how their service was being cut, and how school nurses are being downgraded and de-professionalised to make savings in York.

When the Government switched public health back to local authorities, which have had their grants slashed, public health services also suffered. The irony is that York’s council completely cut funding for smoking cessation services and for NHS health checks. It also cut the health walks programme, which was a service to help people exercise more and lose weight. Therefore, public health measures to address smoking and weight were cut first, and then patients were denied surgery because they smoked or were overweight—you could not make it up. It again shows how fragmentation creates health detriment.

GPs are now actively writing to patients to ask them whether they smoke—not that they have a smoking cessation service to refer them to. They say that it is just “for their records”. Patients who are seen by their GP and who are considered to be in need of an assessment by a specialist for surgery fill out a form. They have to declare their smoking and weight status. One would think that the surgeon would receive a letter, highlighting the risk, and then would make a clinical assessment of that risk—but no. The referral is diverted, and the patient is sent a standard letter and a leaflet, which does not reflect on their own personal circumstances, but tells them that they smoke or are overweight and therefore need to change their ways. As a penalty, they are denied surgery. The specialist never gets the opportunity to assess the patient and make clinical judgments accordingly.

I am sure that the Minister will recall the narrative, which enticed some in this House to support the Health and Social Care Act 2012. We heard that doctors will be at the heart of the NHS and that they, not bureaucrats, will be the ones making the decisions. Then there was, “No decision about me without me.” Here we have a system where clinicians are being undermined by diktats from bureaucrats; patients and clinicians have no say; and clinical evidence is left wanting.

Before I progress, let me turn to this letter that patients are sent. First, it is generic and has no personal advice about the patient’s own clinical circumstances. By the time a patient reaches the third paragraph, they are told how obesity is costing the CCG £46 million and smoking £7.2 million a year, as if that is an issue for the patient who needs surgery. The penalties are then set out. Those who are obese have to lose 10% of their weight or reduce their BMI to under 30, or wait 12 months. Those who smoke have to stop smoking for eight weeks, or wait six months. Enclosed with the letter is a leaflet entitled “Stop before your op” and a web address so that people can find out how to get support. I went through this and the convoluted website. Any public health practitioner would tell you how inappropriate and ineffective this whole system is. There is no real help available.

The Royal College of Surgeons states that denying or significantly delaying access to NHS treatment does not help patients to lose weight or stop smoking. Now those being denied surgery are paying a heavy price. I have spent much time talking to GPs and surgeons about this matter, as well as to patients. I have also talked to the CCG, which knows that the system is totally wrong, but because it is in a financial hole and NHS England has waved it through, it is just complicit. It is not standing up for patients in York.

One more point on the process: in York, patients who were referred for surgery, ahead of this policy being introduced, had their referrals sat on. The first thing that they received was their refusal letter. It is shocking that those patients’ surgery was delayed by the CCG even though their referral was made before the policy came into effect. So what is the impact on patients? Well, it is devastating. We already know that waiting times for surgery are going up, and delay in itself creates detriment. It is true that some patients are exempt—I am talking about those needing urgent care, the removal of a tumour, or trauma surgery. However, if someone requires a joint replacement because they have not mobilised well for some time due to osteoarthritis, is in pain, and, as a result of not mobilising, have put on weight, things are very different. With a new joint, they will be back on their feet. A 12-month delay in being referred will exacerbate their problems. A year of degeneration, pain and not being able to mobilise, an initial clinical assessment and then the wait for surgery will result in a surgeon presented with a more complex operation, and a physiotherapist with a patient who is less mobile and weaker, needing more input and possibly longer in rehab. Bang!—there go all the savings from rationing and more, all at a cost to the patient and a risk that the long-term clinical outcomes will be worse.

The British Orthopaedic Association said:

“There is no clinical, or value for money, justification…Good outcomes can be achieved for patients regardless of whether they smoke or are obese”.

If someone were 20 stone, they would have to drop to 18 stone before having surgery, but if they were 18 stone, they would have to drop to 16 stone 2 lbs. One person asked why surgery is safe at 18 stone in one case, but not the other. I ask the same. A patient has presented to me who was prescribed medication that had a side effect of weight gain. They were on drugs that risked weight gain, required surgery and were denied by the same GPs who gave them the drugs.

I have had a patient who is active and works full time, but is over the weight threshold. She needs surgery to enable her to conceive. She is not young. Surgery is needed now, as recommended by her GP. However, it was denied and could result in her never having a family. A patient with hypothyroidism, a chronic condition that leads to weight gain, needs surgery for gastrointestinal abnormalities but, despite their condition, will be restricted. One patient was a very fit body builder, but was refused surgery because of their high BMI. The case for delay has not been evidenced.

From talking to epidemiologists and reading academic papers on the issue, we know that there is a strong correlation between smoking and obesity, and social and economic deprivation. As the British Medical Association said, this could also be seen as rationing on the basis of poverty. Those with mental health challenges have a higher propensity to smoke, and those with chronic conditions are more likely also to have elements of depression and possible weight gain. Many people find it difficult to lose weight or give up smoking. Minister, you know the figures. This policy is totally discriminatory.

[Madam Deputy Speaker (Mrs Eleanor Laing)]

I am quite sure that the hon. Lady did not mean to address the Chair, but means to ask the Minister whether he knows the figures.

[Rachael Maskell]

Indeed that is the case.

This policy is totally discriminatory and is having further detriment for those with co-morbidities. It is creating problems, not solving them. All surgery carries a risk, and it is for clinicians to assess that risk. As the Royal College of Surgeons says,

“It risks preventing a patient from seeing a consultant who can advise them on the best form of treatment, which may not be surgery. Surgery may be needed to help someone lose weight.”

That point was also made by a patient who was able to mobilise after a joint replacement. This is why clinical decision making is needed. Patients have to be part of this too.

Public health programmes need restoring so that patients can properly engage with people to help to optimise their health. The passive approach of the CCG is setting patients up to fail. David Haslam, chair of the National Institute for Health and Care Excellence, said that rationing of surgery concerned him. He says that the NICE osteoarthritis guidelines make absolutely clear that decisions should be based on discussions between patients, clinicians and surgeons, and that issues such as smoking, obesity and so on should not be barriers to referral. These are the experts.

The Vale of York CCG has gone down this route, and others are now following, with 34% of CCGs looking to ration on the basis of obesity or smoking. Harrogate and Rural District CCG and East Riding of Yorkshire CCG target smokers and those who are overweight with a six-month delay. Wyre Forest, Redditch and Bromsgrove, and South Worcestershire CCGs ration on the basis of pain impact. South Cheshire CCG requires a BMI of less than 35—not 30—as does Coventry and Rugby CCG. The policy is spreading. Although York is the worse example of rationing, every clinician knows that it is wrong and contravenes their professional duty of care.

I am blowing the whistle on this today because the policy is directly discriminatory, clinically contraindicated and financially perverse. I would be the first in this House to advocate health optimisation programmes supporting smoking cessation or providing help to improve diet, exercise, wellbeing and lifestyles, but to leave someone in pain or without a child brings our NHS into disrepute.

This evening, I have made a clear case for why the rationing of surgery must end. As the Secretary of State said to the Health Committee, it is time to step in.