NHS (Rationing of Care)

Mary Glindon Excerpts

Monday 16th July 2012 Commons Chamber

[Mrs Mary Glindon (North Tyneside) (Lab)]

This issue has already been raised today in the debate on a motion in the main business of the House, but I believe that the growing concern about rationing in the NHS justifies further debate tonight. For almost as long as the NHS has existed, rationing has been a matter of concern. Resources are finite, but in the past two years rationing has reached an unprecedented level; more than 125 previously free treatments have now been restricted or even stopped altogether, and they cover the full health care spectrum, from the cosmetic to the essential and all stages in between.

These findings were revealed in a survey, carried out by Labour’s shadow health team, of all NHS primary care trusts and shadow clinical commissioning groups in England. It is important to state the relevance of Labour’s new NHS check, which I will refer to in my speech, because as well as conducting surveys it gathers together the views of those working in the health service and takes into account the views of those receiving the service and their families. The submissions are considered alongside evidence from freedom of information requests to produce an accurate and relevant monthly report, such as the one on rationing.

Labour’s findings are backed by members of the British Medical Association who warn that creeping NHS rationing is making patients suffer unnecessarily, with people who need hip and knee replacements having to wait longer for operations while suffering in pain. GPs believe that the rationing is the result of the drive to make savings in the NHS of up to £20 billion by 2015. That is further borne out by the results of a poll conducted by the BBC in March, which found that more than four out of five GPs expect the rationing of NHS care to increase in response to financial pressure.

The concerns of the medical profession are echoed by other professions in the health service. Ahead of this debate I was contacted by the Chartered Society of Physiotherapy, which is very concerned about the rationing of NHS physiotherapy services and has a number of examples of patient care and outcomes suffering as a result. The CSP opposed the Health and Social Care Bill and the Government’s reforms to the NHS because of concerns about the negative impact on patient care resulting from rationing and the fragmentation of services. It is particularly concerned about the “any qualified provider” model and has found that patient choice is being adversely affected by the clear rationing of treatment and access in some of the “any qualified provider” service specifications, which it has systematically reviewed. For example, in Nottinghamshire the amount of treatment prescribed is limited without regard to patient need. In other areas, no re-referrals are allowed within a six or 12-month period, also regardless of patient need. This rationing is likely to lead to increased orthopaedic referrals and unnecessary surgical interventions.

The CSP has further concerns about the impact of the “any qualified provider” model, including a reduction in patient choice and the quality of care, the loss of clinically and cost-effective innovations such as self-referral to physiotherapy, the negative impact on the physiotherapy profession and the risk of conflicts of interest among private providers. Those are all legitimate concerns from a respected professional body, so I hope that the Minister will address them specifically with the society.

The Minister has denied the relevance of the shadow health team’s extensive survey, the NHS check, but perhaps he should reconsider his opinion of it, because the survey’s findings mirror those of GP magazine, which gathered evidence under the Freedom of Information Act, showing that 90% of primary care trusts were imposing restrictions. The magazine received responses from two thirds of England’s 151 trusts on the procedures that they considered to be non-urgent. The most common restriction was on tonsillectomies, but there was rationing in other areas, too.

[Mr Jamie Reed (Copeland) (Lab)]

Will my hon. Friend give way?

[Mrs Glindon]

I will.

[Mr Deputy Speaker (Mr Nigel Evans)]

Order. You can make an intervention, Mr Reed, but not from the Opposition Front Bench. If you step up to another Bench, you may intervene from there.

[Mr Reed]

Thank you, Mr Deputy Speaker. I trust that this is in order.

Will my hon. Friend join me in asking the Minister, who has indicated that he will not take interventions from me this evening, whether he will undertake a nationwide investigation into the clear rationing that is occurring in the NHS, and whether the Government will publish a list of procedures in which the eligibility criteria for treatment are now being changed? Will she join me also in asking the Government to act where various NHS organisations are breaching NICE guidelines on treatments offered to patients?

[Mrs Glindon]

I certainly will, and my hon. Friend may find that at the end of my speech I reiterate some of what he has said.

There is rationing in other areas, too, with 66% of trusts limiting cataract surgery and more than half rationing weight-loss surgery and hip and knee operations. Dr Richard Vautrey of the British Medical Association describes the situation as a “cost-saving exercise”, saying quite rightly:

“Patients fully understand the NHS doesn’t have unlimited resources...but they don’t understand, or believe it’s fair, when services are provided in one area but not another.”

The Labour party’s survey provides evidence of random rationing throughout the NHS, and of an accelerating postcode lottery. A number of rationed or decommissioned treatments are common across several PCTs and clinical commissioning groups, while some are specific to individual PCTs and CCGs. That demonstrates the wide variation throughout the country.

The survey found that rationing of treatment varies from capping, as in NHS South West Essex and NHS South East Essex, where a cap has been placed on the community diabetes service, to restricting treatment based on age or clinical need, as in NHS Warwickshire, where new criteria require that a patient must complain of intense or severe symptomatology and have a BMI of less than 40 to be listed for a knee replacement.

Evidence also showed, alarmingly, that PCTs and CCGs are diverging from the NICE guidelines, as in NHS Bassetlaw, where needle fasciotomy for Dupuytren's contracture is considered only if the patient is aged over 45 and has a loss of extension in one or more joints exceeding 25°, or if the patient is under 45 years old and has a greater than 10° loss of extension in two or more joints. However, the NICE guidelines do not refer to degree of loss of extension or any specific age criteria, other than to say that the procedure would be more appropriate in older people.

Equally alarming are the findings that show that patients now have to pay for treatments that had been free. In a surgery in Yorkshire, patients needing treatments for cysts, skin lesions and in-growing toenails were told that they were no longer available on the NHS. But the practice had established a private company to offer those minor operations at a cost: £56.30 for the removal of a small cyst; £126 for larger cysts; £146.95 for the removal of an in-growing toenail; and £243 for the removal of a non-cancerous mole. In response to the GP magazine report, the Minister said:

“It is quite unacceptable if this is going on in all those cases. As you’ll appreciate, it is a complex issue. But the defining point is that people should be treated on clinical need, and not financial considerations.”

The findings of the BMA, the concerns of other health professionals, such as the Chartered Society of Physiotherapy, and the results of Labour’s in-depth survey all point to the fact that, because of increasing rationing, people are being treated on the basis not of clinical need, but of financial considerations.

Will the Minister respond positively to Labour’s call for an immediate review of rationing in the NHS and act immediately on the new evidence showing treatment restrictions on cost alone? How will he ensure that national guidelines can be implemented? Will he take action, pending the outcome of the review, to reverse immediately rationing decisions that leave patients in severe pain, restrict mobility, limit their ability to live independently or have a major psychological impact? Will the Government initiate a public debate on whether all other treatments should be provided by the NHS, rather than allowing them to be restricted in a random fashion?

[Mr Reed]

I am grateful to my hon. Friend for letting me intervene once more. Will she also join me in asking the Minister to publish whatever assessment must have been made into the claims forthcoming from the freedom of information requests shown to the Department of Health? Will she join me in asking the Government to publish that assessment of those claims?

[Mrs Glindon]

I certainly join my hon. Friend in asking the Government to publish the assessment.

In denying the findings of Labour’s survey of rationing and the supporting evidence from the BMA and other professional bodies working in the NHS, the Government are denying the people of this country the full NHS service that they deserve and have contributed towards.

[Julie Hilling (Bolton West) (Lab)]

I am listening with great interest to my hon. Friend’s speech. Does the decrease in care free at the point of delivery match the increase in the care that is then paid for by patients? Are the hospitals now offering all that care to people as long as they pay for it?

[Mrs Glindon]

I thank my hon. Friend for that intervention. As I have outlined, one of the terrible things is that people have to pay. However, in some instances, treatment is simply not available any longer.

Finally, I should say that my party accepts that there has to be a debate on some treatments that are of borderline value, but that debate should be part of a national review. I hope the Minister will respond positively to the request for an immediate review, allow a full and positive debate to begin, and arbitrary and unfair rationing in the NHS to end.

--- Later in debate ---

[Mr Burns]

No, I will not; I am going to make some progress. This is not the hon. Lady’s debate and I have only just started.

If the hon. Member for North Tyneside or any other member of her party or of the public brought forth genuine evidence of cost-based rationing—blanket bans on treatment—this Government would act decisively to stamp it out, but the fact is that so far we have been brought no such convincing evidence of that.

The core principle underpinning the NHS is that it is a comprehensive health service, available to all, free at the point of use and based on need and not ability to pay. That principle is enshrined in the NHS constitution and reaffirmed in the Health and Social Care Act 2012.

[Mrs Glindon]

Does the Minister therefore disagree with all that has been said by the BMA and other professionals about their concerns about the rationing that is taking place? Does he doubt them? Does he think that the thousands of people who have contacted Labour’s health check are not telling the truth?

[Mr Burns]

It is not a question of not telling the truth. If the hon. Lady waits, I will deal with the NHS health check that she has mentioned. I am not sure whether she was here for the earlier debate, so she might not have heard me describe it as being as worthless as the piece of paper that Chamberlain brought back from Munich. In the course of my comments, I will outline why that is.

As I said, the core principle of the NHS is that it is a comprehensive health service, free at the point of use for all those eligible to use it. That principle remains as true and relevant today as it was when the NHS legislation was passed in 1946 and enacted in July 1948, and it will remain true in the years and decades to come for as long as the three main political parties continue to subscribe to that core belief.

Before I move on to the specific accusations of rationing that the hon. Lady makes, may I first point out that it is this Government who are protecting NHS budgets and increasing the amount of money available to the NHS by £12.5 billion over the course of this Parliament? It was the right hon. Member for Leigh (Andy Burnham) who described such a commitment as “irresponsible”—a comment that I find particularly bizarre coming from a Labour shadow Health Secretary.

May I ask what the hon. Lady’s party is doing where it is in control of the NHS? Is it increasing spending, or is it cutting it by 6.5%? The lucky escape of the NHS in England is that it has growing budgets under this Government compared with the falling budgets it would have had had her party won at the last election. If the hon. Lady, who looks a bit perturbed, does not understand what I am talking about, I can tell her that I am referring to what is happening under a Labour Government in Wales who are cutting the NHS budget—a warning to anyone living in England.

Of course the financial challenge is a difficult one. On its own, the extra £12.5 billion will not be enough to cover the growing demand for NHS services. It is vital that we get the most value—the very best health outcomes, as we like to say—out of every single penny that taxpayers spend, by cutting out waste and focusing more on prevention. It is true that the hon. Lady’s party recognised this too. When Labour was in office, it established NICE—the National Institute for Health and Clinical Excellence—to help the NHS to improve patient care within the finite resources available to it in order to ensure value for money. Through its world-class commissioning programme, it rewarded commissioners for setting priorities. Furthermore, it first recognised the scale of the £20 billion gap between funding and demand that emerged in 2009. The result was the QIPP agenda—quality, innovation, productivity and prevention—with its focus on improving patient care, increasing innovation and gaining greater accountability.

Since then, the world has changed. Thanks to the horrendous mess in which the hon. Lady’s Government left the nation’s finances, the NHS faces one of the toughest financial settlements in its history, even with its protected budget. That is one reason why the Health and Social Care Act was so vital. To get the best care for patients during a difficult financial settlement, we needed to put clinicians in control—making the connection between clinical and financial decisions, always putting patients’ interests first, and always looking for value for money.

In future, local priorities will be determined by local clinicians, not by administrative organisations that lack sufficient clinical input and are cut off from patients. Commissioning decisions will be based on a far deeper understanding of local need, with clinical commissioning groups working with health and wellbeing boards, local authorities and key community organisations to meet the needs of their local population. There will be better, more effective, more efficient care for patients.

Let me address directly the accusations of rationing. We are clear that it is completely unacceptable for commissioners to impose blanket bans on treatments. That is set out in case law and in Department of Health policy, which requires commissioners to allow exceptions in individual circumstances. We are also clear that commissioners must never restrict access to treatments on the basis of cost alone. That message was reiterated in a letter from Professor Sir Bruce Keogh, the NHS medical director, to the medical directors of strategic health authorities as recently as September 2011. He emphasised that any decision to restrict access to a treatment or intervention must be justified by a patient’s individual circumstances. By that, I mean not their financial circumstances, but their clinical circumstances and condition.

Since then, my ministerial colleagues and I have reiterated the message in our communications with the service that treatments available on the NHS are based on clinical need; that there should never be any arbitrary rationing based on cost, either locally or nationally; and that we will take action against any organisation found to be arbitrarily restricting treatment without clinical justification.

As hon. Lady said, the Labour party recently made a series of serious accusations in its NHS health check—accusations that services are being restricted or decommissioned without clinical justification. Had the hon. Lady done some rudimentary checking of her own, she would quickly have come to the same conclusion that we did: that such claims are nonsense dreamed up in Labour party headquarters.

The NHS health check claimed that there was a blanket ban by NHS Hull on the removal of wrist ganglia. We spoke with NHS Hull. There is no such ban. The health check claimed that 11 out of 100 primary care trusts or clinical commissioning groups restricted laser revision surgery for scars, but such cosmetic surgery has never been routinely available on the NHS, either in the lifetime of the coalition Government or in the 13 years of the last Labour Government. The position has not changed one iota since the Government came to power.

The NHS health check claimed that weight-loss surgery is restricted. It states:

“patients generally have to be over 18 and have a BMI over a certain level to receive weight loss surgery”.

Incredibly, people have to be overweight before they will be considered for weight loss surgery. To me, that seems perfectly logical. Why would the NHS want to treat people who were not overweight? From reading the Opposition’s NHS health check, it appears that the Opposition define rationing as a clinician denying treatment to a patient who has no clinical need for it. That is patently ridiculous. Treatments available on the NHS are based on clinical need. As I said, there should never be any arbitrary rationing based on cost, either locally or nationally. Such practices are totally unacceptable.