Why NHS funding needs a total rethink: The health service no longer offers cradle to grave care, which is free at the point of use. It needs a new financial model.
The Department of Health has traditionally encouraged NHS surgeons to operate a high patient turnover with as short a waiting time as possible – the faster patients are treated, the more "efficient" the service is considered.
But lately, doctors have been under pressure to do exactly the opposite. Operative options for several common conditions are being restricted by the reclassification of certain treatments as "procedures of limited clinical value".
"Limited clinical value" is a term that first appeared as part of the McKinsey report on the future direction of the NHS, which was leaked to the Health Service Journal in 2009. McKinsey estimated that in decommissioning non-essential operations for varicose veins, elective hernias, cataract surgery, hip and knee replacements, and orthodontics, the NHS could save up to £1.2bn per year.
The NHS has often declined to offer certain treatments to patients – for example, purely cosmetic procedures or treatments lacking support from the National Institute for Health and Clinical Excellence. However, the new guidelines have widened the definition of "limited clinical value" to include operations that have clear evidence of clinical benefit.
The Audit Commission has published specific guidance for local primary care trusts (PCTs) on how to decommission many procedures in order to help save £20bn from the NHS budget by 2015. Rules are so stringent that if a surgeon performs an operation outside the agreed PCT guidelines, the hospital risks not being paid by the PCT for the work. Some 90% of PCTs now have extensive lists of procedures they will not fund, which can number up to 100 common operations.
Despite the repeated references to financial savings in most of the official documents on this subject, the Department of Health and politicians repeatedly deny that treatment is being restricted on grounds of cost.
Patients are being told that they can't have treatment for painful varicose veins or hernias. Former health minister Lord Warner argues that the "value proposition of the NHS has to change". In laypersons' terms, that means: "It costs too much – you'll have to go private." This situation also creates a potential conflict of interest for the professionals who act as both gatekeepers for access to care and as providers. In the long run, this conflict may cause lasting reputational damage in the eyes of the public.
Politicians are desperate to find a plausible euphemism for the term "rationing" of healthcare, which is electorally toxic, but the inconsistency between their public statements and the clear reality merely makes decision-makers look weak and untrustworthy.
The reality is that the NHS as a "comprehensive health service, cradle to grave, and free at the point of use" (as declared in its founding statement) is effectively over. The country cannot afford it any more. We require a new model that incorporates a low-cost option for patients unable to afford the high cost of purely private healthcare to be able to obtain treatments no longer funded by the NHS. This may include a system of co-payments or a social insurance scheme. Hiding behind an ever widening definition of "limited clinical value" convinces no one and fails to address the problem.
Whatever the solution eventually turns out to be, the initial requirement is a politician bold and honest enough to admit publicly that the funding of the NHS needs to change radically, so we can start to clear up the current inconsistent muddle. I'm not holding my breath.
Eddie Chaloner is a consultant vascular surgeon at Lewisham hospital and owns the private practice Radiance Health. Guardian Professional.
The Department of Health has traditionally encouraged NHS surgeons to operate a high patient turnover with as short a waiting time as possible – the faster patients are treated, the more "efficient" the service is considered.
But lately, doctors have been under pressure to do exactly the opposite. Operative options for several common conditions are being restricted by the reclassification of certain treatments as "procedures of limited clinical value".
"Limited clinical value" is a term that first appeared as part of the McKinsey report on the future direction of the NHS, which was leaked to the Health Service Journal in 2009. McKinsey estimated that in decommissioning non-essential operations for varicose veins, elective hernias, cataract surgery, hip and knee replacements, and orthodontics, the NHS could save up to £1.2bn per year.
The NHS has often declined to offer certain treatments to patients – for example, purely cosmetic procedures or treatments lacking support from the National Institute for Health and Clinical Excellence. However, the new guidelines have widened the definition of "limited clinical value" to include operations that have clear evidence of clinical benefit.
The Audit Commission has published specific guidance for local primary care trusts (PCTs) on how to decommission many procedures in order to help save £20bn from the NHS budget by 2015. Rules are so stringent that if a surgeon performs an operation outside the agreed PCT guidelines, the hospital risks not being paid by the PCT for the work. Some 90% of PCTs now have extensive lists of procedures they will not fund, which can number up to 100 common operations.
Despite the repeated references to financial savings in most of the official documents on this subject, the Department of Health and politicians repeatedly deny that treatment is being restricted on grounds of cost.
Patients are being told that they can't have treatment for painful varicose veins or hernias. Former health minister Lord Warner argues that the "value proposition of the NHS has to change". In laypersons' terms, that means: "It costs too much – you'll have to go private." This situation also creates a potential conflict of interest for the professionals who act as both gatekeepers for access to care and as providers. In the long run, this conflict may cause lasting reputational damage in the eyes of the public.
Politicians are desperate to find a plausible euphemism for the term "rationing" of healthcare, which is electorally toxic, but the inconsistency between their public statements and the clear reality merely makes decision-makers look weak and untrustworthy.
The reality is that the NHS as a "comprehensive health service, cradle to grave, and free at the point of use" (as declared in its founding statement) is effectively over. The country cannot afford it any more. We require a new model that incorporates a low-cost option for patients unable to afford the high cost of purely private healthcare to be able to obtain treatments no longer funded by the NHS. This may include a system of co-payments or a social insurance scheme. Hiding behind an ever widening definition of "limited clinical value" convinces no one and fails to address the problem.
Whatever the solution eventually turns out to be, the initial requirement is a politician bold and honest enough to admit publicly that the funding of the NHS needs to change radically, so we can start to clear up the current inconsistent muddle. I'm not holding my breath.
Eddie Chaloner is a consultant vascular surgeon at Lewisham hospital and owns the private practice Radiance Health. Guardian Professional.
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