Cost cutters are commissioning NHS elective care for economic value – not patients’ clinical needs

West Yorkshire and Harrogate NHS Commissioners (who only exist because of the 2012 Health and Social Care Act – which was not in ANY party’s 2010 election manifesto – and so have no democratic mandate for anything they do) are finding ways to cut NHS spending through using the so-called “Right Care” approach to planning and buying NHS Services.

Commissioning for Economic Value – that’s what private health insurance companies do

Authorised by the government quango NHS England – also equally without any democratic mandate, for the same reason – “Right Care” provides a set of spending benchmarks for different treatments in order to show their economic value.

In a universal public health care system like the NHS, where treatment is based on patients’ clinical need, how is economic value an appropriate criterion to use when deciding whether patients should receive treatment? That is how private insurance companies work.

It is also how the state-funded Medicare and Medicaid schemes work in the USA. These provide a limited range of health care through Accountable Care Organisations, to people who cannot afford to buy private health insurance.

Who said it is ok to turn the NHS into a UK version of Medicare/Medicaid? Did anyone ask us, the public?

Corporate advice from global consultancy company, McKinsey

Right Care was set up by the Department of Health on the basis of a 2009 report  from the global consultancy company McKinsey, commissioned by the New Labour government to identify how to cut NHS spending after it had bailed out the banks when they crashed in 2008.

(If you are looking for welfare scroungers, start with those banks – and fossil fuel companies that suck up huge amounts of corporate welfare while overheating the planet catastrophically.)

In its slideshow report “Achieving World Class Productivity in the NHS 2009/10-2013/14, McKinsey advised that UK health care could be a £200bn industry by 2030 and should be set on a “world-class” efficiency and productivity drive, in order to be considered as an international growth opportunity rather than a public sector cost centre.

On this basis, NHS England under Chief Exec David Nicholson demanded “savings” (cuts) of £20bn over four years by 2015, demanding all hospitals and Trusts make savings of at least 4 per cent a year.

According to the NHA Party, senior health policy analysts described McKinsey’s advice as‘entirely without evidence’.

Dodgy data?

Adding insult to injury, Right Care data is of questionable accuracy.

It has already been used to justify restricting knee and hip operations in the West Midlands to save £2m. But a recent Journal of Public Health article, Right Care, Wrong Answer, examined the Right Care data for breast, colorectal, and lung cancer and showed that they were full of errors. This led the author, Greg Dropkin, to conclude that,

“RightCare promises illusory savings based on an inappropriate fixed comparator group and faulty statistics…

If RightCare is used to justify savings in NHS budgets, it is acting as a cover for cuts.”

In his Sept 2016 Submission to the House of Lords Committee on NHS Sustainability, Professor Sir Muir Grey – director of Better Value Healthcare Ltd  – explained,

“The NHS Rightcare Programme was set up by NHS England in 2010 and has now been adopted by NHS England as its principal means of managing resources. Its aim is to release £11.5 billion from the £115 billion available and shift it from lower value activity to higher value activity…the NHS is not sustainable unless a new paradigm, the value paradigm is adopted.”

He adds that the meaning of value is “economic” and that the Right Care work is led by Professor Matthew Cripps in the Finance Directorate of NHS England.

“All a bit overwhelming” for GPs

In the North East, for some time referrals have had to be made in line with Value Based Clinical Commissioning Policies. This means that GPs have to tell their patients that a procedure would not normally be funded by the NHS, if their treatment does not fit the economic (value-based) criteria. A North East clinician said,

“This is all a bit overwhelming. I feel uncomfortable as a clinician denying some patients treatment that is not based on evidence of lack of effectiveness but on ‘value for money’ especially with no debate about what the tax paying public should be entitled to from a free NHS.”

However, West Yorkshire and Harrogate NHS Commissioners – who don’t actually have to deal with patients – recently agreed  to standardise clinical thresholds for referral and treatment in line with Right Care commissioning policies – potentially cutting orthopoedic and eye surgery referrals and treatment by 10% – as this would enable:

“better clinical decisions to be made …”

Their Elective Care Standardisation Report adds,

“Technology and decision making support tools would be targeted at the consulting room, learning from best practice such as the approach from Canterbury, New Zealand.”

A cut price version of the Canterbury, New Zealand Accountable Care System

A Kings Fund report, ‘Developing Accountable Care Systems – Lessons from Canterbury, New Zealand’  outlines how this works. It says the Canterbury HealthPathways programme:

“bring[s] together GPs and hospital specialists to agree management and referral pathways for particular conditions….Pathways are available on the HealthPathways website and are designed to be easy to use as part of a patient consultation…Referrals are made via the electronic request management system… If hospital doctors have questions about referrals, they can discuss these directly with the referring GP and GPs receive feedback on their referrals.”

The Canterbury Health Pathways Programme may work well in Canterbury, New Zealand but it wasn’t set up as part of a huge programme of spending cuts – which is what the West Yorkshire and Harrogate Sustainability and Transformation Partnership is doing.

Nor is the New Zealand health service comparable to the NHS. It doesn’t operate on the principle of universal access to treatment that is free at the point of clinical need and paid for out of general taxation. Patients who see a GP in New Zealand have to make a co-payment out of their own pocket at the time of the appointment.

The Kings Fund report warns that:

“[M]any of the changes in Canterbury required significant investment and…they have not cut beds or taken resources from hospitals. This raises questions over the feasibility of ambitions around NHS transformation. Vanguards and sustainability and transformation partnerships are being asked to make significant service changes with little or no additional funding, and services are already under immense financial strain; it is hard to see how the kind of progress made in Canterbury can be achieved in this austere context. Canterbury’s experience also casts doubt over expectations that new models of care will enable disinvestment in acute hospitals.”

Since disinvestment in acute hospitals is exactly what is going on in West Yorkshire and Harrogate – and across the whole of the NHS in England – it seems that the West Yorkshire and Harrogate Sustainability and Transformation Partnership Commissioners have ignored the first and obvious lesson from the Canterbury New Zealand approach to referral and treatment of elective care patients. That you can’t do it on the cheap.

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