Stuplicity Award for NHS England’s 17 Elective Surgery Cuts consultation in Leeds

NHS England’s public consultation meeting in Leeds on 22nd August revealed how threadbare their justifications are for stopping routine funding of 17 elective surgical procedures, and only funding them in exceptional cases.

The procedures include things like tonsillectomy, surgery for carpal tunnel syndrome, breast reduction, varicose veins and grommets for glue ear in children.

Although NHS England call the consultation “Evidence based interventions”, their spokespeople were unable to produce evidence for their plan. Instead they came up with un-evidenced assertions, anecdotes and appeals to authority.

Responses from members of the public, including Protect the NHS campaigners, showed that NHS England’s justifications don’t hold water.

The Consultation is open until 28th September. Please respond if you’ve not already – info here. If you’d like some leaflets and consultation postcards to give to friends, family, colleagues, neighbours, etc, please let us know.

Sorry this is a long post (nearly 3K words).

Who took part

Chief Exec of NHS Clinical Commissioners gives the official spin on the consultation

NHS England’s spokespeople were:

• Julie Wood,  Chief Executive of NHS Clinical Commissioners – the organisation representing Clinical Commissioning Groups
• Ivan Ellul, NHS England Director of Commissioning Policy, based at NHS England’s Quarry Hill offices in Leeds
• Arun Takhar – an Ear, Nose and Throat doctor and NHS England clinical fellow on a Faculty of Medical Leadership and Management scheme

Members of the public were not invited to introduce ourselves, so we can’t say exactly who was there, but there were about 4 tables each seating 4-5 members of the public.

Probably more than half were NHS campaigners (including NHS consultants and primary care clinicians), from ck999, Leeds KONP and Save Chorley A&E. Others present included:

• a representative of people with learning difficulties
• someone else we didn’t know
• someone from Leeds City Council Sensory Advisory service for the deaf and hearing impaired
• someone who worked in contracting at Bradford Royal Infirmary
• another consultant

Topic – Money

Julie Wood denied it’s about money.

Ivan Ellul, NHS England Director of Commissioning Policy said the NHS is cash-strapped. But they are not trying to cut £200m/year from restricting access to the 17 elective surgery procedures – they want to reuse that money for other treatments. The £200m is a tiny percentage of NHS England’s annual budget of around £120bn.

The public said:

The cost savings are weak – that’s not the point. The point is – what’s next? What’s next is the proposal in the consultation document, to remove routine funding from a much wider range of elective procedures in future.

The current list of 17 ‘low value interventions’ echoes that drawn up by management consultants McKinsey in response to the government’s commission to tell it how to cut spending on the NHS after it had bailed out the bankers in 2008.

Clinical Commissioning Group Governing Body meetings have said that they are under pressure from the government’s quangos NHS England and NHS Improvement to do as they tell them, otherwise they will come in and make cuts for them, and that would be worse than the cuts they are making themselves.

Comment: After the consultation meeting, I checked the meetings when such statements had been made. From this, it’s clear that the July 2016 Sustainability and Transformation Plan “financial reset” is the basis for NHS England’s cuts to 17 Elective procedures. 

The first time ck999 heard about ‘Procedures of Limited Clinical Value’ was at the August 2016 meeting of Calderdale Clinical Commissioning Group Governing Body, when the Chief Officer presented the need to cherry pick patients for these procedures, as one way of reducing spending in line with cuts imposed by the Sustainability and Transformation Plan “financial reset”.

Topic – Clinicians’ consensus

Julie Wood, Chief Exec of NHS Clinical Commissioners, said that National Institute for Health and Care Excellence guidelines are that certain treatments are not effective, or only effective in certain circumstances.  She added that it is clinicians’ consensus that such interventions should not be routinely performed. The Royal Colleges and Academy of Royal Colleges agree. The 17 elective surgical procedures cuts plan is led by NHS England’s medical director.

What the public said:

You could say of all medical treatments that they are only effective in certain circumstances.

This is top down rationing, supported by the medical establishment, that overrides individual clinicians and patients. Evidence based medicine is about individual clinicians discussing things with individual patients. All you’re doing is introducing barriers to treatments. For example, benign skin lesions. There are reasons why people want treatment for this. In a cash strapped NHS, are we going to agree there are some things we can’t do?

The decision about whether to offer elective treatments should be down to the clinician and patient – not the commissioners. This is about the move to an insurance-based funding system of “managed care”, where commissioners tell clinicians what treatments they can provide to specific patients, based on financial considerations not clinical considerations.

It is the result of the creation of Clinical Commissioning Groups by the 2012 Health and Social Care Act, which had no democratic mandate as it was not in any political party’s 2010 election manifesto.

The creation of Clinical Commissioning Groups led to the fragmentation of the NHS. Now NHS England wants to reassert control over the NHS by making Clinical Commissioning Groups micromanage clinicians according to its policies.

Topic – Local commissioning by local doctors

Julie Wood asserted that Clinical Commissioning Groups are locally run by local doctors. She said that across the country, they have agreed it’s not enough for individual Clinical Commissioning Groups to stop routine funding of these treatments, because there are wide variations between Clinical Commissioning Groups in their use of these treatments.

What the public said:

If there are such wide variations between Clinical Commissioning Groups in their use of these 17 elective surgical procedures, that is hardly evidence of clinical consensus about cutting their use through NHS England’s national initiative to stop routine funding of them.

Has NHS England identified why there is such a wide variation in the use of these 17 elective procedures across Clinical Commissioning Groups? Surely the solution to this problem is to investigate the reasons for those variations, and then tackle them if they are not good reasons? Rather than to impose a national barrier to carrying out these procedures. Isn’t this taking a sledgehammer to crack a nut?

It’s not true to say that Clinical Commissioning Groups are locally run by local doctors. They are subject to top down direction by the government’s quangos, NHS England and NHS Improvement.

On at least one nearby Clinical Commissioning Group, local doctors are a small minority on the Governing Body.

NHS England’s replies

Ivan Ellul said it is possible that there are good reasons for the variations in use of these procedures across Clinical Commissioning Groups. He then invited Julie Wood to give the Commissioners’ point of view.

Julie Wood avoided answering the question, which was asked 3 times:  had they investigated the reasons for these variations? Instead she answered a question no one had asked, but which she clearly wished we had.

Comment: The only possible conclusion is that NHS England and the NHS Clinical Commissioners organisation have not investigated why there are such wide variations in the use of these procedures across Clinical Commissioning Groups.

Everything is about risks and benefits in discussion with patients

Arun Takhar – an Ear, Nose and Throat doctor and NHS England clinical fellow on the the Faculty of Medical Leadership and Management scheme – recounted an anecdote about a young lady with a blocked nose whom he’d operated on. She came back 2 days later with a bad infection, he had to redo the operation and she was in hospital for 6 weeks on antibiotics. She now has a deformed nose, and needs another operation. She was understandably very unhappy at the end of treatment.

He said he didn’t make it clear enough in consultation with her about the risk of infection, and that consultation should include full discussion with patients about the full risks. (Well yes, duh.)

Everything is about risks and benefits in discussion with patients. (We know that.)

We said:

Anecdote is not evidence.

That anecdote suggests that the solution to the problem is not a blanket national ban on routine funding of such procedures – but better consultants’ discussion with patients about possible risks.

Arun Takhar agreed you could say that, but then continued to try and explain the case for denying routine funding for the procedures, on the grounds that they have been superseded by better more modern treatments or are not effective.

A member of the public produced a countervailing anecdote about the disastrous consequences of denying a patient carpal tunnel surgery – one of the 17 elective procedures subject to the proposed ban on routine funding. You can download this patient story here. (pdf)

Clinicians’ guidelines versus a national commissioners’ ban on routine funding of these procedures

The NHS England spokespeople pointed out that the National Institute for Health and Care Excellence says that 9 of these treatments are not effective, or only effective in certain circumstances. At the moment, Clinical Commissioning Groups can choose to follow or not follow National Institute for Health and Care Excellence guidance. NHS England are now saying, Clinical Commissioning Groups have to follow this evidence from the National Institute for Health and Care Excellence, and other sources. A national initiative to make all Clinical Commissioning Groups stop routine funding is needed.

There is a small number of the 17 elective treatments that don’t work, that NHS England is proposing not to fund – but if a clinician said a specific patient would benefit, there is a backstop position of individual funding request.

A wider group of treatments are effective in certain circumstances – clinicians would have to get prior approval to offer them to a patient.

What we said:

What is the evidence that these elective surgical procedures ARE routinely performed? There are already authoritative guidelines about the circumstances when they should be carried out, that tightly define when it is appropriate.

NHS England had no answer to this question.

Arun Takhar said 9 of the 17 Elective surgery procedures already have National Institute for Health and Care Excellence guidance. The consultation document doesn’t deviate from this guidance.

He gave the example of snoring surgery for people who don’t stop breathing when snoring, but find the noise a problem. The surgery only provides temporary relief and there are other treatments – eg splint etc.

He also gave examples of :

• Back pain injections where there is no apparent abnormality causing the pain – there are better ways than injections to manage pain.
• Benign skin lesions, for which treatment would no longer be offered.
• Knee washout (arthroscopy) – it is better to go straight to knee replacement if surgery is needed. [However, this is contested in a 2017 Open Letter to the Editor of the BMJ from an Orthopaedic Surgeon who is a member of the Royal College of Surgeons, and by various other knee surgeons on Twitter.]

Comment:

The British Orthopaedic Association position on NHS England’s consultation is lukewarm:

“The BOA position overall is that we support the principle of ensuring that procedures are evidence-based, however, we have concerns about some of the procedures being included on this list and some of the evidence being used for these. Our primary concern is ensuring that patients are getting the care they need.”

Update 7 December 2018: Biological Knee Society says misinformed and ill-conceived guidelines are a tool for rationing patients’ access to appropriate healthcare, effectively for financial gain

2nd December the Biological Knee Society published  a statement  on NHS England’s consultation. Highly critical, the statement said that:

• For patients to have access to high quality healthcare for the management of traumatic and degenerative conditions in the knee, requires access to experienced and informed specialists providing evidence-based practice in this field, who are supported by their healthcare organisations.
• This goal has been significantly undermined by some recent misinformed and ill-conceived guidelines that have been published by bodies that do not represent the opinions of specialist knee surgeons in the UK. Some of these blanket guidelines based on limited evidence of moderate quality are inadequate when considering the management of often complex conditions in a heterogenous group of patients with differing demands and aspirations.
• These ‘guidelines’ are in effect simply being used as a tool to ration patients’ access to appropriate healthcare, both in the NHS and via certain insurers in the Private sector, effectively for their financial gain but directly against the best interests of some patients.
• They have also led to the undermining of the type of professional opinion that can only be provided from a proper face-to-face assessment by an experienced consultant orthopaedic surgeon.

How the process of applying for exceptions to the ban on routine funding would work

We asked:

In the example of snoring, how many GPs would refer to surgery and how many would refer for sleep studies etc?

The NHS England people said most referrals to sleep studies would be unchanged. The numbers in the consultation document are on activity – surgery – not about GP referrals. They are targeting the operation – it has no bearing on GPs – it would have no bearing on them referring patients for sleep studies for suspected sleep apnoea (ie when patients stop breathing when snoring).

We said: That contradicts the info on p38 of the consultation document about GP referral.

Ivan Ellul acknowledged that the wording of the consultation document is poor where it mentions GP referrals and needs rewriting

We said: Independent Funding Requests only being initiated by GPs is very problematic, a retrograde step.  People asked many questions about how the Independent Funding Request process from GPs to consultants would work.

Ivan Ellul said they will monitor how many requests for exceptional treatment will be made and if there’s a hike, they would need to review.

Comment:

That whole question of what the process is, for applying for Independent Funding Requests or prior approval, was one the NHS England lot seemed to realise they’d got wrong in the document. I think they said they would have to revisit it. The discussion was confusing though, and there was no chair to sum up and clarify what was said.

We did however get an agreement from Ivan Ellul that they would send us a record of the meeting so we could see what they noted – and anything they missed.

NHS England’s denial that they aim to reduce the referral rate was very interesting, given that this appears to be the entire point of the proposal. It appears incredibly unlikely that a reduction in procedures can result from this plan any other way than a reduction in patient flow.

Effects on other services

Someone asked if NHS England’s modelling of their proposal included the effects on other services – for example: if grommets for glue ear were only exceptionally available, what would the effect be on the increased need for hearing aids as an alternative to surgery – both in terms of costs, and in terms of current difficulties with providing timely access to hearing aids services?

Ivan Ellul said they were trying to work out the substitution costs to clinicians and patients.

Comment:

This answer was lacking – should they not have done this modelling first?

In terms of saving pennies to spend pounds, this is similar to the argument about cost saving from not doing varicose vein operations, versus the cost implication of subsequent leg ulcer management.

Someone asked if NHS England had considered the effect on other services including beyond the NHS. She said this should include the effect on food banks, as now people are needing to get their paracetamol etc from food banks as it is no longer routinely prescribed.

Comment: This made us ponder about the safety issue – monitoring things like suicide risk in dishing out paracetamol in food banks. Paracetamol is a horrid drug to overdose on and it should not be a food bank’s job to consider such a risk  – but indeed the risk is probably much more so there.

Bearing in mind the risk of people losing their jobs and houses while they are denied surgery, NHS England really need to consider to effect on the whole range of other services including DWP and Councils with responsibility for homelessness.

They didn’t concede this point.

Changing the National Tariff and NHS Standard Contract to stop paying providers for delivering the 17 Elective treatments – unless commissioners have approved the operations in advance

The NHS England spokespeople didn’t raise this, but Ck999 said we disagreed strongly with the use of punitive and coercive financial measures. They can never help to provide a patient-centred service, as they compromise the relationship between clinicians and the patients they serve.

We are concerned at the overlapping consultation on the Accountable Care Organisation contract, now renamed Integrated Care Provider contract.

This is going to make it impossible for members of the public to get their heads round the two sets of proposals about changes and alternatives to the NHS Standard Contract.

A Leeds KONP member added that the way that NHS England had framed the discussion of their proposals for this consultation event was all wrong.

Ivan Ellul made an unmemorable reply which I failed to note. Perhaps it was at this point that he said at least NHS England was consulting on the proposals, rather than just going ahead with them without consultation. (More in Consultation section, below.)

Comment:

Hospitals see an issue re the zero payment mechanism. In years gone by, exception reports and IFR used to be piled up on hospital contracting staff’s desks, whereas now there is a mutual understanding that when necessary and clinically indicating, these are not required.

But under these proposals, now hospitals’ contracting staff would need to check out applications for Independent Funding Requests and Prior Approvals, to ensure they would get paid. The focus becomes: how will this trip them up & how will they avoid doing operations they are not going to get paid for?

How is this going to work? For example where a GP refers for specialist opinion where one of the 17 surgical procedures is a possible treatment option, will the specialist then have to go back to the GP with the outcome, to request permission to proceed in order to get payment?

The consultation itself

Ivan Ellul said that at least NHS England was consulting on the proposals. They could have just carried them out without consultation.

We said:

That would not have been possible. This is a major service change and they have to consult publicly on major service changes.

NHS England have not advertised the consultation properly. We were handing out leaflets and consultation postcards in the street outside Leeds Town Hall for an hour before the consultation started. No one knew it was happening – including nurses and doctors from the hospital just up the road.

Explaining the consultation to passersby

There were no signs inviting people to the consultation outside the Town Hall or anywhere round Leeds.

In half an hour, 29 passers by filled in consultation question postcards, which we then handed to the NHS England people. This is more people than attended their consultation event.

Ivan Ellul said the proposal was covered widely in the mainstream media, when NHS England first announced it.

We pointed out that the media reports we had come across only said that NHS England was planning to cut ineffective and risky elective surgical procedures – not that they were consulting the public about their plan.

ck999 said that the consultation was not user friendly.

First because the design principles were disingenuous. They did not acknowledge that nearly all the “low value” treatments in the 2009 McKinsey report, that it proposed stopping in order to “save” £4.7-£6.6m, are included NHS England’s “evidence based interventions” programme. The consultation should be honest. Otherwise people won’t want to respond.

And the consultation was unreasonably difficult – it took us 2 weeks, that included seeking advice from a number of doctors.

Ivan Ellul said that it was difficult, particularly the bits about specific interventions.

We said that was not the difficult bit, the difficult bit was trying to figure out whether there was any evidence underpinning the policy and what the real agenda was, given the disingenuous design principles.