Rationing is happening…. QED. The Welsh BMA and NHSreality wants it to be overt… (The Welsh Green (nearly white) paper on Health – and the BMA Wales response. The candour of honest language and overt rationing, & exit interviews to lever cultural change..)
Patients are being denied mental health care, new hips and knees, and drugs to boost their recovery from illnesses including cancer as the NHS increasingly rations treatments to try to overcome its growing cash crisis.
A survey of doctors reveals that three-quarters said they had seen care rationed in their area over the last year – including treatments such as speech therapy, operations to remove varicose veins, Botox to help children with cerebral palsy move better and even potentially life-saving stem cell transplant surgery.
Disabled children were having to use ill-fitting wheelchairs, teenage girls were banned from accessing medication to tackle male-style hair growth and women had been unable to access surgery to have breast enlargements or reductions as a result of growing restrictions across England, the research concluded.
Medical organisations said the findings showed patients were paying the price because an underfunded NHS was having to force them to wait for care or deny it altogether.
Dr Mark Porter, leader of the British Medical Association, said: “The NHS is being forced to choose between which patients to treat, with some facing delays in treatment and others being denied some treatments entirely. This survey lays bare the extreme pressure across the system and the distress caused to patients as a result.”
Almost four in five (78%) of the 749 doctors in England who took part in the survey – conducted for the Guardian by Binley’s OnMedica, a healthcare data and intelligence provider – said patients who were denied treatment suffered increased anxiety as a result.
One patient killed himself after experiencing a delay in receiving help with mental health problems. Another doctor told how “several teenage girls with hirsutism [male-style hair growth on the face, chest or back] have experienced severe psychological distress and bullying [after being denied drugs to treat it]. Some have self-harmed and been admitted to hospital as a result”.
A 22-year-old woman with relapsed acute myeloid leukaemia died after being denied a second allogeneic stem cell transplant. Her doctor said her late relapse and good response to salvage chemotherapy meant there was a 50% chance that a further transplant would have cured the disease. However, the local GP-led clinical commissioning group refused to fund the procedure, which would have used healthy stem cells to try to help her bone marrow, and she received palliative care instead.
The findings prompted the health minister David Prior to warn that NHS bodies might be acting illegally by rationing. “Treatment decisions should only be made by doctors based on a patient’s individual clinical needs,” he said. “Local health bodies have a legal responsibility to provide services meeting the needs of their local population, and we expect NHS England to act if there is any evidence of inappropriate rationing of care.”
Almost two-thirds (64%) of doctors said patients would be forced to go private. A quarter (26%) said the rationing of procedures, such as hernia repairs, made it more likely that the person would end up being admitted to hospital as an emergency if their health worsened.
Prof Neena Modi, president of the Royal College of Paediatrics and Child Health, said she was concerned that some of society’s most vulnerable children, including those with disabilities and mental health problems, were being affected by NHS rationing. “The financial pressures on the NHS are subjecting vulnerable children to a postcode lottery,” she said.
Most (86%) of the 536 hospital doctors and 213 GPs who took part said rationing was occurring “for financial reasons” and 39% said it was “to help manage demand”. Only 28% said it was because the evidence for the clinical evidence for certain treatments had changed and so they were no longer recommended.
The survey also found that:
- Significant minorities of medics had seen restrictions on the removal of benign lumps and bumps (36%), breast reduction or enlargement (31%), varicose vein treatment (31%) and cosmetic surgery (28%).
- Almost one in four (23%) had encountered drugs being rationed because they were too expensive. Cancer treatments were cited by 13% of doctors and “costly drugs” by 10%.
- The same number (23%) had seen fertility treatment cut back.
- Eighteen per cent had come across mental health care being withheld.
- And 10% had seen hip and knee replacements cut back, despite the ageing population leading to growing numbers of older people needing such surgery.
One doctor in southern England told Binley’s how disabled children forced to wait for more than a year to receive injections of Botox, which is used to treat muscle conditions such as spasticity in children and adults, suffered increased pain or disability as a result. The same doctor said that, due to rationing of wheelchairs, “children waiting for wheelchairs have pain and deformity from ill-fitting chairs, which are contributing to hip dislocation and worsening scoliosis”. In addition, physiotherapists working with children using ill-fitting wheelchairs believed their role was “almost negated by the lack of postural control for these children”.
Modi said: “Of course this is concerning. No child or young person should receive a different level of care because of where they live. Some of the examples cited here involve some of the most vulnerable children – those with mental health problems and with long-term conditions. It’s crucial that these children get the right treatment, and where appropriate equipment, to manage their condition. If this isn’t the case, not only will their quality of life be compromised, but problems will be stored up for the future.”
Doctors are divided on rationing; 94.4% think it will inevitably increase as a result of the rising demand for care and NHS’s tight finances. Three-quarters (74%) believe that the NHS is right to be rationing treatments either because that helps the NHS survive financially, or because not all treatments should be funded by the service or because free NHS services can be abused by patients.
However, one doctor said rationing was “a false economy. If people are not treated early, their problems become more costly to treat and they need to be treated for longer, leading to greater overall cost across the NHS in order to save a little in one part.” Another said restricting care “is detrimental to the patient/doctor relationship if there is a feeling that treatments and tests are withheld on financial grounds only”.
An NHS England spokeswoman said: “The basis on which people receive NHS care – within the funds parliament makes available – should always reflect their ability to benefit from treatment. The NHS strives to ensure we get maximum value from every penny available on behalf of patients.”
The findings come after a National Audit Office report found that one in four patients now struggles to get through to their GP surgery on the telephone, and dissatisfaction with family doctor services is rising. In 2014-15, 27% of patients said it was not easy to speak to their practice by phone, up from 19% in 2011-12.
Three-quarters of patients get an appointment within the timeframe they wanted but, overall, satisfaction is slowly declining, the NAO found. The percentage of patients who get to see their preferred GP always, almost always or most of the time, has also fallen, from 66% in 2011-12 to 60% in 2014-15. A fifth of patients also said opening hours were not convenient, up slightly on 2011-12.