Category Archives: Commissioning

Everyone as an opinion on their Health Service. Enoch Powell saw through its weaknesses in 1976.

The small book by Enoch Powell “Medicine and Politics 1975 and after” (his period was 3 years as Health Minister) should be obligatory reading for all doctors. He could less politely have said that the Emperor has no clothes. . Read a review by retired BMJ Editor Richard Smith. 

He tells us that of course the health care is rationed, and that this is deliberate but covert. He (page 37) discusses some methods of rationing, but since his day we have invented many more than the waiting lists and waiting times that he refers to.

Parkinson’s Law of Hospital Beds (page 43) “asserts that the number of patients always tends to equality with the number of beds available for them to lie in”. But he was not aware that clever administrators can use trolleys, but not count them as beds. Therefore more and new covert rationing….

Finally I wish to quote his last word on rationing:

“It is unfortunate that the nature and value of rationing by waiting and by ineligability in the NHS are not recognised, at least by the professions (and by implication the rest of the country). For these are the features that make it possible to avoid invidious discrimination in administering the service and, at the same time, secure a certain rational allocation of priorities. Instead, these features are treated as evidence of “inadequacy” and as blemishes that it lies within the power of politicians to remove, given the will.”

Richard Smith non-medical blogs on Enoch Powell’s book – The best book ever written about the politics of the NHS

The Socialist Health Association also summarises the book (A large part or almost all – I failed to spot omissions)

The care of autistic children is a disgrace. Covert systems lead to perverse outcomes..

The Times analysis of the situation is summed up well by Oliver Wright but he fails to appreciate that if we need to ration health care covertly, there are fewer votes to be lost in dereliction of duty to those who cannot represent themselves.  Treatment of the mentally ill is a toxic mix of political and NHS failure

n the aftermath of the Winterbourne View care home scandal Jeremy Hunt pledged to make improving the care of vulnerable patients a central mission of his time as health secretary.

But despite speeches, policy documents, steering groups and delivery groups two reports next week will lay bare the continued failure of the system to protect those least able to help themselves. One of those reports was commissioned by Mr Hunt’s successor and Tory leadership rival, Matt Hancock. He won’t be thanking him for it.

Part of the problem is political. For example, despite introducing minimum standards for how adults on mental health wards should be treated in 2014, no such standards exist for children. For that, responsibility rests with ministers.

They are also responsible for a system that provides no incentives to minimise the use of expensive in-patient mental health beds. Those beds are paid for by the NHS whereas community care is paid for by stretched local authorities.

The NHS itself should not be absolved of blame. One former Conservative health minister said they had been shocked by just how unresponsive NHS leaders were to reform. It is certainly true that the NHS has jealously guarded its freedom to set spending priorities.

Finally, despite being the authors of one of the reports the Care Quality Commission, which inspects mental health units, bears some responsibility. That it took a minister, under pressure from the media, to uncover the continued failure of these units is shocking.



Oliver Wright and Greg Hurst report in the Times 18th May 2019: Autistic children are routinely restrained and drugged in care

Autistic children as young ten are being detained and subjected to chemical and physical restraint hundreds of times a month, two reports will say next week.

Ministers are braced for fresh revelations about the inappropriate treatment of children with learning disabilities more than six years after Jeremy Hunt, when health secretary, pledged to end the “normalisation of cruelty” in parts of the care system.

One report from the children’s commissioner reveals that in a single month last year 75 children were restrained 820 times, an average of 11 per child.

In another report the Care Quality Commission is expected to reveal children and adults being subjected to long periods of prolonged seclusion and segregation in secure and rehabilitation mental health wards.

The CQC report was commissioned by Mr Hunt’s successor, Matt Hancock, after revelations of abuse in mental health institutions seven years after the Winterbourne View care home scandal in Gloucestershire which resulted in six workers jailed for abuse and neglect.….


Rationing cataracts gets worse. What about the other areas of covert rationing by exclusion?

Cataract surgery is increasingly rationed: Articles in the Telegraph, and in the BMJ confirm this.

Surely the public has a right to know what is to be excluded. If second cataracts are to be excluded then lets make this National. Citizens then know that they will have options to cover the deficit. Insurance, or simply a health savings (tax exempt) account would be options.

In the kingdom of the blind the one eyed man is king. Desiderius Erasmus‘s Adagia (1500).

Leading ophthalmologist vows to stamp out “unjustified” screening for cataract surgery BMJ 29th May 2019 (BMJ 2019;365:l2326 )

Mike Burdon, president of the Royal College of Ophthalmologists, who also chaired NICE’s guideline committee, said that it was his mission before he stepped down as president in a year’s time to convince clinical commissioning groups (CCGs) to stop rationing cataract surgery and not to label it a procedure of “limited clinical value.” He said that this approach was “unjustified whatever way you look at it.”

He added that it was a false economy for CCGs to apply criteria for cataract surgery as a way to control costs.

Rationing on the rise

Cataract surgery is the most common operation in the NHS, with more than 400 000 procedures performed every year in the UK.

Experts had hoped that NICE’s 2017 guideline would make it harder for NHS commissioners in England to ration treatment for financial reasons. But The BMJ’s analysis shows that rationing has actually risen in parts of the country since then, with patients increasingly having to meet strict criteria before they can be referred for surgery.

Among the 185 CCGs that provided data (95% response rate), the investigation found that almost 2900 prior approval requests or individual funding requests for cataract surgery were rejected last year, more than double the number two years ago. Although the proportion of prior requests for cataract surgery being rejected has fallen since 2016-17, the absolute number is rising (fig 2).

Fig 2

Rejected requests

The investigation follows recent research by the Medical Technology Group, a coalition of patients’ groups, research charities, and device manufacturers, that found that over half of CCGs in England included cataracts in lists of treatments they deemed to be of “limited clinical value.”3

The investigation is the latest by The BMJ to lift the lid on NHS rationing driven by financial pressures. In 2017 it revealed how CCGs were restricting access to a plethora of procedures, including cataract surgery,4 and a follow-up investigation last year found that increasing numbers of patients seeking knee or hip surgery were discovering that they couldn’t have the operations on the NHS.5

Burdon said that The BMJ’s latest findings showed that commissioners were ignoring National Institute for Health and Care Excellence (NICE) guidelines. He said, “Health economists spent 18 months reviewing the evidence for cataract surgery on both first eye and second eye, and they convincingly concluded that there was no justification to ration cataract surgery on the basis of acuity. This was independent of ophthalmologists, including myself.

“What is the point of NICE doing detailed evaluation if CCGs are just going to knowingly ignore that advice? The health service budget is limited, but you should make those spending decisions on the basis of the clinical evidence. Cataract surgery comes out as probably the most cost effective thing in the NHS.”

Graham Jackson, co-chair of NHS Clinical Commissioners, said, “Unfortunately the NHS does not have unlimited resources, and ensuring patients get the best possible care and outcomes against a backdrop of spiralling demands, competing priorities, and increasing financial pressures is one of the biggest issues CCGs face.

“Cataract surgery specifically is an area that is often subject to prior approval. Such clinical decisions are critical in deciding when a patient has reached the stage that an operation will be the best option. Performing surgery is not without risk; a clinical threshold is a good way of defining which patients would best be served by (in this case) cataract removal.”

A Department of Health and Social Care spokesperson said that clinicians were the right people to decide when or whether a patient should have a procedure. “Commissioners should take the latest NICE guidelines into account, to ensure fair and consistent access to the best possible treatment for all cataract patients,” the spokesperson said.