Image: Grommets for glue ear are one of the procedures being largely cut from the NHS. Credit: Travis Isaacs/Flickr, CC 2.0
At the end of June NHS England formally announced its plan to withdraw 17 clinical procedures meaning they would no longer be routinely offered on the NHS. This move means treatments such as knee arthroscopies for patients with osteoarthritis, and snoring surgery, will no longer be available to anyone on the NHS. And procedures such as varicose vein removal, grommets for glue ear in children, hysterectomy for heavy menstrual bleeding, tonsillectomies, and treatments to release carpal tunnel syndrome or to remove benign skin lesions, will no longer be available to anyone on the NHS, unless complex criteria are met.
This is clearly a further step towards introducing a two-tier system with the better off being able to pay for non-NHS treatment, the poorer suffering in silence and private companies making a profit. NHSE is implementing what is arguably a prime example of this government’s long-term agenda – to severely restrict public health care and to promote private health care, and here it is in full flow.
However, treatments cannot simply be withdrawn without consultation. Keep Our NHS Public asks clinicians and the public to complete the online survey (which closes this Friday 28 September) – guidance from Keep Our NHS Public is here.
We need to reject unjustified rationing plans which will force patients to either suffer or seek private treatment, the thin end of the wedge for further cuts to come.
In their 103 page public consultation, NHS England gives the impression that the proposals are fully in line with NICE, whose logo appears on the cover, and that NICE was a source for the proposals.
But in fact, NHS England’s proposals to withdraw 17 NHS clinical procedures contradict existing guidance from the National Institute for Health and Care Excellence (NICE), the recognised authority advising clinicians on the current state of research evidence.
Research undertaken by Keep Our NHS Public paints a very different and alarming picture. It details that for nine of the 17 procedures, NHSE does not cite any evidence at all from NICE. For five procedures the NICE evidence cited does not support the NHSE proposal and for one, the NICE evidence cited gives only partial support. For only two out of seventeen withdrawn procedures does the cited NICE evidence back the NHSE proposal. The government have not listened to clinicians, campaigners or crucially, to NICE in rationing these arguably essential treatments.
Keep Our NHS Public supports evidence-based policy, and where clinical evidence backs it up procedures in certain circumstances may not always be appropriate (e.g. tonsils used to be removed in over 50% of children). But the good practice guidance already exists and NHSE is now seeking to artificially extend it. Grommets for instance may have been overused in the past, but they are subject to guidance now and are still necessary in some cases.
Some NICE guidance (not cited by NHS England) directly contradicts proposals and/or refers to relevant ongoing research. In one case (intervention for snoring surgery), NHS England is bypassing unfinished NICE research which isn’t due to be finished and published until August 2020. It appears that NHSE is ‘cherry-picking’ the evidence available to suit its own ends.
Clinicians should read NICE guidance for themselves rather than take NHS England’s word for it.
Ignoring clinicians, listening to McKinsey
NHS England also make explicit that they intend to “rapidly expand” the restrictions after this consultation. Already, many more so-called “clinically ineffective” treatments are restricted in areas across the country – in Bristol, 104 interventions are being excluded. The threat is explicit that NHS England is looking to replicate this nationally as the government potentially seeks to withdraw ever more NHS provision.
In attempting to ration NHS treatments, NHS England and the government presuppose they know better than qualified and skilled clinicians. It should not be the decision of ministers in Whitehall who can and cannot access much needed medical treatment. Indeed, this decision making should never be taken on the basis of cost as is happening here. The approach appears to derive from a 2009 report by the McKinsey Corporation on how the NHS could respond to the banking crisis, that included hip and knee replacements, hernia and cataract surgery in a list of “procedures of limited clinical benefit”.
NICE guidelines are being ignored when the health and wellbeing of real patients is at stake. Existing NICE and other clinical guidelines are already cautious, conservative, thorough and periodically under clinical review. Clinical practice should change in response to proven research following systematic review, not pre-empt it. NHSE is bypassing unfinished research cited in NICE guidance. Clinicians should take decisions in discussion with patients without bureaucratic referral-blocking processes when guidance exists and is in practice already.