CCGs were “queuing up” behind rationing pioneer to implement same policy, conference hears

BMJ 2015; 350 doi: (Published 23 February 2015) Cite this as: BMJ 2015;350:h1022
  1. Nigel Hawkes
  1. 1London

Controversial plans by one of England’s clinical commissioning groups (CCGs) to ration access to surgery had the unpredictable but financially helpful effect of reducing referrals, a conference was told on Thursday 19 February.

The Devon CCG was forced to backtrack on plans to limit surgery for smokers and morbidly obese patients because of criticisms from the Department of Health, but it nevertheless saw referrals for surgery rapidly decline after the controversy, while referrals for smoking cessation increased.

David Jenner, who chairs two parts of the Northern, Eastern and Western Devon CCG, said at a debate held by the Nuffield Trust that the limitations on surgery had been seen as an “emergency measure,” since the CCG was in deficit and local intervention rates were very high for reasons that were not understood.

“We got quite a lot of support from the public, particularly on smoking cessation,” he said. But after the policy was announced criticism from Simon Stevens, chief executive of NHS England, led to a rapid rethink, he added.

“Will other CCGs do it?” asked Jenner. “Some already do. NHS England, for example, has weight restrictions for knee surgery for the armed services. There were queues of CCGs waiting in line behind us.” He admitted that, in retrospect, the CCG had mishandled the situation and that the public’s support was necessary when taking this kind of action.

Clare Marx, an orthopaedic surgeon and president of the Royal College of Surgeons, where the debate took place, said that the Devon CCG was “the canary in the coal mine,” signalling the real dilemmas of being forced to ration care. The debate, which focused on postcode variations in healthcare, also heard from Nigel Edwards, chief executive of the Nuffield Trust; Karol Sikora, dean of medicine at the University of Buckingham; and Norman Warner, a former health minister.

Ben Page, chief executive of the market researcher Ipsos MORI, set the scene by outlining public attitudes to the NHS, which opinion surveys have shown to be more highly valued than the royal family and second only to Britain’s history as a source of pride. Surveys have also shown that most people support the provision of services more or less regardless of cost and that, while backing the principle of localism, they also support the contradictory belief that services should be the same everywhere. Party political allegiance has had little bearing on these responses.

Edwards argued that the provision of services by area was largely the result of “accidents of history” and that his experience had taught him that attempts to overcome these local variations by rational argument had never worked. In the past, the answer to financial constraints had been to avoid explicit rationing and to “muddle through,” he said, and he expected this to continue.

Warner argued that variation had been institutionalised by divergent systems in the devolved parts of the United Kingdom and that, as a result, local variation in pay rates should also be accepted. But the NHS unions were “addicted to national pay bargaining,” he said, which meant that, relative to local wage rates, some parts of the UK rewarded NHS staff well and others poorly—differences that were reflected in staff retention rates.

Expecting politicians to take hard decisions about rationing care was a delusion, said Warner. “Of all the elected politicians I worked with I can’t think of any—maybe there was one—who would have been prepared to take these decisions,” he said. “And there’s a stockpile of difficult decisions building up.”

He feared that the CCGs really had no mandate to take such decisions but that he saw some hope in local government, particularly in big cities, which showed some appetite for taking over health and care. “Local government at least has a mandate,” said Warner, while acknowledging that it was viewed with distrust by national politicians and the NHS.

Sikora said that some patients, particularly the savvy middle class ones, always found ways to circumvent decisions on rationing. The Cancer Drugs Fund—“a pure political fudge”—had failed to gather much data about the patients who had accessed the drugs it paid for, but he would be prepared to bet that most had gone to patients in higher socioeconomic groups.

Votes taken at the start and end of the debate showed that the vast majority of those present agreed that local variation was “acceptable.” The debate changed no minds on that.


Cite this as: BMJ 2015;350:h1022

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