Is a ‘postcode lottery’ in health justified?

• Twitter hashtag: #NHSrationing

Opening remarks and welcome

Chair: Clare Marx, President, Royal College of Surgeons

Is a ‘postcode lottery’ in health justified?

#NHSrationingWiFi: RCS-Public

Outline of the afternoon16:40: Public attitudes towards rationing of NHS treatments and services.

Ben Page, Chief Executive, Ipsos Mori

17:00: What can the NHS afford to provide: how do you make decisions about rationing and who is best placed to make these decisions?

Chair: Sarah Neville, Public Policy Editor, Financial Times

Nigel Edwards, Chief Executive, Nuffield Trust

Dr David Jenner, Chair, Eastern Locality, NEW Devon CCG

Dr Karol Sikora, Dean of Medicine, University of Buckingham

Lord Warner, Labour Peer, ex health minister

17:55: Closing remarks

Clare Marx, President, Royal College of Surgeons

18:00: Drinks reception (in the Council room down the corridor)4

Context of this debate• The NHS faces significant financial pressures

• £30bn funding gap by 2020/21, according to NHS England• £5.3bn integrated care fund is a good initiative but may cause pressure on acute

budgets in short-term• The need to tackle inefficiency and waste• Tariff uncertainty

• Meanwhile demand continues to increase• Latest HES data shows 2.5% increase in number of episodes of care from

previous year

• Historically the NHS has sought short-term savings by arbitrarily cutting services

• The RCS has monitored these decisions5

Rationing of specific procedures

• In 2014 we collected commissioning policies for 5 procedures from 54 CCGs• Tonsillectomy• Cholecystectomy• Hip replacement• Hernia repair• Surgical treatment of otitis media with effusion

• We compared these policies with available NICE guidance and clinical guidance from the RCS and Surgical Specialty Associations (SSAs)

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Key findings from our report• 73% of CCGs reviewed do not follow NICE

guidance on referral for hip replacement or have no policy in place

• 44% of CCGs had imposed different pain thresholds (Oxford Score) for hip replacement contrary to NICE and clinical guidance

• Only 27% of CCGs complied with NICE or surgical guidance on inguinal hernia repair

• 77% of CCGs did not follow clinical guidance on the commissioning of treatment for glue ear

• Two CCGs had minimum “watchful waiting” periods meaning some patients may not access tonsillectomies for a year and a half 7

The case of NEW Devon

• CCG facing cumulative deficit of £43.7m

• CCG said “urgent and necessary” measures were required to redress the situation.

• BMI (35) threshold for elective activity

• Patients over threshold required to undergo 6 month weight loss programme funded by the CCG

• Smokers to quit 6 weeks prior to surgery 8

CCG under intense scrutiny• Pressure from the RCS

• “It is unacceptable for any CCG to have a blanket ban on elective surgery for people above a certain weight”

• Pressure from NHS England• Simon Stevens, appearing at the Health

Committee, said: “frankly, we do have some reservations about the particular approach that is being proposed there”

• Pressure from the Government?• At a parliamentary debate on events at NEW

Devon Jane Ellison said: “Today I had a telephone discussion with some of the key people involved, including the chief officer of the CCG...”

• The proposals were dropped shortly after that phone conversation…

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Jane Ellison, the Public Health Minister

NEW Devon as the canary in the NHS coalmine?

• The case of NEW Devon is representative of the real challenges commissioners are facing

• Are the CCG’s actions not just a reaction to the realities of their situation?

• They are not alone:• FDS research shows that some commissioners are refusing to

provide dental implants, including to cancer patients• There is on going debate over which drugs to fund on the NHS

(eg in Cancer)10

What does this mean for patients?

• Delayed treatment can result in poorer outcomes and is distressing for patients.

• In rare cases it may also expose the patient to greater risk of medical emergency• E.g. strangulated hernia

• Conservative measures don’t necessarily fix the underlying problem• Pain relief doesn’t overcome the need for

a new hip due to osteoarthritis

• But isn’t there a need to allocate resources fairly? 11

Questions for today

• If local commissioners choose different levels of service provision should there be:• A safety net of care provided?• A process for dialogue between commissioners, patients and clinicians?

• The role of NICE• Should its guidance be mandatory?• Should it be above political influence?

• Should we abdicate all responsibility and leave it all to the politicians?

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Public attitudes towards rationing of NHS treatments and services

Ben Page, Chief Executive, Ipsos MORI

What can the NHS afford to provide: How do you make decisions about rationing and who is best placed to make these decisions?

Chair: Sarah Neville, Public Policy Editor, Financial Times

Nigel Edwards, Chief Executive, Nuffield Trust

Dr David Jenner, Chair, Eastern Locality and Mid Devon sub-locality, NHS Northern, Eastern and Western Devon Clinical Commissioning Group

Professor Karol Sikora, Dean of Medicine, University of Buckingham

The Rt Hon. the Lord Warner, Peer, House of Lords

Closing remarks

Chair: Clare Marx, President, Royal College of Surgeons

Thank you

Thank you for participating. Please join us for drinks and canapés in the Council room.