Surgery slippage - an unwelcome addition to the NHS vocabulary

Whenever I am wearing my project manager hat, one of the major risks I need to identify, avoid and/or fix is ‘project slippage’. The term sounds quite benign but is in fact a posh way of describing missed deadlines, unforeseen problems or even catastrophic events seriously derailing original plans.

I fear that ‘surgery slippage’ may be a phrase that creeps into the NHS psyche as cuts and reform implementation starts to bite. Rationing is a dirty word within healthcare although every sane commentator would have to admit that we don’t live in a perfect world of unlimited funds and treatments must be offered within that context. Health inequality is an even dirtier word as some PCTs (primary care trusts) or CGGs (clinical commissioning groups) take an inconsistent approach to eligibility and funding for certain conditions. I suspect that surgery slippage may become an insidious way of rationing and creating inequality across regions.

Andrew Lansley, UK Secretary of State for Health has said he doesn’t like targets but quotes outcomes instead. He doesn’t want to measure waiting lists but brandishes figures such as ‘reduced hospital admissions’ as though they were a band of honour. We need to look behind any statistics to emerge from the new regimes borne of the Health and Social Care Bill. Comparing apples with pears is never a good thing. Cancelled or delayed operations for those on a waiting list are distressing for the patient and bad PR for the NHS. This is where targets and statistical reporting can be useful in focussing the mind of Trusts to ensure that patients are not kept on waiting lists too long. But with limited funds and a shift of power to CGGs my concern is not just for the lengthening of waiting lists, but the moving of goalposts when it comes to eligibility for surgery.

In the same way that we delay paying the gas bill or get our car serviced a couple of months overdue to keep our cash flow under control at home, it would appear that some NHS Trusts, PCTs and CGGs are changing eligibility for surgery to delay the point at which a patient joins a waiting list.

The Royal National Institute of Blind People has recently reported on data showing that over half of the 152 NHS trusts in England had imposed their own criteria which were tougher than national standards for cataract operations. This means that patients are waiting longer for sight saving and life enhancing surgery, saving money for the trust but diminishing vision and quality of life for their patients along the way.

It’s not just hospitals making these tough decisions. I was speaking to an orthopaedic surgeon this week who told me that he was about to attend a commissioning meeting with is local CGG. That’s great – I thought – perhaps the NHS future forum really did work and GPs are involving other clinicians in key commissioning decisions. Yes, the orthopod agreed that it was good for him to be invited to this meeting. However one of his challenges is that, presumably to balance their books, the local CGG has changed the criteria for hip replacements, so patient’s joints have to demonstrate a more pronounced deterioration before they are deemed eligible for surgery (and therefore delaying their addition to a waiting list). This surgeon told me that he suspects that a year or so down the line – he will start to see patients with more severely damaged hips which will of course make the surgery more difficult and means that the patient has endured the pain of a crumbling joint for longer. Who is best to decide whether surgery is necessary? Surely that has to be the surgeon.

So there you have it – surgery slippage. An effective cost containment initiative, but hard to quantify or prove and with the potential to be significantly detrimental for the very people these reforms are supposed to help – patients.