Friday, 25 May 2012

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.


Chairman Chegwin said...

If this is the road the NHS is going down (and I'd agree with your assessment that it is) then it fraught with risk. Serious risk.

One of the effects of the legislation I'm working on (a new EU Directive on cross-border healthcare) is to extend patient choice into Europe. Any significant rise in waiting lists or overly restrictive thresholds for treatment may encourage people to look for their healthcare beyond Dover - to systems that can treat them more quickly and efficiently.

Any argument on determination of clinical need is a complete non-starter I'm afraid. In European legal terms, the requirements for being a doctor have been harmonised across Member States (via the Directive on the Mutual Recognition of Professional Qualifications). It is therefore not possible under European law to reject the clinical opinion of a doctor from another Member State (provided that doctor is properly qualified, practicing legally etc). The Commission is rejecting this argument out of hand (and it wouldn't last five seconds in Court).

So NHS managers had better be very sure that they are seeking to restrict access on the right grounds and for the right reasons - otherwise those who are able to will vote with their feet, have their treatment elsewhere in Europe, bring the bills back and demand reimbursement for their treatment costs from the NHS that sought to restrict them.

I don't think people have yet grasped what this new EU legislation is all about - when they do, it will make things very interesting indeed since it hands power back to patients...

Finchers Consulting said...

Thank you for your comment Rob - this EU legislation really is highly significant isn't it? We can no longer view the NHS within our own limited context

Chairman Chegwin said...

That is exactly the point Marcia. The NHS needs to be much more aware of the legal obligations that flow from Europe regarding freedom of movement for citizens (patients). This EU legislation is potentially a game changer on a number of fronts and the NHS will have to up its game quite significantly to avoid future challenge in the courts.

At the moment, we are still working out how to implement the Directive's obligations into UK law and systems (that's across 4 different UK territories and versions of the NHS, plus Gibraltar).

There will be a full public consultation later in the year (which I'm currently drafting!)

Finchers Consulting said...

Fascinating stuff - you must get very tired of the smoke and mirrors. A pity Lansley didn't spend more time consulting the likes of you instead of his mishandled PR campaign

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