Is the NHS restricting 17 procedures to cut costs? Yes, but it’s a bit more complicated than that.

There’s been lots of coverage around NHS England’s announcement they will be restricting 17 procedures in order to cut costs.

Understandably, this has caused concern. Social media is full of people saying this is simply more Tory cost-cutting, these changes are ideologically motivated, or they will mean people won’t get the healthcare they need.

But how worried should you be about this announcement? Here’s a list of every option on NHS England’s list. They are proposing the first four move to ‘by-request only’ while the remaining 13 will have to meet certain criteria to be performed.

  1. Snoring surgery – a 2009 review by the National Institue for Health Research (NIHR), the largest clinical trial funder in the UK, found there was no difference between surgical and non-surgical methods to treat snoring.
  2. Dilatation and curretage (D&C) for heavy periods – NICE already recommends doctors don’t offer this procedure as there are better alternatives.
  3. Knee arthroscopies for osteoarthirtis – The Cochrane Collobaration are the finest systematic reviewers in the world, and look at every piece of research on a topic before making reccomendations about treatments. Two separate reviews suggest this offers zero benefit.
  4. Injections for back pain – a Cochrane review suggests no benefit, though there may be specific groups which responds to specific injection therapies.
A man holding his lower back
Credit to SanDiegoPersonalInjuryAttorney
  1. Breast reduction – the availability of this surgery already varies widely across the country. Some areas don’t fund it at all, and in the past, I’ve had to tell a woman she was unlikely to get surgery due to local criteria.

    Most of the concerns I’ve seen online have been surrounding women whose breasts are causing them back pain. Only two randomly controlled trials have been conducted on breast reduction, but a Finnish review looking at these, and lesser quality trials, suggests there are significant quality of life improvements from surgery.

  2. Removal of benign skin lesions – this definition is very broad, and looking for evidence relating to surgery for every benign skin lesion would probably take me as long as my medical degree did. I’d guess NHS England is proposing to restrict these as doing so won’t kill anyone, or do much long term harm.

    I’d expect lesions causing significant physical or mental difficulties (e.g. restricting eye opening, blocking a nostril, large and distressing facial lesions) to meet the criteria for treatment.

  3. Grommets for glue ear – a Cochrane review suggests very limited benefit to this procedure, but warns the research is low to very low quality. They also mention widespread pneumococcal vaccination may impact the success rate of grommets, and new and high-quality RCTs are needed to assess all whether grommets are useful.
  4. Tonsillectomy – while having your tonsils and/or adenouds out used to a bit of a rite of passage, this is no longer the case. A Cochrane review described tonsil removal as having ‘modest impact’, with the most severely affected children getting a small benefit, which had to be weighed up against a small but significant chance of major bleeding.
  5. Haemorrhoid surgery – while the non-surgical treatments of haemorrhoids (e.g. banding, injection therapy, infrared therapy) have higher recurrence, they treat most mild cases sufficiently according to a 2015 review. I struggled to find research directly comparing surgical and non-surgical methods. Similarly to the treatment of heavy periods, I’d expect surgical treatments to remain as a second line therapy once less invasive alternatives have been tried, due to their reduced costs and complications.
  6. Hysterectomy for heavy periods – as with dilation and curretage, NICE already says this shouldn’t be used as first line treatment, and only used as second line in certain circumstances.
  7. Removal of chalazia (a specific type of benign lesion on the eyelid) – up to 80% resolve by themselves with conservative management. There is very limited evidence looking at their management, but I imagine this would be treated similarly to benign skin lesions – if they cause problems (e.g. infection, visual disturbance), then they qualify for surgery.
  8. Removal of bone spurs for shoulder pain – a Lancet review found no clinically significant differences whether bone spurs were removed or not
  9. Carpal tunnel syndrome (CTS) release – a review from the American Association of Orthopaedic Surgeons state surgery and steroid injections/splinting give goood benefits in CTS, but surgery offered better outcomes at 12 months. Currently, NICE recommend trying conservative management for 6 weeks before referring for surgery. Severe CTS (e.g. paralysis, gangrene) should be managed much more urgently, with emergency surgery a possibility.
  10. Dupuytren’s contacture release – Dupuytren’s is a condition where the fingers become permanently bent towards the palm.  Surgery is very effective, with debate among exactly which approach is best. Unfortunately, the condition tends to recur despite surgery.
  11. Ganglion excision – ganglions are benign rubbery lumps found most commonly on the back of the wrist. They are also known as Bible Bumps, watch this video to see why:

    The evidence surrounding surgery is mixed. This 2014 review is very thorough, and essentially boils down to: surgery can be very good, but it’s necessity is questionable. It seems likely gangions are being included for similar reasons to benign skin lesions and chalazion.

  12. Trigger finger release – a Cochrane review from Feberuary 2018 states they can’t be sure surgery is superior to steroids in the long-term, and has increased pain. They are uncertain about the risk of adverse events and nerve or blood vessel injury. There are no studies reporting hand function or patient satsifaction. A mixed bad to say the least.
  13. Varicose vein surgery – a 2017 review suggests similar outcomes from surgery, and non-surgical therapies.

 

Out of the 17 procedures listed:

  • one (breast reduction surgery) seems to be completely inappropriately listed, with the only good review I could find supporting its use
  • one (Dupuytren’s release) where the procedure is very good, but almost inevitably needs repeating. There is likely to be debate about when it is economical for the NHS to pay for the treatment.
  • three (ganglion, chalazia and benign skin lesion removals) seem likely to be included because they are rarely serious enough to require treatment
  • five (snoring surgery, knee arthroscopies for osteoarthritis, injections for back pain, shoulder bone spur removal, and varicose vein surgery) have good quality evidence showing no benefits.
  • five (D&C for heavy periods, grommets, tonsillectomy, hysterectomy for heavy periods, haemorrhoid surgery, CTS release, and trigger finger release) either have very mixed evidence, or there’s evidence a conservative approach prior to surgery is best.

Looking at the whole picture, it’s clear most of these procedures either  have no benefit, or have conservative alternatives worth trying first. All treatments have risks, and doctors always have to weigh up whether those risks are worth the benefits the treatment brings.

If there are no benefits, it’s obvious the risks aren’t worth it. If there are conservative approaches which are just as, or nearly as good, then it’s usually worth going for them first. By my reckoning, 12 of the conditions fit these descriptions.

The five remaining ones seem to be listed on mostly economic grounds.

Dupuytren’s surgery is very effective, but given recurrence is very likely, it seems sensible to wait until its definitely necessary before operating. From a patient’s point of view, repeated operations are annoying, though not as annoying as reduced hand function. From a much colder economic view, when is it worth paying for an operation we’ll possibly need to repeat? Personally, I’d say ‘most of the time’ but I can see why those controlling the NHS’ budget would want to get a more specific answer.

The final three (removal of ganglions, chalazion, and benign skin lesions) raise an interesting question. These conditions rarely cause serious harm, and rarely cause any symptoms. Obviously if they cause either, we should be treating them, but what if they aren’t? Should the NHS be treating things which aren’t causing problems? Clearly, NHS England think the answer is yes.

So overall, is this a cost-cutting exercise? Yes. But it’s also an exercise in clinical improvement. Five of these procedures have no reason to be offered as they offer no benefit. Seven have conservative alternatives worth trying first. Three are things you can easily argue don’t really even need treating at all.

Only two of the procedures seem like they’ve been listed just for economic reasons – Dupuytren’s and breast reduction. Restricting either seems puzzling, but especially so in the case of the latter. Breast reduction is already restricted in many areas, and it’s hard to see what further restrictions can occur without causing harm to patients. I’ll attempt to keep an eye out for NHS England’s consultation on these procedures, and write something about their final decisions.


This is the first blog post I’ve written in 18 months. Constructive feedback very much welcomed. 

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The Budget 2017: three and a half ways it will impact healthcare

If you’re more sensible and more interesting than me, you probably haven’t looked through the thrilling contribution to world literature that is the Spring 2017 Budget.

For those who might still be interested in what our Government plans to do to healthcare spending but don’t have the time or inclination to read all 68 pages of figures, here’s a quick summary of the three healthcare related bits.

(1) £2 billion more for social care

While the NHS is struggling at the moment, social care currently looks like a Curly-Wurly being stretched between two hungry toddlers. Given that, the extra £2bn pledged over three years by Philip Hammond is welcome.

However, it’s estimated social care will need £2.8bn by 2019-20 so unless some more money can be found, or radical new policy solutions are found, social care is likely to be struggling for a while.

(2) £100 million for new facilities in A&E

A&E is in a perpetual state of just about managing, with January 2017 the worst month on record for waiting times. 15% of people had to wait longer than 4 hours to be seen, while the government target is 5%. Whether or not new facilities will stop people waiting longer, having £100 million of new buildings is nicer than not having £100 million to spend on new buildings.

Luckily, the idea proposed by the chancellor – having facilities for GPs to work in A&E – is not mandatory. While in principal having GPs in A&E to help triage patients is not a terrible idea, we don’t currently have enough GPs to fill jobs in GP practices. Transferring some of them to A&E and further exacerbating a community shortage doesn’t seem like the smartest move.

(3) £325 million for locally proposed capital investments.

The Department of Health’s latest wheeze is to get local NHS organisations to restructure themselves using ‘Sustainability and Transformation Plans’. Essentially, this means the NHS has been divided into 44 areas each with it’s own plan for how to make local services address local needs.

While local solutions are great and I’ll advocate localism as a solution for most things, they do allow Jeremy Hunt to say ‘well it’s your own plan’ when something goes wrong, which is probably the main reason they exist. Whatever the motivations, there’s going to be £325 million for local teams to bid for to build new facilities.

However, part of the criteria to receive the money is whether ‘the local NHS area is playing its parts in raising proceeds from unused land to reinvest in local services’. So effectively the policy is ‘sell some of your land, we’ll give you some money’ – which is an interesting way to encourage local creativity.

(3.5) 850 PhDs in Science, Technology and Maths

Not strictly a healthcare related bit, but additional funding for science PhDs is always a welcome thing. Investing in science and engineering always results in future benefits, and the Government has frequently said how much it values scientific research, so its good to see them putting their money where their mouth is.

 

That’s your lot. Nothing too horrendous, but nothing that’s going to radically change health or social care. Though Phillip Hammond has repeatedly said he’s going to make autumn the time when big money changes are made, so perhaps we’ll some more exciting things then.

Slower 999 responses and longer waits in A&E – and it’s not even the winter crisis yet!

Slower 999 responses and longer waits in A&E – and it’s not even the winter crisis yet!

More people are waiting over 4 hours to be seen in A&E than ever before, according to government statistics. Only 84% of people were seen within 4 hours in October 2016, the worst performance ever recorded in October, and 5% worse than last year.

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12 hour waits in A&E tripled between September October in 2016  Credit: John Ferguson

Not only did A&E have its worse October on record, so did 999.  Only 69% of patients who stopped breathing, or had no pulse, had an ambulance arrive within the recommended 8 minutes. This number fell to 63% when other types of life-threatening calls are included (e.g. severe bleeds, strokes).

To top off a truly disastrous triad for the NHS as it approaches the annual ‘winter crisis’, delayed transfers of care took up more time than ever before. Patients spent over 200,000 days in hospital in October, not because they were ill, but because they couldn’t be moved out of hospital. Delayed transfers (horribly known as ‘bed blocking’) occur for  many reasons, the commonest being unable to find spaces in either care homes or other NHS facilities.

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 Delays in providing mobility equipment can delayed people going home, leaving them at risk to infections and other illnesses  Credit: Matt Sawyers

These three indicators (999 waits, A&E waits and delayed transfers) act as a proxy measure for the slack in the NHS. Good numbers in each mean patients are flowing in and out of hospital in a timely manner. Bad numbers mean the NHS is becoming increasingly bottlenecked, and pressure is building up with the system.

Given that all of these indicators typically worsen over the winter, it seems unlikely we’ll be seeing any improvements in the data in the upcoming months. In all likelihood, we’ll see the most pressurised winter in the NHS since records began. Maintaining quality of care in such an environment will be a Herculean task.

 

Parliament ‘sceptical’ about NHS England’s ability to deliver on mental health targets

An influential committee of MPs released a damning report today into the state of Britain’s mental health system. They found that only 1 in 4 people could access the mental health services they needed.

The cross-party Public Account Committee, in charge of making sure the Government spends money efficiently, said pressure on NHS budgets would make the Department of Health’s new mental health standards ‘difficult to achieve’ without taking money away from other services.

The Department of Health has pledged £1bn over 5 years to improve mental health provision but this is not ring-fenced. With the current financial pressures across the NHS, it will be tempting for NHS managers to use that money to plug short-term holes rather than invest in long-term  mental health provision.

Specific problems cited in the report include:

  • A lack of counselling in some schools meaning many miss the chance to have their symptoms identified early  – half of those who experience mental health problems do so before the age of 14 
  • Variability in the provision of services – in some areas 99% of people are seen in 6 weeks, in others it is just 7%
  • Lack of access to mental health care for current and former prisoners – 9/10 prisoners have a mental health problem, 7/10 have two or more

The Public Account Committee recommended, among other things, that the Department of Health and NHS England did the following:

  1. Figure out how much money they needed to pay for its mental health program, and which areas of spending they prioritised
  2. Join up services across government to improve continuity of care for those with mental health needs e.g. housing, social care
  3. Work out how many extra nurses and additional staff they would require to roll out their programs

Why these things were not done prior to rolling out new nationwide standards is not recorded. However, they do show a continuation of the Department of Health’s remarkably lax approach to planning ahead and gathering evidence, as shown by this argument from their lawyer in yesterday’s court case regarding junior doctor contracts.

 

Jeremy Hunt meets with media execs 7 times in 3 months – but doesn’t find time to see the BMA

Jeremy Hunt had meetings with 7 senior media figures between January and March this year, a period that includes 4 days of industrial action by junior doctors.

Jeremy Hunt, the UK Secretary of State for Health and Dr. Mark Davies, Director of Clinical and Public Assurance at the Health & Social Care Information Centre, visited the Kaiser Permanente Center for Total Health for a tour, given by Bernadette Loftus, MD, Mid-Atlantic Permanente Medical Group, Kim Horn, President, Kaiser Permanente, Mid-Atlantic States, and Phil Fasano, Chief Information Officer
UK Secretary of State for Health Jeremy Hunt and Dr. Mark Davies visit the Center for Total Health. Credit: Ted Eytan

These included James Kirkup, Executive Political Editor at the  Telegraph; Hugh Pym, the BBC’s Health Editor and Alastair McLellan, Editor of the Health Service Journal, the trade magazine popular among NHS management.

These meetings follow on from eight meetings he had with media figures between October and December last year, including with the editors of the Sun, Daily Mail and the Telegraph. Hunt met both Amol Rajan, Editor of the Independent, and Tony Hall, Director-General of the BBC, twice in a six month period.

During this period, Hunt has met a grand total of zero times with the Junior Doctor Committee of the BMA, though junior ministers have met with the BMA to negotiate the new contract. Hunt has also met with other sections of the BMA including the Chair of the General Practice Committee, Chaand Nagpaul.

The full list of media figures Hunt met with from October 2015 to March 2016 is as follows:

  1. Fraser Nelson, Editor, The Spectator, October 2015
  2. Amol Rajan, Editor, The Independent, October 2015 and January 2016
  3. Tony Gallagher, Editor, Sun, 27th October 2015
  4. The BBC News editorial team, November 2015
  5. The Daily Telegraph editorial team, November 2015
  6. Tony Hall, Director-General of the BBC, November 2015 and January 2016
  7. The Mail on Sunday editorial team, November 2015
  8. The Daily Mail editorial team, December 2015
  9. Janine Gibson, Editor-in-Chief, Buzzfeed, January 2016
  10. Jim Waterson, Political Editor, Buzzfeed, January 2016
  11. James Kirkup, Executive Political Editor, The Telegraph, February 2016
  12. Alastair McLellan, Editor, Health Service Journal, March 2016
  13. Paul Goodman, Editor of Conservative Home, March 2016
  14. Hugh Pym, Health Editor, BBC, March 2016
  15. Fiona Godlee, Editor, British Medical Journal, March 2016.

Previous attempts to find out the content of these meetings were unsuccessful, with the Department of Health refusing to release details under the ‘development of public policy’ clause allowed under the Freedom of Information (FoI) Act. The BBC declined to release details of the meetings under the exemption granted to it to protect its journalism operations.

A Look at Our New Health Ministers

Under our new PM’s cabinet, everyone in the medical community was very happy to see Jeremy Hunt return in his role as Secretary of State for Health. After all he’s done the impossible and united every health professional and student around one issue, namely the feeling that Jeremy Hunt has no really business being in charge of the NHS.

While our dear leader may not have changed, his underlings have. So say farewell to Ben Gummer (Hunt’s chief lackey), Jane Ellison, George Freeman and Alistair Burt. In come Phillip Dunne, Fiona Blackwood and David Mowat.

Nope, I’ve not heard of any of them either. Here’s a few titbits on each, as well as their voting record on major health bills.

 

Phillip Dunne (Minister of State for Care and Support; senior underling)

  • Voted against smoking bans
  • Didn’t vote on end-of-life assistance for the terminally ill
  • Voted for higher taxes on alcoholic drinks
  • Voted against restricting the provision of services to private patients by the NHS
  • Voted for the Health and Social Care Act 2012

Dunne owns a farm for which he drew £15, 793 from last year. Clearly that’s going well for him. His previous job as the Ministry for Defence Procurement has gone decidedly less so, to the point where problems with defence procurement make nearly every issue of Private Eye. The latest issue points out that the UK has spent $4bn on 9 patrol aircraft when the US managed to get 12 for $2bn. Let’s hope he doesn’t bring this kind of deal making to the cash-strapped Department of Health.

Additionally, Dunne went to Eton and Oxford so it’s good to see that underrepresented demographic get a chance in politics.

 

Nicola Blackwood (Undersecretary of State for Health Services)

  • Voted for smoking bans
  • Voted against end-of-life assistance for the terminally ill
  • Voted for higher taxes on alcoholic drinks
  • Voted against restricting the provision of services to private patients by the NHS
  • Voted for the Health and Social Care Act 2012

Blackwood has longtime experience as a patient in the NHS. Her childhood chronic fatigue syndrome meant she was home schooled for GCSEs and A-levels where she did well enough to go to Oxford. She has Ehlers-Danlos syndrome and postural tachycardia syndrome secondary so stays in regular contact with health professionals, which should help her ear close to the ground. Her fellow MPs thought well enough of her to elect her as Chair of the Commons Science and Technology Commitee in June 2015.

Less happily, she was part of the Tory rebellion in 2012 that killed off House of Lords reform. In  non-health matters, she voted against gay marriage and wants to repeal the ban on fox-hunting, so she’s not the most socially liberal MP out there.

 

David Mowat (Undersecretary of State for Public Health)

  • Voted for and against smoking bans
  • Has never voted on end-of-life assistance for the terminally ill
  • Voted for higher taxes on alcoholic drinks
  • Voted against restricting the provision of services to private patients by the NHS
  • Voted for the Health and Social Care Act 2012

The only non-Oxbridge minister in the DoH, Mowat is a chartered accountant by trade. This should help him get along with the head of the Care Quality Commission, Peter Wyman, who was a beancounter for PricewaterhouseCoopers until 2010.

Mowat rarely rebelled against his party but one of the only times he did was voting against making it clear that sex-selective abortion is illegal, which is an interesting position to hold to say the least.

Aside from this the most interesting fact about Mowat appears to be that he is one of 7 government ministers called David. Depressingly, there are more ministers called David than there are from ethnic minorities. Hooray for diversification.

 

 

 

 

 

Another nail in the coffin of NHS-funded homeopathy as Liverpool ceases funding

Another nail in the coffin of NHS-funded homeopathy as Liverpool ceases funding

Liverpool CCG has decided to decommission its homeopathic services after a public consultation found support for ending funding immediately. This is a swift about-face for the CCG after it approved spending on homeopathic services in February 2015.

The CCG opened a public consultation on homeopathy after a threat of legal challenge from The Good Thinking Society, a pro-science charity. 64% of Liverpool-based respondents indicated they wanted funding stopped, with 30% wanting the service continued. Michael Marshall, Liverpool resident and Project Director of the Good Thinking Society, welcomed the CCG’s decision: “This consultation shows overwhelmingly that the people of Liverpool believe limited NHS funds should be spent on treatments that are shown to actually work.”

The decommissioning of homeopathy in Liverpool continues the demise of homeopathy throughout the UK. Wirral CCG is the only area north of  Watford Gap currently funding homeopathy, and they are currently running a public consultation to determine whether to continue.

Homeopatic pharmacy, Varanasi Benares India
Homeopathy is a popular alternative to conventional medicine in many countries. However, there is no high-quality evidence to suggest it does what its advocates says it does.        Credit: Jorge Royan

In the South West, Bristol Homeopathic Hospital ceased funding homeopathic treatments in October 2015. The only remaining homeopathic hospital in England is in London, which receives funds from 17 CCGs. Limited information is available, but projections on what this totals range from £1.7-3m.

Elsewhere in the UK, Northern Ireland spends no NHS money on homeopathy and Wales spent £250 in 2014/15. In Scotland, 5 health boards funded homeopathy at a cost of approximately £1.9m in 2014/15, with the Glasgow Homeopathic Hospital accounting for the vast majority of this spend.