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October 26, 2010

Should people in Warwickshire move to Birmingham for a new hip? The Health Service Journal picks up on my NHS Warwickshire post
Filed under: Private Eye — Dr. Phil @ 5:35 pm

Good to see the HSJ picking up my story. And the comments are interesting too. Is it legal? Is it ethical? What happens if the money still runs out? What would Bevan do?

PCT halts funding for over 30 procedures to ‘remain sustainable’
26 October, 2010 | By Steve Ford

A Midlands primary care trust has halted funding for a raft of routine procedures, including cataract removal and hip replacements, in order to remain financially viable over the winter.

Until now PCTs have largely made small scale attempts to cut back on actual services offered, for example NHS Warrington ceased funding most IVF treatment last month. However, NHS Warwickshire has written to provider organisation chief executives outlining two lists of non life threatening procedures that it says will either no longer be funded permanently or temporarily – following discussion with its clinical executive committee.

The list of nine permanently banned procedures includes acupuncture, epidurals for back pain and oral vaccination against hay fever. The second list – of more than 20 procedures halted until the end of the financial year – includes new IVF treatment cycles, all routine elective orthopaedic operations, and secondary care back pain management.

All of the procedures in this second list can be accelerated, however, if the patient’s GP concludes the treatment should go ahead immediately, and this view is supported after review by a second GP, who has a specialist in the relevant clinical area.

The PCT has also banned consultants from referring cases to each other from 1 November, as part of moves to reduce the number of assessments and reviews taking place in secondary care that could otherwise be done in primary care. The only exceptions are cancer referrals and accident and emergency to fracture clinics referrals.

In his letter NHS Warwickshire chief executive Paul Jennings said there had been a “continual and significant increases in the demand” for acute services in the area, which had not been slowed by measures such as extending the range of services available in the community.
He said: “With winter now fast approaching we do not see any indications that this situation will improve in the short term.
“We must take urgent and immediate action to ensure that the health system in Warwickshire is sustainable both financially and operationally.”

Mr Jennings also expressed disappointment that a previous policy of defining 14 procedures as low priority and allowing providers to decide which were “sufficiently exceptional” to go ahead had failed to have sufficient impact, leading to the stricter measures.
He said: “Activity in these procedures has continued to grow overall despite these policies and so, we are no longer confident that the criteria laid out within those policies are being rigorously applied. We are therefore changing this process.”

Mr Jennings acknowledged to chief executives that the measures were “not ideal” and would be difficult to implement.
“However, I am sure that you will agree with me that the current situation cannot continue,” he said.
A spokesman for NHS Warwickshire claimed the move had the support of the majority of local GPs.

Readers’ comments (12)

Ian Bowns | 26-Oct-2010 10:18 am

This is an act of desperation. The real key to this specific problem lies in supporting patients’ decision making with information and counselling, which can reduce net costs. The wider issues can be addressed: Grand Junction Colorado has an efficient healthcare system, with low costs and high quality ratings. They describe seven features: leadership by primary care; payment system involving risk-sharing by physicians across sectors; equalisation of physician payments across patient types; regionalisation of specialised services; restrictions on supply of high-cost care; payment of primary care doctors for hospital visits; and good end of life care. All interesting in an NHS context. See


Anonymous | 26-Oct-2010 10:27 am

One significant gap in the NHS across all sectors today: Generally speaking, risk management is feared rather than embraced, hence we have a risk-averse culture that spans clinicians and managers, and NHS organisations. Sadly, it’s considered as important as training and development of staff. Both are major areas of continuous investment in US healthcare, because HMOs and hospitals know they are two enablers that will always yield better performance and efficiency in a targeted manner.

Anonymous | 26-Oct-2010 2:02 pm

and a marvellous piece of the dreaded postcode lottery. Not only is IVF straight to the top of the list again, but live in Warwickshire and you should move to Birmingham to get that new hip…

Richard Russell | 26-Oct-2010 2:35 pm

If a GP says that a hip replacement is needed and refers the patient but the commissioner says they will not fund it where does the legal right of a patient to be treated within 18 weeks fit?

The only way this will save money is if the GP does not make the referral in the first place but the commissioner has sent the letter to the hospital rather than the GPs.

If I needed a hip replacement and it was going to take more than 18 weeks to be treated then the courts have said that I can go wherever reasonable (including anywhere in Europe) to have my treatment carried out within 18 weeks and the commissioner legally has to pay all of the costs.

So the solution is that PCT actually needs to get the GPs to stop referring.

However a patient presents at a GP in pain needing a hip replacement and they refuse to refer them then isn’t the GP opening themselves up to a reasonable amount of clinical governance risk. For example GP agrees that a patient needs a hip replacement, refuses to refer, patient then has an accident directly linked to their bad hip, GP liable?

Will be interesting to see how this works in practice…

Anonymous | 26-Oct-2010 2:56 pm

Arent commissioners supposed to give notice ?? As a provider can i mreject emergency cases because i am not making money from them ?? Its anarchy is this what Secretary of State wants ?? Will he intervene or is down to localism I wait with interest

Anonymous | 26-Oct-2010 3:05 pm

What is even more interesting is how this story has been reported locally……. more spin than on a top! The PCT claiming that this is to ease “winter pressures” on secondary care or even better in another local paper to allow the joints more time to “heal themselves”!! Rather than being really honest and informing the people of the truth …..they have over spent- Staff employed by PCT’s have always historically had higher pay bands than their conterparts in the secondary care sector and have people in post that no one knows what they do….. and please dont contact them after 2pm on a Friday because they have all gone home!

Seems to me that the only thing that they can do is persuade the Warwickshire population not to go to their GP, if they suffer from a condition that may require one of the procedures that have been stopped. Job done! Lets see how that one pans out or even more radically they could look closer to home and hold a mirror up to themselves.

Anonymous | 26-Oct-2010 3:11 pm

The investigation should begin over serious finacial mis-management at NHS Warwickshire over a number of years and why now local patients are having to pay the price for that. This is one place where you can say GP Commissioning, bring it on as it could not be any worse for the population of Warwickshire. Local GP’s should beging to have serious conversations with the SHA and DH about why they should potentailly inherit the deficit of a failing organisation and how they can have their budgets be-based as a result.

Anonymous | 26-Oct-2010 3:14 pm

As for the comment re: notice, that does not seem to bother the PCT. When is a contract not a contact…. ? when signed by NHS Warwickshire obviously.

Anonymous | 26-Oct-2010 3:37 pm

We need to get real. Most PCT’s are having trouble meeting the ever growing demand for health care and are having to make huge savings which often falls on the hospitals who cannot get paid on an activity x price any longer. If you think its getting bad wait until next year. Cutting costs is important but unless we cut demand we will see more headlines like this. Can we afford to offer free, health to people who self harm, perpetual DNA’s and nice to have treatments. In the private sector you have to look at all sides of the P & L, and make substantial changes and not just fiddle around the edges.

Unsuitable or offensive?

Anonymous | 26-Oct-2010 3:42 pm

Stopping elective orthopaedics will not save the full cost of those operations. Orthopods will be under-utilised and theatres will stand empty, incurring cost. A proportion of the patients who would have been treated electively will then end up in A&E for a more expensive operation having deteriorated. This is entirely contrary to QIPP. What happened to “local leaders of the NHS” ?

Unsuitable or offensive?

Bob Neilans | 26-Oct-2010 3:50 pm

Agree fully with Anon 3.42PM – If these elective procedures aren’t enough to prevent the PCT overspending, what is next to be stopped? And of course, because of the funding structure of the NHS we will end up with expensive real estate, equipment and professionals idle. Delaying I can understand, but stopping?

Unsuitable or offensive?

Piushkumar Patel | 26-Oct-2010 4:37 pm

Is no one prepared to stand up and say that we have moved too far away from the NHS envisioned by Beverige and Bevan? We (and this now means myself as a GP commissioner) need to have an honest conversation with the public about what we can and can’t afford. IVF is the most emotive issue, but ultimately it does not fit with the founding principles of the NHS, which were essentially to allow all to work by making sure that they were fit enough. In the (near) future, I will have to say to my patients that they can’t have certain procedures on the NHS. I look forward to it. The NHS has expanded it’s remit into areas of elective care where it simply should not be.