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October 25, 2010

NHS Rationing in Warwickshire
Filed under: Private Eye — Dr. Phil @ 8:39 am

Explicit rationing in the NHS is no bad thing. When he was shadow health secretary, I made Andrew Lansley stand on stage at the NICE conference and say: ‘There is and has to be rationing in the NHS.’ He’s now hoping GP Consortia will do it for him, but NHS Warwickshire is ahead of the game, announcing a list of treatment restictions ‘to manage demand in the acute sector.’ However, there’s no mention of any patient consultation in drawing up this list. Whatever happened to no decision about me without me?

Westgate House
Market Street
CV34 4DE

Tel: 01926 493491

Fax: 01926 495074
8th October 2010

Birmingham & West Birmingham NHST
Management Centre
Dudley Road
B18 7QH

Dear Chief Executive

As you know, throughout this year we have seen continual and significant increases in the demand
for acute services across Warwickshire. In response we have taken action to refresh treatment
policies, remind clinicians of their content and extend the range of services in the community. This
has not had a significant enough impact to reduce the capacity problems that your Trust asked for
our help with, nor will it have enough impact on our projected spend. With winter now fast
approaching we do not see any indications that this situation will improve in the short term. I know
that you will agree with me that this situation is not sustainable.

It is our responsibility to ensure that we deliver high quality care within the resources available and
this can only be achieved through working in true partnership. We must take urgent and immediate
action to ensure that the health system in Warwickshire is sustainable both financially and

At the October meeting of NHS Warwickshire’s Board a proposal to manage the demand for acute
services was agreed. The proposal broadly addresses two areas: stopping or deferring
treatment/procedures for specific conditions that are not life-threatening; stopping all
assessments/reviews by secondary care clinicians that can be undertaken in primary care.

Stopping/deferring specific treatments/procedures:

As you know NHS Warwickshire has previously defined a range of treatments as Low Priority
Procedures, for which we have allowed providers to determine the cases that are sufficiently
exceptional as per the policy. 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. We are also extending the list of
procedures within the LPP policy.

The following list of procedures will permanently not be funded for NHS treatment:

Chairman: Bryan Stoten Chief Executive: Paul Jennings

Endoscopic thoracic sympathectomy
Facial hirsutism
Ganglion treatment
Botox therapy for hyperhidrosis
Oral Vaccine for seasonal rhinitis
Penile implants
Spinal epidural injections for chronic back pain
Therapeutic use of probiotics
The following list of procedures temporarily (until 1st April 2011) requires prior approval for NHS
funded treatment except in instances where the activity is cancer-related (Note: in many instances
we have defined thresholds for treatment against which we will assess the referral for prior

All other procedures included in the current LPP policy – see attached list
Cataracts (including prior approval for a second eye to be treated)
IVF/ICSI (except in cases where the treatment cycle has already commenced or
where the current age criteria will be exceeded if treatment is not commenced before
April 2011)
Bariatric Surgery
All routine elective orthopaedic procedures (to include inpatient, day case and
outpatient procedures)
All secondary care back pain management
All oral and orthodontic procedures in secondary care
No treatments in these areas should be carried out by providers without the prior approval of NHS
Warwickshire. Should providers undertake any of these treatments without prior approval, NHSW will
not fund that activity.

Reducing assessments/reviews in secondary care:

Our ability to manage outpatient demand is being hampered by a number of factors. These include
the range of points of entry to services, confusion over service pathways and the quality of the data
to enable us to identify the causes of activity growth. We are therefore introducing additional
measures with regard to non-GP referrals.

All consultant-to-consultant referrals should cease from 10th October 2010 and the referral be
redirected back to the patient’s GP for consideration with the exception of:
cancer referrals
A&E to fracture clinic referrals

The recorded source of the referral must be transparent for all outpatient referrals. As a
consequence we require providers to stop coding the source of referrals as “97 -other”. From
previous audits activity coded in this way often includes both GP referrals and Consultant to
Consultant referrals.
We will not pay for any consultant to consultant referrals from 1st November, we have assumed
that there will be some referrals in the system during October, but we would expect that no new
referrals will be made. Where the source of the referrals is 97 or has a default code (C999998)
the PCT will not pay for those attendances from 1st November.

Chairman: Bryan Stoten Chief Executive: Paul Jennings

Action for Acute Providers to take to support this plan:

In order to implement the above, with effect from Monday 11th October 2010 the following action
needs to be taken:

No patients to be offered TCI dates for surgery for the above categories with immediate
effect. In line with the acute Trust contract, patients should be offered TCI dates up to 3
weeks in advance so we would expect elective activity in these categories to have ceased by
the end of October 2010. NHS Warwickshire will therefore not pay for any activity in these
categories from November onwards unless Prior Approval has been given.

Providers should send NHS Warwickshire a copy of their Waiting List, by specialty, including
NHS number as at 8th October. This should be received at the PCT by 11th October.

Providers should produce a list of all existing patients (i.e. already referred) who might be
expected to be affected by the changes outlined in this letter and who either did not have a
TCI date as at 10th October 2010 or who have been given a TCI date after 31st October
2010. These patients should be referred through the PCT’s prior approval process for
consideration of funding. These patients will be clinically reviewed by the PCT to determine
whether their treatment should be approved by exception, in accordance with the process.

Where patients have been booked for a First Out-patient appointment, this appointment can
take place as planned, and if the consultant subsequently believes that a procedure is
necessary and meets the criteria, the patient details should be sent to the PCT for approval
through the Prior Approval Process.

Providers shall not accelerate activity in other specialties nor reduce waiting times. . If activity
is accelerated, the PCT will not pay for any activity above the planned forecast, at specialty
level, based on month 4 activity.

If a provider receives a new referral from a Warwickshire GP for one of the above treatments
it should come with a prior approval from the PCT. If it does not come with a prior approval
then the referral should be sent back to the GP.
Action for NHSW to take to support this plan:

The PCT will monitor the shape of provider waiting lists to ensure that activity is not being
accelerated in any specialties. If activity is accelerated, the PCT will not pay for any activity
above the planned forecast, at specialty level, based on month 4 activity.

The PCT will not issue providers with performance notices for breaching the maximum 18
week target for the remainder of this year’s contract.

The PCT has a Prior Approvals Panel which will consider all funding requests for patients
who either meet the thresholds for treatment or who may have individual circumstances that
make them exceptions to the policy. This panel will also review all patients on provider
waiting lists for treatment who have not been given a TCI date as at 10th October 2010.

The PCT will issue guidance to providers on the Prior Approval Process by Friday 15th
October 2010.

The PCT will inform all Warwickshire GP’s of the details of the above changes.

Warwickshire GP’s will be asked to submit all new referrals that could require one of the
above treatments through the Prior Approval Process.
Chairman: Bryan Stoten Chief Executive: Paul Jennings

The PCT will inform all acute providers where it is an Associate Commissioner of the above
changes and require them to institute the action above.

In conjunction with our main acute providers, the PCT will agree standard letters/information
for patients to inform patients and their carers of the nature of the changes being made and
the reasons behind these.
I know that implementing the above steps will be difficult for all of us and this is clearly not an ideal
situation. However, I am sure that you will agree with me that the current situation cannot continue. It
is vital that we take decisive action and move forwards in close partnership so that we can fulfil our
duty to the health economy to deliver a sustainable future.

Yours sincerely

Paul Jennings
Chief Executive

Co-ordinating Commissioners

Chairman: Bryan Stoten Chief Executive: Paul Jennings


Arthroscopy for diagnostic examination of knee joint
Carpal Tunnel Syndrome
Dilatation and Curettage for menorrhagia (D&C)
Facet Joint injections for chronic low back pain
Gallstone surgery (if not symptomatic)
Hysterectomy for menorrhagia
Inguinal hernia in adults (asymptomatic)
Spinal Fusion for disc problems
Tonsillectomy/adenontonsillectomy for recurrent tonsillitis
Trigger Finger release surgery
Varicose Vein surgery
All Aesthetic Procedures

Chairman: Bryan Stoten Chief Executive: Paul Jennings