NHS Incorporated

This is  Labour Party  NHS Check 12  originally published by Labour’s Shadow Health Team in October 2013

  • Survey Reveals NHS On Road To Us-Style Healthcare
  • New Evidence Of NHS Hospitals Charging For Essential Treatments That Were Previously Free And Still Free Elsewhere
  • Thousands Of People Missing Out On Essential Treatment As David Cameron’s Postcode Lottery Grows
  • Labour Calls On The Government To Order An Immediate Review Of Rationing In The NHS And To Intervene To Stop Rationing On Grounds Of Cost

This report shows that hospitals are beginning to charge patients for some treatments which were previously free on the NHS and continue to be freely available in other parts of the country.

A Labour survey has revealed the details of punitive new restrictions put in place by Clinical Commissioning Groups. This follows an investigation by the British Medical Journal which found that as many as 1-in-7 of the new bodies have increased the rationing of treatments.

Last year, Labour found that almost half of Primary Care Trusts were restricting routine treatments. Despite warnings from Labour and professional bodies, the problem has worsened – leaving patients facing an agonising decision of going without treatment or paying for private care.

Increases in rationing are leading to a growing postcode lottery

Labour’s Shadow Health Team surveyed all Clinical Commissioning Groups following reports that increasing numbers of patients were being denied GP referrals for treatment previously accessible on the NHS.

An investigation by the BMJ in summer 2013 revealed that in the last six months, since they took control of the new NHS in April, 27 CCGs of 195 CCGs responding to the survey – close to 1 in 7 – had introduced new treatment restrictions. These included 8 CCGs restricting treatment for Foramen Ovale for recurrent migraines, 3 CCGs restricting hip or knee replacement surgery, 2 CCGs restricting cataract surgery, 4 CCGs restricting Caesarean for non-medical reasons, 2 CCGs restricting treatment for carpal tunnel syndrome, and 8 CCGs restricting therapeutic use of ultrasound. The full list of restrictions is listed in the table below.

  • Asymptomatic gall Stones 9
  • Foramen Ovale Closures for recurrent Migraines 8
  • Therapeutic use of ultrasound 8
  • Ganglions 7
  • Hallux Valgus 6
  • Skin Lesions 5
  • Caesarean for non medical reasons 4
  • Tonsilitis 3
  • Knee Surgery/replacements /hip 3
  • Varicose Veins 2
  • Cataracts 2
  • Carpal Tunnel Syndrome 2
  • IVF 1
  • Dupuytrens Contracture 1
  • Myringotomy 1
  • Hysteroscopy 1
  • Trigger Finger 1
  • Dilation and Curettage 1

Labour’s Freedom of Information survey enabled investigation of the consequences of increasing rationing for access to treatment. It revealed wide variation across the country for the same treatment, with some NHS bodies setting down extra conditions before they fund the treatment. For example:

  • Patients in South Reading are required to lose more of their eyesight before they receive cataract surgery than patients in South Kent who qualify sooner.
  • Patients in the Black Country are forced to prove greater levels of pain and attempted weight loss before qualifying for knee replacement surgery, whilst South West London will fund patients in lower levels of pain.
  • Likewise for hip surgery, South West London and Stoke on Trent and North Staffordshire have different pain criteria.

There is a legitimate debate to be had about the effectiveness of particular treatments or their use in particular contexts. But Labour FOIs have added to the growing evidence that some patients are being unfairly denied access to vital treatments.

And as the next section shows, it seems that some hospital trusts are now introducing new private care options for treatments that are being rationed in the local area.

Postcode lottery in cataract surgery


In the 1990s, it was not uncommon for patients to wait up to two years for a cataract operation. The previous Labour Government took action to address this delay. It included issuing good practice guidance which established eligibility criteria and ensured patients should have access to surgery.

The guidance stated that patients should be referred for surgery by their GP if a cataract leaves them with reduced vision or if it negatively impacts their quality of life.

The guidance did not establish visual acuity thresholds – the measure of vision relating to how far a person can read down an eye chart – before a patient qualifies for treatment.

The Royal College of Ophthalmologists cataract guidelines published in 2010 reinforced this guidance.

Hospital Episode Statistics

The latest figures show that the number of elective admissions for cataract surgery declined between 2010/11 and 2011/12 by over 5,000.

These figures are precisely the opposite of what experts would expect. The RNIB have said “We would expect to see both the number of operations and spells to increase as the population ages and demand for surgery rises.”

The figures suggest that since 2009/10, PCTs and CCGs have been introducing restrictions to cataract surgery.

Clinical commentary and patient impact

“Such absolute restrictions have no clinical imperatives. There is now evidence that early cataract surgery is beneficial to patients, and the over reliance of Visual Acuity as a measure is outdated. Delaying surgery leads to more ophthalmic complications, making surgery more risky, and in the event proves costlier”

CCG referral policies – the variations

Labour has uncovered evidence of CCGs who have implemented new restrictions on cataract operations in the last year. Earlier this year, the RNIB found widespread evidence of CCGs implementing restrictive commissioning policies that are not in line with either Department of Health guidance or Royal College guidance.

South Reading CCG’s commissioning policy states: “cataract surgery is only routinely commissioned for patients who, after correction (eg, with glasses), have a visual acuity of 6/12 or worse in their cataract-affected eye.”

However, Brighton and Hove CCG have no arbitrary restrictions on cataract operations and surgery is based on clinical need.

Postcode lottery in knee replacement surgery

Clinical commentary and patient impact:

“Orthopaedic operations such as knee and hip surgery can be due to a traumatic injury such as a sports injury or accidents, or a degenerative disease such as arthritis. Such rationing would aim to discriminate against the latter mainly, as these are chronic conditions. But the disability, pain, reduced social mobility, will cause a lot of suffering to these patients.”

CCG referral policies – the variations

NHS Black Country Cluster will only operate on patients with a BMI of 40 or over if they have documented proof that they have participated in a “comprehensive weight management programme” of at least 6 months duration prior to surgery.

All other patients (ie those with a BMI of less than 40) are now required to meet a range of other criteria before they become eligible which include:

  • Conservative means (e.g. Analgesics, NSAIDS, physiotherapy, advice on walking aids, home adaptations , curtailment of inappropriate activities and general counselling as regards to the potential benefits of joint replacement) have failed to alleviate the patients pain and disability
  • AND Pain and disability should be sufficiently significant to interfere with the patients’ daily life and or ability to sleep/patients whose pain is so severe
  • AND Underlying medical conditions should have been investigated and the patient’s condition optimised before referral

In contrast, Kingston CCG will fund elective surgery on any patient who has an Oxford Knee score – the questionnaire on function and pain – of less than 20 on the 0 to 48 system or greater than 40 on the 60 to 12 system.

Postcode lottery in hip replacement

Clinical commentary and patient impact:

“ Restrictions on hip replacement could well discriminate against older people, for whom hip surgery is not cosmetic but essential to relieve pain, further worsening of their condition and also major social handicaps if surgery did not happen.”

CCG referral policies – the variations

Stoke on Trent CCG will only commission hip surgery if a patient scores 20 or under on the Oxford Hip Score (the equivalent questionnaire).

Merton CCG will fund surgery for patients with a score of 26 or under.

However, Hammersmith and Fulham CCG’s referral policy makes no reference to the Oxford Hip Score.

NHS hospitals charge for rationed treatment

In October 2012, the Government gave NHS Foundation Trusts the freedom to generate up to 49% of their income from private patients. A Labour Freedom of Information request to hospital trusts, on the income generated from private work in the first year of the new arrangements, reveals a significant increase. In 2012/13, hospitals generated £434 million – an additional £47 million on 2010/11. Meanwhile, trusts’ projections show that they envisage this will increase by a further £45 million to £479 million this year.

Labour’s research has uncovered examples of treatments that are now rationed by the GP-led bodies and charged-for by hospitals– so-called ‘self-funding’ patients. This is where NHS hospitals offer to treat people as private patients but charge “NHS rates”.

  • In the last six months, James Paget University Hospitals NHS Foundation Trust has started offering self-funding options for Ophthalmology. Meanwhile, the local CCG NHS Great Yarmouth and Waveney has a restrictive commissioning policy for cataract operations – out of line with Department of Health and Royal College guidance.
  • Earlier this year, Southampton CCG was “red rated” by the RNIB – labelling its policy on cataract operations “very restrictive”. The local trust, Southampton University Hospitals, has a self-funding option in place for treatment in Ophthalmology services. Private patients can choose to benefit from high quality eye care by local NHS consultants at Southampton General Hospital. The hospital trusts website boasts: “Fewer non-urgent services can be paid for by the NHS but we know that patients still want to see our expert staff and be treated within the advanced care environment of a specialist teaching hospital. We offer the full range of consultations, investigations and treatments that you would expect from a specialist hospital […].”1 Also adding: “Our premier cataract service offers a new option, between the traditional private sector and the NHS, bringing private healthcare within the reach of many more people. This service offers you the option of cataract surgery even if your vision is better than the current level required for NHS surgery. We offer surgery when you feel you need it.”
  • Warrington and Halton Hospitals NHS Foundation Trust now offers a self funding option for removal of varicose veins. Their website states: “There are some treatments provided in the past that may no longer be accessible through local NHS funding… However, we know that many patients still want to have these procedures with us. In order to give our patients choice around their care, we have developed the MyChoice service. This allows you to pay (self-fund) to have these procedures with us at the standard NHS price. Private health insurance may also cover the cost of these procedures with us.”
  • Chelsea and Westminster hospital offer self funding options on “All medical and surgical specialities.” NHS North West London have tightened their criteria on a number of treatments in the last year. In June 2013, they updated their policies on removal of benign skin lesions, dupuytren’s contracture, carpal tunnel syndrome and cataract surgery.