Are 90 per cent of Primary Care Trusts 'rationing' care?

It has been a busy week for health journalists, however one story in particular stood out above all others when it made it to the despatch box at Prime Minister's Questions this week. Labour's Deputy Leader Harriet Harman asked:

"This week a survey showed that 90 per cent of primary care trusts, because of the financial pressure they are under, are restricting access to treatment. This is going to particularly hit older people ... how can you justify an elderly person with cataracts in both eyes being told they can only have surgery in one of them?"

Her concerns were not in isolation. The Guardian and Daily Mail also noticed the story:

Guardian: "Pressure on budgets makes primary health care trusts limit operations ... Freedom of information requests by GP magazine reveal that 90% of trusts hold back on hip, knee and cataract operations"

Daily Mail: "Nine out of 10 NHS Trusts are 'rationing operations'"

The claim sounds startling, but where is it from and what is really happening in the NHS?

The source

Some time ago GP Magazine submitted a series of Freedom of Information requests to all 151 Primary Care Trusts (PCTs) in England. They received useful responses from 101 PCTs of whom they claimed 91 per cent had revealed that restrictions were in place over certain treatment referrals in their Trust.

GP Magazine asked all the Trusts three questions:

1. What measures does the PCT plan to put in place to restrict GP referrals for non-urgent procedures in 2012/13?

2. How much money does the PCT estimate these measures will save?

3. Please confirm or deny whether the PCT's policy on 'non-urgent' procedures (or procedures of 'limited/low clinical value') for 2012/13 will include restrictions on referrals for each of the following: (i) joint replacements operations (ii) cataract surgery (iii) tonsillectomies (iv) bariatric surgery.

After contacting GP Magazine, Full Fact was kindly provided with a complete list of their responses from all 101 Trusts and how they had chosen to categorise each response. A version of that list is available on their website.

But does GP Magazine's analysis stand up to scrutiny?

The responses

The first thing that is noticeable looking through the responses to the FoI requests is that a large number of PCTs, in response to the first question, denied that there were any restrictions taking place. 36 out of 101 (36 per cent) claimed that they had no plans to restrict GP referrals on treatments.

Yet GP Magazine claimed that 91 per cent of the Trusts revealed some restrictions were in place. So why the difference in opinion?

Part of the problem, as the magazine explained to Full Fact, was that many of the Trusts did not strictly define their practices as being 'restrictive'. Take the response from Wolverhampton City PCT, for example:

"The Trust has no plans to restrict referrals, just plans to ensure that referrals are in line with the policies which are based on clinical guidance and clinical consensus. This will be through education sessions."

In fact, as Full Fact found, most of the practices who claimed not to impose 'restrictions' still had policies which could arguably be interpreted as restricting treatment. NHS Central Lancashire, for instance, denied any restrictions were in place, yet have a policy on limiting inclusion for Bariatric surgery (for weight reduction). 

However there were some cases in which GP Magazine's conclusions that 'rationing' was taking place seemed less clear-cut.

In the case of NHS Bedfordshire and Hertfordshire, for instance, who also denied that restrictions were in place, the PCTs pointed out that their GP referrals were only subject to guidance that wasn't actually mandatory. In this case the PCTs have a 'referral management centre' that aims:

"To advise the NHS in Bedfordshire and Hertfordshire as to the interventions and policies that should be given high or low priority, including thresholds for referral and interventions.

This guidance will be advisory, not mandatory for PCTs (so retaining autonomy, but also empowering PCTs by employing a uniform, equitable approach based on evidence of clinical and cost-effectiveness)."

Neither PCT provided any solid evidence for any treatments that were restricted. GP Magazine made clear to Full Fact that it was not their intention to establish actual cases of treatments being restricted, only that thresholds existed. The publication has therefore included Bedfordshire and Hertfordshire as one of the 91 per cent to have restricted treatments.

Is cost the reason?

In response to Harriet Harman in the Commons, Foreign Secretary William Hague made clear that the criteria for restrictions should be clinical and not financial. So the issue here is whether GP Magazine's study actually provides evidence of costs being a factor in these decisions.

Looking through the responses, there are some indications that savings are expected as a result of restricting treatment. NHS Warwickshire estimated they would save £2.25 million as a result of their restrictive measures and just over £1 million was the identified in savings for Oxfordshire.

However these examples aren't definite proof that cost was a factor in in these Trust's decision to restrict some of their referrals. The PCTs do provide some defence of their policies on this. NHS Cornwall and Isles of Scilly claims its restrictions were made on clincial grounds:

"In order to ensure that good quality services are available to those patients with the greatest need, it is necessary to restrict the funding of procedures which have limited or no clinical benefit. These procedures may also be referred to as low priority treatments."

NHS South West London justifies the rationale for their own policy on restricting Bariatric surgery for those with a Body Mass Index (BMI) over 35 in terms of the national guidance on the issue:

"NICE (the National Institute for Clinical Excellence) guidance suggests that bariatric surgery is recommended as a treatment option for adults with a BMI >35 and a significant obesity-related co-morbidity. The proposed threshold will be re-evaluated annually."

NICE are quoted by GP Magazine as claiming that restrictions such as these are justified as "both clinically and cost effective". This might suggest that while cost savings were not the only factor in some Trust's decisions, they nevertheless played a role. 

Conclusion

The research conducted by GP Magazine is certainly thorough and merits serious attention by the Department of Health. The 90 per cent figure does however seem to be much more a matter of interpretation.

Many of the Primary Care Trusts responding to the FOI requests denied that 'restrictions' were in place and in most cases merely referred to these as 'policies' based on clinical guidance anyway. In several cases the policies undertaken by the PCTs seemed to stem from clinical rather than merely financial guidance.

In fairness to the researchers though, it does seem reasonable to conclude that cases in which the PCTs offered denials are essentially restrictions in all but name.

The real issue that arises however is not so much whether there are restrictions in place but whether there are restrictions as a result of intended cost-cutting by the Primary Care Trusts.

GP Magazine uncovered dozens of examples of PCTs making savings as a result of restrictive activity and, while this is not solid proof of cost being a factor in the restrictions, this could go some way to highlighting potential cases that would concern the Department of Health.