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Open letter accuses health trusts of letting public down by branding some elective surgery ‘lower value’ Read the FSSA’s letter Growing numbers of patients are being wrongly denied a new hip, a weight loss operation or even cancer treatment because of NHS cost-cutting, the leaders of Britain’s surgeons have warned. Increasing rationing of operations is forcing patients to endure pain, injury or disability because NHS primary care trusts (PCTs) are ignoring evidence about the effectiveness of certain treatments simply to balance their books. The warning from the Federation of Surgical Specialty Associations (FSSA), which represents the nine major types of surgeon in the UK, is in an open letter passed to the Guardian. It accuses trusts of letting down needy patients by branding forms of elective surgery as of limited clinical value in order to help them cope with the NHS’s tough financial climate. The FSSA, which represents about 15,000 surgeons, says it is “concerned that lists of surgical procedures and interventions, deemed of low clinical effectiveness or of ‘lower value’, are being used by PCTs to limit access to certain procedures … Review of the lists reveals that there is little or no evidence to support the view that many of the procedures are of limited value to individual patients”. The unprecedented statement goes on: “For example, the lists include types of hip, spinal, ENT [ear, nose and throat], dental, bariatric [obesity] and cancer surgery for which there is overwhelming evidence of benefit. The only justification for these lists can be that they are a means of reducing expenditure at a time when the NHS faces a financial crisis.” The surgeons’ move highlights the fact that PCTs across England are increasingly delaying or denying patients access to surgery to repair a hernia, replace an arthritic hip or knee, and remove cataracts, infected tonsils, gallstones, wisdom teeth, adenoids and varicose veins. Some are even restricting the number of patients who can have a hysterectomy or have their baby in a planned caesarean section. Surgeons, heath charities and patients’ groups are increasingly frustrated that PCTs are introducing what they regard as arbitrary lists of treatments of supposedly low or no clinical value despite medical evidence that many help relieve patients’ symptoms. The joint statement says the FSSA is concerned the evidence for the lists is “very poor and it is therefore inappropriate for them to be used to determine patient care without the involvement of the Specialty Associations”. Many PCTs, which commission and pay for healthcare, are struggling with the fact that, after a decade of budget increases averaging 7% a year, the NHS in England has to find £20bn in “efficiency savings” by 2015 and cope with close to zero annual rises during the same period. While they are rationing care, many hospitals and ambulance services are shedding staff. Peter Kay, chairman of the British Orthopaedic Association (BOA), the largest of the letter’s nine signatories and to which 4,000 surgeons belong, said: “This growing rationing is unfair because it is leaving more and more patients in pain, discomfort and misery. But it’s also a false economy because it stops some people from getting back to work and costs the state unnecessarily in welfare benefits for others. Plus conditions like arthritic knees, hernias and varicose veins don’t get better by waiting – they get worse and can cost more to treat when the patient is eventually treated.” Kay said he deplored refusing senior citizens a new hip or knee. “Older people are easy targets. Arthritis means they may be hobbling around and become virtual prisoners in their own home, dependent on friends and relatives, if rationing means they do not get the operation they need.” Surgeons’ leaders have been talking to the Department of Health (DH) since last autumn about the increasing use of the lists. The DH has voiced concern but so far failed to intervene or produce a single national list for England of treatments which can be restricted because agreed evidence shows they have limited effect. “Many tens of thousands” of patients, and potentially as many as 200,000 a year, are affected by the rationing, Kay believes. “This all makes a mockery of [health secretary] Andrew Lansley’s mantra that for patients, there should be ‘no decision about me without me’, as patients are not involved and PCTs aren’t assessing the severity of their condition.” Lansley’s radical reorganisation of the NHS is partly to blame, Kay said. “PCTs are doing anything they can to balance their books by the time that the new GP commissioning consortiums take over in 2013. I think that’s what’s driving this.” The trend would exacerbate existing postcode lotteries in the availability of certain treatments, he added . Last week the Audit Commission said PCTs could save up to £500m a year by carrying out far fewer operations which it said had limited clinical use. The King’s Fund thinktank also urged the NHS in some places to stop removing so many children’s tonsils or varicose veins in order to help it meet what it called “the biggest financial challenge in its history”. The Patients Association has been receiving a growing number of calls from patients who have had elective surgery delayed or denied. One with an arthritic knee told them in January: “I have been to my GP begging for them to speed up my knee replacement, but he says there is no funding and I will have to wait until April. I can’t do anything, not even go to the shops, and it’s so painful if I put any weight on it I scream.” The health department said: “We welcome the leadership of top surgeons and value their commitment. We share their passion for the NHS. We have invested an extra £11.5bn in the NHS and have been clear there is no excuse for waiting times to increase.” The shadow health secretary, John Healey, said: “Short-term decisions are being taken across the health service, in part because of David Cameron’s NHS reorganisation plans. Faced with a huge upheaval and greater financial uncertainty, PCTs are now cutting back on services. People are starting to see the NHS go backwards again under the Tories, with waiting times rising, operations blocked and frontline posts going. So much for David Cameron’s promise to ‘protect’ the NHS.” On Sunday, in a Sky interview, Cameron said that there would be “proper and substantive changes” to the bill setting up the new GP-led consortiums at the end of the two-month pause in its passage through parliament. Stressing that he took “absolute responsibility” for the legislation, Cameron signalled that the fresh consultation now taking place would lead to the membership of the consortiums being widened. NHS Health policy Public sector cuts Public services policy Public finance Health Andrew Lansley David Cameron Liberal-Conservative coalition Denis Campbell guardian.co.uk