The current NHS drive to make efficiency savings has resulted in a worrying trend for commissioners to engage in unilateral action in an attempt to cut costs. Nowhere is this more apparent than in the evolution of lists of “low priority treatments”.
The practice came out of the closet when Croydon PCT published its list in 2005-06. Since then two thirds of PCTs have followed suit and drawn up their own catalogues of low clinical priority procedures.
The appeal of such lists is obvious. The London Health Observatory estimated that the NHS in London would have saved £28m-£93m in 2005-06 if access to the types of procedures which are on these lists had been limited across the capital. In 2011 the Audit Commission calculated that nationally the NHS would save £500m per year. Savings of that magnitude are appealing, but it is an approach that has not been welcomed by clinicians or patients.
In a letter in the Annals of Surgery, Royal College of Surgeons president Norman Williams raised concerns about blanket bans of operations and stated that “lists of such procedures seem to have been drawn up without publicity or consultation”. The Federation of Surgical Specialty Associations has noted overwhelming evidence of benefit to patients from some of these procedures and says the practice is blatant cost cutting. According to the Audit Commission, what consultation has taken place has been mainly with public health professionals. The commission also warned that there was no national consensus on what procedures were included on these lists, creating a postcode lottery for patients.
Blanket bans are not sanctioned by English common law. R vs North West Lancashire Health Authority ex parte A, D and G insists that there is a framework for individual appeal. NHS medical director Sir Bruce Keogh has acknowledged this and stated that blanket bans will not be considered. However the lists drawn up without appropriate consultation remain. This is in spite of the NHS Act 2006, which stipulates that PCTs have a duty of public involvement and consultation in the planning and changing of service provision.
Acting on these concerns, NHS London has been consulting with clinical advisory groups from the specialties offering “low priority” treatments. They have reached a consensus that terms such as “low priority” or “limited clinical effectiveness or value” are inappropriate because they focus on endpoints, whereas it is the clinical journey that should be discussed. Where that journey ends should depend on the clinical presentation and choice of the patient, with a clear understanding of the evidence. Focusing on evidence based pathways will reduce variations in referral and practice and understanding variation should be key in improving productivity. NHS London and clinical advisory groups are developing evidence based commissioning pathways. Representatives of the Royal College of Surgeons have presented this approach to the all party parliamentary group on patient and public involvement in health.
Pathway based commissioning is not a new concept and is not problem-free. The mere publication of nationally accepted guidelines does not remove variation in practice, and implementation remains a complex issue. A consultative process with commissioners, providers and service users is more than a legal duty; it is necessary for engagement and reduction of common cause variation. The evidence underlying these pathways also needs development and clarification by surgeons. The evolution of lists of “low priority treatments” has been made possible as many of the listed procedures have evidence that has been misinterpreted and is of variable quality. Surgeons must continue to consider the quality of their evidence, and be prepared to educate groups outside of their specialties.
Commissioning based on evidence and quality is not easy, and it is not a quick process. It requires consultation, commitment and compromise from all. If all parties accept these challenges then collaborative consultation is possible, allowing the delivery of patient-focused, quality-based healthcare for the future.