Treatment restrictions such as bans on “low priority” procedures or tough referral thresholds are now common across the NHS, HSJ has established.

The moves come as fears grow about primary care trusts’ end of year financial position. Delaying referrals by just a few weeks offers PCTs significant savings in this financial year - but could hit hospital trust revenues.

Common “demand management” techniques include: increasing thresholds for treatment so fewer patients qualify; stopping some non-urgent procedures until the new financial year; deliberately extending waiting times; and stopping all automatic funding for procedures deemed “low priority” (see box, opposite).

Many PCTs do have a policy of reviewing exceptions to any restrictions. However, NHS Confederation acting chief executive Nigel Edwards told HSJ there was a risk that some restrictions could be imposed “with a lack of subtlety and lack of clinical involvement”.

PCTs can make significant savings by imposing restrictions, but they could create a bulge of patients seeking treatment in April.

Mr Edwards said some of the restrictions were “simply about getting financial control back”, but he warned: “Treatment restrictions simply delay the evil day. They push things into the next financial year.”

PCT Network director David Stout also warned restrictions could push waiting times for some treatments beyond the 18 weeks enshrined in the NHS constitution. However, PCTs hope that by delaying the initial referral for the treatment, they will avoid patients breaching the limit.

Some PCTs have already moved to take radical action to control activity over the last couple of months but many others are thought to be considering such action.

NHS Alliance joint GP commissioning lead Amit Bhargava said the rise in restrictions was “happening across the country”. PCTs that have already introduced restrictions told HSJ they have received queries from many others about what they have done and how.

NHS Portsmouth City is making it harder for patients to qualify for treatment by lowering the BMI patients need to reach before they can receive knee and hip replacements. The PCT has calculated that around 100 patients a year will no longer qualify for operations as a result, saving around £500,000.

Elsewhere - in NHS West Kent and NHS Warwickshire, for example - PCTs have stopped funding IVF apart from exceptional cases.

NHS Warwickshire is also banning consultant-to-consultant referrals, requiring patients to return to their GP instead of being referred within the acute system.

Although both Warwickshire and East Kent have safeguards to ensure patients needing urgent care can get treatment and GPs can make a case for other patients to be seen earlier, Warwickshire professional executive committee chair Francis Campbell said few would benefit from those measures.

Other PCTs are requiring that non-urgent referrals are now pre-approved if they are to be funded. NHS Surrey plans to demand a pre-approval system for all routine surgery and NHS Hertfordshire has required prior approval for some conditions since November 2009, which it says has led to about 6 per cent of assessed cases not being approved.

Hospital trusts stand to lose out from many of these changes and some have already expressed concern. NHS Warrington has asked GPs to delay non-urgent referrals, but a spokesman for Warrington and Halton Hospitals Foundation Trust warned a rush of patients referred eight weeks later than normal would affect its revenue.

“We will be seeking to ensure that any actions taken by the PCT do not have a detrimental impact on our own financial position,” he said.

But many PCTs say referrals have soared this year and they are trying to reassert control over the amount they spend. Urgent or emergency cases will still be seen rapidly and there will be opportunities for GPs and patients to argue that exceptions should be made and, in the case of IVF, treatment will not be delayed if a woman is approaching 40.

Many of the changes introduced by PCTs require GPs to make decisions for the general good of the local health economy rather than for the benefit of individual patients.

New Royal College of GPs chair Clare Gerada has warned GPs could come under pressure from patients if they were seen as denying them treatment.

She told HSJ that although some of the treatments being restricted were of limited or no clinical effectiveness, she would be concerned if services were being curtailed or reduced because of financial circumstances.

“I think a lot of places will pick off IVF, but there is great clinical value in IVF,” Dr Gerada said.

She added: “There are things a humane health service should provide.”

NHS Cambridgeshire chief executive Paul Zollinger-Read said his PCT had not needed to adjust thresholds or introduce restrictions for financial reasons. But it had invested in peer review, with GPs talking through referrals with one another.

“It is not sustainable stopping procedures,” he said. “People just come back.

“If you want to manage the money you have to manage the variability [in quality]. We are nowhere near doing that properly.”

PCT restriction plans

NHS Warrington Suspended all IVF treatment for a year from July. This is thought likely to affect around 40 couples. The PCT has now asked GPs to delay referrals for non-urgent elective cases for eight weeks, with potential savings of under £2m. It is still assessing a number of other restrictions which could include automatic delaying of treatment for eight weeks for all non-urgent cases, restrictions on other procedures, and even suspending choice of provider. The PCT says it has to deliver £8m of cost improvements in under six months.

NHS West Kent GPs asked to defer IVF and gender reassignment and bariatric surgery for remainder of financial year - although the PCT says the number of people affected will be “in the tens rather than hundreds”. It must save £29m - £13m of which has already been delivered - but increased demand is hitting finances. 

NHS Eastern and Coastal Kent Stopping “low priority” referrals over the winter and extending waiting times for non-urgent procedures by three weeks to 16 weeks. PCT says it is facing a potential £19m overspend.

NHS Warwickshire Stopping funding of procedures with little clinical benefit (such as acupuncture) and asking GPs not to refer non-urgent patients for a wide range of procedures, including elective orthopaedic surgery and IVF. No consultant to consultant referrals. The PCT hopes to save £5m in this financial year by these restrictions.

NHS Portsmouth City New BMI restrictions for hip and knee replacement patients, second cataract operations not normally funded, and patients requiring carpel tunnel surgery to be offered other treatments first.

NHS Bury Introduced temporary suspension of some procedures, including IVF, in September and tightened up criteria for hip and knee replacements and cataract surgery to cut £1.3m monthly overspend. Admits that “contract control” with secondary care providers will mean some patients will wait longer for treatment.

NHS Surrey Talking to GPs about delaying treatment for smokers until they have undergone a stop smoking course; introducing pre-approval procedures for all routine surgery, stopping new IVF treatment for a year, and not funding many procedures such as acupuncture, excess skin removal and cosmetic procedures. The PCT says that without action it is heading for a £35m overspend.

Lancashire PCTs Reviewing what treatments on its low priority list it is to offer. Initial reviews are likely to be completed by next April with a second batch of procedures assessed by March 2012.

NHS South West Essex One of the most extensive plans, aimed at heading off a £43m overspend. For 2010-11, it is extending waiting times and stopping IVF, stopping private diagnostics, reviewing all referrals, stopping low priority treatments and funding for some health promotion. Stopping non-urgent elective procedures for four weeks and delaying outpatient appointments could save the PCT £8.4m in this financial year.

NHS North Yorkshire and York No new IVF for the last quarter of the year, hoping to save £200,000 through establishing referral criteria for orthopaedics and £1.5m by reducing procedures of limited clinical value. The PCT is facing a £30m overspend.

NHS Derbyshire County and NHS Derby City Introduced restrictions on funding treatments of limited clinical value. Hoping for savings of more than £1m for each PCT.

NHS Medway Referrals for IVF, bariatric and gender reassignment surgery delayed until next financial year. Treatments added to low priority list, although the PCT says this was clinically driven.

NHS Norfolk Prior approval needed for certain treatments since April, with 12 week minimum waiting time.

NHS Manchester Introduced additional thresholds for clinical care, a review of unfunded treatments and no consultant to consultant referrals in September after warnings of £14m deficit.

NHS Nottinghamshire County Reviewed limited value procedures list to include acupuncture and varicose veins. Hopes to save £500,000 a year. Like other East Midlands PCTs, stopping funding for many cosmetic procedures. 

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