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NHS Commissioning and Finance

RCS briefing paper on rationing 

This RCS briefing outlines our concern that financial pressures and policy decisions are leading to restrictions on care, or rationing policies, that disproportionately affect planned (elective) surgery. This includes operations such as hip and knee replacements or heart and brain surgery.  Since we published Smokers and overweight patients: soft targets for NHS savings? in April 2016, we have seen even harsher examples of arbitrary rationing. These broadly fall under four types of restrictions: "financial" rationing; "lifestyle" rationing; "pain threshold" rationing; and individual funding requests. 

RCS warns more than one in three areas of England restrict surgery for smokers and overweight patients

This RCS report, Smokers and overweight patients: soft targets for NHS savings?, shows that more than one in three clinical commissioning groups (CCGs) in England are delaying or denying routine surgery – such as hip and knee replacements – to smokers and overweight patients, in contravention of national clinical guidance.

RCS analysis shows growing demand for elective operations

This RCS briefing analyses the latest Hospital Episodes Statistics (HES) data to illustrate trends in the activity of various surgical procedures. The briefing shows that orthopaedic activity in particular has witnessed an increase, with a 4.7% rise in the number of hip replacement procedures and a 3.26% increase in the number of knee replacement operations. There were further increases for amputations, tonsillectomies, and interventions for varicose veins.

Bariatric surgery meanwhile saw a decline in activity. However, around half of this decline is explained by a coding area at a single hospital, making it difficult to draw any firm conclusions from the data.

Open letter to NEW Devon CCG in response to restrictions on elective surgery

The RCS composed an open letter to North, East and West (NEW) Devon CCG after the CCG imposed a number of restrictions on access to elective surgical procedures. These restrictions include requiring patients with a BMI over 35 to lose 5% of their weight prior to surgery and also requiring smokers to quit at least eight weeks before their operation.

Response to Health Select Committee inquiry on Public Expenditure (November 2014)

The RCS submitted written evidence to the Health Committee's 2014 inquiry examining public expenditure on health and social care. Our evidence sets out a number of short and medium term financial risks to the acute sector, including those arising from the Better Care Fund and the national tariff, and highlights our concerns with a number of issues, including the rationing of surgical services and the impact of financial pressures on the provision of co-ordinated care.

Is Access to Surgery a Postcode Lottery (July 2014)

Research from the RCS warned many clinical commissioning groups (CCGs) are ignoring clinical evidence in their surgical commissioning policies. For example, the report finds over a third of CCGs (44%) require patients to be in various degrees of pain and immobility (with no consistency applied across the country) or to lose weight before hip replacement surgery.

Following publication the report was discussed at Health Questions in Parliament on 17th July with Shadow Secretary of State for Health Andy Burnham highlighting the report’s findings to Health Secretary Jeremy Hunt. In response Hunt said it was “absolutely right people should follow NICE guidance, including all clinical commissioning groups”.

Access All Ages 2 (June 2014)

In this RCS and Age UK report we analysed surgery rates across England’s 211 Clinical Commissioning Groups (CCGs) for six common procedures which are known to be effective in older people. The report shows widespread variation in the rates of surgery for people aged over 65 and 75, depending on where they live. It urges commissioners to explore their data and understand why they may have higher or lower rates of surgical intervention to make sure they are providing the best health service possible for the population they serve.

Response to Health Select Committee inquiry on public expenditure (November 2013)

The RCS submitted evidence to the Health Select Committee's 2013 inquiry on public expenditure and NHS finances. In our response, we focus on our concerns about where financially-driven decisions are undermining patient safety and the quality of care. We also set out our views on how to make cost-saving measures more transparent, and what the RCS is doing to support commissioners.

Future funding of health and social care in England (July 2013)

The RCS prepared this briefing paper for a House of Lords debate on the future funding of health and social care in England, which took place on 11 July 2013. The document sets out our concerns around rationing decisions and explains how we believe service redesign can be supported without undermining patient care.

Reshaping surgical services: principles for change (January 2013)

This report makes the case for a different approach to reconfiguration from one which has been taken in the past. The RCS believes that if surgical, and indeed all medical services, are to change, then the whole pathway of care for patients must be considered.This report asserts that any discussions about reshaping surgical services must be open and transparent, and states firmly that patients should be at the centre of all decision making.

Progress in making NHS efficiency savings (January 2013)

On 14 January 2013, the Public Accounts Committee held a session on progress in making NHS efficiency savings. The College submitted a briefing to the Committee, in which it outlined its concerns with rationing decisions (around procedures such as bariatric surgery) and addressed how we believe service redesign can be supported without undermining patient care.

Governing bodies of Clinical Commissioning Groups (October 2012)

In this statement, the College suggests that the government’s legislative restrictions on the membership of CCGs’ governing bodies are both impractical and undesirable.

Age and access to surgery (October 2012)

The health service needs to adapt to a changing landscape of population demographics and, at the moment, the way in which the NHS approaches the care of older people is not keeping pace with these changes. The Royal College of Surgeons, partnered with Age UK and MHP Health Mandate, produced a report, Access all ages: Assessing the impact of age on access to surgical treatment , which looks to explore these issues and offer recommendations for change. The report was launched in October 2012, the same month a ban on age discrimination came into force in the NHS.

Following the launch, a high-level roundtable was held at the College to explore the implications of the report.

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