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Please don't believe everything you read Alex in the newspapers.
Our problem is that we in public health in PCT land don't have a voice in the media.
Those who have a loud voice which the media always pick up, are those of the hospital clinicians and the patients.
So what is happening now is that the PCTs having written up the cataract policies and having become much wiser to the gaming that goes on in provider territory, they have also written it into their contracts with the providers that if regular clinical audits pick up the fact that they have operated on patients outside the visual acuity range written in the surgical threshold policy for cataracts, they will not pay the provider.
Now a patient comes to the clinican with a very early cataract, and the clinican tells the patient 'You have a cataract, it can be operated on, but I'm not allowed to operate on you because the PCT won't let me.' What do you think the patient will do? S/he will be enraged and rush off to the press and vent his/her grievances as to how the NHS is rationing cataract ops. At no point has the clinician explained to the patient that 'it is no use operating on your early cataract now, because the healthgain is very minimal/marginal, so let's wait a little while longer until your cataract progresses to blah blah blah'.
In relation to tonsillectomies, one of my public health consultant colleagues recently audited the tonsilllectomies done at his local DGH. To his utter surprise, he found one ENT consultant had operated on 146 tonsils in one year. On closer inspection of the audit findings, he found that the reason the consultant had operated on 146 young patients was because in each and every one of them he had positively ticked off the box in the PCT policy which asked whether he thought the tonsils had a chance of being malignant (it was a surgical threshold for tonsillectomy). This is absurd. The clinician was obviously gaming the system because the incidence of malignancy in tonsillectomies in children under 5 is 0.3%. Therefore, if he had seen 1000 tonsils in his OPD in one year, only 3 of them would have been malignant. By operating on 146 patients, he was trying to say that he was seeing 50000 tonsillectomies in one year!! When he was confronted with this evidence by the DPH of the PCT, he went off in a huff and gave an interview to the local paper that he was being harassed by the PCT because he was only doing his job of looking after his patients and the PCT was trying to ration tonsillectomies because of money. This was duly reported by the local newspaper, which  never even bothered to publish the legitimate viewpoint of the PCT.
Regards,
Ash
 
From: Alex Scott-Samuel <[log in to unmask]>
To: [log in to unmask]
Sent: Monday, 1 August 2011, 21:14
Subject: Re: "Reducing spending on low clinical value treatments"

Stories such as this one suggest the situation has gone beyond that which you describe Ash:

http://www.independent.co.uk/life-style/health-and-families/health-news/cataracts-hips-knees-and-tonsils-nhs-begins-rationing-operations-2327268.html

The unnecessary invention of commissioning / purchasing was solely about developing a commercial market in health care. Public health doctors who enjoy clinical epidemiology should work in hospital based teams with clinicians - who should have the final say in clinical decisions. Public health doctors who enjoy public health should work in properly funded local authorities

Alex

On 01/08/2011 20:22, Ash Paul wrote:
Dear Alex,
If you read the actual policies on catatracts and hips and knee replacements that have been written up, what they reflect are the evidenced-based thresholds at which they should be done and where performing those operations will actually bring healthgain to the patient.  Commissioners should be spending money in buying healthgain for their population, not in buying health services.
The policies do NOT restrict any of these ops, they attempt to set surgical thresholds so that unnecessary ops are not provided on the NHS.
Therefore if you have the start of a cataract, it makes no sense just to jump in and operate on the patient straightaway because the evidence states that the healthgain is marginal. 6/12 visual acuity is 50% of the visual acuity of a so-called normal eye at 6/6 vision (but it is important to realise that that 6/12 eye vision does NOT mean that it is 50% less effective than a 6/6 eye vision, a 6/12 vision eye means that it is still 85% as effective as the 6/6 eye vision). The PCTs have tried to redefine at what level of visual acuity is there actually significant healthgain if the catarct op is performed, and at no point have they said that cataract ops are being stopped.
Similar is the case for hip and knee replacements.
Regards,
Ash
From: Alex Scott-Samuel <[log in to unmask]>
To: [log in to unmask]
Sent: Monday, 1 August 2011, 19:39
Subject: Re: "Reducing spending on low clinical value treatments"

Thanks for your letter Ash. If I was the kind of academic you presume, I would I am sure subject it to discourse analysis. However, I am the kind of academic who, far from having 'no practical knowledge of working at the coal face of the NHS', possessed 16 years experience as an NHS public health consultant prior to entering academe. This may explain why I defend the NHS so strongly against those who attack its fundamental principles - including the last Labour government, whose odious and spurious privatisations I have strenuously opposed since their commencement in 2000.

As for EBM, I remain unaware of the evidence suggesting that cataracts and hip and knee replacements are of low clinical priority. And if you inspect the letters in the Journal of Public Health for December 1979, you will find Muir Gray explaining - in response to my paper The Politics of Health, why it is inappropriate for public health doctors to engage in political advocacy - a view I continue to reject.

With respect, Alex


On 01/08/2011 16:36, Ash Paul wrote:
Dear Alex,
You might be interested to know that Sir Muir Gray, the Guru of EBM is the Head of of the QIPP 'RightCare' Workstream, and as a consultant in public health medicine with a specialty interest in evidenced-based health services commissioning, I too am proud to be associated closely with the workstream. I moderate a UK wide public health health services commissioning network which consists of more than 270 consultants in public health who are all specialists in evidenced-based health services commissioning.
While it would be too much to go into all the details of the QIP Workstream, can I add that that if if left-leaning academics like you (who have no practical knowledge of working at the coal face of the NHS and of dealing with tight NHS finances) had supported us when we first put such evidenced-based proposals to the then Labour government to contain burgeoning NHS costs and transfer the savings to reducing health inequalities, we wouldn't have been in such sh-t now. The problem with Labour is that they always speak the right words on reducing health inequalities but they do precious little practically in putting their words where their mouth is, especially where the NHS is concerned. Instead of supporting evidenced-based care (which has to be affordable), Labour pandered to the likes of big pharma and the medical device manufacturers (300 million on setting up 3 proton beam therapy machines to treat 4500 cases, for which there is hardly any robust evidence-base) and the healthcare wants of the vociferous, voluble, well-connected, well-heeled and literate middle class whose votes they were desperately seeking. Today we are reaping the seeds of what Labour has sowed!!! And you all call yourselves supporters of the poor, I say 'shame on you armchair academics'!!!!
The NHS is free for those at the point of healthcare need, NOT at the point of healthcare wants. Labour found it very difficult to make difficult and unpopular prioritisation choices and so now we have a proliferation of healthcare wants, not needs, and the NHS cannot afford it any more.
You might like to read a recent JAMA article that I have co-authored with an eminent american Prof of Oncology and EBM on 'From Efficacy to Effectiveness in the face of uncertainty: indication creep and prevention creep'
I am willing to engage in a full public debate with you or with anybody else on the merits of health care wants versus health care needs, if you want to.
Kind regards,
 
Ash
Dr Ash Paul
Medical Director
NHS Bedfordshire
21 Kimbolton Road
Bedford
MK40 2AW
Tel no: 01234897224
Email: [log in to unmask]
 


From: Alex Scott-Samuel <[log in to unmask]>
To: [log in to unmask]
Sent: Monday, 1 August 2011, 15:20
Subject: "Reducing spending on low clinical value treatments"

I have only just come across this document, which is presumably one of the triggers for the unpublicised, un-consulted-on clinical rationing taking place in many areas. While its encouragement to eliminate ineffective treatments makes total sense, its assertions on treatments with 'a close benefit or risk balance in mild cases' seem questionable. These include cataract surgery and joint replacements.

I would be very interested in your knowledge on how this is being applied nationally, often I gather, in conjunction with "the ‘right care’ workstream" of the so-called QIPP programme.

Thanks, Alex


Audit Commission. Reducing spending on low clinical value treatments. Health Briefing, April 2011.

http://www.audit-commission.gov.uk/sitecollectiondocuments/downloads/20110414reducingexpenditure.pdf



-- 
*******************************************************************
Dr Alex Scott-Samuel 
EQUAL (Equity in Health Research and Development Unit) 
Department of Public Health and Policy 
University of Liverpool 
Whelan Building 
Quadrangle 
Liverpool 
L69 3GB
UK
 
Tel  (+44)151-794-5569 
Fax  (+44)151-794-5588 
 
http://pcwww.liv.ac.uk/~alexss 
e-mail  [log in to unmask] 
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-- 
*******************************************************************
Dr Alex Scott-Samuel 
EQUAL (Equity in Health Research and Development Unit) 
Department of Public Health and Policy 
University of Liverpool 
Whelan Building 
Quadrangle 
Liverpool 
L69 3GB
UK
 
Tel  (+44)151-794-5569 
Fax  (+44)151-794-5588 
 
http://pcwww.liv.ac.uk/~alexss 
e-mail  [log in to unmask] 
*********************************************************************