There’s a painful list of conditions we are no longer treating on the NHS

http://www.theguardian.com/society/2015/apr/07/list-conditions-cant-treat-nhs-gps

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I first told a patient a few years ago that it was unlikely that the NHS would pay for her varicose veins to be treated, this was met with incredulity. I stumbled over my words, somehow feeling responsible for this failure to offer what felt like a lifeline to a patient who was a dancer and a nurse. There have been many similar conversations since, but now I see resigned acceptance when I tell people that their painful ganglion cyst will not be removed or there is likely to be a refusal of tonsillectomy. Exceptional funding criteria apply for many of these “non-essential treatments” but is difficult to access. Some applications are evidence-based, others less so. The policymakers can sugar-coat this, but in reality many of these decisions are down to costs.

I accept that we have finite amount of money and cannot fund everything – no matter how heart-wrenching a patient’s experience. Urgent care, outpatient waiting times, cancer diagnoses and management should be some of our priorities. But what is disappointing, is that there is no consistency in which treatments are rationed. The existence of clinical commissioning groups (CCGs) means that we also see a variation in the funding of service provision across the country. It is easier, for example, to get carpal tunnel surgery in some CCG areas in England compared to others. This surgery has been shown to have modest benefit in patients, but non-surgical interventions such as wearing splints for many weeks are not always helpful. Many patients have to go through hoops before they can be treated surgically, and delays can sometimes impair long-term recovery, resulting in more lost work days and increased cost to the individual and state in the long run.

For many treatments, patients are now waiting substantially longer than the 18-week target from patient being referred by their GP to being seen in clinics. This is frustrating and often distressing for patients who may be debilitated or in pain. It also adds pressure to primary care: with GPs holding patients who ideally need to be treated in secondary care. Jemma is a patient of mine with chronic back pain, for which she has previously been treated by the hospital spinal team. She has now been waiting many months to be seen in its pain clinic. She takes a significant number of tablets including strong opioids, anti-inflammatory and neuropathic medications. She is only 38, but cannot drive, work or walk properly. She is increasingly feeling desperate, low in mood and tearful, and needs fortnightly GP appointments to offer her psychological support.

It can take five months to see a physiotherapist, which is unacceptable when patients often have pain and limited joint function. Mental health services are so overwhelmed that unless referrals have suicidal tendencies, it can take a year to see a psychiatrist. Mental health patients should ideally be managed in primary care but only if there is adequate specialist input from counsellors, psychologists and consultants. However, there is a long wait for our patients to see a counsellor, so instead, we see them fortnightly to offer support.

Many CCGs are looking to triage some or all of their GP referrals, to limit how many cases are sent to hospitals. Dermatology, ENT, musculoskeletal medicine, neurology, gynaecology and cardiology are some of the many overstretched specialties. While we can limit some referrals through better education of GPs – we all have our blind spots – for others this only wastes time, for example when a GP has already exhausted all treatments in the community and needs a specialist opinion.

Politicians have passed on the poisoned chalice of rationing to commissioners, but they must still remain accountable for unevidenced cost-cutting rationing of services, increased waiting times and regional variations that are impacting on long-term health and making us question whether we still have a national health service. Yes, we can hold more patients and refer less, but as I have said before, only if we have easy access to community physiotherapists, falls nurses, counsellors, community psychiatric nurses, and many more who are integral to what we provide.