By George Berger (@Georgeberger )
On 3 October 2014 NHS England (henceforth, E) published an online document that purports to describe its 2015/16 plans for prioritising ‘Prescribed Specialised Services’ [1]. E’s stated goal is to meet ‘the central challenge of improving patient outcomes whilst constraining levels of spend to match available resources’ (p.5). As we are never told what ‘improve patient outcomes’ means, the document is imprecise, for there are no ordered priority lists, and crucial services are incompletely described. Indeed, it’s not about prioritising anything; it concerns three ways of delegating responsibility for providing some or all services that are now (2014) prescribed by E in one unordered package. Readers familiar with ‘new public management,’ the NHS pricing schemes within HRG (healthcare resource groups) [2] and a bit of medical science might well notice these defects. Is this a medically acceptable way to publicly announce a scheme for a near-future NHS? If so, why were we underinformed? If not, why was it put online? Surely, more explanation should have been added.
The package is to be split into three parts. It is claimed that this will enable ‘investment and disinvestment’ (p.5) of money, where a disinvestment is an unannounced privatising cut, a devolution of financial responsibility to Clinical Commissioning Groups (CCG). In the near future then, E might well simply take your money and distribute some or all it to the CCGs, which will finance care within their own service and provision limits, priorities and whims, hence at least partially ending prescription [3].
First, some wheelchair services and outpatient nervous system referrals ‘should no longer be commissioned by NHS England and should be reflected in CCGs contracts from April 2015.’ Second, E will handle, e.g., ‘some adult oesophageal procedures’ from April 2015. Third, E ‘has recommended’ [my italics] that some renal dialysis procedures and all surgery for morbid obesity be disinvested (all on p. 7). We have then, a desire, a decision and a suggestion. These are parts of a ‘[s]trategic direction’ for change. Details will appear in ‘a Five Year Forward View in the autumn [2014]’ (p. 6). They will let E ‘work with a smaller number of leading hospitals,’ as ‘long term partners’, given ‘the medium term financial context within which the whole NHS is having to operate’ (p. 6). Other changes should be driven by clinical developments in this period, for example, the use of ‘a reduced number of fractions’ in ‘Radiotherapy for Prostate Cancer’ (p. 21).
One source of imprecision is the use of ‘some.’ Some wheelchair services suggests that either the planners have not yet decided which such services to disinvest, or that they do not wish to tell us which wheelchair services they have decided to disinvest. Perhaps there are other reasons. We should be told, so that one can prepare for the financial change in time. This criticism also holds for some renal dialysis procedures. The dialysis announcement scared many. Shouldn’t the responsible authority have been more precise? Why weren’t they? Why is this disinvestment recommended, i.e. suggested quite strongly? Again, some adult oesophageal procedures is imprecise and in fact potentially dangerous. Acid reflux (a.k.a. heartburn) can cause a cellular windpipe change called Barrett’s oesophagus. It is precancerous, can become malignant and is often deadly. Why was this opportunity to inform us missed?
My final textual critique is that a reduced number of fractions has frightened many, owing to its medical incompleteness. Will men with prostate cancer diagnosed next year be short-changed? Won’t this increase the number of deaths from this illness, starting next year? Not necessarily. Each case of prostate cancer is assigned to one of four or five ‘risk strata,’ from very low to very high risk. A fraction is one session of radiotherapy, usually an exposure to a directed stream of photons whose intensity and duration partly depends on the risk stratum and type of apparatus. The most effective immediate outcome depends on these factors and the number of fractions needed to expose the patient to a clinically adequate total dose. This dose lies within a small, well-known, range. Thus, a radiation oncologist can reduce the number of fractions used in one case, if he/she decides, for example, to increase the intensity of all or some fractions (I omit some details for clarity, without loss of accuracy). On the other hand, since radiotherapy devices are becoming ever more expensive, the planners might wish to cut costs by indeed short-changing some men. Would they admit that? I doubt it and am worried, as I know that radiotherapy is big business throughout the USA and the UK, at least. Is male health less important to the planners than the profits dished out to medical equipment giants like General Electric and Lockheed Martin? Will Virgin have a hand in this? Do they now?
In my opinion a public medical document should have an appendix that explains details such as these, preferably with references. These basics are not rocket science. As I do not know why clarification is lacking, I cannot answer the title question. Perhaps E wants to test public opinion by provoking reactions. These might well be used to write actual policy, by judging which sorts and degrees of disinvestment and prioritisation E can get away with. The you can trust me facial expression of the woman on the document’s cover elicits my extreme suspicion. What is the purpose of the photograph? Why give an NHS Intranet address for Commissioning Intentions posted on the Internet? [4].
NOTES
- https://www.england.nhs.uk/wp-content/uploads/2014/10/comms-intents-2015-16.pdf.
- https://www.hscic.gov.uk/casemix/costing
- https://www.opendemocracy.net/ournhs/caroline-molloy/devon-canary-in-nhs-coalmine is important. See its reference to Mark Britnell.
- I learned about the DRG system from the excellent and disturbing Swedish book by Maciej Zaremba, Patientens Pris: ett reportage om den svenska sjukvården (Weyler Förlag, 2013).
This translates as The Patient’s Price: a report on Swedish healthcare. Its first four chapters are here, from the daily that published them: https://www.dn.se/kultur-noje/hur-mycket-ar-en-patient-vard/. The Five Year Forward document is here: https://www.england.nhs.uk/ourwork/futurenhs/.
