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New wave of postcode rationing as CCGs struggle to balance books

Doctors’ individual funding requests in England surge by 47% in four years

Caroline White

Wednesday, 05 July 2017

Postcode rationing is on the rise again as clinical commissioning groups (CCGs) struggle to balance their books, reveals an investigation* by The BMJ.

Patients across England are being denied access to routine care that just a few months ago would have been granted without question, increasingly forcing doctors to plead with commissioners to make an exception on their behalf, it shows.**

The investigation, which draws on Freedom of Information data from 169 CCGs in England, reveals a recent surge in the number of individual funding requests (IFRs) submitted by doctors for treatments that are no longer routinely funded locally.

The data show that the overall number of IFRs received by CCGs in England has jumped by 47% in the past four years. Requests over the past 12 months alone have shot up more than 20% from 60,400 to 73,900, suggesting that CCGs are under increasing financial pressure.

There is substantial variation around the country, but the types of treatment being restricted include cataract removal, hip and knee replacements, and mental health care.

The total number of IFRs for cataract removal in England rose from 359 (1.6% of the total) in 2013-14 to 1034 (3.4%) in 2016-17. Similarly, IFRs for hip and knee surgery went from 49 (0.2% of the total) in 2013-14 to 899 (3% of the total in 2016-17).

A consistently high number of mental health requests were made through IFR between 2013-14 and 2016-17, despite a concerted government push to boost access to mental health care during this period.

Stephen Cannon, vice president of the Royal College of Surgeons, suggested that commissioners were misguidedly imposing restrictions on some treatments to save money to the detriment of patients.

Just over half (52%) of the requests made in 2016-17 were approved. But the sharp increase in the overall number means that thousands more patients are being turned down for funding every year, while many others are forced to wait for their treatment while their request is considered.

Richard Vautrey, a GP in Leeds and deputy chair of the BMA’s GP committee, called for “an open and honest discussion” on rationing. He urged NHS England to set out clear guidelines on which treatments should be routinely available and which should require an IFR.

“It's clearly unfair for patients to be subjected to this postcode rationing and it also adds further to GPs' workload as they are called on to provide more and more evidence to support each application,” he said.

But Julie Wood, who heads up NHS Clinical Commissioners (NHSCC), which represents CCGs, insisted that commissioners had to make “difficult decisions” over which services to fund.

“Unfortunately the NHS does not have unlimited resources and ensuring patients get high quality care against a backdrop of spiralling demand and increasing financial pressures is one of the biggest issues CCGs face,” she explained.

NHSCC is holding a joint event today with health think tank the King’s Fund for commissioners and providers from the NHS and local government, to explore the key factors to consider when making “difficult commissioning decisions.”


* Iacobucci G. Pressure on NHS finances drives new wave of postcode rationing. BMJ 2017;358:j3190
** Iacobucci G. Exceptional requests for care surge as rationing deepens. BMJ 2017;358:j3188

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