Forum topic: You have 21 days to influence a decision on rationing of NHS operations

It may have escaped your attention, but we are already nearly a third of the way through a "public consultation" about rationing NHS knee, hernia and other operations and medical procedures for Enfield residents.

The consultation period - outrageously short for such an important question - began on 1st March at a poorly advertised public meeting and finishes on 31st March.  Between now and then there will be only two more public meetings, both during the working day, one on the 22nd and the other on the 30th, in both cases at Community House in Fore Street.

The question:  Should the Enfield Clinical Commissioning Group (CCG) tighten up the criteria used to judge eligibility for knee replacements, removal of bunions, some types of breast restoration and operations for hernias?  (Just some of the procedures - see the list in the box lower down the page.)

If (or rather when) the new rules are introduced, they will be implemented by adding an extra, essentially bureaucratic, layer between GP and hospital consultants.  If a GP thinks that a patient needs a knee replacement or an operation for a prolapsed womb, their referral will first be sent to a "referral service" or "clinical assessment service", who will decide whether or not to approve the referral.  The referral service will not actually see the patient, they will process the request "on paper" (ie these days, on a computer).

The consultation document is couched in terms of benefit to patient outcomes, addressing questions such as whether it is sensible to subject the patient to the risks and unpleasantness associated with surgery or whether a "conservative" approach (eg physiotherapy) might be a better solution, or whether the pain endured by the patient is sufficiently bad to warrant an operation.

These are sensible questions that need to be asked before anyone is operated on.  But they already are, both by the GP and by the specialist at the hospital, who actually gets to examine the patient thoroughly.

What Enfield CCG's consultation really amounts to is a bid to get public buy-in to a system that will allow the CCG to ration access to these medical procedures.  Depending on how flush with funds the CCG is at any given time (and at the moment they have built up a huge "deficit"), they will relax or tighten up the criteria for approval, just like turning a tap.  If the doctor were allowed to refer the patient directly to a hospital, as at present, the specialist there would make the decision, but purely on the basis of clinical need.

The consultation questionnaire asks about each of the individual operations or procedures.  In most cases, a layperson would have difficulty answering, and in fact there is an option to say that you don't really understand.  A likely outcome therefore is that the CCG will be able to conclude that the public would prefer to leave it to the experts to decide.  But, as I've already said, the end result will be that the experts (the hospital specialists) will be elbowed out of the way by the bean counters.