Health chiefs in the West Midlands have caused outrage by proposing to ration hip and knee replacements according to pain.

They want to save money by reducing the number of operations and they’re they introducing new criteria. Potential patients may have to wait until the pain is affecting their daily life or their ability to sleep before they get treatment. The Royal College of Surgeons and campaigners for the elderly are outraged. But the move is simply a reaction to the shortage of funds. Is this sort of rationing justified or do we need to find new ways of tackling the problem of shortage of cash in the NHS?

Three clinical commissioning groups, run by GPs in Redditch and Bromsgrove, South Worcestershire and Wyre Forest are trying to save about £2.1m a year by reducing the number of hip replacement operations by 12% and knee replacement operations by 19%, a total of about 350 operations. In England and Wales as a whole around 160,000 such operations are carried out each year and the figure has been rising by about 8% a year as the population ages. But the number of operations conducted on people under 60 has also been rising: by 76% to 18,000 a year over the last decade. To some extent this rise in the number of younger patients has been caused by the obesity epidemic. There’s no sign of that ending any time soon, so the expectation is that the demand for hip and knee replacements among middle-aged people can only grow.

The West Midlands CCGs are using a technique known as the Oxford scoring system which is based on levels of pain and discomfort to assess whose needs for replacement surgery are greatest. Inevitably this means that people needing a new knee or hip will have to endure greater pain before getting them. The Health Service Journal reports this as meaning that only cases of ‘severe to the upper end of moderate’ pain would be treated and that ‘a patient’s pain and disability should be sufficiently severe that it interferes with the patient’s daily life and/or ability to sleep.’ It has also been suggested that obese patients with a body/mass index of 35 or over should be required to lose 10% of their weight before being treated.

Julie Wood, the chief executive of the NHS Clinical Commissioners, said: ‘Clearly the NHS doesn’t have unlimited resources, and it has to ensure that patients get the best possible care against a backdrop of spiralling demand and increasing financial pressures’. She added: ‘On a daily basis commissioners are going to be forced to be making difficult decisions that balance the needs of the individual against those of the wider population.’

But Paul Green of Saga did not agree. He said: ‘To suggest that it is acceptable for people to have to wait until they are unable to sleep before they are eligible for an operation is an outrage. How would these people feel if that was their mother or father or grandparent?’

Stephen Cannon, vice-president of the Royal College of Surgeons, took a similar view. He said that the ‘decision to restrict access to NHS care, based on arbitrary pain and disability thresholds, is alarming.’ He went on: ‘It is right to look at alternatives to surgery but this decision should be based on surgical assessment, not financial pressures.’ He added that the whole approach was also short-sighted because it ‘overlooks the longer-term impact on patients of delayed treatment, prolonged pain and potentially higher costs of treatment. For example, patients affected by these changes may require additional pain relief medication and may still require surgery further down the line.’ He pointed out too that with different CCGs taking different decisions, there would be a postcode lotter: ‘It is absolutely iniquitous that you have this sort of system.’

But to many others it seems rationing of some sort is unavoidable in a health system where treatment is free at the point of use and where demand is rocketing as a result of an ageing population, innovations in health treatments and where there is a growing problem arising from the unhealthy lifestyles of many younger people. They say demand has to be curbed. If, for example, younger people are presenting themselves for new knees and hips because they have lived a life without taking exercise and allowing themselves to become obese at an early age, then it is right that they should be required to do something about their lifestyles, like reduce their weight, before they can have access to the NHS’s scarce resources.

But bwhat if  this risks discriminating against people whose unhealthy lifestyles may not be their own fault but rather the result of how they have been brought up and the circumstances in which they now live? The NHS could have saved a lot of money by refusing to treat people who smoke, for example, but it has always refused to take such a punitive line on the grounds that smoking can become an addiction and therefore something that needs treatment not censure.

On this view, avoiding the sort of choices the West Midlands CCGs have found themselves having to make can be achieved only by increasing the resources of the NHS. But how should this be done? One option is to increase the charges made for certain sorts of treatment. But that risks undermining the principle of the NHS being free at the point of use. And if charges are taken too far, it’s argued, some treatments become available only to the well-off.

The other obvious approach is simply to raise more cash through taxes to finance the NHS. A lot more. It can’t be done simply by ‘taxing the rich’: there aren’t enough rich people to make the sums add up. It means that the tax levels for the great majority of people would have to rise. Some argue that the standard rate of income tax, at 20%, is low by recent historical standards and could be raised. Others say we need a special health tax levied on income so that people can see that their higher taxes are going on the NHS. They argue too that it is inevitable that the proportion of our income going on health spending should rise as we become a richer country with an ageing population and point out that we spend far less, proportionately, on health than many other comparable countries do.

What is clear is that something has to give. Either we accept the sort of rationing that has led to the controversy over hip replacements on the West Midlands, or we cough up more money.

What do you think we should do? Is the decision of the West Midlands CCGs to save money by rationing hip and knee replacements according to pain justifiable? And if it isn’t, how should our society deal with the NHS’s shortage of money?

Let us know what you think.  

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