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Health: Treatment Rationing

Volume 771: debated on Tuesday 26 April 2016


Asked by

To ask Her Majesty’s Government what is their response to the Royal College of Surgeons report showing that Clinical Commissioning Groups are rationing treatments by the use of restrictions on routine surgery for patients who smoke or who are overweight or clinically obese.

My Lords, we would not support CCGs imposing arbitrary restrictions on patients. However, there are often sound clinical reasons for encouraging patients to lose weight or stop smoking—for example, to get the best clinical benefit from joint replacement surgery. CCGs should support patients to reduce their tobacco usage or reduce their weight and signpost them to the appropriate services. It is for CCGs to ensure that their local commissioning priorities use resources in the best interests of their patients.

My Lords, I am very grateful to the noble Lord for that Answer because it is clear that these blanket bans are nothing more than crude rationing and cause great distress to patients. Will he issue instructions to CCGs that they are not to embark on these kinds of blanket bans? Does he agree that the programmes to support weight management and smoking cessation should be part of the treatment programme rather than be used as a barrier to treatment?

Yes, my Lords. The noble Lord has quoted almost verbatim from the recommendations of the Royal College of Surgeons report, which I have in front of me. I agree with him completely.

My Lords, does the Minister agree that CCGs should be obliged to publish their evidence base for their policies? If he does not, will he say why not? Further, what recourse does a patient have to challenge their CCG when they do not receive surgical treatment because of the latter’s policies?

My Lords, the noble Lord will be aware of the Atlas of Variation, which encompasses a new programme, Right Care; it looks at variations in medical and surgical practice across different populations and tries to spot unwarranted variation. That is the best way to identify where different CCGs are not delivering the kind of care that we would expect. In view of what we have just said, I am tempted to say that where an individual does not get the treatment he expects, he should complain to his local Healthwatch. That would be one way to do it but every hospital has a PALS and he could always write to his MP. There are lots of ways in which individuals can raise concerns if they wish to do so.

As a surgeon, I had cause to cancel or delay operations on patients who were obese or were smokers, but those decisions were based on clinical grounds from the knowledge I had of the individual patient. Clinical commissioning groups can give guidance but they should not provide diktats. What assurance will the Minister give that clinical decisions will be left to those who have the best interests of the patient at heart and who know their patients?

The noble Lord has encapsulated well the recommendation of the report of the Royal College of Surgeons, which is that all decisions about individual patients should be taken on clinical grounds as they affect the particular patient.

My Lords, does the Minister accept that the reduction in expenditure on public health of £200 million a year may make it harder to reduce the prevalence of tobacco smoking and obesity, and that in these circumstances patients referred to smoking cessation courses or weight management courses may find it more difficult to get the support they need? In those circumstances, they may need more guidance and support on how to challenge the decisions of CCGs, if they are being discriminated against unfairly and in breach of national guidelines.

My Lords, the success that this country has had on smoking reduction has been pretty exceptional. The strategy on obesity that the Government will announce soon will mark a new priority in addressing the problems of obesity. I do not think there is any evidence to suggest that the reductions to which the noble Lord referred are having any discernible impact on the number of people receiving support on smoking cessation and obesity reduction before surgery.

My Lords, selective dorsal rhizotomy, the spinal injuries operation for young people with cerebral palsy, has been not only restricted but withdrawn in both England and Scotland. Numerous paediatric neurosurgeons have given testimony to the near-miraculous benefits of such surgery, which transforms the lives of young people who were previously thought to be wheelchair-bound for their lifetime to one of mobility and independent walking. Therefore, will the Government reconsider this decision, write to me and put a copy in the Library so that this issue is transparent and young people who need this surgery, and whose families are desperate for it, can have the same chance as everybody else in the National Health Service?

My Lords, I cannot answer the noble Lord’s question now, but I agree to his request to write to him and will place a copy of my letter in the Library.

Does the Minister not agree that everybody in this country must know that smoking and being overweight are bad for them? Does he not think that individuals should be encouraged to take greater personal responsibility for their health, rather than less?

There is clearly a balance between the obligations of individuals to take responsibility for themselves and the obligation of society to help people to do so. Getting that balance right has characterised the success we have had in reducing smoking in this country and which I hope we will have in reducing obesity as well.

My Lords, in relation to the reduction in smoking, last week the Government published an impact assessment of the European Union tobacco products directive, which comes into force on 20 May. Does the Minister agree with the estimate by London Economics that aspects of that directive, including the ban on vaping liquids of 20 milligrams per millilitre or more, could increase deaths across Europe by 105,000 people?

My Lords, I am not able to answer that question, as I do not have the facts at my fingertips. However, I will investigate it and write to the noble Viscount.

My Lords, the Minister said that the obesity strategy would be coming out soon. What is his interpretation of “soon”?

What action does the Minister intend to take against clinical commissioning groups which are commissioning services based on arbitrary, discriminatory decisions rather than on evidence?

My Lords, the whole purpose of local commissioning groups was that they would be guided and directed by local clinicians. They must be allowed to set their own local priorities. It would not be right for me to direct local commissioning groups how to behave.