The Abolition of Health Care in Yorkshire

"Have some wine," the March Hare said in an encouraging tone. Alice looked all round the table, but there was nothing on it but tea.
"I don't see any wine,"she remarked.
"There isn't any," said the March Hare.
"Then it wasn't very civil of you to offer it," said Alice angrily.

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Two GPs who are partners in a large general practice in Yorkshire have sent Dr Crippen full details of the cost saving strategies that have been introduced by Dr Janet Soo-Chung CBE who is the Chief Executive of North Yorkshire and York Primary Care Trust.

I have scanned in the two letters because I fear that if I merely presented selected excerpts there is a danger that readers might not believe what is going on.

Click on each one to enlarge.

First, the letter to the Chief Executives of the Hospitals



Second, the letter to all the GPs



Finally, the full details of the health care cuts to be introduced under the “Prior Approval” system.

North Yorkshire & York PCT

Commissioning Hospital Services
Prior Approval for a Range of Elective Treatments and Diagnostics

The concept of Prior Approval is already well established for non urgent care and diagnostic services in the NHS and currently applies to the commissioning of a range of these including cosmetic surgery and morbid obesity surgery. Under Prior Approval, the PCT, is able to regulate access to a particular service through direct clinician referral and institute a system in which referrals for a range of services are assessed by the PCT and approved for specialist opinion.

From the 1st January the PCT has introduced Prior Approval system for access to a range of common elective treatments. Decisions are based on patients needs and evidence of clinical effectiveness. Access to these services will now only be available through Prior Approval and only in exceptional circumstances. The PCT has defined exceptional circumstances as those in which:-

• Denying access to the treatment or diagnostics would place the patient’s safety and/or health at significant risk
• Denying access to the treatment or diagnostics would significantly alter the longer term outcome of any future procedure
• Denying access to the treatment or diagnostics would significantly impair the patient’s ability to maintain their current occupation
  

The introduction of Prior Approval will be for an initial 3 month period during which the PCT will formalise future commissioning arrangements. The PCT recognises that these measures represent a constraint on current clinical practice, however given the severity of the financial situation, the PCT Board believes these measures are unavoidable. The PCT accepts the clinical responsibility for these actions.

Details of Treatments and Diagnostic Services under Prior Approval

The PCT has reviewed the evidence base and the clinical benefits of a range of common procedures and treatments and proposes to implement Prior Approval as follows:-

Group 1 – Services suspended indefinitely

• Lumbar spine X-rays for lower back pain except by prior agreement with local Radiologist
• Facet joint injections for chronic lower back pain
• Anal skin tags
• Treatment/removal of all non malignant skin lesions

Group 2 – Services suspended for 3 Months

The PCT proposes to temporarily suspend access to these services in secondary/tertiary care providers for 3 months whilst further work is carried out to determine future commissioning arrangements and care pathways.

• Varicose veins
• Epidurals for chronic lower back pain
• Wisdom teeth extraction
• Joint injections – should continue in primary care, referral into secondary care will require prior approval.
• Palmar fasciectomy for Dupytren’s disease
• Carpal tunnel procedures – injections should continue in primary care, referral into secondary care for carpel tunnel will require prior approval
• Bunion surgery
• Ganglions – aspiration should continue in primary care, referral into secondary care will require prior approval.
• Trigger Finger – injections should continue in primary care, referral into secondary care will require prior approval.
• Vasectomy
• Female Sterilisation
• Circumcision
• Penile Implant surgery
• Therapeutic Arthroscopy
• Grommets
• IVF
• Tonsillectomy
• Hysterectomy for menorrhagia

Group 3 – Diagnostic Procedures Suspended for 3 Months

The following diagnostic procedures are being temporarily suspended for 3 months whilst the PCT carries out further work to determine future commissioning arrangements and care pathways:

• Diagnostic Arthroscopy
• Dilatation and curettage
  

Group 4 – Diagnostic Imaging Services Suspended for 3 Months

The PCT is reviewing the capacity of Diagnostic Imaging services and will suspend for 3 months GP direct access to the following services. These will continue to be available via Prior Approval.

• Direct access MRI
• Direct Access CT
• Direct Access Dexa

GP Referrals and the Prior Approval Process

The above measures are intended to ensure that only those patients whose needs are exceptional will be able to access the above treatments and diagnostic services over the course of the next 3 months. The PCT are requesting that colleagues in Primary Care try to ensure that those patients referred to the Prior Approval process are exceptional in nature. Whilst they recognise the difficulties that this presents to GPs, they are asking colleagues not to simply re-direct all referrals that would previously have been made. This will only result in delays in the approval process and create difficulties in identifying the exceptional cases. Those patients whose needs are not considered exceptional should be informed of the position. There is further information for patients on the restricted access to common surgical and other treatments is intended to support GPs in this process.

If a GP feels that there are urgent and/or exceptional reasons why a particular patient should be considered for one of the above treatments, then the case should be referred to the PCT Exceptions Panel for Prior Approval. Cases should be sent to ‘The Exceptions Panel’, Commissioning Department, North Yorkshire and York PCT, Sovereign House, Kettlestring Lane, Clifton Moor, York, YO30 4GQ using the Exceptional Circumstances Submission form. A copy of the referral letter should be attached to the form.

The Exceptions Panel will meet as often as necessary to ensure timely and efficient decisions can be made and communicated. All decisions will be communicated to the GP and the patient within five working days. The PCT Exceptions Panel Office will ensure that the process is transparent, challengeable and equitable across the North Yorkshire and York PCT patch. The Panel will be medically led by PCT Directors of Public Health, Medical Directors and supported by senior PCT Management. Referrers wanting to discuss an individual case before referring to the Panel are invited to contact one of the medically qualified Director of Public Health or the Medical Director.

Appealing Against the Decision of the PCT Exceptions Panel

Patients and/or referring clinicians are able to appeal against the decision of the PCT Exceptions panel. The process for registering an appeal is set out in the PCT Appeals Process.

Referrals in the System

Patients who are already listed for one of the above treatments and who have been issued with a TCI date will be able to have their treatment on the appointed date. Patients who have been listed for treatment but not yet issued with a TCI date will remain on the waiting list but will be subject to the minimum waiting times being implemented as part of the PCT action plan. For routine inpatient/day case admissions, the patient will wait a minimum of 16 weeks prior to admission,

If a patient has been recently referred and has been issued with a new outpatient appointment, Trusts will be asked to honour the appointment. However, if during the outpatient consultation, it is confirmed that the patient’s intended management involves one or more of the above treatments, the consultant responsible for the clinic should either:-

• Refer the patient back to the referring GP, indicating that the patient’s intended management would require prior approval. The GP can then consider whether the case is exceptional. If so, they should refer to the PCT Exceptions Panel, making it clear that the patient has already been seen in outpatients. Any such cases approved by the PCT Exceptions Panel can then be directly listed for treatment.
• Refer the patient directly to the PCT Exceptions Panel if, in their view, the patients condition is considered exceptional. If approved, the patient can be directly listed for treatment and the GP informed by the Exception Panel office.
• If a patient has been recently referred but not yet issued with an outpatient appointment, Trusts are asked to assess the referral in the light of the new Prior Approval System. Referrals clearly intended for any of the treatments covered by the Prior Approval process should be returned to the referring GP indicating that the referral now requires prior approval. The referring GP can then consider whether the patient should be referred to the PCT Exceptions Panel. If it is not clear that the referral is for one of the treatments covered by the Prior Approval process, the Trust may issue a clinic appointment (subject to minimum waiting times criteria) and follow the process outlined above for the management of patients seen in an outpatient clinic.
  

New Referrals Received by Trusts

Local GPs have been asked to work with the PCT to ensure that any new referrals made are managed in line with the above processes. However, local NHS Trusts are asked to apply the same procedures outlined for referrals in the system to any new referrals received with immediate effect.


January 2007

I despair.

Doctors throughout the country will be horrified and need no guidance from me. But a few points for patients.

This is about preventing you from getting hospital care. It is saying that your GP is no longer allowed to arrange for you to see a specialist without "prior permission" from the "PCT Exceptions Panel". And who will sit on this panel? It will be all the usual suspects. All those plausible mediocrities who pop up on these committees time after time. The dead wood of nationalised industry bureaucracy. Doctors who have not seen a patient in years, over-promoted nurses who have not seen a patient in years, and second rate bureaucrats who have never seen a patient and who are working in the public sector because no one in the private sector would employ them. Yes, there are one or two notable exceptions, but that is about the size of it. Actually, it does not matter who sits on these wretched committees, because although they sit under the banner of "decision making", their real mission is delay and deferral.

Let us look briefly at some of the restrictions.

Services suspended indefinitely

Lumbar spine X-Rays

[Yes, too many of these are probably done, but nontheless, they do pick up unexpected diagnoses of malignancies, osteoporosis and so on.]

"Treatment/removal of all non-malignant skin lesions."

[Clinical assessment of skin lesions, whether it is done by the Professor or the nurse specialist, is often a guessing game, and the "removal" is organised to find out if the lesion is malignant. Still, all the GP needs to do now is say "I fear this lesion is malignant"]

Services suspended for 3 Months

Epidurals for chronic low back pain

[Cruel and unnecessary punishment of a number of patients who are crippled with back pain]

Palmar fasciectomy for Dupuytren's Contracture

Dupuytren's Contracture

[This condition can be crippling. Margaret Thatcher had it. I bet they did not delay her surgery.]

Bunion Surgery

Bunions

[Try to get a pair of shoes to fit these feet.]

Trigger finger



Circumcision

Paraphimosis

Delay doing a circumcision for a tight foreskin and, when retracted, it may get stuck. Doctors call this a "paraphimosis". It is not much fun.

And so we go on.

A load of bureaucrats with no medical training have picked a random list of procedures that they consider to be unimportant, and banned them. Of course, they will say that they are not banned. All the GP has to do is get "permission" from a committee to make a referral. And if he disagrees with the decision of that committee, he can always appeal.

This is the New Labour way.

Two more layers of bureaucracy to plow through before you can get anything done. And remember, bureaucrats draw salaries, and have plush offices, and lap top computers, and pensions. This is where your money is going.

Patricia Hewitt's NHS now resembles shops in pre-1989 Iron Curtain countries. They are all "free at the point of entry" but cross the threshold and there is nothing there.


P.S. Does anyone know why Dr Janet Sooo-Chung was awarded a CBE?