How ‘self-pay’ is shrinking the English NHS by stealth

Warrington and Halton Hospitals NHS Foundation Trust’s Chief Executive Mel Pickup last week said she had “paused” the so-called MyChoice scheme.

The scheme was widely condemned after the Trust published adverts stating:

“Did you know that some hospital procedures previously available may no longer be available on the NHS? However, with the MyChoice service at Warrington and Halton hospitals, you have the option to self-fund some procedures. Self-funded procedures – by the NHS, for the NHS.”

Local NHS bosses (Clinical Commissioning Groups in the Cheshire and Merseyside Sustainability and Transformation Partnership) no longer routinely fund a range of treatments. The Mirror reported last week that 20 of these treatments appeared on the lengthy MyChoice list of 71 private treatments.

As many have objected, it’s not a “choice” if you don’t have £2,479 to pay for knee arthroscopy, £1,577 to pay for a Carpal Tunnel Syndrome operation or £1,646 for insertion of grommets – all operations that NHS England last year ordered Clinical Commissioning Groups not to routinely fund.

The “MyChoice” scheme also includes operations like hip replacement surgery (costing £7,060 to self-pay patients), that the NHS still routinely funds without any requirement that Clinical Commissioning Groups give prior approval.

West Lancashire MP Rosie Cooper has called on Mel Pickup, the Hospital Chief Executive responsible for the My Choice scheme, to stand down from her role as head of the Cheshire and Merseyside Sustainability and Transformation Plan.

The hospitals say the “pause” is so that they can make sure that the scheme will not interfere with NHS-funded operations. They claim that, “so far no NHS patients have been impacted.”

But how did we get here?

The MyChoice scheme has been around for several years. Back in 2013, Warrington and Halton Hospitals were amongst the one in six of hospitals in England that introduced new payment options including MyChoice self-pay operations. As now, the claim was that this gave patients access to treatments that the NHS no longer routinely funded – in the case of Warrington and Halton Hospitals at the time, varicose vein surgery was advertised.

The implementation of the 2012 Health and Social Care Act allowed Foundation Trusts to earn up to 49% of their income from commercial sources. At the same time, NHS underfunding started to bite, with a projected £30bn funding shortfall between 2011-2015 identified as a “challenge”, and further funding shortfalls since.

Unlike traditional private patients, ‘self-funded’ patients pay at cost, rather than the higher rates traditionally charged, and are treated in the same facilities as NHS patients.

Since then, alarmed patients have been finding that a range of procedures is no longer normally funded by the NHS.

They have either had to go without treatment, accept substitute NHS-funded treatments that they have found less clinically effective – or self-pay for operations if they have the money.

The process is now accelerating – boosted, it would seem, by the withdrawal of NHS routine funding for a range of procedures erroneously described as having ‘low clinical value’. This has already significantly reduced the number of these operations that the NHS provides, and that is set to continue.

Local NHS commissioners in Cheshire and Merseyside claim that the operations they no longer routinely fund are only of value in the right clinical circumstances. But as campaigners pointed out to NHS England at their Leeds consultation event on withdrawing routine funding for 17 procedures, this is true of all operations.

So why start withdrawing routine funding for some of them?

They also claim to have run “significant public engagement and consultation” on their local cuts. But although a public consultation in the Warrington area ended on 29th May 2019, a local resident said the handful of public meetings had been “mainly held in office hours when everyone’s at work” and that the publicity about them “did not make it clear, the significance of the consultation, or the proposals.”

Their “Criteria-Based Clinical Treatment policy”, which identifies treatments they no longer routinely fund, states, “It is evident that the need and demand for healthcare is greater than the resources available to a society to meet it.”

Evident to whom? The sixth richest country in the world is perfectly able to provide a universal, comprehensive health service. Particularly when the NHS costs a smaller share of the Gross Domestic Product, compared with health services in comparable countries.

This is the lie of austerity. And it gets worse…

The ethical dilemma at the heart of NHS ‘self-pay’ schemes

If it’s wrong to expose patients to the risk of surgery for limited clinical benefits, how can Warrington and Halton consultants possibly justify offering such operations to patients whom the local NHS commissioners have refused to fund?

Conversely, if the consultants (and the GPs who refer the patients to them) judge that patients will benefit from these operations, the NHS should pay – not the patients.

I put this conundrum to both Warrington and Halton hospitals and Warrington Clinical Commissioning Group, who said, “other than aesthetic treatments which are not funded by the NHS, there should be no condition for which there is a health benefit to treatment which would go unfunded…The [Cheshire and Merseyside Criteria Based Clinical Treatment] policies do not require the Trust to charge for any treatment or to offer treatment not meeting clinical criteria.”

But a Warrington and Halton hospitals Executive said, “The Trust considers that there is still scope for an individualised clinical judgement. There may be differences between patients not covered by the commissioning guidelines…The CCG criteria are based on a national evidence-base. MyChoice was developed in response to that document of guidelines to give patients more choice and in recognition of individualised patient differences locally.”

This makes no sense. The Foundation Trust appears to be suggesting that there’s some sensible clinical reason why national criteria don’t actually apply to Warrington patients. Meanwhile, the CCG are saying they would fund all operations whenever the consultant identifies demonstrable clinical benefit to the patient.

So either Warrington hospital (and others going down this route) is wrong, or the criteria CCGs are following are wrong.

Furthermore, even though Warrington’s advert says MyChoice is about procedures that the NHS no longer routinely funds, in fact it seems to be a ragbag of operations without any discernible logic. The suspicion remains that waiting lists are a factor, with self-payment attractive to folk with dosh who don't want to stand in line. But they can't say that because it goes against the code for private patients in NHS hospitals.

Reductions in NHS operations elsewhere

The MyChoice scheme – and more generally, the expansion of private patients in the wake of recent cuts to NHS eligibility – is by no means limited to Warrington. In 2017 Calderdale and Huddersfield NHS Foundation Trust anticipated that “Changes to Commissioning clinical thresholds [and] growth in regional and national waiting lists” could lead to an “upside” – that it could increase income from independent sector patient income. In its plans to “reconfigure” services, it aimed to maximise this growth potential, running the planned care operating theatres on three session days and 7-day services.

The Secretary of State for Health ruled that aspects of the proposed reconfiguration were not in the public interest, so that Full Business Case has been now ditched.

But Calderdale Councillor Colin Hutchinson, Co-Chair of Calderdale and Kirklees Joint Health Scrutiny Committee, warns:

"We need to watch out for any re-emergence of such plans in the next version of the Trust's Full Business Case. Underfunding of hospitals is forcing them to supplement their income by courting self-paying patients and colluding with reductions in the availability of NHS services. It is important that the public understand that the effect will be to stimulate the demand for health insurance and the perception that the NHS should be seen as a safety net, rather than a comprehensive service equally available to everyone."

West Yorks and Harrogate Integrated Care System, which CHFT is part of, estimates its hospitals will reduce by 40% the 17 operations that NHS England has identified as no longer routinely NHS funded.

That must amount to a significant chunk of hospital income; and the number of operations that the NHS no longer routinely funds is set to grow, as NHS England admitted in last year’s “Evidence Based Interventions” consultation document.

The pressure to increase income from self-pay operations will be considerable. But ironically, in a recent study the Centre for Health and the Public Interest concluded, “A lack of clear accounting of costs makes it impossible… to say whether the NHS benefits financially from devoting resources to the treatment of private patients.”

The dismantling of the NHS over the past decade has predictably led to a state of chaos overseen by unaccountable quangos.

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