NHS 'rationing leaves patients in pain'

Hospital operationImage copyright JohnnyGreig

Vital NHS operations and treatments are being increasingly rationed in England, leaving patients in pain, doctors say.

The treatments affected include hip and knee replacements and cataract surgery to help restore sight as well as drugs for conditions such as arthritis.

Such care is normally given routinely, but the British Medical Journal has found evidence it is being cut back.

The joural obtained data showing more doctors are having to resort to special appeals to get their patients treated.

Local health bosses have blamed the tighter restrictions on a lack of funding.

But medics and patients' groups said the restrictions being placed on non-emergency treatment were "unfair" and meant patients spent longer in pain or were going without treatment.

Image caption Cataract surgery is one of the procedures that doctors are seeking special requests to carry out

When care is not being funded on the NHS, doctors can use the the exceptional cases system to appeal to local health bosses to get the treatment for their patients.

It is normally associated with new drugs not yet available on the NHS, to pay for expensive treatments in unusual circumstances or to get care that there are legitimate restrictions on, such as cosmetic surgery.

But the BMJ has gathered evidence from clinical commissioning groups which shows the special requests are increasingly being used for vital non-emergency services.

Responses from 169 of the 209 clinical commissioning groups, which control local budgets, showed:

  • In 2013-14 there were just 49 requests made for hip and knee surgery, but by last year the figure had reached 899
  • Over the same period, the number of cataract appeals trebled to more than 1,000.
  • Overall the number of requests being made through the special cases route rose by 47% to 73,900
  • Just over half of all requests were approved

Patient:'I'm left in pain waiting for drugs'

One patient who has been caught up in the squeeze is Helen Cole, from west London.She was diagnosed with rheumatoid arthritis 11 years ago.

She relies on a drug called rituximab, but it is not being routinely funded by her local health bosses so her doctor has to make a special request for it every six months.

This has led to delays in her getting the drug and gaps in her treatment.Last time, she had to wait 10 weeks to get her next treatment.

"I had a lot of pain in my joints and really big problems with fatigue.It can be really challenging day to day."

She said she finds the whole process "stressful" and believes it "makes no sense".

"The whole point of treating a disease like rheumatoid arthritis is to try to keep it under control at all times," she added.

How treatment is rationed

Exceptional requests for funding can be made by doctors when they believe their patients should get treatment that is not normally funded locally.

They make an appeal to a local panel who decide whether to allow the treatment.

This is done when a treatment is either not funded or where the patient does not qualify because their condition is not considered severe enough.

For example, for hip and knee replacements doctors use a scoring system to assess how much discomfort and lack of mobility a patient has.

By increasing the bar at which a referral for an operation is made the NHS can help restrict the numbers getting treatment.

Which treatments are most commonly requested as special cases?

  1. Removal of skin tags
  2. Cosmetic surgery
  3. Varicose vein surgery
  4. Plastic surgery
  5. Fertility treatment
  6. Mental health care
  7. Cataract removal
  8. Carpal tunnel syndrome (nerve damage to wrist)
  9. Hip and knee surgery
  10. Breast surgery

Is this a sign of a major problem?

Doctors said the trend was a clear indicator that care was being rationed.

For every case where an exceptional argument has been made, there will be plenty more where patients will have gone without care and their doctor has not appealed.

But it should also be seen in the context of the large number of non-emergency treatments that do take place - more than 15 million a year.

Image copyright stockvisual Image caption There are more than 15 million planned operations and treatments each year

Julie Wood, chief executive of NHS Clinical Commissioners, which represents CCGs, said despite seeing more patients than ever, the NHS was still struggling to keep up with demand.

"Unfortunately, the NHS does not have unlimited resources and ensuring patients get high-quality care against a backdrop of spiralling demand and increasing financial pressures is one of the biggest issues CCGs face.

"As a result there are some tough choices that have to be made, which we appreciate can be difficult for some patients."

But Stephen Cannon, of the Royal College of Surgeons, said local health managers were "unfairly and unnecessarily prolonging the time patients will spend in pain, possibly immobile and unable to carry out daily tasks or to work".

Helen Lee, of the Royal National Institute of Blind People, said restricting access to cataract treatment was a "false economy".

"Patients with cataracts are at risk of social isolation, depression, and fall-related injuries," she added.

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  1. ^ Read more from Nick (www.bbc.co.uk)
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Grenfell Tower fire: Three hospitals fail fire safety checks

Fire fightingImage copyright Getty Images

Three hospitals in England have failed fire safety checks ordered in the aftermath of the Grenfell Tower fire.

Buildings at London's King's College Hospital, Sheffield's children's hospital and the North Middlesex Trust have been found to have combustible cladding.

Those three trusts along with another 16 have also introduced 24-hour fire warden patrols to improve safety.

Checks on cladding used at five sites have yet to be finished.

Of the three that failed, one - the building at King's College - is an office block and does not house patients.

The other two sites have failed on buildings that house patients, but do not keep them in overnight.

Steps are under way at all three to improve safety.

But a spokesman for NHS Improvement, which regulates hospitals, said there would be "no disruption to patient services" while changes were being made.

Image copyright EPA Image caption The checks at hospitals were ordered following the Grenfell Tower fire

The urgent checks were ordered by Health Secretary Jeremy Hunt following the Grenfell Tower fire.

A total of 38 trusts were identified last week as being of highest risk as they were already known to have been struggling with basic fire standards or had high-rise buildings that had cladding.

The review has now found the cladding at 11 sites passed the checks, while the other 19 sites which flagged up potential fire safety issues have been told they do not need to take further action.

King's College Hospital has already removed the cladding from its office building as a "precautionary measure", while steps are being made at the other two sites to remove it.

In Scotland, health boards have confirmed combustible cladding has not been used on any buildings....

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Patient prescription fines 'double in a year'

Prescription, pen and pillsImage copyright Getty Images Image caption Prescription medicines are free for some long-term health conditions

Fines issued to patients in England claiming free prescriptions while not eligible have doubled, figures show.

NHS Business Services Authority (NHSBSA) issued 979,210 fines in 2016-17 - bringing in £13.3m - compared with 494,129 in 2015-16.

Patients can be fined a maximum of £100 for obtaining free medication after an exemption certificate has expired.

The British Medical Association (BMA) said those on low incomes and with long-term illnesses were often hit.

The Royal Pharmaceutical Society said fines often stemmed from patients not knowing or forgetting to renew their paperwork.

The NHSBSA said it was the patient's responsibility to ensure they were entitled to claim free-of-charge prescriptions.

Mistakes 'cost millions'

The health body issued £13,277,877 in fines to people in England in 2016-17, up from £8,601,349 in 2015-16.

The data - obtained by the BBC under the Freedom of Information Act - has only been recorded since 2015 because responsibility for checks moved from local NHS trusts to the central NHSBSA in September 2014.

Image copyright Getty Images Image caption Prescriptions are free for everyone in Scotland, Wales and Northern Ireland

Patients should present an exemption certificate and sign the back of the prescription form to say that they are exempt of any charge.

The NHSBSA makes random checks when they think a claim for a free prescription has been made incorrectly.

If a patient cannot prove they were entitled to claim at the time, they are liable to pay a fine of the original prescription charge, plus five times that amount up to £100.

Brendan Brown, from the NHSBSA, said:"Where a patient makes a declaration on the back of the prescription form it's their responsibility to make sure that they do hold that exemption that they are declaring that they have.

"Fraudulent and other mistakes...do cost the NHS millions of pounds which could be spent on frontline NHS services."

'Last resort'

England is the only country in the UK to still charge for prescriptions.The charge is currently £8.60 for each medicine or appliance dispensed.

The Royal Pharmaceutical Society said pharmacists largely rely on people's honesty when dispensing medicines free-of-charge.

Spokesman Neal Patel said:"What we've found is that people who've perhaps not done the correct paperwork, or their prescription exemption has run out of date because they've forgotten to renew it, those people are getting fined.

"We want to spend time making sure people can use their medicines, not policing the prescription charging system."

Image caption Louise Jarman was fined after not renewing her exemption card

Louise Jarman, 45, from Chesterfield, has been diabetic since she was six years old and is entitled to free prescriptions, but was fined when she was told her exemption card had expired.

She said:"I received a letter out of the blue saying that I have not got an exemption card or a letter saying that I get free prescription, and they were fining me £50.

"I didn't know the card went out of date.They said they were fining me and I couldn't get any more prescriptions until I paid the fine.

"Eventually they dropped the charge but I was told I would have to pay for my previous prescription that I'd had, and any more until my card was renewed."

Dr Richard Vautrey, of the BMA, said no patient should have to pay for their care.

"Fining people should be a last resort.Often those people who may be fined are probably the least able to afford to pay.

"They're often people who have multiple conditions who may need regular prescriptions and that costs an awful lot of money."

Who gets free prescriptions?

Those over 60, under 16 or aged 16-18 and are in full-time education

Women who are pregnant or have had a baby in the last 12 months and have a valid maternity exemption certificate

People with a specified medical condition who hold a valid medical exemption certificate

Those with a continuing physical disability that prevents them from going out without help from another person and have a valid exemption certificate

Hold a valid war pension exemption certificate and the prescription is for your accepted disability

An NHS inpatient

You may also be entitled to free prescriptions if you or your partner receive certain allowances, such as income support...

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Extreme gardening to help tackle malaria

Prosopis julifloraImage copyright Malaria Journal Image caption The Prosopis juliflora shrub occupies millions of hectares of Africa

Gardening could be a powerful weapon against malaria, culling mosquito populations by cutting off their food supply, say researchers.

A team tested their idea in nine villages in the arid Bandiagara district of Mali, West Africa.

Removing flowers from a common shrub appeared to kill off lots of the older, adult, female, biting insects that transmit malaria.

Without enough nectar the "granny" mosquitoes starve, experts believe.

Killing granny

Getting rid of the mature females can stop the cycle of malaria transmission.

Image copyright RolfSt/Getty

These Anopheles mosquitoes carry the malaria parasite in their salivary glands and pass it on to people when they bite and draw blood.

The infected person can then infect other younger, biting, female mosquitoes - which are looking for a rich blood meal as they become fertile and make eggs - because their blood now contains the parasite.

It takes about 10 days for a newly infected young female mosquito to become contagious to humans.That may not sound long, but for an insect, it is.

By the time she can transmit malaria, she's pretty old.

Although she will feed on blood, she also relies on flower nectar for energy to stay alive.


In the Bandiagara district of Mali, there is one invasive plant that researchers believe is a feeding ground for malaria-transmitting mosquitoes.

The flowering Prosopis juliflora shrub is a bit of a horticultural thug and now occupies millions of hectares of the African continent.

Native to Central and South America, it was introduced into Africa in the late 1970s in an attempt to reverse deforestation and "green up" the desert.

Experts in Mali, along with researchers from the Hebrew University of Hadassah Medical School, Israel, and the University of Miami in the US, set up a horticultural experiment to see if removing the flowers from this plant might help kill off local mosquitoes.

They picked nine villages - six with lots of the flowering shrub and three without.

In three of the six villages, they hacked down the flowers.

They set light traps around all the villages to catch mosquitoes so they could see if the "gardening" had helped cull the insects.

Villages where they removed the flowers saw mosquito numbers collected in the traps fall - the total number of mosquitoes across these villages decreased by nearly 60% after removal of the flowers.

Importantly, the number of old female mosquitoes dropped to similar levels recorded in the three villages without any of the shrubs.

They don't have direct proof, but the researchers believe the mosquitoes died of starvation.

The reported their findings in the journal Malaria Research[1].

Prof Jo Lines is a malaria control expert from the London School of Hygiene and Tropical Medicine.

He says the novel approach holds amazing potential, alongside other malaria prevention strategies.

"It appears to show that by changing the landscape, not using insecticides or drugs, we can make a difference."

But he said it might not work so well in lush tropical regions where nectar-rich plants are in abundance.

Follow Michelle on Twitter[2]...


  1. ^ Malaria Research (malariajournal.biomedcentral.com)
  2. ^ on Twitter (twitter.com)

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FGM: More than 5,000 new cases in England

Girl holding her stomachImage copyright MShep2/Getty

The NHS in England recorded 5,391 new cases of female genital mutilation (FGM) in the past year, data reveals.

Almost half involved women and girls living in London, NHS Digital[1] found.

A third were women and girls born in Somalia, while 112 cases were UK-born nationals.

The practice is illegal in the UK and it is compulsory for family doctors, hospitals and mental health trusts to report any new cases in their patients.

FGM - intentionally altering or injuring the female external genitalia for non-medical reasons - carries a sentence of up to 14 years in jail.

It is the second time that NHS Digital has released annual FGM figures for England.

Most of the cases were spotted by midwives and doctors working in maternity and obstetric units.

The majority had originally had FGM done to them abroad and as a young child.

Funding concerns

The NSPCC says more should be done to end the practice:"FGM is child abuse.Despite being illegal for over 30 years, too many people are still being subjected to it and it is right that health services have started to properly record evidence of this horrendous practice.

"It takes courage to report concerns as many feel ashamed or worry they will betray friends and family.But we need to end the silence that surrounds FGM to better protect children."

The National FGM Centre, which is run by the children's charity Barnardo's and the Local Government Association (LGA), tries to prevent the practice, but its director Michelle Lee-Izu is warning it could be at risk of closure if government funding is withdrawn.

Cllr Simon Blackburn, from the LGA, said the government "must act now" to secure the National FGM Centre's "long-term future" by providing guaranteed funding.

He said:"Social work provision to girls and families affected by FGM has been quickly and significantly improved through the intervention of Centre social workers, embedded in council safeguarding teams, and hundreds of referrals have been received in areas that previously only recorded a handful of cases each year.

Mr Blackburn added that the government needed to back its commitment to ending FGM in the UK "with the long-term funding required to make that vision a reality".

Grassroots reporting

Anyone concerned about someone who has suffered, or is at risk of FGM, can contact the NSPCC FGM Helpline anonymously on 0800 028 3550 or visit nspcc.org.uk.

Wendy Preston, from the Royal College of Nursing, said:"Mandatory reporting and compulsory sex-and-relationships education are important weapons in the fight against FGM, and school nurses play a vital role in both educating children and young women, and spotting those who may be at risk.

"The government must act to attract and retain school nurses, to help address the problem at grassroots level, and maintain momentum in the fight to eradicate FGM."

A government spokesman said the start-up money for the centre came from the £200m Children's Social Care Innovation Programme, and was designed to lead to self-sustaining work, not ongoing core funding.

But he added:"Protecting women and girls from violence and supporting victims is a key priority for this government and a personal priority for the Minister for Women and Equalities, Justine Greening."...


  1. ^ NHS Digital (digital.nhs.uk)

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