How rationing in the English NHS stops patients seeing specialists
Over the past decade and a half, the NHS in England has offered some modicum of patient choice. The instigator was Tony Blair, who was determined that patients should receive treatment within 18 weeks of being seen by their GP. And so, he introduced a range of reforms to cut waiting lists, including the introduction of Choose and Book.
Choose and Book was a system whereby for a range of conditions, such as joint pain and eye problems, patients were offered a choice of hospital. Instead of automatically being sent to their local NHS trust, they could also choose from availability in private hospitals, with the NHS picking up the bill. Patients loved the opportunity to select a faster appointment, and this helped cut NHS waiting lists.
Of course, the NHS establishment hated the reform, believing that the money from operations should stay in the public sector. Over time, the NHS has undermined it. First, the software was rebranded from “Choose and Book”, a nice, patient-friendly term which encouraged selection, to the bland-sounding “e-Referral System”. Then a new form of rationing was introduced which stopped it working as well. For many health problems needing a referral to a specialist, GPs are now banned from making that referral directly. The e-Referral System now only allows them to refer a patient to an NHS referral management service.
Referral management services exist to cut the number of patients seeing specialists. GPs apparently can’t be trusted to decide whether a patient needs to see a specialist, so NHS bureaucracies all over England have been created to decide if they should block the patient’s visit. A typical experience once referred to a referral management service is that a patient receives a letter saying that their case is waiting to be examined and that they should not call to enquire on progress for at least two months.
By the time the referral management service gets round to examining the patient’s record, some patients will have simply given up or gone private, saving the NHS money. Then the game is to try to get the patient to accept some form of care that doesn’t involve seeing a hospital specialist. For example, if the patient has joint pain, she might be encouraged to do some exercises at home, download an app or read some online literature. Alternatives to surgery are encouraged, such as physiotherapy – which is often the best treatment anyway – or the patient might be encouraged to put their knee in a brace rather than have knee surgery. All this saves money and cuts down on referrals to specialists.
We can think of this approach in two ways. On the one hand, many patients who see a specialist will be offered something other than surgery anyway. After all, it’s better for a patient to avoid an operating theatre and have some less invasive treatment if they can. By discouraging or preventing a patient from seeing a specialist, it saves the NHS money. On the other hand, this approach could be perceived as a bit cynical. Indeed, it could actually be seen as discriminating between different types of patients. Pushy middle-class professionals will insist on seeing a specialist, whereas less well off patients might be fobbed off more easily. Far from the NHS in England offering equality, it is possible that access to NHS specialists is now affected by wealth and confidence.
The upshot is that the experience for NHS patients in trying to see a specialist is often pretty bad. The gap between this and the private sector is huge and increasing. If a private patient is paying out of pocket for her own treatment, she may not even need to see a GP: she can book straight in with a specialist within days, and get an assessment and advice from a specialist.
I suspect that most people, given the choice, would rather have their case examined by a specialist rather than an official in a call centre or a less qualified clinician. And they certainly would rather not have the hassle of NHS bureaucrats slowing down and trying to block their treatment.