There has been a lot of comment and discussion recently about the NHS preventing certain patients from accessing treatment.
The official line is that some medical conditions are considered to be of 'low clinical priority' - in other words they are not sufficiently serious for the NHS to be bothered with.
Of course the main driver behind these changes is to save money. The fewer cases the NHS does, the less money it will spend on the equipment needed, the staff costs involved and so on.
Varicose veins have been one of the conditions subject to restrictions in this area. GP's are told not to refer patients to hospital with varicose veins. Surgeons are told not to put patients on operating lists unless they meet certain 'severity criteria' - in some areas the surgeon has to fill in an extensive form for each individual patient to get prior approval from the commissioning group before surgery can take place.
In this article I will outline the nature of the severity criteria that most NHS groups use to decide who is and who is not eligible for NHS treatment and what one can do about it if turned down.
Doctors grade varicose veins on a scoring system of 1 to 6. One is the most minor grade and 6 the most severe.
Grade 1 veins are essentially tiny thread veins most commonly seen on ladies with fair skin. They are mainly a cosmetic matter
Grade 2 veins are 'isolated varicose veins' - in other words a little bit swollen but quite small - also essentially cosmetic.
You won't be surprised to hear that the NHS won't treat grade 1 or 2 veins and that is reasonable - one wouldn't expect the Health service to be providing cosmetic treatment for patients.
It gets more interesting with grade 3 and grade 4 veins......
Grade 3 veins are larger bulgy veins that are being filled from a leaky vein deeper inside the leg that can't be seen with the naked eye. This is the commonest category of vein patient that goes to see a doctor because usually the veins are causing pain and discomfort. The symptoms patients complain of are typically aching, throbbing, leg swelling and soreness on standing for long periods.
In the past, the NHS would treat grade 3 veins but the goalposts have been moved and these patients are now not eligible for treatment. They are required to use compression stockings instead of having surgical operations.
Grade 4 veins cause complications including phlebitis (where the vein gets inflamed, hard and lumpy) or venous eczema where the skin at the ankle becomes dry and itchy.
Grade 5 veins have severe skin damage to the skin at the ankle which becomes discoloured with a brown pigment.
Grade 6 veins are a venous ulcer - and that is very bad news indeed - very painful and hard to heal.
Patients with grade 4, 5 or 6 veins are still allowed to have surgery on the NHS to prevent an ulcer from developing or to try to get one to heal up.
Many patients ask me why grade 3 veins can't be operated on in order to prevent them deteriorating - surely that makes sense in the long run and would eventually reduce costs?
The more perceptive reader may have worked out why the rules are written in this way. Firstly, the majority of patients with varicose veins have grade 3 veins - so by targeting this group the NHS can make the biggest reduction in operations and save the most money.
Next, although many patients with grade 3 veins have significant discomfort, it is very difficult to 'prove' pain. In addition, if compression stockings are worn, this will usually reduce the pain of grade 3 veins - although the stockings themselves are uncomfortable - so there is an 'alternative' to surgery in these cases.
Finally the argument runs that surgery with the old high tie and strip method wasn't really very good - the outcomes were not great and the recurrence rate was very high - so the NHS can argue that surgical treatment is inadequate to treat the problem.
There is some justification for this last argument, because the 'high tie and strip' really wasn't very good, but it fails to take into account the massive advances in varicose vein treatment over the last 10 years - the increasing use of endovenous laser treatment (EVLT), done under local anaesthetic, has revolutionised the outcomes from varicose vein treatment, which now rarely recur after treatment and can be fixed with minimal risk, so surgical treatment these days is quick, safe and highly effective.
Whatever the right and wrongs of the policy, there is no doubt that it is being enforced nationwide with increasing rigour and it is becoming extremely difficult to get vein surgery done on the NHS unless the veins are bad enough to be graded as 4, 5 or 6. Whilst there are appeals processes in place in most areas, in my experience it is very unusual for patients to get funding approved if they have grade 3 veins only.
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