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Eddie Chaloner Headshot

NHS and the Shrinking Definition of Medical Need

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Most people would probably agree that a national health service funded by general taxation should prioritise capital for the most pressing medical conditions.

Medical interventions, such as types of cosmetic surgery, are often a lifestyle choice rather than medical requirement- a state-funded system does not exist to provide these kinds of treatments.

The more serious the condition, the more urgent is the need for treatment. That sentiment is straight-forward and underpins the relatively new NHS concept of procedures of limited clinical value (PLCV).

PLCV is officially described as a quantitative way to establish the ranking importance of clinical needs. In reality, though, procedures of limited clinical value is a term used to justify removing funding for an increasingly lengthy list of treatments in order to reduce health service expenditure.

What concerns me is the widening definition of PCLV to include proven operations known to enhance health and improve quality of life. Many of the procedures now deemed 'low value' are actually those which prevent complications and more serious conditions developing later in life.

My own specialty is varicose vein treatment. The NHS has always declined to treat patients for whom the condition is purely cosmetic- those patients have, quite reasonably, always had to seek treatment in the private sector. However there is now a substantial increase in the number of uninsured patients referred to me privately by NHS GP's- patients who, in my opinion, are medically deserving of subsidised treatment.

Current policy is very strict. Most NHS Primary Care Trusts only permit vein surgery to be carried out in cases where varicose veins are so severe that the patient has skin damage or an established ulcerated area on the lower leg. Patients have to suffer through the pain and discomfort caused by varicose veins, only awarded treatment when the condition has worsened. The alternative is to self-fund within the expensive private sector.

This option is being faced by more and more people. In 2003-2004 the NHS carried out over 46,000 varicose vein operations, but by last year this figure had fallen by almost half.

The most affected patients are those who can't afford the high cost of private healthcare. A painful condition that can be cured almost completely with a proven and successful 30-minute local anaesthetic procedure has been placed far out of reach for thousands of people.

Viable alternatives to our current 'all or nothing' state healthcare system are common in other countries, where co-payment schemes for drugs and treatments that fall outside of the state's remit work well. Patients can access low-cost subsidised treatment for services that the state cannot afford to fully fund.

France, Germany, Australia and Ireland already operate funding systems where the Government covers a percentage of healthcare cost. Patients are covered by low cost, state-subsidised insurance plans, self-funding the excess. Low-income or unemployed patients are fully funded. Variations of schemes like this are found in almost all developed countries outside of America. Except, of course, in the U.K.

The refusal of the NHS to hold a dialogue about similar co-funding arrangements means that patients are suffering in order to preserve the ideological purity of state medicine that is 'free at the point of use.' I don't think that is reasonable.

The problem is largely political rather than clinical or administrative- the electorate are fearful of any change to the NHS, which is often perceived as a cornerstone of British society. But in a week where the NHS has been expanding plans to commercialise its brand and franchise abroad, it's ironic that our domestic funding options are embarrassingly inflexible compared to the rest of the developed world.

As the budgetary squeeze tightens and the list of procedures defined as being of 'limited clinical value' expands, the need for radical change to the NHS funding model is becoming increasingly apparent. Continuing a dogmatic adherence to current legislation restricts access to treatment, limits patient choice, and stifles competition- and that puts our healthcare a long way behind the rest of the developed world.