Rationing in the NHS: audit of outcome and acceptance of restriction criteria for minor operations

General practitioners' referrals for skin lesion excisions constitute a large proportion of cases seen at plastic surgery clinics. Escalating rates of skin cancer have increased the numbers of urgent referrals due to suspicious looking skin lesions. As a result, patients with clinically benign lesions spend long periods on waiting lists, exceeding the waiting times agreed in negotiated contracts.

In March 1999, a total of 666 patients had been waiting over one year for minor plastic surgery at Salisbury District Hospital. In response, Salisbury Health Care NHS Trust and Wiltshire Health Authority proposed a new system of contract exclusions, whereby only patients with lesions that suggested malignancy or that were disfiguring or potentially disfiguring would be seen. The health authority and the trust assumed that excluded patients would not be seen or treated elsewhere. The consultant plastic surgeons reviewed the referral letters for patients who were not given an operation and returned the letters with explanatory notes.

This study aimed to assess the acceptability of the new system among patients and general practitioners and to determine the outcome of cases excluded under the new criteria.

Methods and results

Details of all referrals rejected under the new system were collected for six months after its inception on 1 September 1999. In each case, the site and description of the lesion were recorded. General practitioners and patients were contacted by telephone to assess their satisfaction with the system and to determine whether further referrals for excision had been made. The histological diagnosis was obtained for lesions excised after re-referral.

In six months, 112 referrals were rejected. Of these, 99 contactable patients (134 lesions) were followed up; 103 lesions (77%) were in the head and neck. In many referral letters the clinical description was non-specific but did not suggest malignancy or disfigurement.

Nineteen (19%) patients later had their lesions excised; 18 patients had benign pathology, and one had a squamous cell carcinoma. The patient with the carcinoma had been refused treatment solely on the basis of a referral letter—on grounds that this was a cosmetic problem—and afterwards sought a private consultation and subsequent excision.

Most patients (77%) and general practitioners (63%) were dissatisfied with the new contract exclusion criteria; 23% of patients and 36% of general practitioners were satisfied with it. In all, 51% of general practitioners re-referred their patient either to another hospital (36%) or back to the original unit (15%).

Comment

There is low acceptance among general practitioners and patients of recently imposed contract exclusions. Subsequent re-referrals transfer patients from one waiting list to another, wasting NHS resources without making waiting lists shorter. It is worrying that one patient with a malignancy was refused NHS treatment under the new system, and this error is consistent with the findings of previous research suggesting that it is unreasonable to expect general practitioners to have the diagnostic and therapeutic skills of specialist clinicians.¹ These findings raise questions about the general practitioner's role in diagnosis and management in the context of restricted secondary services.

Rationing of health services is emotive, involving issues of ethics, finance, and standards of care.²,³ Although possibly a legitimate factor in modern healthcare provision, rationing may be unacceptably restrictive to patients and clinicians. In Florida in 1996, Medicare's decision to restrict funding of excision of actinic keratoses resulted in litigation (although unsuccessful) by the American Academy of Dermatology, the Florida Society of Dermatology, and the Seniors Coalition.⁴

With rising political and financial pressures to cut NHS waiting lists, patients with urgent problems are given priority. Those with apparently benign conditions may wait for years to be seen in clinics, or they could be excluded from waiting lists altogether.⁵ If similar restrictions on service provision continue, this could constitute implicit acknowledgement of an “acceptable level” of missed malignancy. Although rationing of services may be necessary, care must be exercised in its application.