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Ever wondered why the NHS won’t fund liposuction for cosmetic reasons or you can’t have a free sex-change? Health Editor Madeleine Brindley looks at the long list of interventions not normally undertaken in Wales
Over the last six decades the public’s perception about these founding principles has shifted somewhat and it is now widely regarded that the NHS should be providing every treatment or procedure that every patient could conceivably need.Liposuction
To refuse to perform a particular operation would be tantamount to a betrayal of Aneurin Bevan’s vision for a publicly-funded health service, which supports the health of all from cradle to grave and is regarded as a refusal of an individual’s basic rights.Liposuction
But just as there are a whole host of medicines and drugs – usually new and high-cost drugs – which are not routinely available on the NHS because they have been deemed not cost-effective, there is also a long list of procedures that will not ordinarily be carried out.Liposuction
This is a list publicly available – five of the seven health boards responded to the Western Mail’s Freedom of Information request for the documents to be published – but rarely seen.
Featuring the catchy title of Interventions Not Normally Undertaken, the lists outline those procedures which are either never performed or can only be used under certain circumstances.
Some are based on a 2007 National Public Health Service document, which was due to be reviewed by Public Health Wales (the successor body) this month, while a few health boards have developed their own lists, which are strikingly similar.Liposuction
Decisions about whether surgeons should perform a tonsillectomy on a particular patient, for example, are not arbitrary but based on the most recent clinical guidelines.
Cardiff and Vale University Health Board’s policy states: “The NHS has historically identified either marginally effective or ineffective treatments/procedures that are currently deemed to have limited clinical value.Liposuction
“It is acknowledged that the evidence base for some clinical practice is lacking and frequently has not been subject to review by the National Institute of Clinical Excellence (Nice) or guidance in the form of a national service framework or the subject of peer-reviewed journals of high scientific quality.
“In these circumstances, the evidence base available, including an assessment of potential health gain against potential harm, is considered along with an economic assessment of impact on a resource-limited NHS.”Liposuction
The National Public Health Service document, which outlines a series of procedures which should only be funded in “exceptional circumstances”, also makes the point that in deciding whether to commission a particular intervention, all health boards must be guided by a series of principles.
These include a question of legality and the principles of the Human Rights Act; safety – “first do no harm” – and whether an intervention is both clinically and cost- effective.Liposuction
In the case of tonsillectomies, which were once a routine operation, Betsi Cadwaladr University Health Board’s policy states that these should not be performed unless a patient meets all the criteria – sore throat is due to tonsillitis; five or more episodes of sore throat per year and symptoms for at least one year.
Patients must also have a history of disabling sore throats which prevent normal functioning and even then the guidelines, developed by the Royal College of Paediatrics and Child Health, recommend a “six-month period of watchful waiting” before surgery to “establish firmly the patterns of symptoms and allow the patient to consider fully the implications of the operation”.
The number of tonsillectomies performed were significantly higher than the Welsh average in North Wales, South West Wales and the South Wales valleys, suggesting either rates of recurring and debilitating tonsillitis are higher in these areas or that the three health boards – Betsi Cadwaladr, Abertawe Bro Morgannwg and Cwm Taf – have a more liberal interpretation of the guidelines.
Dr Ciaran Humphreys, a consultant in public health with the Public Health Wales Observatory and author of the report, said at the time of publication in November: “Health services face a constant challenge of meeting the health needs of their population within available resources.Liposuction
“The amount of a particular procedure undertaken is influenced by a large number of factors including underlying clinical need, demand for services, supply of facilities and staff as well as clinical practice.”
“For the NHS such procedures can incur unnecessary cost, unnecessary clinical risk, longer waiting times for elective surgery and a potential increase in occupied bed days.”Liposuction
There are a number of interventions which should not be funded in Wales under any circumstances, including hair grafting for male baldness, gender reassignment surgery and caesarean sections for non-clinical reasons.
The NHS will not fund laser surgery to correct short sight because “a systematic review has determined the safety and efficacy of this procedure against other alternative cost-effective procedures is yet to be established”.Liposuction
For example, tattoos will be removed if they were inflicted against the patient’s will – a so-called “rape tattoo” – if the patient was not competent, and therefore not responsible for their actions at the time of the tattooing, and exceptions will also be made for tattoos inflicted under duress during adolescence or disturbed periods where it is considered that psychological rehabilitation, break-up of family units or prolonged unemployment could be avoided, given the treatment opportunity.
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