Pressure on NHS finances drives new wave of postcode rationing.

An investigation by The BMJ has shown stark local variation in the number of exceptional funding requests that doctors in England are having to make on behalf of their patients, and the types of treatment being restricted. The analysis shows that the overall number of individual funding requests (IFRs) received by clinical commissioning groups in England increased by 47% in the past four years (fig 1⇓). But there is substantial variation around the country. For example, Rushcliffe Clinical Commissioning Group in Nottingham received no IFRs last year, while Chiltern CCG in Amersham, Buckinghamshire, processed nearly 3800. The proportion of IFRs being approved increased slightly in the past four years from 43% (20 515/47 626 with data available) to 52% (35 222/68 051). But the sharp increase in the overall number of requests means that thousands more patients are being turned down for funding each year, while many others are forced to wait for their treatment while their request is considered. Again, there is much variation in how many requests are approved. Southern Derbyshire CCG received just 14 requests last year for procedures such as cataract surgery but approved none. In contrast, Stafford and Surrounds CCG processed 2123 requests, including 764 for skin excision, 232 for cataracts, and 163 for hip or knee replacement, but approved them all. Doctors’ leaders told The BMJ that the increase in the requests and the wide variation in access was discriminating against patients in some parts of the country. One patient whose request for treatment for rheumatoid arthritis has to be resubmitted as an individual funding request every six months told The BMJ that the process was slow, stressful, and painful (box 1). The findings come against a backdrop of unprecedented financial pressures in the NHS. NHS Clinical Commissioners, the organisation that represents CCGs, recently warned that CCGs would have £5.72 less to spend per person in 2019-20 than in 2016-17 under the current funding settlement from the government. In common with previous years, most IFRs in 2016-17 were for surgical procedures such as excision of skin tags, removal of varicose veins, and other forms of plastic and cosmetic surgery (box 2). What might be more surprising is the surge in requests for hip and knee surgery, cataract removal, and carpal tunnel surgery over the past four years and the consistently high number of mental healthcare requests. These areas were all among the top 10 most commonly requested treatment areas in 2016-17. In 2013-14 only mental health featured in the top 10. Hips and knees