Cohort survey of heart valve replacement patients: does the valve card scheme have room for improvement?

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. 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. 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. 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. 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.