The selection of patients for breast reduction: should health commissions have a say?

Selective or restrictive access policies operate for breast reduction, despite proven benefits. The rationale for these policies, in particular the requirement of psychiatric assessment prior to a plastic surgical consultation, as an aid to patient selection by the health commission, was examined in 57 general practice referrals to a plastic surgical unit. In 22 cases, these policies deterred the patient or GP from pursuing the referral further. Sixteen cases were funded by the health commission directly, 16 patients required psychiatric or orthopaedic referrals, and three patients were refused funding outright. The decision to fund, reject or refer to a non-plastic-surgical specialist was not statistically related to the patients' symptoms. Non-plastic-surgical assessment resulted in referral for a plastic surgical opinion in 15 of 16 patients. We conclude that these selective policies are unsatisfactory, since patient management is not related to symptoms and the use of non-plastic-surgical opinions by the health commission as an aid to rationing is of little benefit.