BOA/BHS response to Royal College of Surgeons report on access to surgery
Royal College of Surgeons Report: Is access to surgery a post-code lottery?
A British Orthopaedic Association (BOA) and British Hip Society (BHS) response to the report by the Royal College of Surgeons of England
The BOA and BHS are concerned by the findings of this report on variations in commissioning policies for surgical procedures including total hip replacement.
Our view is that total hip replacement is a highly cost effective procedure. Broadly speaking, the cost effectiveness of THR is £10 per week if it survives 10 years (of which there is a 95% probability) and £7.50 per week if it survives 15 years (of which there is a 85% probability). Early and appropriate surgical intervention results in better post operative scores and outcomes, and patients risk unintended harm if referral is delayed.
The RCS / BOA / BHS produced a commissioning guide in 2013 on Pain Arising from the Hip in Adults, and we urge commissioners to refer to it when commissioning hip replacement surgery. This can be downloaded from our Commissioning Guidance page.
Specific comments
The report has found:
That sixteen of the CCGs surveyed imposed an Oxford hip score threshold as part of a case management approach.
The view of the BOA and BHS is:
The Oxford Hip Score is a reliable, responsive and validated outcome measure to assess results following arthroplasty. There is no evidence for using Oxford Hip Score as a screening tool and it has never been validated in this role. As such suggesting a cut-off threshold for referral would not be appropriate. In fact the pre operative Oxford score predicts final post operative score so an unintended consequence of low scores for access to hip surgery would be a limit on post operatively achievable Oxford scores. This would be unacceptable.
The report has found:
That seven of the CCGs surveyed had some form of criteria related to weight or body mass index (BMI).
The view of the BOA and BHS is:
A patient’s BMI should not be used as a criterion to refuse referral. There is no consistent evidence that patients with high BMI do better or worse than other patient groups. The patient should still be seen by the surgeon and their individual circumstances discussed. In many cases a weight management programme may be appropriate, but this may not be the case universally. Arthroplasty is still an effective treatment in obese patients. The pain and suffering in obese patients with advanced arthritis is not lessened. This may be unethical.
The report has found:
That some CCGs are requiring that patients receive 6 months of conservative measures before surgery.
The view of the BOA and BHS is:
It is standard practice to try conservative measures before surgery, but not necessarily for a period as long as 6 months. The RCS / BOA / BHS commissioning guide includes reference to a time interval of 12 weeks: “Referral to secondary care: if persistent pain and disability has not responded to up to 12 weeks of evidence based non-surgical treatments, this time to include any manual therapy (including physiotherapy) received in primary care.” If standard conservative measures have not worked within 12 weeks, we know of no evidence that these measures become increasingly effective by 26 weeks.
The guidance also references situations for a more urgent referral: “Emergency referral to secondary care: hip pain associated with systemic symptoms, signs of infection, known primary malignancy, severe muscle spasm, sudden inability to bear any weight, history of a fall” and “Immediate referral to secondary care: severe pain unresponsive to analgesia and persistent loss of function affecting employment.” There is a wide spectrum in the range of presentations with arthritis. Rapidly Progressive Coxarthrosis (RPC) is a condition that causes rapid destruction of the hip joint and if left will cause destruction that increases complexity of reconstructive surgery and adversely prejudices the outcome of arthroplasty surgery.