Rationing in orthopaedic surgery
By Lucy Reason1 and Jonathan Phillips2
1Fourth year medical student at University of Exeter Medical School
2Consultant Orthopaedic Surgeon at Royal Devon and Exeter Hospital
Corresponding author e-mail: firstname.lastname@example.org
Published 20th August 2021
A previously predicted £30 million funding gap by 20201 is pressuring CCGs to limit spending resulting in rationing of elective procedures. Proposals for rationing of orthopaedic surgery have varying evidence for their efficacy. There is strong evidence in support of these orthopaedic interventions as demonstrated by excellent QALYs, a NICE recognised assessment. However, some elective procedures are not considered a core medical need and so rationing of these procedures have been implemented2. There is a lack of conclusive evidence in the use of lifestyle factors and scoring systems such as the Oxford hip and knee score for rationing. It is therefore often viewed negatively by the orthopaedic community2,3. Despite this, CCGs have applied rationing to certain procedures, potentially preventing patients from accessing required healthcare.
Increased waiting time for elective orthopaedic surgery is a reflection of limited National Health Service (NHS) resources and recent events with the Covid pandemic have compounded these challenges. Prior to the pandemic, to address the financial funding gap the clinical commissioning groups (CCGs) responded with financial cutbacks, limiting referrals to health services, including total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, in the midst of this is a growing ageing population, coupled with an obesity epidemic, requiring differing healthcare needs, particularly in orthopaedics2,4. This article aims to review if rationing of orthopaedic surgery is hindering patient care and whether it is justified or not.
Are procedures cost effective?
Although elective orthopaedic surgery can arguably be considered as a non-essential medical need, it is still justified and important. If a patient’s quality of life and independence is restored through increased mobility and reduced pain, they are then able to continue a more normal lifestyle allowing them to contribute to society5. Orthopaedic surgery is proven to have exceptional Quality Adjusted Life Years (QALYs) and value for money. The cost per QALY for THA and TKA was £1,372 and £2,101 respectively, meeting the NICE requirements of below £20,000-£30,0002,6. It has also been reported that the general health of patients was also improved following these elective procedures, particularly following THA, lessening the burden on other specialities6,7.
There have been attempts to generate a scoring system for THA and TKA, allowing the CCG to set a value above which patients are not eligible2. The Oxford Knee and Hip score relies on patient reported outcome measures (PROMs), assessing a patient’s perception of pain. Developed in the 1990s, this 12-item questionnaire has been adapted and studied, however it is not recognised by the BOA as an effective means of rationing3,8. The results were variable in different groups of patients, putting into question its reliability. What it did demonstrate was that those patients awaiting treatment continued to deteriorate before surgical intervention, resulting in lower pre and post-operative scores. This suggests that implementing rationing protocols preventing those patients who are not deemed to have severe enough pathology, reduces the effectiveness of the procedure when done in the future. The arbitrary nature of the scoring system is flawed, designed to create a situation where demand meets supply, but the system fails to consider whether surgery is clinically indicated8,9. Despite seeing the greatest improvements in PROM values in a particular subset of patients, all showed improvement irrespective of pre-operative value.
Rationing based on lifestyle
Rationing of services based on lifestyle factors, including body mass index (BMI) and smoking status, has faced backlash from many orthopaedic groups2. The BOA argues these factors are often unrelated to clinical need, with limited evidence to suggest otherwise10. Devon attempted to limit services to those with a BMI <35, an arbitrary value determined by the CCG. Although surgery for obese patients is more complex and carries additional risks, the patient benefits cannot be overlooked. It remains unclear from current literature whether weight loss is enough to eliminate the need for surgery in obese patients4. Some CCGs have proposed bariatric surgery prior to orthopaedic treatment, an expensive endeavour, when exercise has strong evidence promoting weight loss. However, patients with end-stage arthritis often have limited mobility, requiring orthopaedic surgery first2. Without orthopaedic intervention, there can be strain on primary care to manage the progressive decline of patients suffering with orthopaedic pathology that should be treated surgically.
With NHS England targets of 18 weeks for elective surgery for 92% of patients, and only 83.4% reached as reported by the BOA in 2018, waiting lists are growing11. These figures were taken prior to the COVID-19 pandemic, which has only exacerbated this pre-existing problem. During this time, patients continue to deteriorate, and thus the ability to improve their post-operative PROMs declines8. This form of rationing, due to financial constraints, is out of the control of CCGs. There is opportunity for lifestyle interventions to be undertaken by patients with advice from primary and secondary care. This would reduce complications from surgery and be cost-effective if implemented with proper guidance.
Can national joint registries be utilised more?
Rationing of procedures with supposed limited evidence of effectiveness (PLCV), for example in shoulder surgery can potentially hinder development of future cost-effective procedures, whilst unethical in patients who require treatment. The orthopaedic community is demonstrating responsible practice by utilising the national joint registries and regular audits to monitor practice2. This can be used alongside randomised control trials, allowing further developments and medical breakthroughs to contribute to new guidelines.
Where are we now?
The 2017 five-year-forward view12 expected an increased NHS budget for elective surgery, but did not specify the nature of the elective surgery, something still largely determined by CCGs. However, having had a forced postponement of elective work following the COVID-19 pandemic, the backlog of procedures and increased strain on the NHS may again impose increased pressure on CCGs to ration an already limited resource.
Currently there is no solution to funding shortages. But with rationing protocols suggested by CCGs coming under great scrutiny from many orthopaedic surgeons, and often being redacted, it begs the question if rationing of services is hindering the health of patients. The decision whether to operate should be made on an individual basis at the surgeon’s discretion, provided they are operating within guidelines. If implemented, rationing requires further research to evidence its effect on the overall health of the population. Utilising national joint registries allows a reliable and transparent method to do this. Many proposals discussed in this article hinder patient care and due to a lack of evidence are currently unjustified.
- National Health Service. The NHS Five Year Forward View, 2014. Available at www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf. [Last accessed 23 April 2021].
- Dodd I, Sharpe I, Mandalia VI, Toms AD, Phillips JRA. Rationing of orthopaedic surgery in the UK. Bone and Joint 360 J, 2015;4(6):2-5.
- Dowsey MM, Choong PFM. The Utility of Outcome Measures in Total Knee Replacement Surgery. Int J Rheumatol. 2013;2013:506518.
- Hill DS, Freudmann M, Sergeant JC, Board T. Management of symptomatic knee osteoarthritis in obesity: a survey of orthopaedic surgeons’ opinions and practise. Eur J Orthop Surg Traumatol. 2018 Jul;28(5):967-74.
- Ferket BS, Feldman Z, Zhou J, Oei EH, Bierma-Zeinstra SMA, Mazumdar M. Impact for total knee replacement practise: cost effectiveness analysis of data from the Osteoarthritis Initiative. BMJ. 2017;356:j1131.
- Jenkins PJ, Clement ND, Hamilton DF, Gaston P, Patton JT, Howie CR. Predicting the cost-effectiveness of hip and knee replacement. Bone Joint J. 2013;95-B:115-21.
- Dakin H, Gray A, Fitzpatrick R et al. rationing of total knee replacement: a cost-effectiveness analysis on a large trial data set. BMJ Open. 2012;2:eooo332.
- Hamilton DF, Giesinger JM, Patton JT et al. Making the Oxford Hip and Knee Scores meaningful at the patient level through normative scoring and registry data. Bone Joint Res. 2015;4(8):137-44.
- Gwynne-Jones DP, Iosua EE, Stout KM. Rationing for Total Hip and Knee Arthroplasty Using the New Zealand Orthopaedic Association Score: Effectiveness and Comparison With Patient-Reported Scores. J Arthroplasty. 2016;31:957-62.
- British Orthopaedic Association (2017). Arbitrary Barriers: Rationing of Orthopaedic Services. Available at: www.boa.ac.uk/resources/arbitrary-barriers-rationing-of-orthopaedic-services.html. [Last accessed 23 April 2021].
- British Orthopaedic Association (2018). BOA Response to NHS England Figures on people waiting over 18 weeks for T&O surgery. Available at: www.boa.ac.uk/resources/boa-response-to-nhs-england-figures-on-people-waiting-over-18-weeks-for-t-o-surgery.html. [Last accessed 23 April 2021].
- NHS England (2017). The NHS Five Year Forward View. Available at: www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf [Last accessed 23 April 2021].