Letter to The Times on rationing hip and knee replacements

The Times
1 London Bridge Street
SE1 9GF

Dear Sir,

I read with interest your article on rationing by CCG’s of hip and knee replacements - an issue which is so important to many of our patients. It is unfortunate that a number of myths continue to be perpetuated in this debate, some of which you have focused upon in your article. There are many further pieces of information which support your comments.

Firstly there is robust evidence that having a BMI between 30 and 40 does not increase your risk of a poor outcome following either hip or knee replacement. Indeed there is some evidence that this group of patients is actually the ‘happiest’ with their outcome. If your BMI is over 40 your complication risk goes up marginally, but if you have an uncomplicated outcome you are as happy with the outcome as thinner patients.

A hip replacement costs £7.50 a week and 90% of hip replacements will still be in place having required no further treatment (beyond 15 years in many cases) at the end of a patient's life. Patients prior to a major joint replacement will attend their GPs, on average, a couple of times a month. Post joint replacement they need to do so only a couple of times a year.

The Oxford hip and knee scores were not designed as a pre-op screening tool to eliminate large sections of the population from a qualitative life improving procedure: they were designed as a tool to measure outcomes in large populations and not in individuals. There is evidence that timely surgery has the best effect on patients’ general health, the implication being that if you wait, their general health deteriorates. There is also good evidence that although patients with a very bad score pre-operatively may make greater improvements in some respects, they tend not to reach such a high level of functioning or such a low level of disability after their operation as those who start off with a lower level of disability.

Using the well-intentioned aim of an overall improvement of the populations’ general health as a justification for limiting access to very effective treatment is neither acceptable nor ultimately cheaper. In an era where patients should be fully advised as to their options and choice of treatment, this stance will inevitably lead to endless appeals and a further waste of resources to deal with them.

The Department of Health says there is no more money. This is an assertion which can easily be challenged as in the UK we spend much less of our money on health care than do most of the developed western nations. However, if the government is absolutely adamant that they will provide no more funding, there are two things that should be considered before such arbitrary rationing. Firstly, the enormous increase in NHS management costs, which have at least tripled in terms of percentage spend over the last two decades, needs to be cut radically. Secondly, if some form of rationing is deemed essential, it should not be targeted at treatments that are cost effective and will help maintain the fitness and independence of patients. This clearly applies to total hip and knee replacement as two of the most cost effective treatments available across the whole of health care. Preventing patients accessing these life enhancing treatments smacks of moral bankruptcy.

Yours sincerely

Ian Winson FRCS
BOA President