Rationing of Elective Orthopaedic Procedures by Clinical Commissioning Groups
There is an increasing trend of Clinical Commissioning Groups (CCGs) adopting, or proposing, policies which restrict access to elective orthopaedics, and that are not supported by robust clinical evidence.
Whilst T&O surgeons empathise with the financial position of commissioners, we have a professional responsibility to oppose these rationing measures due to the harm they cause patients.
Typically these policies consist of barriers to referral for Hip and Knee Replacement, for example, and can require a patient to:
- Lose weight or stop smoking before referral1
- Be experiencing extreme levels of pain or immobility2
- Score above a certain threshold on a clinical scoring tool3
All such thresholds contradict BOA4 and NICE Guidance5 and are based on either weak, or no, clinical evidence.
Other referral thresholds with similarly detrimental effects may be in place or become apparent. The BOA cannot support any thresholds which apply more stringent criteria for referral than those published either by NICE or in BOA NICE-accredited Commissioning Guides. In areas where there is no guidance, the CCG should consult the BOA, or its local Regional Advisers and Clinical Champions, to obtain a balanced clinical view.
There is also a risk that commissioners may temporarily suspend non-urgent referrals. This would delay access to surgery for orthopaedic patients, as well as undermine historical initiatives to reduce waiting lists. Such pauses usually result in chaos and fail to achieve the desired long term reduction in costs.
Rather than ration services, The BOA recommends that CCGs:
- use our NICE-accredited Commissioning Guides as a best practice resource when designing pathways, and seek support from our Regional Advisers and Clinical Champions who can offer practical clinical advice suited to the local area
- acknowledge the high cost effectiveness of many orthopaedic procedures, as illustrated by low QALY costs of Total Hip and Total Knee Replacement6
- acknowledge that the Getting it Right First Time programme, supported by NHS improvement and the BOA, has the potential to save £2 Billion over a five year period7 – making rationing measures increasingly inappropriate
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1 RCS (2016) Smokers and overweight patients: Soft targets for NHS savings?
2 Sarah-Kate Templeton (2016) ‘cataract patients offered surgery for only one eye’, Sunday Times , July 24th 2016
3 Royal Colleges of Surgeons of England (2014) Is Access to Surgery a Postcode Lottery, page 11
4 BOA Commissioning Guides on Pain arising from the Hip in Adults and Painful Osteoarthritis of the Knee
5 NICE (2014) Osteoarthritis: care and management
6 Jenkins PJ, Clement ND, Hamilton DF, Gaston P, Patton JT, Howie CR (2013) “Predicting the cost-effectiveness of total hip and knee replacement: a health economic analysis”. Bone and Joint Journal Jan, 95-B (1):115-21. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23307684
7 Briggs (2015) A national review of adult elective orthopaedic services in England :Getting it Right First Time, page 57