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NHS chiefs warn against arbitrary rationing of hip and knee surgery

A warning has been issued by NHS England to some clinical commissioning groups over the arbitrary rationing of hip and knee surgery, it has been revealed.

The Health Service Journal (HSJ) reports that an email was sent from an NHS England official to clinical commissioning groups last month.

The correspondence states the body is aware a "number of CCGs in England are rationing large joint replacements using arbitrary cut offs from (the) Oxford scoring (system)".

"In addition some CCGs are restricting surgery for smokers and obese people as opposed to a period of slimming support and smoking cessation support for surgery," the email adds.

The HSJ said the email was sent by a director in an NHS England regional team, but it is not clear if the same requirements have been sent to all CCGs.

Instructions within the email require CCGs to inform NHS England if they have already rolled out such approaches, the publication claims.

In future CCGs will have to request regional level agreement before implementing such policies.

The intervention comes after a number of CCGs looked to ration hip and knee replacement surgery in a bid to cut costs - including three in the West Midlands.

Redditch and Bromsgrove, South Worcestershire, and Wyre Forest CCGs said they intend to slash the number of people who qualify for hip replacements by 12% and introduce a 19% cut over who is eligible for knee replacements.

This would include only treating "severe to the upper end of moderate" cases, and people who are obese with a body mass index of 35 or over needing to lose 10% of their weight unless their problems were very severe.

Board documents said a "patient's pain and disability should be sufficiently severe that it interferes with the patient's daily life and/or ability to sleep".

Hoping to save around £2 million a year, the proposals aim to prevent about 350 operations each year.

The HSJ also reports that at the same time as the email, another letter was sent to all leaders of CCGs by NHS RightCare national director Matthew Cripps, and Peter Kay, a consultant hip and knee surgeon.

Within it, they advise CCGs should be more cautious about restricting access to hip and knee replacement surgery and state how to use NHS England's RightCare programme to commission these procedures, the HSJ claims.

The letter reads: "For some indicators, such as elective activity, investment cannot be interpreted as poor or good value without further investigation ... There is strong evidence that hip and knee replacements are extremely cost-effective interventions when warranted by clinical need and patient preference."

Royal College of Surgeons president Clare Marx welcomed NHS England's warning to CCGs to "discourage clinically unacceptable rationing of surgery in the NHS".

"There have been growing examples of commissioning groups ignoring Nice guidance and imposing arbitrary pain, weight, or smoking thresholds to defer or prevent patients from receiving timely surgery as a way of saving money," she said.

"In particular, NHS England has reminded CCGs that patient-specific factors such as smoking or obesity should not be barriers to referral for hip and knee replacement surgery."

She said making it a condition for a patient to quit smoking or lose weight before gaining access to treatment is "unjust".

Ms Marx said the guidance in the letter is a "very welcome start" but only criticises the "rationing of hip and knee surgery".

"Patients are left wondering about the validity of restrictions to other types of surgery and NHS treatment," she added.

"Given this very clear intervention from NHS England we strongly encourage CCGs to reverse any existing discriminatory policies."

An NHS England spokesman said: "Ultimately these are legally decisions for CCGs, but informed by best evidence and national guidance where appropriate."

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