Feature / Flow control

Limiting the use of procedures
where evidence shows there is limited value makes sense. But putting such mechanisms into place can be fraught with difficulties. Steve Brown examines how the issue has hit the headlines and looks at one area’s detailed approach to review treatment policies

Increasing numbers of clinical commissioning groups are reviewing commissioning guidelines in attempts to ensure they maximise value from thinly stretched budgets. This has been portrayed in some media as rationing of services, driven by the need for efficiency savings. But others suggest it is essential prioritisation of spending at a time when the service cannot afford to spend scarce resources on procedures with limited benefit or to undertake invasive procedures when other interventions could be more appropriate.

The issue hit the headlines at the end of January, when three clinical commissioning groups in the West Midlands – South Worcestershire, Wyre Forest, and Redditch and Bromsgrove – changed the threshold for routinely funding hip and knee replacement surgery. Headlines suggested patients would now have to prove that pain was keeping them awake at night before a joint replacement would be sanctioned.

The three CCGs acknowledged that surgery guidelines had been revised. However, they said this followed a review of RightCare data that had highlighted spend on hip and knee replacement that was ‘around £2m higher’ than comparable CCGs. They added that the change in threshold for routine funding used a scoring system that recognises that many patients will benefit from physiotherapy and weight loss before considering surgery. 

Oxford scoring system

Using the Oxford hip and knee scoring system used in the national patient reported outcome measures programme, the CCGs have reduced the threshold from a score of 30 to 25. ‘[This] brings the Worcestershire CCGs in line with what other CCGs already do and would help to reduce this spend difference,’ a spokesperson for the three CCGs said. 

They added that a number of CCGs across the country had an Oxford hip and knee score threshold of 20 or lower and that the individual funding request (IFR) mechanism still enabled patients not meeting the pre-set criteria to have the surgery in exceptional cases.

They are not alone in examining service restrictions. In December, West Kent CCG launched a review of compliance with its existing procedures of limited clinical value list and other restricted services, such as alternative medicine and cosmetic surgery. Having previously undertaken a similar audit with its main NHS provider, this further review would focus on activity undertaken at independent providers. 

With the relevant activity in the independent sector worth an estimated £5m, the CCG has estimated that this could lead to savings of £375,000 in 2016/17 – on the basis of discovering 10% non-compliance and allowing for double counting. A spokesperson for the CCG said the compliance review ‘should be completed by March’.

It is also considering changes to the access criteria under which cataract surgery is routinely funded, following similar changes to the pathway for hip and knee surgery last autumn. The hip and knee access changes introduced a triage and lifestyle advice service as an extra step to ensure patients’ fitness to proceed to surgery where needed. 

In a more media-eye-catching move, the CCG also suspended non-urgent activity for the rest of the current financial year to enable it to remain within budget for the year. 

CCG chair GP Bob Bowes said the decisions were ‘never easy but they are necessary’ – if the CCG did overspend this year, it would be likely to mean more severe cuts in future. He also flagged up that exceptional cases would still be considered on a case-by-case basis.

‘The reality is that here in West Kent, as across the country, the health and social care system is not set up in the right way to meet the changing needs of local people and make the best use of staff and funding available,’ he said. The changes set out in the local sustainability and transformation plan would avoid having to take such short-term measures in the future.

The Academy of Medical Royal Colleges is leading a Choosing wisely campaign to address a ‘growing culture of overuse of medical intervention’ and challenge the idea that more is better. It encourages shared decision-making between clinicians and patients, ensuring patients understand any risks of treatment and alternative options.

As part of the campaign, all royal colleges were asked to identify five treatments or procedures commonly used in their field that are of questionable value and would warrant careful discussion with patients before being carried out. This seems in line with the idea of CCGs being clear about evidenced-based restrictions on routine commissioning. But it appears to be how lists are managed in practice – and the direct inclusion of financial considerations – that creates disagreement.

For example, both the above cases drew an angry response from the Royal College of Surgeons, which is involved with the Choosing wisely campaign. College president Clare Marx described West Kent’s surgery suspension as ‘unprecedented and unfair’, with short-term savings potentially having major consequences for patients. ‘Clinical decisions must not be made purely on a financial basis,’ she said. 

Vice-president Stephen Cannon similarly condemned the Worcestershire CCGs’ threshold change for hip and knee surgery, based on ‘arbitrary pain and disability thresholds’ as ‘alarming’. ‘It is right to look at alternatives to surgery, but this decision should be based on surgical assessment, not financial pressures,’ he said. 

Support in principle

The college also raised concerns that similar restrictions were ‘happening up and down the country affecting thousands of patients’.

In a statement to Healthcare Finance, the Royal College of Surgeons says it supports the use of lists of procedures of limited value in principle. ‘However, we are also very clear that CCGs must base their decisions about what procedures are put on these lists on good clinical evidence and in accordance with NICE guidance. Too many CCGs are introducing policies that restrict access to certain procedures as a way of saving money, rather than because there is any clinical justification for their decisions.’ It adds that the RCS found more than a third of CCGs had implemented policies that restrict access to surgery for smokers and obese patients and are in direct contravention of NICE guidelines.

It also has concerns that extending these lists to other procedures, or raising thresholds, will lead to a large increase in funding requests, making the system slower and leaving patients ‘waiting too long in pain or discomfort’.

However, West Kent’s Dr Bowes insists: ‘The decision to stop non-urgent surgery involved a number of clinicians. It was agreed initially by the clinical strategy group, a group that mostly comprises GPs. And following that, the decision to implement was taken by the governing body of the CCG, chaired by myself and with a GP majority, and whose members include five lay and independent members.’

Julie Wood, chief executive of NHS Clinical Commissioners (NHSCC), says that in an environment of spiralling demand, finite funding and a requirement to balance the books, CCGs have to look at reprioritising their spend. Stopping or restricting access to certain services are the difficult consequences of this situation. But she says CCGs look to do this responsibly, informed by variations in the volume of activity delivered in different services across similar CCGs and guided by evidence of clinical and cost effectiveness.

‘Decommissioning is an act of commissioning too,’ she says, adding that achieving value for money (measured in outcomes, quality and cost) is the responsibility of providers and commissioners. ‘If there are things in a hospital setting that add little value, hospitals should be doing their bit to stamp them out and CCGs need to reinforce this by making it clear that they won’t pay for these activities,’ she says. 

Ms Wood stresses that a health service pound can only be spent once, and there is a duty to get the best value possible
from it. That means taking some difficult decisions upfront, and commissioners are right to consider the thresholds used in their areas to access some procedures, which may vary from consultant to consultant even if presented with the same patient (see box for how one group of CCGs has taken this review process forward).

‘If a patient needs an intervention, then the CCG wants them to get that intervention. But if you can put in place alternatives that mean they don’t need that intervention – or put the patient in a better condition to have a successful outcome – that is the right thing to do,’ she says.

Again, Ms Wood stresses that CCGs are not barring activities in most cases, but setting criteria for when they will be routinely funded. Mechanisms using IFRs are in place to enable exceptional cases to proceed. She accepts that if there are very high levels of these requests, this might suggest the threshold has been set at the wrong level. But she acknowledges that more CCGs are currently reviewing commissioning policies, driven by the extreme financial pressures placed upon them.

In January, the OECD published a report – Tackling wasteful spending on health – which suggested that about one-fifth of health expenditure currently makes no or minimal contribution to good health outcomes. Low-value procedures were identified as a contributor to this waste. ‘Low-value procedures can be found at all stages of the care pathway,’ it says, adding elsewhere that ‘variations in clinical patterns are the main and most powerful tool offering insights into the magnitude of waste due to low-value care’. However, identifying ‘waste’ is far from straightforward and CCGs have found that any move away from the status quo can meet with opposition.