Royal College urges CCGs to reconsider plans to restrict surgery

BMJ 2016; 353 doi: (Published 06 April 2016) Cite this as: BMJ 2016;353:i1993
  1. Gareth Iacobucci
  1. The BMJ

The Royal College of Surgeons (RCS) has written to six Clinical Commissioning Groups (CCGs) in Birmingham to express its concern about their plans to restrict access to surgery.

The commissioning groups are consulting on plans to place thresholds on several planned surgical procedures—including hip and knee replacements and hernia repair—on the basis that they are lower clinical value.1

But in an open letter published on 5 April,2 the RCS urged the groups, which commission care for six million people in the region, to reconsider their position.

The college said that it was particularly concerned that guidance from the National Institute for Health and Care Excellence (NICE), the college, and surgical specialty associations had been “misrepresented and incorrectly referenced” during the development of the commissioning policies.

It cited examples of proposed policy changes that contravened guidance, including only funding surgery for irreducible or partly reducible inguinal hernias or those that cause pain that limits daily activity, or are strangulated or obstructed; and only referring children for grommets treatment after five or more episodes of glue ear are documented.

The CCGs also planned to restrict referrals for hip and knee surgery to patients with a BMI below 35, as well as only referring patients for adenoidectomy if the procedure is undertaken at the same time as grommets or tonsillectomy, and only surgically treating more advanced cases of varicose veins.

The document produced by the CCGs, which details the policy says, “CCGs have limited budgets; these are used to commission healthcare that meets the reasonable requirements of its patients, subject to the CCG staying within the budget it has been allocated. By using these policies we can prioritise resources using the best evidence about what is clinically effective, to provide the greatest proven health gain for the whole of the CCG’s population.”

Paul O’Flynn, Royal College of Surgeons council member and lead for commissioning, questioned the evidence base on which the CCGs had made their decisions in his letter to the groups. He wrote, “The Royal College of Surgeons believes patients’ access to treatment must be based on clinical assessment and evidence based practice.

“We strongly urge you to reconsider your position [on the points of concern above]. The RCS has produced clear guidance, accredited by NICE, and this should be fully taken into account in CCGs’ commissioning policies. In this case, our guidance has been misrepresented and incorrectly referenced in many places.”

A spokesperson on behalf of the CCGs across Birmingham, Solihull, and the Black Country said, “Along with a number of key stakeholders, the RCS was asked for their views as part of our procedures of lower clinical value engagement process; we have only just received their formal feedback.

“We have already taken into account many of the valid points raised by the college as part of feedback received through the engagement process, and will continue to do so as we work through each policy.

“Naturally, the review of procedures of lower clinical value policies is very detailed, and includes reviewing all the comments that we have received from our stakeholders to inform our decisions.

“We are very pleased that the college has now formally commented, to enable us to make sure their views are considered fully and appropriately.”


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