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Nearly 1700 requests for knee and hip surgery were rejected in England last year

BMJ 2018; 362 doi: (Published 18 July 2018) Cite this as: BMJ 2018;362:k3002
  1. Gareth Iacobucci
  1. The BMJ

Increasing numbers of patients seeking knee or hip surgery are finding they can’t have operations on the NHS, an investigation by The BMJ has found.

In 2017-18 a total of 1675 exceptional funding requests (1188 for knee surgery and 487 for hip surgery) were turned down by clinical commissioning groups (CCGs), show the data obtained under a freedom of information request. This was a 45% increase from 2016-17, when 1155 requests were rejected (766 for knee and 389 for hip surgery).

Exceptional funding requests have been used since the 2000s to limit cosmetic procedures and fertility treatment. But as NHS finances have been squeezed, some CCG areas have started to use them for a wider range of treatments. GPs refer patients to specialists as normal, but there is no guarantee that if they recommend a treatment it will be funded. Instead the patient’s GP then has to submit an exceptional funding request to the CCG, and a panel decides whether to fund it.

As The BMJ first revealed last year,12 these types of requests have surged in recent years as CCGs try to keep down costs.

The BMJ’s latest analysis shows stark variation across the country in how CCGs are applying restrictions on surgery (box 1). For example, Buckinghamshire CCG had 1298 exceptional funding requests for knee surgery last year and rejected 18% (fig 1), while Doncaster had far fewer requests through this route (24) but rejected all but one.

Box 1

How access to hip and knee surgery varies across England

CCGs with highest numbers of exceptional funding or prior approval rejections in 2017-18

Knee surgery

  1. Buckinghamshire: 230 rejections, from 1298 requests (18%)

  2. East and North Hertfordshire: 198, from 1575 (13%)

  3. Wiltshire: 62, from 194 (32%)

  4. Basildon and Brentwood: 52, from 280 (19%)

  5. East Berkshire: 46, from 280 (16%)

Hip surgery

  1. Basildon and Brentwood: 99, from 216 (46%)

  2. Buckinghamshire: 91, from 907 (10%)

  3. East and North Hertfordshire: 37, from 802 (5%)

  4. Wiltshire: 28, from 108 (26%)

  5. Vale of York: 19, from 31 (61%)

CCGs with highest proportions of exceptional funding or prior approval rejections in 2017-18*

Knee surgery

  1. Doncaster: 96% rejected (23 of 24 requests)

  2. Hull: 92% (11/12)

  3. Vale of York: 90% (28/31)

  4. Rotherham: 88% (28/32)

  5. Barnsley: 87% (13/15)

Hip surgery

  1. Rotherham: 100% (11/11)

  2. Doncaster: 90% (9/10)

  3. East Riding of Yorkshire: 73% (16/22)

  4. North East Essex: 70% (7/10)

  5. Harrogate: 67% (8/12)

  • *Includes only CCGs that processed 10 or more requests.

Fig 1
Fig 1

CCGs with highest numbers of rejections of requests for exceptional funding or prior approval

Ian Eardley, senior vice president of the Royal College of Surgeons, said, “Hip and knee surgery has long been shown to be a clinically and cost effective treatment for patients. We are therefore appalled that a number of commissioning groups are now effectively requiring thousands of patients to beg for treatment.”

Doctors say that applying for exceptional funding is stressful for them and their patients, while restrictions on numbers of operations also affects surgical training.

Graham Jackson, co-chair of NHS Clinical Commissioners, which represents CCGs, said it was right to follow clinical evidence to try to reduce unwarranted variation and bring thresholds for surgery to a consistent and appropriate level. But he acknowledged that some CCGs may be overzealous in imposing criteria that make some patients ineligible for surgery because of financial pressures.

Figures show that almost 200 000 surgical hip and knee procedures were performed by the NHS in 2016-17.3

Commissioners said that the winter crisis (when elective procedures were effectively cancelled), ongoing financial pressures in the NHS, and CCGs’ efforts to reduce unwarranted clinical variation had all contributed to the rise in the number of patients being refused knee and hip surgery in the past year.

Julie Wood, chief executive of NHS Clinical Commissioners, said, “The money has in effect run out, and CCGs have got to find ways of delivering greater efficiencies. CCGs might, for example, decide that they need to commission a lower amount or apply different thresholds.

“We have to be very honest and upfront. It needs to be a conversation with the public about what the NHS should be providing.”

NHS England declined The BMJ’s request for a comment.

The GPs’ view

The BMJ’s analysis, based on responses to freedom of information requests from 167 of England’s 195 CCGs (a response rate of 86%), shows that GPs are increasingly having to make requests on behalf of their patients for knee and hip replacements. There is a also a sharp rise in the number of requests being turned down.

The figures obtained by The BMJ show that in 2017-18 Wiltshire CCG rejected 62 of 194 (32%) exceptional funding requests for knee surgery and 28 of 108 (26%) requests for hip surgery. This compared with 32 of 59 (45%) requests for knee surgery and 12 of 27 (44%) for hip surgery rejected in the previous year.

Helena McKeown, a GP and vice chair of Wiltshire Local Medical Committee, said that the process of applying for funding placed strain on GPs and their patients. “It’s a source of extra work for GPs at a time when we are desperately short of clinical GP time,” she said.

In 2017-18 Rotherham CCG budgeted for a 25% reduction in the number of hip and knee replacements it commissioned as it sought to save money.4 But in September 2017 it reported overactivity, with 177 procedures carried out in the first three months of 2017-18, against a forecast of 138. Across 2017-18 as a whole Rotherham received 32 exceptional funding requests for knee surgery, 28 (88%) of which it rejected. It also received 11 exceptional requests for hip surgery, all of which were rejected.

Rotherham has applied thresholds for referring patients for hip and knee surgery since 2016,5 and it is now developing policies with other local CCGs in South Yorkshire to ensure greater consistency. Like Rotherham, several of these CCGs also rejected a high proportion of exceptional funding requests for hip and knee surgery last year.

Neil Thorman, a GP and medical secretary of Rotherham LMC, said that while the motivation for imposing thresholds was financial, the CCG had been “as fair and objective as they could have been” and had engaged with local GPs.

Impact on patients

Even if a patient’s request for exceptional funding is approved, the process of applying for it creates delays, because requests must be assessed by local panels.

Ian Eardley, senior vice president of the Royal College of Surgeons, said, “The use of funding requests means patients will spend more time in pain with potential deterioration of their condition, thereby generating further costs for a system already under acute financial strain.”

McKeown said that the laborious process of submitting an exceptional funding request may act as a barrier to treatment. “Patients have to be prepared to give up their identity and clinical info to a panel, not all of whom are clinical. Some patients feel that this is a price they are not prepared to [accept] and so don’t pursue exceptional funding,” she warned.

John Kell, head of policy at the Patients Association, said that exceptional funding requests shouldn’t be needed to access “well established and highly effective interventions such as hip or knee replacements.”

He added, “Patients shouldn’t be forced into making a ‘hail Mary pass’ such as trying to use a mechanism that’s really intended for something else [treatment that is not routinely offered] to access relatively basic care.”

Ananda Nanu, president of the British Orthopaedic Association, said, “My concern is that we have elderly, very vulnerable people who are being affected.”

But Thorman said that conditions for referral in his area had largely been accepted by patients. “When it’s explained to patients that there might be less invasive, safer, or more conservative way of managing the problem . . . it’s unusual for them not to be willing to try those before moving forwards,” he said.

Are more patients going private?

Some evidence is emerging that more patients are choosing to go private for hip and knee surgery because of the NHS’s restrictions and longer waiting times.

Spire Healthcare, one of the largest providers of private healthcare in the UK, saw a 12% rise in revenue from self paying patients in 2017.6

Certain areas have seen a particularly high surge in patients paying for care. Spire Little Aston Hospital, near Sutton Coldfield in the West Midlands, reported a 60% growth in patients paying for orthopaedic procedures in 2017. Spire said that some of this demand was driven by lengthening NHS waiting lists.

In the company’s most recent annual statement, Justin Ash, chief executive officer of Spire Healthcare, said that he expected these trends to continue this year. “It is clear to all UK healthcare stakeholders that demand for healthcare provision by the independent sector will continue to rise rapidly as the NHS remains severely financially constrained, and waiting lists and rationing, especially for elective work, continue to grow,” he said.

“Huge problem” for surgical training

The restrictions on hip and knee procedures are having a negative effect on orthopaedic surgery training, surgeons report. The British Orthopaedic Association’s president, Ananda Nanu, said that half of training directors at a recent meeting he attended said that they had had to move a trainee, consider moving them, or extend their training period because of the lack of training opportunities.

“It’s a huge problem,” he said. “In certain areas of the country there has been a complete moratorium on hip and knee surgery for several months.”

Patrick Williams, a trainee orthopaedic surgeon and education representative for the British Orthopaedic Trainees Association, said that during a recent placement he had carried out less than a quarter of the number of joint replacements he needed to complete his training.

In the longer term, Williams said, higher treatment thresholds could have “very long reaching effects” if surgical trainees weren’t able to carry out as many simple procedures.

“The hip and knee replacements that we [trainees] are doing are likely to become more complicated because patients are being seen later,” he said. “Less experienced trainee surgeons who would be doing simple ones will suddenly have to cope with doing more advanced ones. Some consultants will say, ‘Okay, it’s a harder one, you do it,’ but others will say, ‘This one’s a bit tricky: you’d better not.’ That would certainly have an effect on training and potentially on patient outcomes.”

What’s being done to tackle variation in access?

The BMJ’s analysis shows that the proportion of funding requests for hip and knee surgery rejected by CCGs remained broadly static last year at around 10%. But there were more rejections, because the number of funding requests increased substantially, by 56% for knees (from 6894 to 10 755) and 46% for hips (3704 to 5414).

A major concern is the disparity uncovered across the country, with CCGs acting independently to restrict access to procedures to balance their books.

Nanu said that some CCGs had imposed “draconian” restrictions. “Access to healthcare in different parts of the country seems to be determined not by clinical factors or by patient factors but by how the money is to be spent,” he said.

To eliminate what it describes as “unwarranted variation” in activity, NHS England is currently consulting on nationwide proposals to stop funding 17 procedures it considers are clinically ineffective, including knee arthroscopy for patients with osteoarthritis.7 The initiative follows work to reduce GPs’ prescribing of low value medicines,8 and NHS Clinical Commissioners, which helped draw up the plans, said that the initiative may eventually look at hip and knee replacements too.

Alongside this, the NHS is considering, as part of its Elective Care Transformation Programme, whether the current locally driven approach to hip and knee surgery commissioning needs to be reviewed to create more standardised thresholds across England.

Nanu said he was concerned that moves to standardise access may lead to stricter thresholds for access to hip and knee surgery if financial savings were prioritised. “The key question is: do you take everybody up to the highest common factor or do you take everyone down to the lowest common denominator?” he said.

But NHS Clinical Commissioners’ co-chair Graham Jackson said that consensus should be possible if policies were clinically led and based on sound evidence. “There are cases where we have put joint replacements in people that have not improved their outcome, cost money, and created morbidity,” he said.

“If you use knee replacement as an example, we should be able to standardise that to a clinically appropriate threshold, whether its a BMI threshold, an activity measure, [or] a quality of life issue. There may be CCGs which are then overlaying something on top of that, but that’s the challenge, because of the fact that there isn’t enough money in the system.”

Jackson said that all clinicians had a responsibility to avoid using NHS funds inappropriately. “It’s not about pitching different parts of the service against each other. It’s coming to collective consensus about what the right thing to do is,” he said.

But agreement is not always possible. In May this year doctors in London attacked draft NHS plans to refer patients with osteoarthritis for a knee or hip replacement only if there was a “substantial impact on quality of life.”9 And last year the Royal College of Surgeons criticised three CCGs in Worcestershire over plans to raise the eligibility threshold, using the Oxford hip and knee score system, for patients requiring hip and knee replacements.10

NHS Clinical Commissioners’ Julie Wood said, “Where the evidence is clear, it should be possible to achieve consensus. But where there is disagreement, sadly we may not.”

Box 2

How The BMJ carried out its investigation

The BMJ asked each of England’s 195 CCGs how many requests for exceptional funding or prior approval they received over the past three years for hip and knee surgery, and how many of these requests were approved.

In total, 191 CCGs responded to The BMJ’s request (98% response rate):

  • 167 CCGs (86%) provided comparable data

  • 5 CCGs provided incomplete data

  • 19 CCGs didn’t provide data, or their data were combined with those of other CCGs.


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