Nearly 1700 requests for knee and hip surgery were rejected in England last year
BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3002 (Published 18 July 2018) Cite this as: BMJ 2018;362:k3002
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The response below is a familiar scenario.
Interesting how the bait and switch tactics of those forcing IFR and similar rationing, claim to 'put patients at the centre' - but then become catatonically unresponsive when patients rightly complain that they are being denied access to care.
I have been fighting for over four years against IFR panel's refusals to fund a patient's £600 treatment.
The IFR's costs alone must have hit £10,000 by now. It may end up in court.
These restrictions will do far, far more harm than good.
Competing interests: No competing interests
The IFR (Individual Funding Process (also referred to among patients as the 'Invidious Funereal Process')) is not only unfair and unreasonable, it is detrimental to doctors as well as patients.
In 2005 I had difficulty accessing a course of MLD (Manual Lymphatic Drainage) to treat NHS cancer treatment-induced midline lymphoedema, but eventually the PCT (Primary Care Trust) commissioned an intensive course at a hospital trust which usually only treated arm lymphoedema. The course was monitored at beginning and end by a specialist in this field and pronounced 'successful' with an estimated 3 litres of fluid lost.
The benefits of treatment lasted several years, but then the lymphoedema clinic I attended told me they would only be treating new patients in future. I moved to a hospice-based clinic, but found I could no longer obtain any support pantyhose previously supplied by the hospital-based clinic, which would now cost me around £50 each. Also, the clinic could not afford to offer that intensive MLD treatment, so I asked my GP for help. The GP had to apply via the IFR process and the application was denied. Over the last few years my supportive GP has made several similar applications to the CCG but without success and each time I have felt caught up in a Kafkaesque situation.
The CCG did not appear to have any knowledge of what services were available: they suggested I apply to the hospital which only treated arm lymphoedema, but, unlike the PCT, did not commission a course of MLD, so my application was turned down. They suggested I apply to the very hospital clinic I had left (which had decided to treat only new patients). Strangely, I was told an appointment had been arranged at the surgical department of the hospital that only treated arm lymphoedema, which, being inappropriate, had to be cancelled, along with ambulance transport. Finally, the CCG told me to apply to the hospice clinic (where I was already enrolled but which had already stated it could not afford to treat me).
With every IFR application the psychological effects of raised hopes and disappointments combine. Thanks to the IFR, there is no NHS help for an NHS treatment-induced condition. Add to this the effect on a GP's job satisfaction and workload – and the guilt I feel for having added to their burden.
Competing interests: No competing interests
Following the banking collapse in 2008 - and its bailout from the public purse - the banking sector is doing fantastically well, while a full ten years later public services including health, Police, education, social care, welfare and housing are parlous and unable to serve the immediate needs of the population. The City has never felt the need to repay its public debt and so far, it hasn't been asked to. Neither has this govt felt the need to bail out the NHS as being 'too big', or too important, to fail.
The increasing list of restricted procedures and numbers of patients being refused effective treatments, is the thin end of the wedge. Procedures which - through advancing consensus - doctors have anyway reduced treating, are conflated with treatments where poorly substantiated evidence of ineffectiveness are considered grounds for prohibiting them. In my 28yrs experience (and I know how little that means), it is older people who benefit most from many of the prohibited procedures eg for spinal injections, fusion, Dupuytren's. In older patients for whom regular spinal injections have preserved their ability to leave the house and self-care, denial of these treatments will reduce quality of care provided to these patients, while also increasing financial, medical and social costs where pain and disability persist through lack of treatment. It is the better selection of the subsets of patients who do benefit from these procedures that we should be aiming for.
The example of Doncaster demonstrates how the restriction list is both clinically inappropriate and negatively cost effective.
It is pretty certain that most of the 24 out of 25 patients refused knee replacement will end up having it done anyway. It's clear that this is doubly detrimental: to the patient who is left with progressive disability and pain for months or years, and may suffer further harm from falls or medications; and to the NHS, which incurs clinical and admin costs - perhaps including litigation - as a result of the delay.
‘Getting It Right First Time’ starts to look like just another slogan. ‘Reducing Unwarranted Variation’ starts to look like just another race to the bottom.
I don't accept that these restrictions are a sensible and pragmatic response to planning provision for the population within an artificially constrained budget. I fear this may be implicit formal introduction of a two-tier system, dressed up as a conglomeration of 'prudent' clinical practice and 'living within one's means'. The IFR (Individual Funding Request) process creates unnecessary and costly barriers to patients receiving care which the patient, a GP and a Specialist will have jointly agreed, is warranted. Rationing hip and knee surgery - effective and cost-effective procedures - along with benign skin lesions, creates a conflated basis for contraindicating care.
Shifting between pretexts of ‘clinically obsolete’ and ‘too expensive’, the nature of the slippery slope towards a two-tier service is crystal clear. This is an insidious rationing policy. It's neither clinically nor cost effective; it's not necessary; it deprofessionalises doctors and places conflicts within the doctor-patient relationship; it prevents doctors from acting in each patient's best interests; it creates a societal pressure for patients to pay to seek care instead from the private sector.
While NHSE makes these decisions, individual CCGs will take the rap, from patients and from the courts. We cannot let ourselves be forced into this position. Perhaps this is why NHSE were less than keen to comment.
Competing interests: No competing interests
Following the banking problems of 2007, the western world feared financial Armageddon. This was avoided and no sensible person can say reduced spending on public services was not a necessity. Money doesn’t grow on trees.
However, I do worry that restrictions on access to surgery may have significant costs to the health economy. No matter how well researched a CGC policy limiting access to surgery is, there is no one better placed to decide if a person is suitable for a procedure than the potential operating surgeon.
It requires little wit to suppose a sharp eyed lawyer will find a flaw in a policy designed to restrict surgery - and then seek compensation for a patient not getting timely joint replacement surgery (or whatever). And this being repeated many many times. Thus costing far more than the restrictions on surgery was expected to save.
Competing interests: No competing interests
So, the Clinical Commissioning Groups ration certain procedures to cut costs to the NHS?
A patient, immobile and in pain, sits at home consuming paracetamol or something stronger.
Might become depressed. Then more medicines, prescribed ones, from the NHS.
More burden on friends, relatives, on their earning capacity.
Could the BMJ please investigate how much money is spent on running these modern quangoes or sub-quangoes.
Could someone tell me how many weeks a CCG may take before replying to a patient’s letter?
How do DOCTORS justify participating in these committees?
Competing interests: A bias against anyone or anybody intruding in to the relationship between a patient and the doctort
Re: Nearly 1700 requests for knee and hip surgery were rejected in England last year
Dear Colleagues
In response to BMJ Investigation: Hip and Knee surgery, BMJ Vol 382, July 2018.
That increasing numbers referred for cost effective and ‘quality of life’ transforming joint arthroplasty surgery are being required to apply for exceptional funding, increasingly being refused, is a huge concern. Many patients with hip arthritis are correctly and successfully managed conservatively. However, many cases will progress, developing restricted joint mobility and function, and an ever-increasing level of pain. Hip arthroplasty surgery has a profession-wide reputation as a cost effective and versatile way of returning patients to excellent function with reliable pain relief. Previously, long waiting lists meant worsening deformity, muscle wasting and bone loss, which resulted in the eventual surgery carrying more risk, with worse outcomes and increased complications. As such, appropriate timing of referral for intervention is critical. Similarly, with surgical outcomes ever more transparent, it is increasingly in the surgeon’s interest to ensure that only appropriate patients are considered for excellent surgery.
That the UK healthcare environment is under challenge is not under debate, however, tax payers and those who are eligible for NHS care, should not be denied access for financial reasons to a cost effective, versatile, durable and clinically reliable intervention.
Anecdotally, hip surgeons are seeing an increase in the number of patients seeking a private opinion, having found the complex ‘loops’ that have been interposed between primary and secondary care assessment, intolerable. Many of these patients actually have severe and limiting arthritis and are prime and worthy candidates for surgical intervention. The majority will go on to have surgery, most within the NHS.
It is indeed important to be ‘honest and upfront’. It is clear from my own experience, that many patients receive misinformation about the merits, outcomes and indications for hip surgery. That negative information, (‘you are too young’, ‘hips only last 5 years’ ‘you can only have one replacement’) can be used to justify what is essentially, as suggested by both Dr Thorman and Mr Nanu, financial reasons to limit the number of patients referred for secondary care assessment.
Primary Care colleagues, are aware of the potentially life changing outcomes of hip surgery. Many are fully aware of the appropriate level of symptomatic limitation that warrants secondary care review. With that threshold reached, to then be required to refer patients into a complicated series of assessments and treatment pathways, must be as frustrating to hard pressed and over-burdened GP colleagues, as it is painful for their patients. Hip surgeons work within a team and are no longer the sole decision maker in secondary care. Surgeons would whole heartedly support appropriate referral within a more integrated primary and secondary care decision making process regarding who does, and who does not yet, warrant consideration for surgery.
The British Hip Society is aware of the increasing variation in how hip surgery is commissioned in different parts of the UK. More coordinated and agreed referral criteria should be established. Such is the concern amongst Orthopaedic surgeons, that this issue has been chosen for specific discussion and debate within the British Hip Society revalidation session to be held at the BOA Centenary Congress in Birmingham later this year.
The excellent and informative series of articles published in the BMJ Vol 382, July 2018, should serve as a catalyst for ever more communication and interaction. Against the background of an aging yet increasingly active population, the numbers of hip arthroplasty procedures will be expected to increase. Having been introduced and developed in the UK, in the 50s and 60s, the story of Primary Hip Arthroplasty Surgery is inextricably linked to that of the 70yr old NHS. If that link is to be maintained, Orthopaedic surgeons must accept their responsibilities to the wider healthcare economy. They must be cost-effective and evidence-based in their decisions and fastidious in their surgery, to optimise outcomes on every parameter. Clinicians must communicate and produce pathways that will allow fellow tax payers and our political paymasters to be reassured that what was described as the operation of the last century, will retain its pre-eminence in this one.
Yours faithfully,
Andrew Manktelow
President of the British Hip Society
And
Consultant Orthopaedic Surgeon
Nottingham University Hospitals NHS Trust
Competing interests: No competing interests