Big rise in rate of rejection of requests for knee and hip surgery

There has been a significant rise in the rate of rejection of requests for knee and hip surgery on the NHS over the past year, with almost 1,700 rejections in England last year, a BMJ investigation has revealed.

In 2017-18 a total of 1,675 exceptional funding requests (1,188 for knee surgery and 487 for hip surgery) were turned down by clinical commissioning groups (CCGs), according to data obtained by the BMJ under a Freedom of Information request. This was a 45 per cent increase from 2016-17, when 1,155 requests were rejected (766 for knee and 389 for hip surgery).

Responding to the figures Steve Tolan, the CSP’s head of practice, said ‘It is hard to consider necessary hip and knee surgery as non-essential when we analyse the impact of missing out’.

He said that these consequences include the impact of pain and immobility on quality of life, ability to work, the potential need for carer support, increase use of prolonged pain medication and the likelihood of developing other physical and mental health issues as a result.

‘While we may ask the question, how can we afford to provide timely access to this surgery when needed we may instead need to ask how can we afford not to?’ he added.

CCGs told the BMJ that the rise was due to the winter bed crisis, ongoing financial pressure in the NHS, and CCGs’ attempts to ‘reduce unwarranted clinical variation’. Although exceptional funding requests have been used to limit cosmetic procedures and fertility treatments since the 2000s, some CCGs have started to use them for a wider range of treatments include orthopaedic procedures as NHS finances come under increasing pressure.

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.

The initiative follows work to reduce GPs’ prescribing of low value medicines. The BMJ says NHS Clinical Commissioners, which helped draw up the plans, said that the initiative may eventually look at hip and knee replacements too.

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.

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