Procedures of clinical value being limited by CCGs

CCGs are creating lists of treatments that they either don’t offer to patients or place thresholds on patient access. Increasingly these lists include treatments that are proven to be effective and beneficial to patients.

Overview

Hernia: 95 CCGs, almost half, currently have hernia repair listed in their Procedures of Limited Clinical Value (PoLCV) or threshold list. CCGs are increasingly taking a ‘watchful waiting’ approach to hernia management which could mean an increase in emergency cases and worse patient outcomes.

Cataracts: 104 CCGs, that’s over 50%, include cataract removal on their list of PoLCV and over a third, 76 CCGs, include a visual acuity threshold. Cataract removal is the most common procedure performed on the NHS and is proven to be effective. Both NICE and the Royal College of Ophthalmology state that treatment decisions should not be based on visual acuity.

Continuous Glucose Monitoring: 12 CCGs do not commission Continuous Glucose Monitors (CGM) and a further 7 CCGs only commission via independent funding request. CGM is recommended by NICE as part of diabetes management and is proven to help people manage their diabetes.

Hip and knee Replacement: 78 CCGs include hip and knee replacement on their PoLCV lists. Hip and knee replacements are proven to be effective and have been supporting people to keep mobile for over half a century.

PoLCV

‘Procedures of Limited Clinical Value’ traditionally referred to treatments that do not have sufficient data to prove their cost effectiveness or clinical benefit. It was originally applied to treatments such as alternative and complementary therapies and cosmetic procedures. Procedures included on these lists were generally not funded by NHS commissioners.[1]

However, commissioners are increasing using PoLCV as a way to control spending by limiting access to treatments and technologies that are proven to be effective. Ration Watch conducted analysis of all 195 CCGs to look at the types of procedures they include on PoLCV lists.

Ration Watch found a number of proven treatments included on PoLCV lists. Four of the treatments listed most frequently were – hernia repair, cataract removal, Constant Glucose Monitoring and hip and knee replacements. Most commonly with these procedures, CCGs are using access thresholds to limit patient access.

What we found:

Hernia

A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall, several surgical techniques exist to fix hernia. Hernia repair is one of the most common procedures performed in the UK, with around 80,000 taking place each year.[2] There is guidance on hernia repair from NICE[3] and the Royal College of Surgeons[4]. The National Institute for Health and Care Excellence (NICE) guidance states that surgical repair should be undertaken in most individuals with an inguinal hernia in order to close the defect, alleviate symptoms of discomfort and/or prevent serious complications, such as obstruction or strangulation of the hernia.[5] The Royal College of Surgeon’s guidance is clear on the impact of delaying treatment, ‘CCGs should not set criteria for referral and treatment for inguinal hernias outside that recommended in this guidance, as this approach produces worse clinical outcomes and has not been shown to be cost effective’. There is a strong evidence base and proven record of successful outcomes following hernia repair operations.

Despite this, ration watch found that 95 CCGs, almost 50%, include hernia repair on their PoLCV lists or lists of Threshold Policies.  The type of policies related to hernia repair commissioning are often described as a ‘watchful waiting’ approach. Whilst this type of approach may be appropriate for some patients, using this approach more widely could mean more and more patients will only receive treatment when their condition deteriorates and they require an emergency intervention.

Cataract Removal

Cataract surgery involves replacing the cloudy lens inside your eye with an artificial one. It’s the most common operation performed in the UK, with a high success rate in improving your eyesight.[6] The Royal College of Ophthalmology has clear guidance for commissioners on the commissioning of cataracts.[7] There is also a NICE guideline in relation to cataract management.[8] The Royal College of Ophthalmology are clear on the need to treat patients early stating that the ‘presence of cataract causes disability and increases the likelihood that individuals will suffer adverse events such as falls’ and that ‘…Cataract surgery is the only effective intervention to treat cataracts and is cost effective.’[9] Both NICE and Royal College of Ophthalmology say that access to cataract removal should not be restricted on the basis of visual acuity.

Despite this guidance and associated evidence, Ration Watch found that 104, more than 50% of CCGs include cataract removal on the PoLCV or threshold lists. Alongside this, 76 CCGs include a visual acuity threshold in their commissioning policy.

Continuous Glucose Monitoring

A Continuous Glucose Monitor is a small device that you wear just under your skin. It measures your glucose (sugar) levels continuously throughout the day and night, letting you see trends in your levels and alerting you to highs and lows.[10] It helps people manage their diabetes by allowing them to constantly track their sugar levels, identify high and low trends and even sound an alarm at high and low levels. NICE guidelines in relation to the management of diabetes in adults include guidance on how to commission CGM. NICE guidance sets out clear criteria for the commissioning of CGM and the type of user that should be considered.

Despite clear guidance on the use of CGM, Ration Watch found 12 CCGs who do not commission CGM and a further 7 who will only do so via an independent funding request. That is around 10% of CCGs placing some form of barrier to CGM.

Hip and Knee Replacement

Total hip replacement and total knee replacement are proven orthopaedic interventions that have been supporting people for many years. In total around 200,000 hip and knee replacements take place each year in England.[11] There is clear evidence supporting hip and knee replacement. The National Joint Registry has highlighted the results of a patient satisfaction assessment which shows that 92% of patients describe themselves as feeling either ‘excellent’, ‘very good’ or ‘good’ six months after treatment.[12] The British Hip Society has guidelines for the commissioning of total hip replacement, which sets out the benefits – ‘Total Hip Replacement (THR) is cost effective, returning 90% of patients to their previous job, and enabling the elderly to keep independent. The National Tariff for THR is cheaper than long-term conservative treatment for osteoarthritis of the hip’.[13]

The Royal College of Surgeons have spoken out against the use of blanket bans on access to treatment, stating that ‘blanket bans do not best serve patient care.’[14] Despite this guidance and the evidence supporting access to treatment, Ration Watch found 78 CCGs currently include hip and knee replacement surgery on their PoLCV or threshold lists. Often the policy includes a BMI threshold, something not supported by the Royal College of Surgeons.

Conclusion

The inclusion of evidence based treatments on PoLCV and threshold lists will result in huge variation in the treatments patients receive. NHS England recently launched their ‘Evidence Based Interventions programme’. This set out 17 treatments where research evidence has shown that the treatments in question are not clinically effective or are only effective when they are performed in specific circumstances. This process is clinically led and based on the available evidence. NHS England’s work to assess treatments of limited value will be undermined by individual CCGs including treatments that are supported by decades of use and an effective evidence base.

What Ration Watch would like to see

Any decision on patient treatment should be based on clinical need. Ration Watch are calling on NHS England to set clear guidelines on which procedures can be included in PoLCV and threshold lists and which procedures should not be included. Where individual CCGs are seen to have an unfair policy, NHS England should intervene.

 

 

[1] Royal College of Surgeons, Procedures of Limited Clinical Value briefing, https://www.rcseng.ac.uk/-/media/files/rcs/library-and-publications/non-journal-publications/rcs-briefing–procedures-of-a-limited-clinical-value–jan-11.pdf

[2] Hernia Outcomes Campaign, http://www.herniaoutcomes.org/the-latest-report/

[3] NHS England, Abdominal Wall Hernia Management and Repair in Adults – https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/N-SC001.pdf

[4] Royal College of Surgeons, Groin Hernia Commissioning guide – https://www.rcseng.ac.uk/-/media/files/rcs/standards-and-research/commissioning/groin-hernia-commissioning-guide_published-2016.pdf

[5] Laparoscopic surgery for inguinal hernia repair

https://www.nice.org.uk/guidance/ta83/resources/laparoscopic-surgery-for-inguinal-hernia-repair-pdf-2294817305029

[6] NHS, Cataracts – https://www.nhs.uk/conditions/cataract-surgery/

[7] RC Ophthalmology, commissioning of Cataracts https://www.rcophth.ac.uk/wp-content/uploads/2018/02/Cataract-Commissioning-Guide-January-2018.pdf

[8] NICE Guideline NG77 – https://www.nice.org.uk/guidance/ng77/chapter/Recommendations#referral-for-cataract-surgery

[9] RC Ophthalmology, commissioning of Cataracts https://www.rcophth.ac.uk/wp-content/uploads/2018/02/Cataract-Commissioning-Guide-January-2018.pdf

[10] Diabetes UK, CGM – https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/testing/continuous-glucose-monitoring-cgm

[11] NJR, Annual Report – http://www.njrreports.org.uk/Portals/0/PDFdownloads/NJR%2015th%20Annual%20Report%202018.pdf

[12] NJR Annual Report – http://www.njrcentre.org.uk/njrcentre/Portals/0/Documents/England/Reports/10th_annual_report/NJR%2010th%20Annual%20Report%202013%20B.pdf

[13] British Hip Society, Commissioning guidance – https://www.boa.ac.uk/wp-content/uploads/2014/08/Pain-arising-from-the-hip-in-adults_updated_Final.pdf

[14]  Royal College of Surgeons, Smokers and overweight patients: Soft targets for NHS savings? https://www.rcseng.ac.uk/-/media/files/rcs/about-rcs/government-relations-consultation/rcs-briefing-paper-on-rationing.pdf

“In February this year, the CCG in West Kent implemented a policy to suspend all elective surgery until the end of the financial year in an attempt to save £3.2 million. More recently, Cambridgeshire and Peterborough CCG proposed a new policy requiring patients to wait a minimum of 12 weeks for surgery . While that decision was later reversed, it is a worrying example of the kind of policy we may see spreading across the country as the financial situation of the NHS continues to deteriorate. It is not just in surgery where such rationing applies: earlier this year, I responded to a debate in Westminster Hall on infertility treatment, and it was revealed that of 209 CCGs in England, just four follow in full the National Institute for Health and Care Excellence ‘s guidelines on IVF treatment.

The individual funding request process, once reserved for rare conditions, is routinely applied by CCGs for a range of treatments. In some areas, including east Berkshire, routine hip and knee replacements are now being considered only if an individual funding request is made. Analysis by The BMJ found that the number of individual funding requests has increased by 47% in the past four years.”

Justin Madders MP

Speaking in Westminster Hall Debate