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Patients face severe pain before hip surgery

CCGs propose raising pain threshold for referral to cut £2.1m from joint replacement surgery costs

Louise Prime

Friday, 27 January 2017

Patients in three clinical commissioning groups in the West Midlands could have to be suffering such severe pain that it affects their daily functioning and sleep before they can be offered hip surgery, under the CCGs’ proposed plans to cut costs, it has emerged. NHS Clinical Commissioners (NHSCC) has publicly defended the proposal to even more tightly ration hip surgery by increasing the pain threshold for referral, pointing out that CCGs need to balance demand with their limited resources.

Board meetings yesterday for two of the three Worcestershire CCGs – NHS Redditch and Bromsgrove CCG, NHS South Worcestershire CCG and NHS Wyre Forest CCG – had on their agenda discussion of “an opportunity to reduce expenditure on hip and knee replacement surgery by circa £2,123,420 per annum”, as part of the financial recovery process across the Worcestershire CCGs. The documents read: “The revised MSK Commissioning Policy proposes a reduction in the Oxford Hip and Knee score from 30 to 25, focussing [sic] more on the severe to upper end of moderate. Further refinements to the policy include a BMI of 35 with a requirement to reduce weight by 10%.”

The plans have been met with public outrage, and BBC Radio 4’s Today programme this morning demanded to know how just much pain patients should be in before they get a hip operation. It suggested that in many areas, the policy regarding hip operations now seems to be: “Don’t do them unless the patient is in real pain, and unable to function and to sleep because the pain is so bad.”

NHS Clinical Commissioners chief executive Julie Wood avoided a direct answer, but pointed out that the NHS simply does not have the resources to cope with unlimited demand. She said: “Clearly the NHS doesn’t have unlimited resources and it has to ensure that patients get the best possible care against a backdrop of spiralling demand and increasing financial pressures that we all see. … The GPs who are looking at these sorts of decisions are taking in to account all of the different priorities that they have to cope with, and are assessing what is the right thing to do for their patients and the population. CCGs have to live within their financial resources, they have to look at access to A&E and emergency care, and they have to look at balancing competing priorities.”

The NHSCC later issued an official response, in which it stressed clinical commissioners’ commitment to getting the best possible outcomes from surgery, which might for example mean asking people to lose weight before hip, knee or other joint surgery. But it added that patients also needed to realise that tough choices have to be made given the NHS’s limited resources.

It said: “With increasing pressures being felt across the whole health and care system, the NHS has to review services to ensure they are sustainable and improve the health of their population. As clinical commissioners we have a responsibility to consider the needs of our whole population, reduce inequalities and improve quality of care while making the most effective use of the limited NHS pound.”

Dr Mark Porter, BMA council chair, said patients were "unfairly suffering the consequences of a deliberately underfunded health system".

"Decisions on patient care should be made on the ground of individual clinical need and following royal college or other evidence-based standards. What we have here is penny-pinching, cost-cutting, and patients in pain," he said.

“The government must address the £30bn funding shortfall that is undermining the NHS, and produce a long-term strategy that addresses the fundamental workload and funding challenges that are currently overwhelming health services,” he added. 

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