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Huge surge in rejection of requests for knee and hip surgery

CCGs blame surge on winter crisis, NHS funding squeeze and efforts to cut clinical variation

Louise Prime

Thursday, 19 July 2018

There has been a huge 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 – and there is also wide variation in rejection rates across the country. Clinical commissioning groups (CCGs) have blamed the surge on the winter crisis, ongoing financial pressure in the NHS, and CCGs’ attempts to “reduce unwarranted clinical variation”.

The BMJ’s Gareth Lacobucci explained that although exceptional funding requests have been used to limit cosmetic procedures and fertility treatments since the 2000s, some CCG areas have started to use them for a wider range of treatments as NHS finances come under increasing pressure. Under this system, GPs refer patients to specialists as usual, 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.

Data obtained by the BMJ following a freedom of information request revealed that last year CCGs rejected 1,188 exceptional funding requests for knee surgery and 487 for hip surgery – a 45% increase since 2016-17 when 1,155 such requests were rejected (766 for knee surgery and 389 for hip surgery).

The data also reveals wide variation in the rate across England in how CCGs are applying restrictions on surgery. Those CCGs with highest proportions of exceptional funding or prior approval rejections in 2017-18, were (among those that processed 10 or more requests), for knee surgery: Doncaster 96%; Hull 92%; Vale of York 90%; Rotherham 88%; and Barnsley 87%. For hip surgery, the highest rates of rejection were in Rotherham 100%; Doncaster 90%; East Riding of Yorkshire 73%; North East Essex 70%; and Harrogate 67%. In contrast, Buckinghamshire CCG rejected 18% of the 1,298 exceptional funding requests that it had for knee surgery.

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

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

In the BMJ report, senior vice president of the Royal College of Surgeons Ian Eardley commented: “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.”


*Iacobucci G. Nearly 1700 requests for knee and hip surgery were rejected in England last year. BMJ 2018; 362: k3002 doi: 10.1136/bmj.k3002.

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