A senior NHS official has admitted that funding shortages mean hip and knee replacements will have to be rationed according to pain levels in some parts of the country.
Three clinical commissioning groups (CCGs) in the West Midlands have proposed reducing the number of people who qualify for hip replacements by 12%, and knee replacements by 19%. To qualify under the proposed rules, patients would need to have such severe levels of pain that they could not sleep or carry out daily tasks.
Julie Wood, the chief executive of the NHS Clinical Commissioners, said the proposal was a response to financial pressures.
“Clearly the NHS doesn’t have unlimited resources,” she told BBC Radio 4’s Today programe. “And it has to ensure that patients get the best possible care against a backdrop of spiralling demand and increasing financial pressures.”
She admitted that decisions on hip and knee replacements “will vary in different parts of the country”, amid reports that other areas were already using pain levels to ration such operations.
Pressed on whether people in some parts of the country would have to accept they had to be in considerable pain to qualify for an operation, Wood said: “On a daily basis commissioners are going to be forced to be making difficult decisions that balance the needs of the individual against those of the wider population.”
Board papers reported by the Health Service Journal suggest an “opportunity to reduce expenditure on hip and knee replacement surgery” by £2m a year.
This would include only treating “severe to the upper end of moderate” cases, and very obese people with a body mass index of 35 or over after they had lost 10% of their weight, unless their problems were severe.
Documents said a “patient’s pain and disability should be sufficiently severe that it interferes with the patient’s daily life and/or ability to sleep”.
Redditch and Bromsgrove, South Worcestershire, and Wyre Forest are the CCGs that intend to change their scoring system for eligibility, hoping to reduce the number of such operations by about 350 a year. But the Royal College of Surgeons has said there is “no clinical justification” for their plans.
The move is the latest in a round of cost-cutting by CCGs – with some slashing access to treatments, expensive drugs and IVF despite guidelines from the National Institute for Health and Care Excellence (Nice).
Stephen Cannon, the vice-president of the Royal College of Surgeons, said the idea was futile and unfair.
“There’s going to be a postcode lottery. It is absolutely iniquitous that you have this sort of system,” he said.
Cannon said he accepted that operating on everyone who needed hip and knee replacements would require “significant extra resource”. But he said the solution should be extra funding not rationing. “The answer is we must really, really look at the funding of the NHS,” he told Today.
In a statement earlier, he said: “While the CCGs have stated they hope this policy will save them £2m a year, it is unclear whether they have considered the costs of not treating a patient. This could include the cost of pain relief medication and a later operation when the patient does meet the required pain and weight thresholds.
“Delaying access to surgery also adversely affects a patient’s quality of life and surgical outcomes, meaning the operation may not be as beneficial as if it had been carried out earlier.”
He said the scoring system used by the CCGs – known as the Oxford scoring system – were designed to measure outcomes of care and “should not be used to create barriers to care”.
He added: “Such criteria are in explicit contravention of Nice and surgical commissioning guidance, and have no clinical justification in being applied to a general population to determine who gets NHS treatment. This policy is the latest demonstration of how NHS financial pressures are directly affecting patients.”
Paul Green, from Saga Group, which focuses on the needs of over-50s, said: “To suggest that it is acceptable for people to have to wait until they are unable to sleep before they are eligible for an operation is an outrage. How would these people feel if that was their mother or father or grandparent?
“Remaining mobile is fundamental for people’s mental as well as their physical wellbeing, it appears an unkind cut and the bean-counters should examine their conscience.”
A spokesman for NHS Redditch and Bromsgrove CCG said: “The Oxford scoring system is a guidance for clinicians and they recognise that many patients will benefit from physiotherapy and weight loss before considering surgery.
“If a patient feels that they require this surgery but do not meet these criteria, there is a clear appeals system via individual funding requests whereby the effects can be considered upon the patient and the decision made regarding eligibility for funding.”
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