Sharp rise in requests for knee and hip surgery being turned down

Nearly 1,700 requests rejected last year, a 45% increase from 2016-17, reveals an investigation by The BMJ.

Increasing numbers of patients seeking or are finding they can't have operations on the NHS, an investigation by The BMJ has found.

Last year 1,675 exceptional funding requests by doctors on behalf of their patients (1,188 for knee surgery and 487 for hip surgery) were rejected by clinical commissioning groups (CCGs), show data obtained under a Freedom of Information request from 167 of England's 195 CCGs.

This was a 45% increase from 2016-17, when 1,155 requests were rejected (766 for knee surgery and 389 for hip surgery).

Doctors apply to CCGs for exceptional funding if the CCG requires specific criteria to be met before patients are referred for certain treatments or procedures.

Exceptional funding requests have been used since the 2000s to limit cosmetic procedures or fertility . But as NHS finances have been squeezed, some areas have started to use them for a wider range of treatments. GPs refer patients to specialists as normal, but there is no guarantee that if they recommend a treatment it will be funded.

The BMJ's latest analysis shows stark variation across the country in how CCGs are applying restrictions for surgery.

For example, Buckinghamshire CCG had 1,298 exceptional funding requests for knee surgery last year and rejected 18% while Doncaster CCG had far fewer requests through this route (24) but rejected all but one of them.

Ian Eardley, senior vice president of the Royal College of Surgeons, said, "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."

Commissioners said that the winter crisis, when elective procedures were effectively cancelled, ongoing financial pressures in the NHS, and CCGs' efforts to reduce unwarranted clinical variation had all contributed to the rise in patients being refused knee and hip surgery in the past year.

Doctors say that applying for exceptional funding causes stress for them and their patients, while restricting operations affects surgical training.

"It's a huge problem, in certain areas of the country there has been a complete moratorium on hip and knee surgery for several months," said British Orthopaedic Association president Ananda Nanu.

Evidence is also emerging that more patients are choosing to go private for hip and knee because of restrictions and longer waiting times in the NHS.

A major concern is the disparity uncovered across the country with CCGs acting independently to restrict access to procedures to balance the books. So what is being done to address variations in access?

The NHS is considering whether the current locally-driven approach to hip and knee commissioning needs to be reviewed to create more standardised thresholds for treatment across England.

But Ananda Nanu is concerned that moves to standardise access may lead to stricter thresholds for access to hip and if financial savings are prioritised.

Graham Jackson, co-chair of NHS Clinical Commissioners (NHSCC), said that consensus should be possible if policies are clinically-led and based on sound evidence.

But agreement is not always possible. For example, in May this year, doctors in London attacked draft NHS plans to only refer patients with osteoarthritis for a knee or hip replacement if there is a "substantial impact on quality of life." And last year, the Royal College of Surgeons criticised three CCGs in Worcestershire over plans to decrease the eligibility threshold for requiring hip and knee replacements.

Julie Wood, NHSCC chief executive, agrees that where the evidence is clear, it should be possible to achieve consensus. "But where there is disagreement, sadly we may not."

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