Three Clinical Commissioning Groups (CCGs) in the West Midlands, responsible for determining how funding is divided among key NHS services, recently announced changes to patient eligibility for hip and knee replacement surgery. The CCGs have raised the threshold at which patients will be assessed as being suitable for these operations, based on standardised scoring systems gauging pain and disability.
The criteria for patient eligibility for hip and knee replacements will now be higher, equating to severe pain or "the upper end of moderate", interfering with daily life or ability to sleep. The CCGs are also excluding all patients with a body mass index (BMI) over 35 until they have lost 10% of their weight unless their problems are particularly severe.
The move will enable these CCGs effectively to cut the number of knee replacements by 19% and the number of hip replacements by 12%, a total of around 350 fewer operations a year.
Andrew Clayton of Penningtons Manches' clinical negligence team has a particular interest in knee and hip replacement surgery and comments: "These three CCGs have admitted the steps they are taking to reduce hip and knee replacements is primarily a response to the current funding pressures they face. It is estimated that it will save over £2 million a year, but it is not clear to what extent that saving takes account of the wider cost implications for the NHS and social care system of the likely increase in GP appointments, medication and care from delaying joint replacement – let alone the cost of the appeals from those unhappy at being refused surgery under the new criteria. In the meantime, hundreds will be left to live with prolonged, worsening pain and with deteriorating function. Separately, there is no evidence that BMI between 30 and 40 increases the chances that the surgery may have a poor result.
"There is no doubt that there is massive financial pressure on the NHS, but these criteria go against NICE guidelines and are arbitrary. The specific scoring system these CCGs are using was never designed for clinical decisions or treatment pathways; it was intended to measure the outcome for patients who had already had the surgery, to gauge its success. Decisions about patient suitability for joint replacement should be based on proper clinical assessment and with the informed agreement of patients."