Hip and knee replacements: BMI and smoking thresholds are not the answer

Despite our empathy for CCGs, we have a responsibility to advise against Body Mass Index (BMI) and smoking-based funding thresholds. There is no clinical, or value for money, justification for these policies and they are a distraction from the important work of improving value in the NHS.

Broadly, both smoking and high BMI are risks to manage with patients as soon as they are referred to a surgeon, by providing services to help improve their health. This is entirely comparable with how other risks, such as uncontrolled diabetes, should be managed. Hard-and-fast rules denying or delaying surgery to patients in pain are unethical.

More specifically, it is difficult to overstate the value hip and knee replacements offer obese patients. Done well, surgery in patients with high BMI can be as or even more effective than in other patients. Revision rates are no higher and improvement in function and pain can be better.

This helps explain why, in 2014, nearly a quarter of primary knee replacement patients had a BMI of or over 35. How many more patients could have benefited from life-transforming treatment were it not for these thresholds?

Beyond these points, there is a bigger ‘value for money’ picture. Typically these operations improve mobility, and reduce pain, for a price equivalent to just £7.50 a week – provided expeditious access to treatment, before prolonged disability and pain. In these financially squeezed times, we need to prioritise cost-effectiveness and the best option in this respect may well be surgical intervention.

We invite all commissioners to talk to us about how we can work together to improve value in the NHS. Many of these clinical issues can be easily misinterpreted if selective publications are examined rather than obtaining a balanced clinical view. In light of this, we are developing our network of Clinical Champions and Regional Advisers to work with commissioners. This will be a long road to walk down, but will get us all much further than restricting access to surgery.

In addition, we encourage responses when our currently-under-review Commissioning Guides, referred to in the Royal College report, are consulted on in mid-to-late summer. Full details will be on the BOA website in due course. 

Tim Wilton is President of the British Orthopaedic Association, the surgical specialty association for Trauma & Orthopaedic Surgery.