NHS England should strike surgery for common hand conditions from list of ‘ineffective and risky treatments’

The Royal College of Surgeons (RCS) has urged NHS England to remove surgical treatments for carpal tunnel syndrome, Dupuytren’s contracture, trigger finger and wrist ganglion from a list of clinically ineffective interventions.  NHS England is proposing to stop or reduce routine commissioning of 17 interventions where it says less invasive, safer treatments are available and just as effective. 

Responding to NHS England’s consultation on evidence based interventions, the RCS says it supports the inclusion of the majority of the surgical interventions covered in the first phase of the Evidence Based Intervention programme. NHS resource should be used wisely and proportionately, with only effective, evidence-based treatments routinely funded.

However, it raises concerns that the evidence base for limiting access to surgical treatments for four hand conditions has not been appropriately considered. The RCS’s concerns echo those of the British Society for Surgery of the Hand (BSSH).

The RCS says that these common conditions can have a significant detrimental effect on quality of life and although mild cases may resolve with non-operative treatment, timely surgical treatment is effective in relieving symptoms and preventing irreversible loss of function that can occur in neglected cases. 

For example, the BSSH state that surgery is an effective treatment for patients with severe persistent carpal tunnel syndrome symptoms and provides a permanent and complete cure in 80 – 90% of patients.1 Evidence, including that from randomised controlled trials, has shown that surgery is more clinically effective than non-operative treatment for moderate and severe disease.2 A related study showed that surgery is also more cost effective.3

Mrs Scarlett McNally, a Consultant Orthopaedic Surgeon and Royal College of Surgeons Council Member, said:

“NHS England must look again at its decision to include carpal tunnel syndrome, Dupuytren’s contracture, trigger finger and wrist ganglion on its list of ‘ineffective and risky treatments’. 

“I have frontline experience of how badly these conditions can affect some people’s quality of life. I have also seen how quickly and effectively they can be resolved with surgery. 

“Patients may experience symptoms ranging from pain and numbness that makes it difficult for them to carry out day-today tasks to total loss of function, preventing them from being able to work. 

 “Some of the alternatives to surgery that NHS England’s programme sets out are not supported by clinical evidence. For instance, they suggest physiotherapy and splinting as an alternative to surgery for Dupuytren’s contracture. However, the RCS is not aware of any published evidence that these alternative treatments are of benefit.

“There are of course instances where surgery is not appropriate and other treatments can be used. However, overall, the choice of treatment should be determined in discussion between a patient and their surgeon, taking the severity of their condition, the rate of progression and their background, for example the work they do, into account.” 

The RCS’s consultation response also raises concerns about the use of Individual Funding Requests (IFRs) to limit the appropriate use of some of the interventions on NHS England’s list. The RCS is of the view that a lack of central guidance or template from NHS England for clinical commissioning groups (CCGs) on IFRs increases regional variation for patient access to treatment. This is because CCGs can introduce policies with a wide variety of criteria and timescales. 

The RCS says NHS England should seek to monitor patient outcomes from the commissioning of treatments on its list, so as to ensure that CCGs do not misinterpret the programme’s messaging to mean a procedure is totally banned and to make sure that the list of treatments identified continues to align with clinical evidence. 

Notes to editors

1. https://www.bmj.com/content/362/bmj.k2903/rapid-responses 

2. Gerritsen AA1, de Vet HC, Scholten RJ, Bertelsmann FW, de Krom MC, Bouter LM. Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. JAMA. 2002 Sep 11;288(10):1245-51. 

3. Korthals-de Bos IB1, Gerritsen AA, van Tulder MW, Rutten-van Mölken MP, Adèr HJ, de Vet HC, Bouter LM. Surgery is more cost-effective than splinting for carpal tunnel syndrome in the Netherlands: results of an economic evaluation alongside a randomized controlled trial. BMC Musculoskelet Disord. 2006 Nov 16;7:86.  

4. The Royal College of Surgeons of England is a professional membership organisation and registered charity, which exists to advance surgical standards and improve patient care.

5. For more information, please contact the RCS Press Office: telephone: 020 7869 6047/6052/6229; email: pressoffice@rcseng.ac.uk; for out of hours media enquiries: 07966 486832.