Many CCGs are ignoring clinical evidence in their surgical commissioning policies

Many clinical commissioning groups are ignoring clinical evidence in their surgical commissioning policies, warns new report.

New evidence that some patients are facing long delays for surgical treatment because clinical commissioning groups are ignoring evidence-based guidance on when to provide surgery is revealed today.

A new Royal College of Surgeons’ report finds that CCGs are imposing arbitrary referral restrictions and denying access to vital surgical procedures, which can significantly improve the quality of life for patients.

The report: Is Access to Surgery A Postcode Lottery? is one of the first investigations of its kind and analyses information obtained under the Freedom of Information Act gathered in April. It reveals that 73% of the CCGs reviewed do not follow NICE and clinical guidance on referral for hip replacements, or have no policy in place for this procedure. Over a third of CCGs (44%) require patients to be in various degrees of pain and immobility (with no consistency applied across the country) or to lose weight before surgery. The report states that this is unacceptable.

The study investigated commissioning policies relating to four common surgical procedures carried out on the NHS and compared those policies to evidence-based guidance published by The Royal College of Surgeons, the surgical specialty associations and NICE.

The commissioning policies for each procedure were sought from 58 CCGs, 27% of the total 211 CCGs in England. In total 52 CCG polices were analysed. The procedures investigated were: tonsillectomy, hip replacement, inguinal hernia repair and surgical treatment for glue ear (Otitis media with effusion).

The report discovered that only 27% of CCGs reviewed had policies that complied with NICE or surgical guidance on inguinal hernia repair, while 58% have no policy at all. 15% required evidence of a hernia increasing in size or a history of reoccurring problems, even if a patient is suffering from debilitating pain.

Tonsillectomy, the removal of tonsils, is one of the most common surgical procedures on the NHS and is predominantly performed on children. However, two CCGs had minimum ‘watchful waiting’ periods, meaning that some patients may not have the surgery for a year and a half. Eight CCGs also required documented absence from school or work.

Miss Clare Marx, President of the Royal College of Surgeons, said: “This report seems to show that local commissioners are imposing arbitrary rules governing access to some routine surgery. The motivation may not be financial but it is clear that some CCGs do not commission services using clinically accepted evidence-based guidance.”

The paper highlights that rationing access to treatment can impact on the outcome of surgery. It says that referrals to treatment should be driven by need based on clinical assessment and must not be compromised by financial pressure.

It recommends that the Government and NHS England need to review what further action is required to ensure the NHS is providing equitable access to high quality surgical care.

Notes to editors

Please contact the press office for a full copy of the report.

• The CCGs chosen comprised two groups: wave 1 and deficit. Wave 1 CCGs are made up of the 35 commissioning groups that were assessed in the first wave of authorisation by NHS England during 2012-13. They were chosen for this investigation because, by virtue of having been in the first wave of commissioning organisations authorised, they should theoretically have in place the most developed commissioning plans. 
• The group of ‘deficit CCGs’ consists of the 24 CCGs identified in November 2013 that were forecasting a deficit for their first year of operation. This group was selected in a bid to assess whether those CCGs in greater financial difficulties are more likely to have restrictive referral criteria in place. 
• Freedom of Information requests were submitted to each of the CCGs identified in April 2014. Of the total 58 CCGs we received responses from 54. Two of these refused to disclose their policies, citing section 22 of the Freedom of Information Act 2000 (future publication). One of these CCGs, Bury, was a wave 1 CCG while the other, Oldham, was a CCG in deficit. The total number of commissioning policies obtained was therefore 52.

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