West Yorks & Harrogate STP meeting to decide on £50m cut to knee and hip replacement surgery

The West Yorkshire and Harrogate STP Joint Clinical Commissioning Committee – whose claim to lawfulness is based on legislation cooked up in secret without any Parliamentary scrutiny or vote  – is meeting today at
11am – 1pm, Kirkdale Room, Junction 25 Conference and Meeting Venue, Kirkdale House, Armytage Road, Brighouse, HD6 1QF. On the agenda is a proposal to cut £50m/year by 2020 by restricting access to elective care and so-called Procedures of Limited Clinical Value. They call this:

“managing demand to a more affordable level.”

Others call it cherrypicking patients.

They aim to start with orthopoedic procedures (things like knee and hip replacements) and eye care services.

The report to the Joint Clinical Commissioning Committee meeting says that elective orthopoedics cost the WYH STP around £100m/year.

Across the STP area, there are variations in waiting times from referral to treatment, as well as in experience of care and costs. One of the stated aims is to reduce the variation in inpatient length of stay across orthopaedic procedures within WY&H. This

“is contributing to excess hospital bed days and high bed occupancy rates; reducing this represents a significant opportunity for efficiency and productivity gains.”

NHS England says that opthamology in the WYH STP area is “challenged”. It is second only to orthopoedics in the numbers of people waiting for assessment or treatment. Across WY&H, 87.75% of patients are treated within 18 weeks of referral, compared to the national average of 89.3% – while within WYH the percentage varies from 69.4% – 98.8%.

Commissioning policy for so-called Procedures of Limited Clinical Value is also to be standardised.

The Elective Care commissioning standardisation programme is based on “more challenging areas for generating cost savings” that were announced over a year ago in the Chief Officer’s Report to the 11 August 2016 Calderdale Clinical Commissioning Group (CCG) Governing Body meeting .

At that time, Calderdale CCG was short of £1.1m “cash saving” cuts and was looking for ways to cut spending through using the Right Care approach which provides a set of spending benchmarks (and is not the same as the Right Care Right Time Right Place hospital cuts proposals).

Denying some patients treatment based on ‘value for money’

A business concept, Right Care provides spending benchmarks for Clinical Commissioning Groups to achieve by comparing their performance on a number of indicators to other Clinical Commissioning Groups.

Right Care has been used to justify restricting knee and hip operations in the West Midlands,  to save £2m.

In his Sept 2016 Submission to the House of Lords of NHS Sustainability, Professor Sir Muir Grey – director of Better Value Healthcare Ltd  – explained,

“The NHS Rightcare Programme was set up by NHS England in 2010 and has now been adopted by NHS England as its principal means of managing resources. Its aim is to release £11.5 billion from the £115 billion available and shift it from lower value activity to higher value activity…the NHS is not sustainable unless a new paradigm, the value paradigm is adopted.”

He added that the meaning of value is “economic” and that the Right Care work is led by Professor Matthew Cripps in the Finance Directorate of NHS England.

In the North East, for some time referrals have had to be made in line with Value Based Clinical Commissioning Policies  – meaning that GPs have to tell the patients that a procedure would not normally be funded by the NHS if their treatment does not fit the economic (value-based) criteria.  A North East clinician said,

“This is all a bit overwhelming. I feel uncomfortable as a clinician denying some patients treatment that is not based on evidence of lack of effectiveness but on ‘value for money’ especially with no debate about what the tax paying public should be entitled to from a free NHS.”

How reliable is the Right Care data?

A recent Journal of Public Health article (Right Care, Wrong Answer)  belies NHS England’s claim that “Right Care” is ‘a proven approach that delivers better patient outcomes’ and identifies opportunities for savings and quality improvements.

In the article, Greg Dropkin examined the Right Care data for breast, colorectal, and lung cancer and showed that they were full of errors. This led him to conclude that,

“RightCare promises illusory savings based on an inappropriate fixed comparator group and faulty statistics…

If RightCare is used to justify savings in NHS budgets, it is acting as a cover for cuts.”

The West Yorkshire & Harrogate STP Elective Care commissioning standardisation report says that standardising clinical thresholds for referral and treatment of Procedures of Limited Clinical Value and elective orthopoedic surgery would potentially reduce demand by 10%.

That means 10% of patients won’t get referred or treated. But the report describes this as enabling

“better clinical decisions to be made … Technology and decision making support tools would be targeted at the consulting room, learning from best practice such as the approach from Canterbury, New Zealand.”

Trying to copy the Canterbury, New Zealand District Health Board

A Kings Fund report, Developing Accountable Care Systems – Lessons from Canterbury, New Zealand, outlines these Canterbury technology and decision making support tools. The HealthPathways programme

“bring[s] together GPs and hospital specialists to agree management and referral pathways for particular conditions….Pathways are available on the HealthPathways website and are designed to be easy to use as part of a patient consultation…Referrals are made via the electronic request management system… If hospital doctors have questions about referrals, they can discuss these directly with the referring GP and GPs receive feedback on their referrals.”

So less money to spend on patients, more money to spend on digitech. Funny old world.

The West Yorks & Harrogate STP Elective care commissioning standardisation scheme will reserve outpatients follow up appointments for patients “whose clinical needs rely on the technology or skills” of hospitals. Leaving the rest of the patients without outpatient follow up appointments will require:

“a new approach to communication between primary and secondary care clinicians…Adoption of communications technology and sharing of information and images will be a critical success factor.”

Sounds like GPs are going to have to do more work if they have to fill in for the non-existent outpatients. Where are they going to find the time and resources?

England is not like New Zealand, where people make co-payments for GP appointments that account for around half of general practice income. And in Canterbury a primary care network which involves 109 practices delivering care to more than 365,000 patients, supports general practices and provides a range of primary and community services.

The Kings Fund report warns that:

“… [M]any of the changes in Canterbury required significant investment and…they have not cut beds or taken resources from hospitals. This raises questions over the feasibility of ambitions around NHS transformation. Vanguards and sustainability and transformation partnerships are being asked to make significant service changes with little or no additional funding, and services are already under immense financial strain; it is hard to see how the kind of progress made in Canterbury can be achieved in this austere context. Canterbury’s experience also casts doubt over expectations that new models of care will enable disinvestment in acute hospitals.”