West Yorkshire and Harrogate Integrated Care System clinical commissioners are being told to restrict patients’ access to 17 elective surgical procedures, in line with NHS England’s guidance. At their meeting on 8th January, the Joint Clinical Commissioning Committee considered a report that summarised NHS England’s guidance and recommended accepting it.
The Joint Committee agreed the adoption of the NHS England Evidence based intervention policy in the nine CCGs and also agreed to explore appetite and options for a single WY&H approach to implementation. Implementation will be immediate except where local criteria are tighter, when it should be within 12 months.Email 17 Jan 2019 from Stephen Gregg, Governance Lead, Joint Committee of Clinical Commissining Groups, West Yorkshire and Harrogate Integrated Care System (aka Health and Care Partnership).
This will mean around a 40% cut to the elective surgical procedures covered by this policy.
Cuts justified by claim that patients have been operated on with no benefit
Both NHS England and the Joint Clinical Commissioning Committee report claim that many patients have been operated on, who will not benefit from these surgical procedures. And that this is the reason for restricting patients’ access to them.
NHS England’s guidance tells Clinical Commissioning Groups to only pay for four of these operations if they have approved Individual Funding Requests, and for the others, to require doctors to show that the patient meets the specified clinical criteria through a prior approval system. Who knows how this prior approval system will work?
NHS England’s guidance was published at the end of November, following the quango’s poorly-publicised public consultation on the proposed cuts to the 17 elective procedures.
CK999 questions for the Clinical Commissioning Groups
We asked these questions at the 8.1.19 meeting of the Joint Clinical Commissioning Committee.
What is the evidence, if any, that these procedures have been offered to West Yorkshire and Harrogate patients who will not benefit from them?
The JCCC response:
National benchmarking information shows that more of these procedures are currently being performed in WY&H than in other parts of the country.Minutes of the Joint Clinical Commissioning Committee Meeting, 8.1.19. Item 07/19 – Elective care/standardisation of commissioning policies – NHS England evidence-based interventions
We’ll take this evasive answer as meaning they don’t have any evidence that these procedures have been offered to patients who won’t benefit from them.
Potential financial benefits
Our question: The report identifies £9.38m “potential financial benefits” from imposing Individual Funding Requests and Prior Approval to referrals to the 17 elective procedures (although this doesn’t take account of the costs of providing alternative treatments and that in the majority of cases these costs will partially or wholly offset the cost savings from not carrying out the procedures).
What clinical innovations, and innovations in prescribing and technology to improve individuals’ ability to self-care, is the Joint Clinical Commissioning Committee proposing to spend the net savings on? (If there are any, once the costs of providing alternative treatments are factored in.)
The Joint Clinical Commissioning Committee response:
Any ‘savings’ are theoretical. The purpose of the policy is to divert clinical activity to treatments which make a real difference to patients.Minutes of the Joint Clinical Commissioning Committee Meeting, 8.1.19. Item 07/19 – Elective care/standardisation of commissioning policies – NHS England evidence-based interventions
So why does their report identify £9.38m “potential financial benefits” from imposing Individual Funding Requests and Prior Approval to referrals to the 17 elective procedures? Should we take everything else in the report as equally “theoretical” and not applicable to the real world?
How many Clinical Commissioning Groups have aligned incentives contracts with their District General Hospitals?
Our question: The report says the Commissioners don’t know where in the “system” the “savings” from cutting the procedures will accrue, because that depends on local contracting arrangements, such as: the presence of aligned incentives contracts, the degree to which these interventions are included in the aligned incentives contract, and the proportion of the activity that takes place in the private sector.
- How many of the West Yorkshire and Harrogate Clinical Commissioning Groups have aligned incentives contracts with their District General Hospitals?
- How many have included these procedures in the Aligned Incentives Contract?
- How will Aligned Incentives Contracts distribute any savings, from restricting patients’ access to these procedures, between commissioners and hospitals?
- If the savings accrue to hospitals not commissioners, how will commissioners make sure that hospitals spend the savings on innovative clinical interventions and prescribing and technology for patients’ self care?
The JCCC response:
The Health and Care Partnership does not hold information on which CCGs have aligned incentives contracts with providers covering these procedures.
There are two main ways in which provider organisations are paid for their elective activity in West Yorkshire and Harrogate. These are Payment By Results (PBR) and Aligned Incentive Contracts (AIC). In a PBR contract a provider is paid a tariff for delivering the procedure, and this is constant for each procedure. With an AIC arrangement the commissioner and provider will agree jointly an estimate of how many interventions will be carried out, and a payment for these is agreed as part of a wider contract for services. They will also agree a risk or gain ‘share’ i.e. if a provider delivers more than the agreed procedures, how much of the cost the provider will bear, and how much additional funding will be found by the CCG. Conversely if the provider does fewer procedures, how much of the gain will the provider keep and how much will be returned to the CCG.
In reality, if a provider performs fewer procedures as a result of the implementation of the NHS England Evidence Based Interventions policy, the ‘gain’ of bed capacity, theatre capacity and workforce capacity will be redeployed into delivering other interventions. The overall impact on the total number of elective procedure may then be negligible, but the service delivered will be more clinically effective.Email 17 Jan 2019 from Stephen Gregg, Governance Lead, Joint Committee of Clinical Commissining Groups, West Yorkshire and Harrogate Integrated Care System (aka Health and Care Partnership).
Given the system-wide financial control powers it claims for itself in its new Memorandum of Understanding, it is very surprising – and lazy – that the West Yorkshire and Harrogate Integrated Care System (which likes to call itself the Health and Care Partnership), doesn’t know which Clinical Commissioning Groups have aligned incentives contracts with providers.
A simple question to each Clinical Commissioning Group on the Joint Clinical Commissioning Committee would produce the answer.
Which local clinical criteria are tighter/looser than in NHS England’s statutory guidance?
Our question: Which elective surgical procedures in which Clinical Commissioning Groups’ areas are currently subject to tighter local clinical criteria than in NHS England’s statutory guidance? Are they now going to loosen the local criteria? And which of the procedures in which Clinical Commissioning Groups’ areas are currently subject to looser local clinical criteria than in NHS England’s statutory guidance?
JCCC response: See West Yorkshire and Harrogate Evidence-based interventions policy
The local clinical criteria relating to Evidence Based Interventions are published on the Health and Care Partnership website, together with a range of other information here: WY&H evidence-based-interventions-policyEmail 18 March 2019 from Stephen Gregg, Governance Lead, Joint Committee of Clinical Commissining Groups, West Yorkshire and Harrogate Integrated Care System (aka Health and Care Partnership).
This is the relevant para on that webpage:
For some areas, there will be no difference to the current situation but this standardisation will result in some differences for other areas. This could be that more people become eligible for the treatments, or it could be that fewer people will be eligible. This EBI ‘mapping and gapping’ document details the current situation for all nine CCGs and what the differences will be once the new EBI policy is in place. As detailed in this document, not all CCGs currently have policies in place for some of the interventions. In most cases this is because the number of times that the particular intervention is carried out in that area is so low that there has been no need to put a formal decision making process in place.
The West Yorkshire and Harrogate evidence-based interventions policy basically says all the 9 Clinical Commissioning Groups in the area are adopting NHS England’s policy guidance.
As already noted, this will mean around a 40% reduction in these 17 elective interventions – the West Yorkshire and Harrogate evidence-based interventions policy says:
In West Yorkshire and Harrogate, around 16,700 EBI procedures are carried out every year and it’s estimated that this figure will fall to below 10,000 under this new policy. By not carrying out such procedures, capacity and resources can be freed up for other things that have been proven to work effectively. The potential efficiency savings of around £9 million would be reinvested to provide appropriate treatments and interventions that provide better outcomes for patients.https://www.wyhpartnership.co.uk/news-and-blog/news/nhs-englands-evidence-based-interventions-policy-be-implemented-west-yorkshire-and-harrogate
Ah: that £9m “potential efficiency savings” rears its head again – despite the Joint Clinical Commissioning Committee dismissing it as “theoretical” and beside the point, in their answer to our question 2.
Is NHS England’s guidance mandatory or not?
Our question: The report says that NHS England’s statutory guidance can be regarded as mandatory and that this means that no local engagement is needed. Saying that this guidance “can” be regarded as mandatory implies that it can also be regarded as not mandatory. In the NHS England consultation, patients and public consistently rejected the proposals, with only a small minority agreeing with the proposed restrictions. So why does the update recommend acting on NHS England ’s guidance – which it seems may or may not be mandatory – without asking West Yorkshire and Harrogate patients and the public if we agree with it?
JCCC response: NHS England’s statutory guidance is mandatory. (Stated in the 8.1.19 Joint Clinical Commissioning Committee meeting.)
Additional Q&As recorded in Minutes of the 8.1.2019 Joint Clinical Commissioning Committee meeting
These questions and answers are recorded in Item 07/19 – Elective care/standardisation of commissioning policies – NHS England evidence-based interventions.
Q: Will data be collected on the number of times that patients are not referred for procedures covered by the policy?
JCCC Response: No. The policy is not designed to stop people from getting the right care. It provides a policy basis to enable clinicians to make decisions.
Q: Will GPs be discouraged from submitting Individual Funding Requests?
JCCC Response: No. If GPs believe that their patients will benefit from a procedure, but fall outside the guidelines, they will still be able to exercise their clinical judgement and make a funding request. The policies provide an evidence based framework to help their decision making.
Q: What are you going to tell patients about the policies?
JCCC Response: We will tell patients that the policy will help clinicians to decide whether patients meet the criteria. People who meet the criteria will be able to access the interventions. The policy will help stop causing avoidable harm to people who do not meet the criteria.
Summary of West Yorkshire and Harrogate policy on cuts to 17 elective surgical interventions
The 9 Clinical Commissioning Groups are withdrawing routine funding for the following four interventions, which will now only be available in “rare” circumstances if GPs make a successful Individual Funding Request to their Clinical Commissioning Group:
- snoring surgery (where the person does not have obstructive sleep apnoea (OSA);
- dilatation and curettage (D&C) for heavy menstrual bleeding;
- knee arthroscopy (keyhole surgery) for patients with osteoarthritis;
- injections for non-specific low back pain where the person does not have sciatica.
They are also withdrawing routine funding for 13 other interventions. These will now only be available to patients through prior approval from the Clinical Commissioning Group. GP patient referrals will be “managed” to identify if specific clinical criteria are met, if symptoms do not resolve after an alternative or less invasive treatment, for example.
Once the EBI policy is implemented by all nine CCGs from April 2019 the clinical thresholds for the 17 interventions will be the same for everyone across the region. These are the 13 interventions:
- breast reduction;
- removal of benign (harmless) skin lesions;
- grommets for glue ear in children;
- tonsillectomy for recurrent tonsillitis;
- haemorrhoid surgery;
- hysterectomy for heavy menstrual bleeding;
- chalazia (eyelid cyst) removal;
- shoulder decompression;
- carpal tunnel syndrome release;
- Dupuytren’s contracture (curling of the fingers) release;
- ganglion cyst removal;
- trigger finger release (difficulty bending a finger or thumb); and
- varicose vein surgery.
These 13 interventions are largely taken from McKinsey’s 2009 report on how to cut NHS costs, that was commissioned by the-then Prime Minister, Gordon Brown following the government’s bail out of the bankers after they crashed the global economy.
Leeds KONP continues to investigate outstanding questions about the clinical criteria for deciding if these 13 treatments are appropriate.