Wave 3 of £2bn cost-cutting restrictions on 17 more elective procedures due in December

The so-called ‘Evidence Based Interventions’ List 3 Guidance is due for publication in late December 2022, according to the Academy of Medical Royal Colleges. (As of 5.1.2023, the publication date’s been pushed back to early 2023.)

As reported on this blog, (here and here) the first two lists covered 48 elective procedures that are no longer routinely funded by the NHS.

Previous waves of restrictions on so-called Procedures of Limited Clinical Value haven’t gone down too well with doctors or patients – although some NHS hospitals have tried to profit by offering the procedures to patients who pay for them.

Varicose vein surgery was one of the 17 procedures that had routine NHS funding stopped under Wave 1 of this so-called Evidence-Based Interventions programme. Now surgeons say the unregulated varicose vein industry is causing serious health complications in ‘clients’.

As a predictable consequence of withdrawing NHS funding for the procedures, there has been a boom in beauticians without medical supervision providing varicose vein surgery and injections across the UK, with the equally predictable consequence of serious health complications among ‘clients’ for these procedures. The Observer has reported,

“A recent rush of beauticians offering the treatments in the UK appears to have been spurred by a wave of new courses, including some that are online only and appear to be run by non-healthcare professionals.”

The newspaper did not make the link with the removal of routine NHS funding for varicose vein procedures.

List 3 procedures guidance seems to be mostly about cost cutting and controlling GPs’ referrals of patients to hospitals

Withdrawal of routine funding doesn’t seem to be so much of a feature of the proposed guidance for List 3 procedures, although cost-cutting is still a theme.

It seems to be much more about the use of standardised criteria to reduce variation in GPs’ referrals of patients to hospitals for the procedures.

For some procedures this is seen as leading to a decline in referrals, for others, it would lead to an increase.

But overall, the list is apparently seen as an important means of cutting £2bn costs of NHS elective procedures, as well as the long waiting lists for these procedures.

For the three ophthalmology procedures on list 3, the proposals aim to reduce hospital eye services’ workload and cost, without any obvious consideration of the impact on community and primary care services of having to take on this workload and cost.

These are the 17 interventions in list 3

Breast surgery

Male gynaecomastia reduction surgery
Breast prosthesis removal
Corrective surgery for congenital breast asymmetry

Ophthalmology

Optical coherence tomography (OCT) use in diabetic retinopathy referral
Shared decision making for cataract surgery
Glaucoma referral criteria

Ear, Nose and Throat and Endocrinology

Thyroid nodule referral and investigation

Vascular

Asymptomatic carotid artery stenosis screening
Management of abdominal aortic aneurysms (AAAs)

Upper gastrointestinal surgery

Referral for bariatric surgery

Plastic surgery

Abdominoplasty or apronectomy
Liposuction
Diastasis recti repair

Cardiology

Angioplasty for PCI (percutaneous coronary intervention) in stable angina

Urology

Non-visible haematuria
Needle biopsy of prostate

Paediatric Urology

Penile circumcision

Until the guidance is issued, it will not be clear how GPs will be able to refer patients for these procedures

But there are clues in the EBI List 3 Clinical Guidance Proposals.

For the breast surgery procedures, the proposals are for standardised criteria for Individual Funding Requests for Male gynaecomastia reduction surgery and Corrective surgery for congenital breast asymmetry. (Both procedures are not routinely provided by the NHS.)

Breast prosthesis removal patients are to have “consistent and fair access to the removal, and possible replacement, of breast implants across England” through standardised criteria for consideration of NHS funding, which is not routinely provided.

For the ophthalmology procedures, the proposals are to reduce referrals “that are unnecessary.”

There is also a proposal that the referral pathway for diabetic patients to be seen by hospital eye services (HES) is updated across England to “include Optical Coherence Tomography (OCT) as the detailed images from OCT are much more sensitive and accurate, reducing unnecessary referrals.” OCT could be conducted at a clinic in the main hospital’s eye service, at a diagnostic hub or mobile unit in the community or in primary care optometry enhanced services. “It offers an obvious opportunity to reduce the workload and therefore cost of the core hospital eye service…” (But what about the workload and cost of community or primary care services?)

The proposal for cataract patients’ pathway to referral for surgery is that it is updated to include shared decision making.

A risk stratification tool to identify people at highest risk of sight loss should be incorporated into glaucoma referral pathways.

For Thyroid nodule patients, the proposals are for “consistent management in the referral and investigation of thyroid nodules across England.”

For asymptomatic carotid artery stenosis screening, the proposal is that this screening would cease.

For Management of abdominal aortic aneurysms (AAAs), the proposal is for consistent referral and management of AAA across England, with centres and networks that are capable of offering all options.

Update 9.1.2023

Medical device companies that make and promote devices used in treating this condition gave more than £300,000 to the Vascular and Venous All Party Parliamentary Group to secure a u turn in National Institute of Clinical Excellence Guidelines, to benefit their companies.

The National Institute of Clinical Excellence (NICE) had been about to end its recommendation to treat abdominal aortic aneurysms using endovascular aneurysm repair (EVAR). Instead they were proposing open surgery for the condition. But NICE changed its mind after MPs on the Vascular and Venous All Party Parliamentary Group (APPG) lobbied NICE and the-then Health Secretary Jeremy Hunt, in 2018.

SInce 2016, the Vascular and Venous APPG had received donations from medical device companies including Medtronic, Terumo, Gore Medical and Cook Medical, which all make and promote devices used in EVAR and stood to lose from the NICE guidelines’ recommendations.

The Vascular and Venous APPG’s lobbying campaign to challenge the NICE guidelines was coordinated by a consultancy firm, HealthComms, that also acted as the APPG’s secretariat. HealthComms was formerly known as PB Consulting – a firm founded by Paul Bristow, now Tory MP for Peterborough, whose wife now acts as its managing director.

More information here.

Update ends.

For Referral for bariatric surgery, the proposal is for equitable access to bariatric surgery, improving patient health, across England. Overall, there would be an increase in the number of referrals for the consideration of bariatric surgery.

The same is proposed for Abdominoplasty or apronectomy, Liposuction and Diastasis recti repair.

For Angioplasty for PCI (percutaneous coronary intervention) in stable angina, the proposal is that this should only be performed in patients with stable angina that fulfil specified criteria, after optimisation, and are properly consented with documented shared decision making.

For Non-visible haematuria, the proposal is for criteria-based consistency in referral and investigation.

For Needle biopsy of prostate, the proposal is that use of specified criteria will lead to consistency in the management of patients across England. The driver for inclusion of this procedure seems to be that studies now show that multiparametric MRI (mpMRI) scans, which produce a more detailed picture of the prostate gland than a standard MRI scan, are highly sensitive in detecting clinically significant cancer and reduce the number of people who need a needle biopsy – which has until now been the traditional means of diagnosing prostate cancer.

For penile circumcision of children, the proposal is equitable access across England, and a reduction in non-evidence based, non reversible interventions.

Compared to Lists 1 and 2, the proposed guidance in List 3 seems more geared to equitable and consistent access to procedures than to withholding routine funding. Although cost reduction is a clear consideration.

In theory, shared decision making between patient and doctor is central to the proposed guidance for quite a few procedures

However, a July 2021 online survey by the Patients’ Association found that only around half of the respondents said they had experienced aspects of shared decision making.