NHS England will consult on the first national move to strictly limit access to a list of 17 interventions on the NHS, it has announced.
In the first move of its kind to be taken nationally, the national commissioner is planning to stop or significantly narrow routine commissioning of the interventions, which include breast reductions and snoring surgery.
The NHS has often seen moves by local commissioners to limit access to some interventions, and over the past year NHS England has put in place national restrictions on NHS funding for some medicines, but there have been major national curbs on surgery in the past.
NHS England is working with NHS Clinical Commissioners and the Academy of Medical Royal Colleges on the project, and intends to consult on its proposals from next week.
A statement said: “Patients would be spared more than 100,000 unnecessary procedures a year, freeing up an estimated £200m that can be spent on more effective treatments.”
The treatments will continue to be offered in some specific circumstances, such as after other cheaper and less invasive approaches have been tried.
Academy of Medical Royal Colleges chair Carrie MacEwen said: “Whilst it has been for individual medical royal colleges or specialist societies to comment on the specific specialty recommendations the Academy of Medical Colleges supports the overall programme which will benefit patients, clinicians and the NHS as a whole by reducing harm and targeting those who will benefit most.”
Graham Jackson, co-chair of NHSCC, said: “There have been a number of attempts to implement this before but this is the first time we have had a national clinical consensus across commissioners, providers and national bodies to make sure the procedures we are offering on the NHS are safe for patients, deliver good outcomes and, are both clinically and cost effective in order to secure the very best value for the limited NHS pound.”
NHS England chief executive Simon Stevens said: “The NHS is already independently ranked as one of the most efficient health services in the world. But with more money about to go in, we’re going to step up reform to drive remaining waste out.
”Precisely because the NHS is owned by the public, all the savings we now make will be directly reinvested in better frontline cancer, mental health and other critical services.”
The statement also said: ”In recent years, the NHS in England has consistently outperformed the overall UK economy’s productivity, and it has saved £27bn cumulatively over the past five years compared to the NHS’ average funding growth over the rest of its 70 year history.”
Four treatments proposed to be offered only when a patient makes an individual request:
- Snoring surgery: shows limited clinical evidence of effectiveness and also poses significant risks to any patients who undergo it.
- Dilatation and curettage for heavy menstrual bleeding: a minor surgical procedure, which NICE recommends is not offered as a test or treatment option for this condition, as there is little evidence to suggest the procedure works, and when it does, only provides temporary effectiveness and has been replaced by better tests and treatments.
- Knee arthroscopies for osteoarthritis: an operation which inserts a camera into the knee to drain fluid, but does not alleviate symptoms, reduce pain or improve how well the knee works.
- Injections for non-specific back pain: injection of steroids into the spine, which work only as well as less invasive, less distressing procedures or treatments like behavioural therapy or exercise programmes.
Thirteen interventions proposed only when specific criteria are met:
- Breast reduction: this treatment can result in permanent loss of the lactation function, scarring, bleeding and bruising. Surgery can be offered to women in very specific circumstances and where alternative approaches have been tried and do not relieve the symptoms like back pain.
- Removal of benign skin lesions: treatment to remove non-cancerous skin marks can lead to bleeding, infection and scarring. Removal of skin lesions that affect daily life will be offered, according to specific criteria set out in the consultation document but lesions will not be removed solely to improve appearance.
- Grommets for Glue Ear: a surgical procedure to insert tubes into the eardrum. The recommendation applies to cases where grommets for children can be offered to treat Glue Ear; provision of grommets in other clinical conditions should continue to be normally funded. Glue Ear will improve in most cases without surgery, and the recommendation is that it is only offered to children when persistent in both ears and affecting the hearing, parents should also be offered a hearing aid as suitable alternative before proceeding with surgery
- Tonsillectomy for sore throats: this procedure will continue to be offered where sore throats caused by tonsillitis are disabling and recurrent; however not all sore throats are due to tonsillitis and can be caused by other infections, so removing tonsils will not be effective in these cases. The procedure carries asignificant risk of bleeding that can require emergency surgery, in addition it is a very painful operation that can require rehospitalisation for pain control.
- Haemorrhoid surgery: surgery, which can lead to complications including fissuring and infection, is a much more invasive approach to more simple solutions which can be just as effective for mild haemorrhoids, like eating more fibre and drinking more water. Where these alternatives are not effective then treatments less invasive than surgery, like banding, could be effective.
- Hysterectomy for heavy menstrual bleeding: NICE recently consulted with patient groups who agreed with guidance recommending that the removal of the uterus must not be used as a first-time treatment for heavy periods, and should be considered only when other treatments have failed.
- Chalazia (lesions on eyelids) removal: a procedure involving an incision to clear Chalazia (a blockage of an oil gland and swelling in the eyelid), which generally resolves within six months, and can be accelerated with the application of warm compresses and massage. Surgery is uncomfortable, can cause bruising and further swelling, as well as risk of infection. An alternative to this procedure is a smaller injection. When Chalazia becomes larger or more persistent, then removal can be considered.
- Anthroscopic compression for subacromial shoulder pain: a procedure to remove bone spurs and soft tissue related to specific forms of shoulder pain, is recommended to be offered only in appropriate cases. The recommendation does not apply to conditions caused by associated issues like rotator cuff tears or joint pain. In the specific cases included, non-invasive treatments like physiotherapy and exercise are both effective and safe.
- Carpal tunnel syndrome release: a surgical procedure to release a trapped nerve causing pain in the wrist. Although carpal tunnel syndrome is common, mild symptoms will improve over time, whilst in some cases, an injection should be considered as a first treatment. Surgical outcomes are poor in patients with very mild symptoms, and can come with complications including infection and pain but surgery should be offered for severe cases according to the proposed criteria set out in the consultation document.
- Dupuytren’s contracture release: Dupuytren’s contracture causes tightening of fingers, and clinical advice is that surgery is avoided where symptoms do not impair the functioning of someone’s hand. NICE evidence shows even after surgery, the problem returns after three to five years. A small injection could be more effective and less invasive than surgery.
- Ganglion excision: ganglia are small, noncancerous lumps on the wrist or hand. They are usually painless, however where there is any uncertainty over the cause of the swelling, then diagnostic tests should be performed, before referring, where appropriate, to a specialist. Patients will still be offered the treatment when the condition causes mobility issues or other harm.
- Trigger finger release: this is where a finger or thumb become locked and although in most people the condition does not cause serious harm, surgery is recommended to be offered where alternative measures, like steroid injections have been unsuccessful. Surgery can take many weeks to recover from and can be associated with pain, infection, stiffness and nerve damage.
- Varicose vein surgery: effective treatments for the variety of varicose vein conditions will still be offered. Less invasive treatments like injection or laser to the varicose vein which can be effective alternatives to surgery. People with varicose vein conditions that meet the criteria set out in the consultation document will be referred to a vascular service, and anyone with a bleeding vein will be referred immediately for treatment. This is in line with NICE guidance.
NHS England statement
30 June 2018