• Three West Midlands CCGs to decrease the eligibility threshold for patients requiring hip and knee replacements
  • Changes would see a 12 per cent decrease in patients eligible for hip replacements and a 19 per cent decrease for knee replacements
  • Royal College of Surgeons says there is “no clinical justification” for CCGs’ approach
  • Data suggests “opportunity to reduce expenditure on hip and knee replacement surgery” by £2m a year, board paper says

The Royal College of Surgeons has said there is “no clinical justification” for three CCGs’ plan to greatly reduce eligibility for knee and hip replacements, which could save £2m a year.

Redditch and Bromsgrove, South Worcestershire, and Wyre Forest clinical commissioning groups intend to change their scoring system for hip and knee replacement surgery, which could reduce eligibility by 12 and 19 per cent respectively – affecting hundreds of patients.



The changes could reduce the number of surgeries by around 350

The royal college has criticised the CCGs for using the Oxford scoring system to rate patients’ eligibility. An RCS spokesman said: “Oxford scoring systems were designed to measure patient outcomes and should not be used to create barriers to care.

“Such criteria are in explicit contravention of NICE and surgical commissioning guidance, and have no clinical justification in being applied to a general population to determine who gets NHS treatment.”

The Oxford scores are patient reported outcome measures designed to assess function and pain in patients who have hip and knee replacement surgery.

In a board paper, published on 23 January, Redditch and Bromsgrove CCG said: “Utilising the Right Care packs provided to CCGs, the data suggests there is an opportunity to reduce expenditure on hip and knee replacement surgery by circa £2,123,420 per annum.

“The revised musculoskeletal commissioning policy proposes a reduction in the Oxford hip and knee score from 30 to 25, focusing more on the severe to upper end of moderate. Further refinements to the policy include a BMI of 35 with a requirement to reduce weight by 10 per cent.”

The document added: “Around 10 per cent of activity is undertaken in patients with hip and knee scores [greater than or equal to] 30. A reduction of [hip and knee scores] to [less than] 25 will achieve a 12 per cent and 19 per cent decrease in patients eligible for hip and knee surgery respectively.”

According to the paper, reducing the eligibility score to 25 or less could lead to 353 fewer surgeries and savings of up to £2.1m a year across the three CCGs.

It said a score of less than 25 means “patient’s pain and disability should be sufficiently severe that it interferes with the patient’s daily life and/or ability to sleep”.

Only patients with a BMI of less than 35 would be eligible for surgery unless they can demonstrate a 10 per cent loss in weight; they are in danger of losing their independence; or the level of joint destruction would increase if surgery was delayed.

HSJ reported last year that the CCGs had outlined proposals for restrictions on certain NHS treatments, including knee and hip replacements, in order to close a £25m funding gap.

The Redditch and Bromsgrove board paper also forecast that it will miss its end of year financial target by £8m.

An RCS spokesman said: “We appreciate that the CCGs’ face significant financial challenges, which now mean they are looking at which groups of patients they can target to save money.

“While the CCGs have stated they hope this policy will save them £2m a year it is unclear whether they have considered the costs of not treating a patient.

“This could include the cost of pain relief medication and a later operation when the patient does meet the required pain and weight thresholds. Delaying access to surgery also adversely affects a patient’s quality of life and surgical outcomes, meaning the operation may not be as beneficial as if it had been carried out earlier.

“This policy is the latest demonstration of how NHS financial pressures are directly affecting patients.”

A spokeswoman from Redditch and Bromsgrove CCG said: “The CCG has reviewed the criteria for those patients requiring hip or knee replacement surgery.

”The Oxford scoring system is a guidance for clinicians and they recognise that many patients will benefit from physiotherapy and weight loss before considering surgery.

“If a patient feels that they require this surgery but do not meet these criteria, there is a clear appeals system via individual funding requests whereby the effects can be considered upon the patient and the decision made regarding eligibility for funding.”