One of the country’s leading clinicians has claimed a flagship government policy to link payment by results to the quality of outcomes could deny care to those “who need it most”.

The Department of Health has revealed to HSJ that it is working on specific plans to link a “small proportion” of payments for hip and knee surgery to the results of patient reported outcome measures.

The measures are based on a series of questionnaires, which include condition-specific questions as well as others covering general health. They are answered by patients before and after surgery.

A DH spokesman said that as part of the “sense check” exercise undertaken on the development of payment by results, the department was seeking to “link a small proportion of reimbursement for hip and knee replacements to patient outcome, as measured by PROMs”.

“The aim of doing this will be to reduce unexplained variation in patient outcomes,” the spokesman said.

No timescale was given for the plan.

NHS medical director Sir Bruce Keogh told HSJ the DH intended to “link quality to payment”, as set out in the 2010 NHS white paper.

He said that before the DH “rushed into” delivering the change, it was important to “really understand” what the PROMs scores were revealing about service quality.

However, British Orthopaedic Association president Peter Kay – a member of the DH PROMs board – has written to Sir Bruce, in a letter seen by HSJ, warning the move would restrict healthcare for “the very people that probably need it the most”.

He wrote: “Rather than try to understand this data and get the maximum of benefit from it, elements within the DH [have] chosen to use the data not only prematurely and erroneously as a basis for future payment, despite our concerns, but also for reasons that can be only about managing demand.”

Mr Kay is particularly concerned that the DH gives undue weight to PROMs measuring general health, as opposed to condition specific measures.

Mr Kay told HSJ this move would discriminate against patients with “other problems or co-morbidities” besides hip or knee problems and incentivise “cherry picking” of healthier patients.

He said: “The danger would be… some patients may not be offered surgery because it would be very hard to demonstrate a significant improvement [using PROMs].”

He expressed concern that the DH wished to “discredit surgery in the NHS by deliberately choosing to be very economical with the data they publish”. He added: “If we are going to ration healthcare we need to say so.” He warned that to use PROMs data in the opposite way it should be was “disingenuous in the extreme and damaging to patients”.

A DH spokesman responded to the letter saying: “Providing the best possible care for patients is our priority. Decisions on the appropriate treatments should be made by clinicians in the local NHS in line with NICE guidance.

“PROMS data gives patients a voice and provides the NHS with vital insight into their views on the effectiveness of the care they receive. This data will inform but not replace clinical decision making.”

British Medical Association consultants committee chair Mark Porter said PROMs were a “valid research tool”, but should not be linked to payment.

“I have no doubt that it will become something [in which] people develop ways to game the system,” he said. “Once you start attaching significant amounts of money there will be imaginative methods that people will explore to make sure that people answer questionnaires to make [providers] look good.”

PROMs project lead David Nuttall said the DH was also seeking to extend the PROMs system. It is currently used for hernias and varicose vein operations, in addition to knee and hip replacements.

Rather than deciding which conditions PROMs could be applied to, the DH was “thinking about which conditions it wouldn’t work in”, he said.

Sir Bruce said the DH was looking at developing a simplified “outcomes and experience questionnaire” for patients that would “fit on one side of A4”, leading to “higher return rates”.

A DH spokesman said: “Providing the best possible care for patients is our priority. Decisions on the appropriate treatments should be made by clinicians in the local NHS in line with NICE guidance.

“PROMS data gives patients a voice and provides the NHS with vital insight into their views on the effectiveness of the care they receive. This data will inform but not replace clinical decision making.”

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