• NHS England says some CCGs are using “arbitrary” methods to “ration” hip and knee surgery and restricting treatment for smokers and obese people
  • CCGs must report on whether they have implemented restrictions, and in future seek NHS England’s permission
  • National RighCare team has also written to CCGs about hip and knee surgery
  • Royal College of Surgeons welcomes NHS England’s “intervention” but warns over other procedures

NHS England has issued a warning to commissioning groups accusing some of “rationing” surgery using “arbitrary cut offs”, amid growing concern about the issue, HSJ can reveal.

An email from an NHS England official to clinical commissioning groups said the national organisations was aware that “a number of CCGs in England are rationing large joint replacements using arbitrary cut offs from [the] Oxford scoring [system]”.

It adds: “In addition some CCGs are restricting surgery for smokers and obese people as opposed to a period of slimming support and smoking cessation support for surgery.”

The warning comes after growing numbers of CCGs in recent months have introduced or proposed restrictions on hip and knee surgery, in several cases saying it is linked to NHS England’s RightCare programme. According to RightCare, its aims is to address variation in care and increase value from commissioning spend.

The email seen by HSJ was sent to CCGs by a director in an NHS England regional team at the end of last month. It also requires CCGs to report to NHS England on whether they have already implemented such policies, and says they will have to request agreement “at regional level” before putting them in place in future.

It is not clear whether the same warning and instructions have been sent to all CCGs.

However, at the same time NHS England sent another letter to leaders of all CCGs in England from the organisation’s national leaders, also indicating they should be more cautious about restricting access to hip and knee replacement surgery.

This letter, from RightCare national director Matthew Cripps and Peter Kay, a consultant hip and knee surgeon from the Whittington Hospital,  clarifies how to use RightCare to commission this type of surgery.

The letter says: “For some indicators, such as elective activity, investment cannot be interpreted as poor or good value without further investigation… There is strong evidence that hip and knee replacements are extremely cost-effective interventions when warranted by clinical need and patient preference.”

The Royal College of Surgeons welcomed that “NHS England has now intervened to discourage clinically unacceptable rationing of surgery in the NHS”, although it also warned about other types of surgery.

Ms Marx, told HSJ: “It is extremely welcome news that NHS England has now intervened to discourage clinically unacceptable rationing of surgery in the NHS. There have been growing examples of commissioning groups ignoring NICE guidance and imposing arbitrary pain, weight, or smoking thresholds to defer or prevent patients from receiving timely surgery as a way of saving money…

“Patients should always be encouraged to quit smoking and lose weight for their overall health. However making it a condition of their treatment is unjust.”

She added: “However, it only criticises the rationing of hip and knee surgery. Patients are left wondering about the validity of restrictions to other types of surgery and NHS treatment.

“Given this very clear intervention from NHS England we strongly encourage CCGs to reverse any existing discriminatory policies.”

NHS England nationally has been approached for comment.