Unneeded surgery may be costing the NHS millions

Calculations by HSJ suggest at least £144m is being spent annually on carrying out operations on people who either have no significant complaints about their health before surgery or report that their condition is unchanged or worse afterwards.

If figures collected for the Department of Health in a trial of patient questionnaires accurately reflect the national picture, nearly 20,000 people reporting no problems with pain or discomfort are undergoing groin hernia and varicose vein procedures each year.

Of all patients undergoing the operations, 13,500 would report no change after the procedure and 17,400 would say they feel worse.

Of patients undergoing hip and knee replacements, the figures suggest 9,100 experience no change after the operation and 7,200 say they are worse.

Last month, all NHS hospitals began asking patients undergoing the four procedures to rate their health before and three months after operations.

The results, known as patient reported outcome measures, are expected as early as November, and will be used to compare hospitals and potentially clinical teams on the basis of how much patients’ health improves.

But they will also highlight acute trusts, primary care trusts, teams and individual clinicians operating on patients with less severe symptoms and who are less likely to benefit.

Analysis of an element of the trial data by a group of health economists, led by Office of Health Economics research director Nancy Devlin, revealed surprisingly large proportions reporting no problems before surgery and no improvement after.

Professor Devlin said that although the results were based on a small patient sample, and used survey questions which may not pick up subtle improvements in patients’ conditions, they raised questions about the NHS’s ability to select patients who would benefit most from procedures.

She said: “If [a PCT] is responsible for a budget and has a third of patients not reporting a problem [before surgery], you have to wonder whether it is defensible.”

PCTs should ask themselves whether there was a way of making sure patients could really benefit from surgery, she said.

Central Lancashire PCT chief executive Joe Rafferty said the results would be used to get patients to “engage with quality of life and health as a product” and demonstrate surgery may not be their best option.

They could be used to suggest alternative treatments such as pain relief or physiotherapy, rather than carrying out an intervention simply because it exists, he said.

He said: “The other opportunity it creates for commissioners is [that] if people don’t receive the benefits, we need to create markets to provide an alternative.”

King’s Fund chief economist John Appleby said PCTs would be able to use the results to “point the finger” at the quality of clinicians’ decisions about when to operate on a patient.

“PROMs will be a way for hospitals to start benchmarking themselves and for PCTs to start to look at the data and ask hard questions of their providers - comparing not just between hospitals but between clinicians,” he said.

“You have to dig deeper - it is not simply a case of saying those patients should not get an operation.”

NHS North West chief economist Kirsten Major said PCTs could use PROMs results to calculate the relative cost effectiveness of spend by “quality years” added to patients’ lives.

“When combined with cost you can come up with sophisticated arguments about where priorities should lie,” she said.

A DH spokesman warned the relatively small sample may not be representative of the NHS.

But he added: “Patient reported outcome measures data is intended to help to identify where patients are not getting the expected benefits of surgery.

“We expect hospitals to use PROMs data to drive improvements in quality.”

For HSJ’s calculations, Professor Devlin’s paper and the London School of Hygiene & Tropical Medicine report on PROMs for the DH, see right.