FINANCE: Surgical procedures for prostate cancer, hernias and cataracts are among a raft of treatments that could be restricted or stopped in one of the country’s most financially challenged health economies.

Northern, Eastern and Western Devon Clinical Commissioning Group has shared a list of 24 procedures it is considering for decommissioning with local NHS leaders and GPs (see box below).

Surgeons

The CCG has proposed restricting follow-ups after general surgery

While decisions are due to be taken later this month for implementation from December, documents seen by HSJ say the “majority” of proposed restrictions are “likely to be enacted in some form”.

The list proposes changing the criteria for offering prostate surgery to give greater consideration to an approach of “watchful waiting”. It also suggests looking at the “management” of hernias, cataracts and bunions.

Criteria for elective shoulder surgery will also be revisited while IVF will be suspended entirely, along with “aspects” of services for patients with fibromyalgia and chronic fatigue.

The document suggests clinicians stop offering these treatment options immediately and says it “may be necessary” to apply the restrictions to patients at the start of pathway who have not yet had a decision about their treatment.

It said: “The interim commissioning positions are not judgements on whether those procedures or services are beneficial or not for individuals.

“[They] are a judgement on whether the temporary withdrawal of service is bearable in the context of commissioning for NEW Devon’s population as a whole in order to safeguard the availability of services of higher priority.”

The document says there will be a further round of service reductions in January and asks providers for suggestions of areas that might be feasible, including “opportunities for watchful waiting on 18 week pathways” and avoiding premium rate clinics and theatre capacity.

The announcement of the proposed restrictions follows warnings from the £1.1bn turnover CCG that it would finish the year with a cumulative deficit of almost £30m.

It needs to find £26m of in-year savings and has already announced plans to require obese patients to lose weight before they can undergo a hip and or knee replacements.

The CCG is also considering introducing the same requirement for routine surgery as well as requiring smokers to quit the habit.

A spokeswoman for the CCG said it had not identified how much would be saved through the proposals as the list had “been arrived at clinically”.

She said NEW Devon had historically had less restrictive policies for access than some other commissioners and work was being undertaken to understand these different approaches and “fixing” NEW Devon’s position.

The document also warns providers that any additional capacity created as a result of the restrictions should not be used to shorten waiting lists beyond the required 18 week waiting time targets.

It says there will be a further round of service reductions in January and asks providers for suggestions of areas that might be feasible, including “opportunities for watchful waiting on 18 week pathways” and avoiding premium rate clinics and theatre capacity.

First phase of service changes being evaluated for disinvestment

  • Suspension of ultrasound guided steroid injections
  • Suspension of shockwave therapy for tendinopathies
  • Secondary care ear wax removal
  • Elective shoulder surgery
  • Choice of Avastin for wet macular degeneration
  • Criteria based fluorescein angiography on wet AMD pathway
  • Restricted follow-ups after general surgery
  • Prescribing of over the counter medicines and related promotion of appropriate self-care
  • Restricted follow-ups after cataract surgery
  • Suspension of IVF
  • Restrict sequential use of anti-vascular endothelial growth factor drugs in wet AMD
  • Restrict elective caesarean without medical grounds
  • Restrict facet joint and lumbar spine injections
  • Criteria for offering robotic prostatectomy versus other radical prostatectomy versus brachytherapy versus watchful waiting
  • Suspending aspects of fibromyalgia services
  • Suspending aspects of chronic fatigue services
  • Smoking cessation prior to a wider range of routine surgery
  • Weight loss prior to a wider range of routine surgery
  • Use of botulinum toxin
  • Management of hernias
  • Management of haemorrhoids
  • Management of cataracts
  • Management of bunions
  • Pathways leading to hysterectomy