• Patients expected to endure “uncontrolled, intense, persistent” pain for six months before referral, under CCG plans
  • Proposals part of wider restrictions which could save seven Sussex CCGs £20m
  • Governing bodies being asked to accept proposals this week

Patients could be at risk of opiate addiction while waiting for surgery under policies being considered by seven clinical commissioning groups, the British Orthopaedic Association has warned.

Patients would have to endure “uncontrolled, intense, persistent” pain which substantially affects their daily life for six months before being routinely referred for a hip replacement, in a policy being considered by the seven CCGs in Sussex.

If adopted, the policy would mean patients are expected to have taken painkillers including opioids, had physiotherapy, and tried to lose weight, if necessary, for six months before referral for surgery.

Ananda Nanu, president of the British Orthopaedic Association, said: “While the policy that Sussex CCGs are looking to implement does not contravene NICE guidelines, the BOA takes the view that the restrictions are not putting patients’ needs and well being as the priority.

“The BOA is also concerned that opiates are being championed for the management of a chronic condition such as arthritis where the treatment and solution is clearly surgical. These are strong, highly addictive controlled drugs that are intended for acute pain of short duration. The evidence shows that patients using opiate pain killers prior to total hip replacement have higher complication rates afterwards.

“It would be irresponsible to follow recommendations that will leave vulnerable people with an additional lifelong dependence on controlled medication, when there is no indication to prescribe opiates for a chronic condition that is so readily amenable to a tried and tested surgical remedy. All the current recommendations will do is postpone inevitable surgery at the expense of a possible dependence problem.”

The restrictions are part of a swathe of new policies being considered by Sussex CCGs which would limit patient access to treatments such as hip and knee replacements, gallbladder removal and hernia surgery unless they met county wide criteria. Patients who did not do this might still get funding through an individual funding request.

The CCGs have a “total financial opportunity” of £20.1m if just the top nine policies are implemented, according to governing body papers. This is based on a comparison with other similar CCGs who spend less. Hip and knee replacements alone could save £12.1m across the CCGs.

Another tranche of restrictions, including interventional treatments for back pain, are still being considered and could save another £4.5m. Future restrictions could include In vitro fertilisation, vasectomy, planned Caesarean section and bariatric surgery.

Work on the “clinically effective commissioning” has been delayed because of the complexity of getting the county’s seven CCGs to approve the policies, and some policies have had to be excluded because not all CCGs could agree them.

Mr Nanu added: “Many CCGs are unfortunately seeking to limit patient access by establishing maximum body mass index thresholds and withholding treatment from smokers. The impact of these arbitrary barriers and delays is clear, patients will have worse outcomes and it will add to the cost of procedures as more complex intervention may be needed.

“Hip and knee replacements greatly improve mobility and reduce pain for patients, which increases their ability to maintain independence and resume normal life functions, including return to work.”

A spokesman for the CCGs said: “Our policies reflect NICE guidance which states “If paracetamol or topical nonsteroidal anti-inflammatory drugs (NSAIDs) are insufficient for pain relief for people with osteoarthritis, then the addition of opioid analgesics should be considered. Risks and benefits should be considered, particularly in older people.”

The CCGs’ guidance say the patient should be taking optimal tolerated doses of analgesia and patients should have gained an understanding of their correct uses (paracetamol, NSAIDs or opioid analgesics).

In their statement the CGGs said: “The Clinical Effective Commissioning programme aims to bring a uniform systematic approach to policy review and implementation across all the Sussex CCGs in the STP to remove unwarranted variation and apply sound clinical decision making within mutually agreed policies.

“This ensures equity of access, improved clinical outcomes, better patient experience and efficient demand and capacity management across the system.”

The CCG was unable to respond to the BOA’s concerns around opiates by the time of publication.

The CCGs’ statement added: “Our standardised policy was agreed following detailed review of the available evidence by commissioners, GPs and orthopaedic surgeons. This included mirroring National Institute for Health and Clinical Excellence guidance.

“Our policy, therefore, supports referral dependent on the person’s pain causing a substantial impact on their quality of life.

“The £20m represents the total financial opportunity compared to best five ‘Right Care’ demographic peers. We believe that realistically it would not be possible to materialise this kind of saving which is why our ambition for 2018-19 is less than 20 per cent of that.

“Up until this point, the focus of the work has been on clinical engagement to ensure there is agreement of the areas where there is little or no evidence of clinical benefit for patients. This has involved detailed evidence reviews being carried out for each treatment area, capturing all NICE and any other national guidelines, which is then carefully evaluated to ensure a representative policy is formulated. Equality impact assessments have also been carried out for the policies which identify the impact from an equality point of view.”


*story updated at 11.49am July 24th to include additional comment from the CCGs*