NHS cuts may reduce levels of hospital care for patients

Health chiefs and doctors have drawn up agreements setting out new thresholds before patients are given routine operations including hip and knee replacements, wisdom teeth and cataract extractions, and tonsillectomies.

The measures are part of moves to eliminate postcode lotteries which mean patients in some parts of the region are as much as five times more likely to undergo hospital treatment than others.

But NHS bosses estimate the thresholds could also generate savings worth £45m in the next three years. Reducing demand for hospital care is a key element of plans to make NHS efficiencies worth £1.6bn in Yorkshire by 2015 under plans highlighted yesterday by the NHS Confederation which called for an end to the “hospital-or-bust” model of medical care, claiming one in four NHS patients was better off being treated at home than in hospital.

Early evidence in Sheffield suggests there have been 12 per cent fewer hospital referrals for hip and knee problems since June using the thresholds.

In North Yorkshire, there was a 17 per cent fall in cataract operations between April and October, with nearly 500 fewer procedures carried out compared to 2010, but 120 more wisdom teeth extractions over the period – a rise of 26 per cent.

Other procedures are being added to the programme amid evidence of huge variations in availability of treatments depending on where people live, prompting claims some patients are being treated unnecessarily.

Across Yorkshire, more than £70m is spent each year on around 15,000 hip and knee replacements but numbers carried out vary by as much as three fold from one district to another, while there is a 2.5-fold variation in access to 30,000 cataract treatments carried out each year.

Numbers of wisdom teeth extractions carried out in hospitals varies five-fold – but one analysis in Doncaster found around half of 300 referrals did not need to be dealt with in hospital.

Despite the new thresholds, variations will remain as health chiefs in some parts have opted not to use them, while stricter guidelines remain in place in others.

Leading surgeon Prof Joe Dias, president of the British Orthopaedic Association, expressed concern that cuts in knee and hip replacements could increase unmet need.

He said national guidance warned NHS commissioners against using what he described as “unproven ways of arbitrarily setting thresholds to withhold care”.

“The commissioners must be convinced that their patients are being effectively looked after and not just being denied the best care,” he said.

Evidence suggested hip and knee replacements offered significant benefits and were cost-effective compared to alternatives.

“Whenever people talk about ‘unneeded’ surgery, I become concerned because none of us operate for the heck of it,” he said.

“We know these are financially troubled times and we all have to work within that but we have to do our best for patients and withholding care is not part of that.

“Our population is ageing, demand is increasing and demand management is like sticking a finger in the dike – it will only stop the flood for a short time.”

David Stout, deputy chief executive of the NHS Confederation, said variations in clinical practice were “vast” in some cases.

He added: “One reason for these protocols is financial to make the best use of finite resources. The other is more clinical because without clear thresholds for referrals and treatment it means patients can be treated unnecessarily sometimes with very invasive techniques when they don’t need it.”

GP Zak McMurray, clinical director for NHS Sheffield, said the orthopaedic threshold was being implemented following discussions with local clinicians and reflected the city’s needs. “Since June when the city-wide roll out was complete, we have seen a 12 per cent fall in the number of first hospital appointments with the orthopaedic services looking at lower limbs,” he said.

“We are confident that this shows that Sheffield is now offering a better service, with patients who really need surgery getting surgery, and other patients with less pain able to benefit from other non-surgical interventions such as physiotherapy, joint injections and effective pain management.”

Bid to tackle care ‘lottery’: Page 5; Comment: Page 12.