Agenda item

Attending for this Item were:

David Mehaffey, Director of Strategy, Transformation and Planning for the Worcestershire Clinical Commissioning Groups (CCGs)

Dr Anthony Kelly, Chairman of South Worcestershire CCG

By way of presentation, it was reported that a review of the Commissioning Policy for Hip and Knee Joint Replacement Surgery was required as part of the need to save £36m from the combined Worcestershire CCG budgets for 2017/18.  During a budget consultation in 2016, the general public was not supportive of restricting joint replacement surgery. 

The three Worcestershire CCG areas had different clinical activity, resulting in unexplained variations in hip and knee replacement activity with Redditch and Bromsgrove CCG having a higher level of activity when benchmarking nationally. A different approach to treating hip and knee replacement was taken between the north and south of the County, with physiotherapy offered prior to more radical treatment in the South.  This was not offered in the North.

Although there had always been a Commissioning Policy for providers to comply with, the variations across the County were as follows:

One of the objectives of the refreshed Commissioning Policy would be to reduce the variation across the County and for patients to consider other routes before resorting to major surgery.  Ways in which this could be achieved include the consistent use of the Oxford Scoring Tool as part of the clinical review which would be required before surgical referral and routes including considering weight loss and appropriate physiotherapy.  Prior Authorisation would also be required. 

It was reported that in 2016, 90 procedures were undertaken outside of the Commissioning Policy.  

In the ensuing discussion, the following main points were made:

·         It was clarified that there had always been a Commissioning Policy and the proposals were intended to tighten up procedures and ensure a more consistent approach across the County.  The number of hip and knee replacements in Redditch and Bromsgrove were higher than the other two CCG areas and the Policy would tackle the clinical variation

·         It was noted that due to a shift in national policy, the proposal around the use of the Oxford Scoring Tool was on hold, awaiting further national guidance

·         Surgery should be seen as the last resort, as joint replacement surgery was major surgery, an aspect which patients often overlooked.  Lifestyle changes could make a difference, such as weight loss or physiotherapy, and had the potential to reduce symptoms

·         When asked why the rise in numbers, it was suggested that Worcestershire's demographic profile had been well documented and the rise in the number of older people was a contributing factor.  Alongside this, it was known that nationally that there was a decrease in physical activity which was a clear contributing factor

·         Pain was difficult to interpret as everyone was individual.  However, questions around the level of mobility for example proved useful when undertaking a clinical review

·         When considering cost effectiveness, it was suggested that roughly 200 physiotherapy appointments could be provided for the same cost as a hip replacement operation

·         It was clarified that a knee replacement would provide pain relief, not better mobility

·         When asked whether the higher levels of replacements in North Worcestershire was as a result of the type of employment undertaken, it was unknown whether this was a contributing factor as employment was not recorded.

Simon Adams, Chief Operating Officer of Healthwatch Worcestershire was invited to comment on the discussion.  He reported that Healthwatch had concerns over the level of consultation undertaken and referred to the national concern over the use of the Oxford Scoring Tool.  However, Healthwatch welcomed the move away from a 'postcode lottery'.

In response, the Director of Strategy stated that wider consultation was not required as there was no substantial change proposed, rather a tightening up of clinical criteria.

Councillor Mike Johnson from Worcester City Council asked whether the proposals would result in surgery avoidance or just delaying surgery.  In response, it was stated that Physiotherapy appointments had the lowest referral wait time and patients often benefitted from targeted sessions.

Dr Frances Howie, the Director of Public Health, added that there was a key public health message regarding weight loss.  There had been limited success in weight loss surgery and it was known that weight was a contributing factor to a number of conditions.  Dr Howie went on to say that the behavioural change was supported by the 'Living Well' service and 'Prevention & Self Care' was a key priority in the Sustainability and Transformation Plan.