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GPs facing raised referral thresholds for hip and knee ops

By Lilian Anekwe

Exclusive: Cash-strapped PCTs are raising their referral thresholds for orthopaedic procedures, a Pulse investigation has shown.

Our figures show that the number of hip replacements and resurfacing procedures, and knee replacement operations, has fallen or stalled in the last three years.

Primary care organisations funded an average of 507 knee replacement operations in 2009/10 at an average spend of £2.7m – down from 514 procedures in 2008/9 at a cost of £3m.

An average 502 hip replacement and resurfacing procedures, at a cost of £2.8m, were funded in 2009/10 - barely changed from the average of 505 procedures at a cost of £2.9m in 2008/9 and 501 at a cost of £2.7m in 2007/8.

The Pulse figures – from 119 PCOs responding to a Freedom of Information request - belie official hospital episode statistics suggesting that nationally the number of hip and knee procedures both increased by 3% between 2007/8 and 2008/9.

NHS Mid Essex reviewed its ‘clinical priorities policy' on hip and knee procedures in May 2010, and will no longer accept referrals if the patient has a body mass index of 40 kg/m2 or higher. Their policy also states that even where patients meet criteria, ‘prior approval must be sought'

NHS Lincolnshire has also changed its policy and insists from this financial year patients that patients being referred for hip surgery must have a BMI of less than 35 kg-m2, although a spokesperson for the trust insisted that patients with a higher BMI would be considered if GPs made a strong enough case.

NHS Surrey has placed knee and hip procedures on its list of low priority procedures and other procedures with restrictions or thresholds.

NHS Gloucestershire and NHS Nottingham City both admitted that their policies and commissioning procedures on hip and knee replacements were currently subject to review, while NHS Berkshire said the trust does not provide individual patient funding.

GPC chair Dr Laurence Buckman said some criteria in place were ‘stupid' – but warned that the stricter criteria may remain when PCTs are abolished and GPs begin commissioning orthopaedic services.

He told Pulse: ‘PCTs that have contracts with private organisations to provide hip surgery have for a long time had very restrictive criteria given to them by the private providers. So much so that you've got to be an Olympic athlete to get your hip replaced in some places.'

‘I think those criteria are stupid, and all that will happen of course is in the commissioning world, GPs won't commission from services that put that level of restriction on referral.'

‘There are several people who presently are offered treatment for various illnesses who may not be offered treatment in the new world. If there's evidence to show that that's actually better for them, that the treatment is worse for them, then that's not bad care, that's good care. But where restrictions are put in merely to save money, I don't think any of us would accept that.'

The number of knee replacement operations and hip replacement procedures has fallen or stalled in the last three years The number of knee replacement operations and hip replacement procedures has fallen or stalled in the last three years Hip and knee surgery – less of a clinical priority?

NHS Mid-Essex: no longer accept referrals if patient has a BMI of 40 kg/m2 or higher
NHS Lincolnshire: patients must have a BMI of 35 kg/m2 or lower
NHS Surrey: knee and hip procedures now on "low priority procedures" list
NHS Gloucestershire, NHS Nottingham City: policies subject to review

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