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GP referrals for operations wrongly blocked

By Lilian Anekwe

Exclusive: Ministers have said PCTs should not be blocking GP referrals purely on the basis of statistical analyses of effectiveness, after it emerged trusts had tightened criteria for access to hip and knee replacements based on unreliable data.

The first full analysis of patient-reported outcome measures (PROMs) found more than 90% of patients having joint replacements saw their conditions improve, refuting suggestions from a preliminary analysis that the operations often did little good.

The Government began collecting PROMs in April 2009, by distributing questionnaires about patients' health to all those admitted for hip and knee procedures, as well as groin-hernia surgery and varicose-vein operations.

Figures published by the NHS Information Centre include for the first time a comparison of responses to questionnaires before and after patients underwent procedures.

They show 96% of hip-replacement respondents and 92% of knee-replacement respondents recorded joint-related improvements following their operations, as measured by questions based around the Oxford Hip and Knee Scores.

The results refute claims made in a previous analysis by the Office of Health Economics, suggesting NHS cash was being wasted on hip and knee operations and predicting large proportions of patients would report no problems before sur-gery and no improvement after.

It calculated that nationally £144m was being wasted on procedures on patients who would report no clinical benefit, and of patients undergoing hip and knee replacements, 9,100 would experience no benefit and 7,200 would say they were worse.

Earlier this month a Pulse investigation found PCTs were tightening referral criteria for hip and knee procedures on the basis of that analysis, with many placing the operations on their list of procedures of ‘low clinical priority'.

But the new figures show of 15,709 hip-replacement patients surveyed, only 95 reported feeling the same after and 544 reported feeling worse.

The figures for knee replacements show that of 17,505 patients, only 228 reported no improvement and 1,197 reported a decline.

A Department of Health spokesperson said PROMs should not be used to deny patients' procedures: ‘PROMs data alone should not be used to judge whether surgery is appropriate for any given patient. Assessment should be determined between a clinician and patient based on clinical considerations.'

Of the four procedures for which PROMs are collected, hip and knee procedures far outstripped outcomes for varicose-vein and groin-hernia operations.

Some 87% of hip-replacement respondents and 77% of knee-replacement respondents recorded improvements in general health following their operation, compared with 52.5% for varicose veins and 49% for groin hernias.

Dr Syed Naqvu, a GP in Solihull, Warwickshire, said PCTs tightening their criteria would not save money in the long-run: ‘If they take into account the analgesia taken due to arthritis and its side-effects, is this really cost-effective?'

Dr Michael Blackmore, a GP in Ringwood, Hampshire, said: ‘Would managers take the same view if they had painful osteoarthritis, or their mother or father did?'

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