BOA speaks out on plans for restrictions on referrals for hip replacement surgery

On Tuesday 24th July the HSJ published an article on referral restriction plans by seven Sussex CCGs.  According to the policy being considered, patients would have to endure “uncontrolled, intense, persistent pain” which substantially affects their daily life for six months before the CCG would fund a primary hip replacement.  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 the CCG would allow them to have surgery.
The following is the statement released by BOA President, Ananda Nanu:

CCGs implementing increasingly restrictive criteria for hip and knee replacement surgery is unfortunately becoming more common.  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.
The US is in the throes of dealing with an opiate crisis caused by less strictly controlled prescribing of analgesia than is currently the case in the UK. 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.
Additionally, many CCGs are unfortunately seeking to limit patient access by establishing maximum BMI 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.
At the BOA we are very concerned that decisions about who should receive an operation are being made by CCGs, rather than by the clinicians and patients in partnership, and despite strong evidence for good outcomes from these procedures.  A patient’s symptoms of pain in an arthritic joint should be used first and foremost to decide whether joint replacement surgery is appropriate.
 
Ananda Nanu
President
British Orthopaedic Association
Further Reading
Referral restriction plan ‘puts patients at risk of opiate addiction’: https://www.hsj.co.uk/quality-and-performance/referral-restriction-plan-puts-patients-at-risk-of-opiate-addiction/7022996.article.
NHS rations hip operations while paying bosses £300,000 salaries: https://www.telegraph.co.uk/news/2018/07/27/nhs-rations-hip-operations-paying-bosses-300000-salaries/.