A July 2014 report by Royal College of Surgeons showed that in too many instances local NHS commissioners in England are imposing arbitrary referral criteria for essential care despite clear clinical evidence and guidance from the Department of Health, NICE and surgeons. Integrated personal commissioning may be a way to avoid postcode lottery for access to elective surgical treatment.

Problem statement – Widespread lack of evidence based commissioning in hip surgery

73% of CCGs reviewed do not follow NICE and clinical guidance on referral for hip replacement or have no commissioning policy in place for this procedure. In some cases arbitrary referral criteria are used. The overall result is huge local variation (postcode lottery) in access to joint surgery. A change is needed to comply with NHS’ new CEO Simon Stevens’ 2015 initiative on “Integrated personal commissioning (IPC) to give patients “real power” – including frail elderly at risk of care home admission. There is compelling evidence that total knee and hip arthroplasty supports active life of the elderly (65+) preventing or postponing locomotive syndrome (loss of muscle mass + weakness and frailty) which is a significant predictor of care home admission.

From patient’s perspective

Total hip and knee arthroplasty improve the activities of daily life and improve quality of life dramatically. In particular, pain and physical functioning scores improve significantly. Long term results for the elderly are comparable or superior to those in younger patients. These effective improvements can prevent or postpone care home admission. Patients could challenge their CCG, via their local Healthwatch if necessary, if they feel they are being denied access to necessary surgical treatment. Simon Stevens said: “We need to stop treating people as a collection of health problems or treatments. We need to treat to them as individuals whose needs and preferences should be seen in the round and whose choices shape services, not the other way round.”

From commissioners perspective

CCGs needs to review their referral policies against the clinical evidence to help them avoid both under and over-commissioning for procedures, ensuring equitable access to the highest quality surgical care for their local populations.

From providers perspective

IPC will give people the freedom to call upon services and support when they need it most, as patients’ conditions can improve and worsen over the course of many years, therefore reducing the probability of unnecessary appointments and hospital admissions.

What actions could be taken

High-needs patients entered into the IPC programme will be given the power to decide upon how services are commissioned for them. By the end of July 2014 an IPC prospectus will be released, with NHS England working with local government, CCGs, patient groups and voluntary sector to produce this.

IMED Hospitales suggest that a CCG cross-border care contract with innovative patient pathways (ERICA) combining highly efficient joint surgery combined with progressive resistance training (evidence based well tolerated by elderly) could be one of the opportunities for personal control with regard to how services are commissioned for them to prevent locomotive syndrome and care home dependency.