NHS Cutback Planned for 'Ineffective' Treatments

Peter Russell

July 02, 2018

Medical treatments deemed to be "ineffective" or "risky" could be curbed for tens of thousands of patients in England under proposed plans.

NHS England's board of directors will meet this week to consider proposals to stop or reduce routine commissioning of 17 treatments, including breast reductions, snoring surgery, and hysterectomies for heavy menstrual bleeding.

The plans could halt more than 100,000 procedures and free up an estimated £200 million to be spent elsewhere in the health system, according to the NHS.

The British Medical Association (BMA) warned that NHS treatments should not be rationed.

Reducing 'Waste' in the Health System

Prof Stephen Powis, NHS England's national medical director, said: "If we want the very best clinical care for our patients, we need to stop putting them through treatments where risks and harms outweigh the benefits. By reducing unnecessary or risky procedures for some patients we can get better outcomes while reducing waste and targeting resource to where it is most needed."

Routine treatments would be targeted where less invasive, safer treatments were available and shown to be just as effective, NHS England said.

"While the procedures will not be banned outright, NHS England wants to ensure that they are carried out only where there is compelling evidence that they will benefit patients," said Simon Stevens, NHS England chief executive. "In most of the 17 interventions to be considered, alternative treatments like physiotherapy, a minor injection or change of diet are likely to be effective. 

"Any patient at risk of serious harm from their condition will continue to be offered treatment, and medical professionals will continue to follow guidelines from NICE when recommending treatment."
 

Treatment Procedures Being Targeted

Under the proposals, four of the 17 procedures would be offered only when a patient specifically requested them. These would be:

  • Snoring surgery, which has shown limited clinical evidence of effectiveness and poses "significant risks" to patients

  • Dilatation and curettage for heavy menstrual bleeding, which is not recommended by NICE and may only provide temporary relief from symptoms

  • Knee arthroscopies for osteoarthritis, which do not alleviate symptoms or improve joint function

  • Steroid injections into the spine for non-specific back pain which are no more effective than other treatments such as behavioural therapy or exercise programmes.

 

NHS England sent Medscape News UK a list of the remaining 13 procedures and a brief explanation of the reasons why they might be curbed and the circumstances where they might still be offered. These were:

  • Breast reduction: this treatment can result in permanent loss of the lactation function, scarring, bleeding and bruising. Surgery can be offered to women in very specific circumstances and where alternative approaches have been tried and do not relieve the symptoms like back pain.

  • Removal of benign skin lesions: treatment to remove non-cancerous skin marks can lead to bleeding, infection and scarring. Removal of skin lesions that affect daily life will be offered, according to specific criteria set out in the consultation document but lesions will not be removed solely to improve appearance.

  • Grommets for glue ear in children: a surgical procedure to insert tubes into the eardrum. Glue ear will improve in most cases without surgery, and the recommendation is that it is only offered to children when it is persistent in both ears and affecting hearing. A hearing aid should be offered as a suitable alternative before proceeding with surgery. The recommendation applies only to grommets for glue ear in children; provision of grommets in other clinical conditions should continue to be normally funded.

  • Tonsillectomy for sore throats: this procedure will continue to be offered where sore throats caused by tonsillitis are disabling and recurrent; however not all sore throats are due to tonsillitis and can be caused by other infections, so removing tonsils will not be effective in these cases. The procedure carries a significant risk of bleeding that can require emergency surgery, in addition it is a very painful operation that can require rehospitalisation for pain control.

  • Haemorrhoid surgery: surgery, which can lead to complications including fissuring and infection, is a much more invasive approach to more simple solutions which can be just as effective for mild haemorrhoids, like eating more fibre and drinking more water. Where these alternatives are not effective then treatments less invasive than surgery, like banding, could be effective.

  • Hysterectomy for heavy menstrual bleeding: NICE recently consulted with patient groups who agreed with guidance recommending that the removal of the uterus must not be used as a first-time treatment for heavy periods, and should be considered only when other treatments have failed.

  • Chalazia removal: a procedure involving an incision to clear chalazia (blockages of oil glands causing swellings in the eyelid). These lesions generally resolve within 6 months, which can be accelerated with the application of warm compresses and massage. Surgery is uncomfortable and can cause bruising, further swelling and risk of infection. An alternative to this procedure is a smaller injection. When a chalazion becomes larger or more persistent, removal can be considered.

  • Arthroscopic decompression for subacromial shoulder pain, a procedure to remove bone spurs or soft tissue related to specific forms of shoulder pain, is recommended to be offered only in appropriate cases. The recommendation does not apply to conditions caused by associated issues like rotator cuff tears or joint pain. In the specific cases included, non-invasive treatments like physiotherapy and exercise are both effective and safe.

  • Carpal tunnel syndrome release: a surgical procedure to release a trapped nerve causing pain in the wrist. Although carpal tunnel syndrome is common, mild symptoms will improve over time, whilst in some cases, an injection should be considered as a first treatment. Surgical outcomes are poor in patients with very mild symptoms, and can lead to complications including infection and pain, so surgery should be offered for severe cases according to the proposed criteria set out in the consultation document.

  • Dupuytren's contracture release: Dupuytren’s contracture causes a fixed flexion deformity of the fingers, and clinical advice is that surgery should be avoided where symptoms do not impair the functioning of someone’s hand. NICE evidence shows even after surgery, the problem returns after 3 to 5 years. A small injection could be more effective and less invasive than surgery.

  • Ganglion excision: ganglia are small, noncancerous lumps on the wrist or hand. They are usually painless. Where there is any uncertainty over the cause of the swelling, diagnostic tests should be performed, before referring, where appropriate, to a specialist. Patients will still be offered the treatment when the condition causes mobility issues or other harm.

  • Trigger finger release: this condition, where a finger or thumb becomes locked when bent, does not cause serious harm in most people. Surgery can take many weeks to recover from and can be associated with pain, infection, stiffness and nerve damage. It is recommended only where alternative measures, like steroid injections, have been unsuccessful. 

  • Varicose vein surgery: effective treatments for the variety of varicose vein conditions will still be offered. Less invasive treatments, such as injection or laser to the varicose vein, can be effective alternatives to surgery. People with varicose vein conditions that meet the criteria set out in the consultation document will be referred to a vascular service, and anyone with a bleeding vein will be referred immediately for treatment.

Consultation Period

NHS England said it would consult publicly on the proposals from July 4th and that interested parties would have until September 28th 2018 to submit comments. Following the consultation period, the NHS England board would be asked to approve the final changes for implementation in 2019-20.

Prof Carrie MacEwen, chair of the Academy of Medical Royal Colleges (AOMRC) said: "In the interests of patient safety, quality of care and the effective use of resources this review has identified a number of interventions which are of limited clinical benefit and therefore of low effective value. These are evidence-based proposals, which have been subject to clinical scrutiny. 

"Whilst it has been for individual medical royal colleges or specialist societies to comment on the specific specialty recommendations, the Academy of Medical Colleges supports the overall programme, which will benefit patients, clinicians and the NHS as a whole by reducing harm and targeting those who will benefit most."

Dr Graham Jackson, co-chair of NHS Clinical Commissioners, commented: "It is important that we have an honest conversation with the public, patients and clinicians about what can be expected from the NHS within the constrained funds it has available."

The BMA described the proposals as "a tough pill to swallow". Its Council Chair, Dr Chaand Nagpaul, said that "while it's correct some surgical procedures are now shown to be clinically ineffective", recent spending pledges by the Government "should allow patients to get the care they expect from the NHS, and allow doctors to provide the care they need, not ration it".
 

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