Comparison of local policies and national guidance on who can access operations reveals lack of consistency

Local policies and national guidance about who can be given operations vary in terms of the evidence they cite and the criteria for access, according to a new study published in the Journal of Health Services Research & Policy.

NIHR Applied Research Collaboration West (ARC West) and University of Bristol researchers compared policies for eight common operations for which rates and money spent varied across Clinical Commissioning Groups (CCGs). CCGs commission healthcare for local areas across England. The operations were:

• hip arthroscopy (keyhole surgery to view the hip joint)
• hip replacement
• knee arthroscopy (keyhole surgery to view the knee joint)
• knee replacement
• rotator cuff repair (muscles and tendons in the shoulder)
• subacromial decompression (removing a bony spur in the shoulder)
• surgery for Dupuytren’s contracture (a hand condition, where one or more fingers bend towards the palm)
• surgery for trigger finger (a hand condition, characterised by difficulty bending fingers or the thumb)

The researchers analysed 35 policies from 14 regions and 22 documents from the National Institute for Health and Care Excellence (NICE) which included national guidance.

They compared the wording of policies and categorised the variations they identified. They also explored how these policy variations relate to national guidance.

All policies included criteria that needed to be met before patients could access treatment. But there were inconsistences in the evidence they cited.

The study found patterns of variation in:

• Which non-surgical approaches needed to be tried before moving to surgery
• How much time patients needed to spend trying non-surgical approaches
• How strict the criteria for diagnosis were. For example, if the patient needed an x-ray or MRI scan
• How severe the condition needed to be before moving to surgery. For example, how painful it was or how much movement was impaired
• How terms and phrases used in the policy documents could open up or restrict access to care. For example, adding the term ‘where clinically appropriate’ left the clinician to decide (which may be appropriate), but not all policies included this

National guidance tended to describe possible treatments without specifying detailed criteria for accessing the procedures. This made it difficult to compare with regional policies. Subacromial decompression was the one exception, where more detailed access requirements were described in national commissioning guidance, whilst still suggesting these ‘can be modified according to the needs of the local health economy’. Local policies for this procedure still varied, compared to this national guidance.

Dr Leila Rooshenas, Senior Lecturer at the University of Bristol and lead author of the study, said:

“We were already aware that policies for accessing treatment can vary, even within a single national healthcare system like the NHS. We felt it would be useful to draw out some common, recurring ways in which policies for different procedures can differ. Comparing policies across different regions and specialties was certainly a challenge and took time – we had to be inventive with our methods, but we hope the categories of variation we’ve identified will serve a practical purpose for policy developers.

“Our findings raise questions around who is best placed to draw up and review these types of policies. There are certainly pros and cons around commissioners or national organisations developing these. We’re currently exploring some of these issues in our NIHR-funded study, which seeks to evaluate a national initiative to implement centrally-developed policies for accessing elective treatments, similar to those we looked at in this study.”