Agenda item

14.1     The Committee considered a report providing an update on Clinically Effective Commissioning.

14.2     Ashley Scarff, Deputy Chief Officer and Director of Strategy, High Weald Lewes Havens Clinical Commissioning Group (HWLH CCG); and Dr Shivam Natarajan MS FRCS, Clinical Lead from Clarity Consulting, answered questions from the Committee.

Reason for reviewing procedures with limited clinical effectiveness

1.1.        Dr Shivam Natarajan explained that there are approximately 2,500 hip and knee operations in the STP area per year. Out of those, 150 were for revisions of previous operations which means that they were either not done appropriately or properly.

1.2.        An initial knee operation costs £5-10k but a revision costs £110k. The Clinically Effective Commissioning (CEC) programme is looking at the first point in the surgical pathway at which these unnecessary revisions can be prevented, which is to ensure that the policies of all CCGs in the STP area are clear about who the appropriate people are who should receive the surgery and when the appropriate time is in the clinical pathway for them to receive it. This has two benefits: appropriately giving the right person the knee operation will avoid the unnecessary expense of complications, and by having the right people have the surgery additional people who do require the surgery can receive it in a timely manner.

1.3.        Dr Natarajan explained that the appropriate thresholds for patients to receive each type of surgery will be set out in STP-wide policies that are in line with the Royal College guidelines and clinical best practice, for example, the current policies for a hysterectomy differ across each CCG, with some saying patients may have one after six months of conservative management and others after 12 months. However, the clinical evidence says there should be three stages/ types of conservative management that should be tried if possible before major surgery. The policy being developed, therefore, says that patients should go through three stages of conservative management before going to surgery. Changing the eligibility for surgery to fit with clinical best practice is not a purely financial exercise but in the interest of good patient care; and may result in more surgeries for some CCGs, or a greater number of surgical procedures for some illnesses.

1.4.        Dr Natarajan added that Clinically Effective Commissioning will also tie into other clinical work such as Get it Right First Time and the STP’s acute care workstream by highlighting the various avoidable variations in care and eliminating waste. Within the STP only half the surgeons involved with hip and knee replacements are carrying out 30 or more knee or hip operations per year the remaining half are only doing a handful. This variation in quality that this causes should be avoided and is something that could be addressed through this other work, for example, agreeing as part of the acute care workstream to do knee operations in only three major centres of excellence. Ashley Scarff clarified that this process would not result in a limitation in choice but balance choice with quality and better outcomes. Choice is enshrined in the NHS Constitution and the CCGs will uphold that.

Shared Decision Making

1.5.        Dr Natrarajan explained that shared decision making has only recently become a formal process within the NHS – although it has been practiced individually by clinicians beforehand. It involves the clinician explaining to the patient the reasons why they should or should not opt for a surgical procedure, for example, the potential complications and the rate at which these complications occur, and the patient’s current need for surgery compared to other treatments. This provides patients with the ability to take a judgement based on the positive and negatives of having, or postponing, surgery. 

1.6.        The policies will also make it clear when during the clinical pathway the shared decision should be made based on national guidelines. This is because it is not always possible to make a shared decision at the primary care stage as the GP may have insufficient knowledge about the illness. In these cases the shared decision may be taken with a specialist clinician following appropriate assessments and investigations.

1.7.        Dr Natarajan said that patients will be informed about their rights with regards to shared decision making through a revision of the patient information leaflets.

Procedures chosen for further investigation

1.8.        Dr Natarajan said that Clarity Consulting reviewed 150 procedures across the STP area and shortlisted 50 for further investigation across general surgery, eye, musculoskeletal, obstetrics and gynaecology. They were shortlisted as these surgical procedures had a lot of activity that contained the largest variations in the number of surgeries per CCG. Once these 50 procedures have been reviewed it will be rolled out as far as possible across other procedures.  Dr Natarajan confirmed that East Sussex CCGs are an outlier in 10 to 15 of these 50 procedures, either because more surgeries are performed here than the STP average, or they are performed at a higher cost than national guidelines recommend.

 Accelerated Savings

1.9.        Dr Natarajan explained that Accelerated Savings is a piece of work over and above the clinical policy rationalisation work. The Accelerated Savings workstream is looking at other areas of waste within the system, for example, improvement in procurement processes for acquiring knee replacements (prosthesis) where all 8 CCGs procure prostheses from the same few vendors at 8 different prices between £400 and £2,000. This variation in cost does not reflect the variation in clinical outcome, where data shows that the £2,000 prosthesis has  poorer results than the £400 one in some studies. Dr Natarajan said that about 50 areas were looked at during August as part of Accelerated Savings and around 10 were identified as areas where improvements could deliver significant benefits across the STP, including procurement optimisation, medicines management and patient transport system inefficiencies. Ashley Scarff clarified that this is the beginning of the process and no decisions have been made yet.

Involvement of CCGs in Clinically Effective Commissioning

1.10.      Dr Natarajan explained that there has been a high level of clinical engagement during the CEC project and GPs have been involved at several levels including as CCG Chairs; at four workshops involving multi-disciplinary teams, including GPs; and through a GP engagement exercise where members of the CEC project attended local GP meetings or clinical reference groups to communicate to GPs about the CEC project.

1.11.      The Committee RESOLVED to:

1) note the report;

2) request a further update at the March 2018 Committee meeting; and

3) to provide details of the 10 possible areas for improvement to be pursued during 2017/18 as part of the Accelerated Savings process.