Procedures of limited clinical value

 

a repost and slight update of an old blog

It’s back

This particular policy zombi was one of the issues I first cut my public health teeth on as a shiny new SpR (thanks Sohail!) I quickly saw it was pretty futile then as a method of financial savings. I’ve played the game a good few times since, my view is unchanged.

4 key questions that I often ask

1. Inequality – I cant see enforcement of further rescrictions would improve equity, it would likely make it worse. Has the inequality impact assessment been robustly done. This is more than a EqIA (protected groups)

2. Clinical sign off – it IS a CLINICAL commissioning group. There’s nothing inherently wrong with NICE / SIGN etc, but remember its clincial guidance, designed to guide a clinical decision (terms used advisedly). Engagement with GPs and secondary care clinicians – in the spirit of CLINICAL commissioning – is there full clinical sign off. There may be an appreciable harm from restricting surgery. Has this been assessed

3. in the spirit of accountable care and the like it doesn’t seem very collegiate to be commissioner imposed – not in the spirit of ACS ACP etc

4. workable and worth effort – four sub questions

• Where do we stand data and benchmarking wise? Worth the effort given the likely collateral damage

• Workable in real world. Will it be gamed? Is there the capacity or capability to audit against policies

• Collateral damage in terms of loss of clinician engagement

• Might be worth reflecting that as this is a policy idea that comes around every few years – WHY does it keep coming round. Each time I hear, ahhh but it will be successful this time round

Don’t get me wrong, Commissioning policies are good. Consistency of policy from place to place is better. The policy should be clinically sound, agreed with clinicians and method of execution proportionate to the issue and not place new administrative burdens on busy clinicians

What does the evidence say. A few thoughts.

Individual policies

Goes without saying that any evidence on which the individual policies are based should be based on NICE / SIGN or equivalent. If not, will need a good reason.

Accept points made by many on deviating from NICE and commissioner perspective. I’ve made similar points in past myself. Cost effective, affordable etc.

Broader evidence base around implementation

I’ve played this game many times now, Im sure we all have!

My last effort to summarise my thoughts on the procedures of limited clinical value train, and inc some of the evidence base was here.

I haven’t yet summoned the will to live to update it, and likely never will

See the Schwartz (2.7% of all spend = PCLV) and Black ref (cant be justified on VFM grounds) esp.  Obviously UK context is different, but enough to give pause for thought…. This is a policy

I don’t know if RCS kept their procedures data up to date. Looks like up to date up to 15/16, but on quick skim I cant seem to get at it. Cue everyone grumbling cos its not up to date….. I cant see that the story in this finiancial year is any different to previous.

At one point in the dim and distant past I had a chat with a PCT medical director on this. It was a place that had gone down this line, against the recommendation of both DPH and MD.

I asked if it had saved £ –  answer, well my recollection of it, was no, unequivocally no it hadn’t. MD and DPH had argued strongly against implementing the policy at PCT board, PCT chose to adopt the policy and implement it. MD & DPH were good corporate citizens and supported implementation. there was an initial reduction in activity but then crept back up again for a number of reasons, by which time the PCT also had to pay for heavy duty tier of implementation (referral management and vetting etc) so was significant net cost. In the end DG view was backfired as pissed of pretty much every GP in the PCT area and most of the surgical workforce. This caused untold collateral damage to relationships.

The end result of such approaches is most likely that clinicians in primary and secondary care are just all fed up with the bureaucracy, nobody is entirely sure how the process works- very poor information provided prior to launch- and activity seems to be fairly static. Most of the threshold checklists are just tick box lists, there isn’t the capacity to audit policies properly ie by cross referencing against the clinical notes.

The other end result is a lot of distressed patients who don’t understand why their particular problem or diagnosis is considered to be of low clinical value and a large increase in referrals to IFR, very few of who are exceptional to the clinical threshold policy.

It’s likely there’ll be a lot of MP letters to respond to.

See this brilliant editorial by Wilson

My last effort on summarising evidence around referral management was here. Hopefully eval of local schemes this time round will prove me wrong.

It is worth a look at the evaluation on the USA Choosing Wisely campaign. Again context is completely different, but some parallels. The Rosenberg study is the best I’ve seen eval wise. Brilliantly summarised in this blog

Most recently (April 22) The NHSE evidence based medicine programme was a national policy led effort to implement this policy idea. The write up in BMJQS was excellent. Credit to the evaluators and to NHSE for publishing it, but TDLR limited to no impact

Key points

Results We found only small differences between the treatment and control group after implementation, with reductions in volumes in the treatment group 0.10% (95% CI 0.09% to 0.11%) smaller than in the control group (equivalent to 16 low value procedures per month). During the month of implementation, reductions in volumes in the treatment group were 0.05% (95% CI 0.03% to 0.06%) smaller than in the control group (equivalent to 7 low value procedures). Using triple difference estimators, we found that reductions in volumes were 0.35% (95% CI 0.26% to 0.44%) larger in NHS hospitals than independent sector providers (equivalent to 47 low value procedures per month). We found no significant differences between clinical commissioning groups that did or did not volunteer to be part of a demonstrator community to trial EBI guidance, but found reductions in volume were 0.06% (95% CI 0.04% to 0.08%) larger in clinical commissioning groups that posted a deficit in the financial year 2018/19 before implementation (equivalent to 4 low value procedures per month).

Conclusions Our analysis shows that the EBI programme did not accelerate disinvestment for procedures under its remit during our period of analysis. However, we find that financial and organisational factors may have had some influence on the degree of responsiveness to the EBI programme

By comparing trends against a control group, we provide early evidence that the evidence-based interventions programme has not accelerated disinvestment for low value procedures in the first 11 months after implementation.

Despite the lack of effectiveness to date, the evidence-based interventions programme has developed a structured and transparent approach to identify candidates for disinvestment.

Moving forward, the evidence-based interventions programme needs to consider how to balance both bottom-up and top-down implementation to achieve sustainable and consistent reductions in low value care

I am not in any way disputing the financial challenge faced by NHS commissioners, but the savings from aggressively tacking this one I fear are illusory at best, maybe worse than this once you’ve taken into account implementation costs and factored in collateral damage. There’s simply no evidence that these sorts of proposals save any money

I don’t think I can summon the will to live to stick any more blades into this zombie.

 

How to implement (2016) https://gregfellpublichealth.wordpress.com/2016/02/20/how-to-implement-procedures-of-limited-clinical-value/

Stop before your op https://gregfellpublichealth.wordpress.com/2016/10/09/you-cant-have-yer-op-till-youve-stopped-smoking/