Variations in policies for accessing elective musculoskeletal procedures in the English National Health Service: A documentary analysis

Abstract

Objective The overall aim of this study was to investigate how commissioning policies for accessing clinical procedures compare in the context of the English National Health Service. Our primary objective was to compare policy wording and categorise any variations identified. Our secondary objective was to explore how any points of variation relate to national guidance. Methods This study entailed documentary analysis of commissioning policies that stipulated criteria for accessing eight elective musculoskeletal procedures. For each procedure, we retrieved policies held by regions with higher and lower rates of clinical activity relative to the national average. Policies were subjected to content and thematic analysis, using constant comparison techniques . Matrices and descriptive reports were used to compare themes across policies for each procedure and derive categories of variation that arose across two or more procedures. National guidance relating to each procedure were identified and scrutinised, to explore whether these provided context for explaining the policy variations. Results Thirty-five policy documents held by 14 geographic regions were included in the analysis. Policies either focused on a single procedure/treatment or covered several procedures/treatments in an all-encompassing document. All policies stipulated criteria that needed to be fulfilled prior to accessing treatment, but there were inconsistences in the evidence cited. Policies varied in recurring ways, with respect to specification of non-surgical treatments and management, requirements around time spent using non-surgical approaches, diagnostic requirements, requirements around symptom severity and disease progression, and use of language, in the form of terms and phrases (‘threshold modifiers’) which could open up or restrict access to care. National guidance was identified for seven of the procedures, but this guidance did not specify criteria for accessing the procedures in question, making direct comparisons with regional policies difficult. Conclusions This, to our knowledge, is the first study to identify recurring ways in which policies for accessing treatment can vary within a single-payer system with universal coverage. The findings raise questions around whether formulation of commissioning policies should receive more central support to promote greater consistency – especially where evidence is uncertain, variable or lacking.

Access to hip and knee arthroplasty in England: commissioners’ policies for body mass index and smoking status and implications for integrated care systems

“…Variation in musculoskeletal commissioning policies [20] and arthroplasty access criteria [15,21] have been previously documented in England, and BMI thresholds for arthroplasty are also in use internationally [22,23]. The proportion of hip and knee arthroplasty patients with obesity or who smoke is 49%, and 11% respectively in the UK [24,25], meaning policies with BMI criteria have implications for the majority of patients.…”

Did the evidence-based intervention (EBI) programme reduce inappropriate procedures, lessen unwarranted variation or lead to spill-over effects in the National Health Service?

“…However, attempts to reduce established healthcare interventions often fail [8][9][10]. In the English National Health Service (NHS), local health budget holders (known, until 1 st July 2022, as clinical commissioning groups) developed evidence-based, but often divergent, policies regulating access to surgical interventions for their populations [11]. This is likely to be one factor resulting in variation in geographical access to surgery in England [12].…”