Performance of Restricted Procedures by Health Trusts HTML

Performance of Restricted Procedures by Health Trusts

Introduction

1. The Health and Social Care system aims to provide comprehensive care, which is free at the point of use, to the whole population of Northern Ireland (NI). However, there are pressures at every level of this system. These include the rising costs of delivering care, challenging budgets and insufficient workforce in many areas resulting in significant delays to patients accessing care. It is, therefore, essential that the health service’s resources are managed effectively and used appropriately.

2. In 2006, NI’s Department of Health (DoH) produced the Effective Use of Resources (EUR) policy which aimed to “make the best use of resources in plastic surgery and related specialties”. This policy set out the limited criteria under which a small number of procedures would be commissioned. However, the EUR policy was updated in October 2022 to “guide the allocation of limited resources to those areas of greatest clinical benefit and support clinical staff to better manage patient expectations”. It aims to ensure that interventions are provided with the greatest proven health gain within the context of the needs of the overall population. This followed health officials in England and Wales identifying a higher number of procedures which they considered to be of ‘low clinical value’, and then developing policies for limiting the commissioning of these procedures.

3. Following the October 2022 update, NI’s EUR policy now outlines six procedures which should no longer be performed by the public healthcare system in NI. The policy also details 23 procedures which should only be performed in ‘special’ circumstances. For these procedures to be carried out, patients must meet specific medical criteria. In total, therefore, the policy now contains information regarding the restricted commissioning criteria for 29 different procedures (see Appendix 1). The Department’s Strategic Planning and Performance Group (SPPG) is responsible for monitoring adherence to the EUR policy. Consultants and GPs are responsible for acting in line with the policy. The October 2022 update of the policy also relied on input from other DoH officials and the Public Health Agency (PHA).

There are a number of procedures that should not be performed and a number that should only be performed in limited circumstances

4. All the 29 procedures contained in the EUR policy are restricted in some way. Six of these are not permitted at all. For the others, GPs should not make referrals for restricted procedures which do not meet the standards outlined in the policy. Likewise, consultants should not carry out the restricted procedures unless specific medical criteria detailed in the policy are met.

5. There are limited cases whereby restricted procedures can be performed even when they do not fit the criteria outlined in the EUR policy. However, for this to be the case, ‘exceptionality’ must be demonstrated by the consultant or GP making the case on their patient’s behalf before then being approved by an appeals panel. Any panel should be led by SPPG, with input from regional Health Trusts and the PHA. The EUR policy outlines how a finding of exceptionality is made by the appeals panel. Firstly, a patient’s case must be proven to be “significantly different to the general population of patients with the condition in question”. Secondly, the individual must be shown to be “likely to gain significantly more benefit from the intervention than might normally be expected for patients with that condition”.

Methodology

6. As part of this short investigative report, we reviewed the procedures in place to monitor compliance with the EUR policy. The review assessed the extent to which oversight frameworks have effectively provided assurance that Trusts are complying with the EUR policy. In addition, we assessed the allocation of resources towards procedures restricted by the policy. As part of this, we reviewed relevant documentation and datasets produced by the regional Health Trusts in Northern Ireland. We also engaged with SPPG and Trusts around their oversight of the EUR policy.

7. We obtained average costing information for the performance of each of the restricted procedures in the EUR policy from SPPG (see Appendix 2). Using this information, our review has produced analysis on the estimated cost of procedures which have been carried out by Trusts in 2023-24. We have made no conclusions about the medical appropriateness or otherwise of the performance of procedures restricted by the EUR policy. However, we have highlighted the extent to which assurance can be provided that these procedures were carried out in line with the EUR policy.

There is very limited oversight of the policy to ensure that it is being complied with

8. Following the revision of the EUR policy in October 2022, correspondence was circulated by DoH to regional Health Trust Chief Executives in May 2023. This letter outlined how the EUR policy had been reviewed and updated to take account of emerging clinical evidence from the National Institute for Health and Care Excellence (NICE) and similar organisations, across a broad range of procedures. It was left for Trusts to take forward the implementation of the updated EUR policy. SPPG expected that proportionate implementation arrangements would be established.

9. The letter continued by stating that Trusts should be responsible for ensuring compliance with the commissioning position in secondary care. It also highlighted that Trusts will be accountable for any deviation from the commissioning position and will therefore need to have arrangements for monitoring referrals and activity pertaining to the procedures detailed in the commissioning position. In addition, the letter said this will include routinely collecting data on the number and type of procedure (by unit and surgeon) and the indication for the procedure.

10. This correspondence clearly sets out responsibilities for Trusts to ensure medical staff adhere to the terms of the EUR policy. However, our review has found Trusts have not put in place arrangements to verify that medical staff are complying with the policy. Despite SPPG stating in the May 2023 correspondence that it would seek annual assurance from Trusts that the EUR policy is being fully applied by March 2024, our review has found that no such assurance was sought by SPPG – nor has it been provided by Trusts.

11. The EUR policy states that the policy should be subject to biannual review to ensure it reflects any new or emerging clinical evidence. However, it has not yet been updated since October 2022. SPPG has told us its latest update of the EUR policy took account of practice throughout Britain and the National Institute for Health and Care Excellence (NICE) guidelines.

Performance of restricted procedures has continued with over £20 million associated costs in a single year

12. Our review found almost 12,000 cases of procedures, restricted by the EUR policy, were carried out by Trusts in NI in the 2023-24 financial year. This equates to an average of over 40 such procedures per day. Our review also found that the estimated costs associated with these procedures are almost £21.8 million. Trusts were unable to provide details of restricted procedures in all cases. This, alongside inadequate approaches in relation to data recording across Trusts, has meant relevant costing information in some instances is also limited. Therefore, true costs of the performance of procedures restricted by the EUR policy are likely to be even higher.

13. Analysis of the information received from the Belfast Trust shows there were almost 3,200 procedures, restricted by the EUR policy, carried out in the Trust in 2023-24, at an estimated cost of nearly £4.2 million. Meanwhile, more than 1,500 of these restricted procedures were carried out in the Western Trust – with associated estimated costs of more than £2.5 million. In the Southern Trust, more than 2,400 were performed. Estimated costs in the Southern Trust were almost £5.1 million. In the Northern Trust, almost 1,700 procedures restricted by the EUR policy were carried out at an estimated cost of nearly £3.8 million. In addition, in the South Eastern Trust over 3,000 of these were performed and were estimated to have cost almost £6.2 million in 2023-24.

Figure 1: Almost 12,000 procedures restricted by the EUR policy were performed by Trusts in 2023-24

14. However, the true cost of the performance of restricted procedures in the Belfast Trust are likely higher than the almost £4.2 million found by our review. More than 40 per cent of the almost 3,200 procedures restricted by the EUR policy which were performed in 2023-24 are not included in the almost £4.2 million estimated cost as SPPG could not provide costing information for outpatient cases. These cases mostly relate to 1,263 skin lesion excisions which were outpatient cases. These costs are likely to be significant. However, they also include two liposuctions and 39 hip arthroscopies.

15. Other cases for which costings are unavailable were recorded in other Trusts, but these are relatively minimal in number. Had these been included, the estimated costs our review has found to be associated with the performance of procedures restricted by the EUR policy would again be slightly higher.

16. Trusts have emphasised that the data assessed in our review could include procedures which are permitted under the EUR policy. However, limitations in the data recording and monitoring means no assurance can be provided over the proportion of cases which fall into this category. As a result, it would not be feasible for NIAO to establish the proportion of the procedures restricted by the EUR policy which were appropriate or inappropriate. Our review also found 20 cases of procedures being performed which the EUR policy dictates should only be carried out if there has been an appeals panel led by SPPG. These relate to repair of split ear lobes, labioplasty and correction of nipple inversions. However, SPPG could provide no instances of this appeals panel approving any restricted procedures in 2023-24.

17. SPPG told us clinicians must make judgments on compliance with the policy, including in cases of injury or trauma, and there is not always time to seek exceptionality. SPPG also advised it is possible that restricted procedure cases include patients who were already on the treatment list before the 2022 EUR policy was updated and therefore new criteria could not be applied to them.

Close to £6 million is estimated to have been spent on tonsillectomies

18. Our review found that in 2023-24, the Belfast Trust recorded that almost £1.5 million was spent on 472 tonsillectomies, close to £1.1 million was spent on 547 benign skin lesions, over £660,000 on 535 carpal tunnel decompressions and more than £100,000 on 94 epidural/facet injections. Similarly, the Western Trust was estimated to have spent nearly £780,000 on 249 tonsillectomies, over £730,000 on 370 benign skin lesion excisions, more than £217,000 on 176 carpal tunnel decompressions and over £560,000 on 525 epidural/facet injections.

19. The Southern Trust is estimated to have spent over £3.7 million on 1,865 benign skin lesions and almost £1.1 million on 343 tonsillectomies. In the Northern Trust, over £1.9 million is estimated to have been spent on 969 benign skin lesions, almost £1.4 million on 436 tonsillectomies and almost £168,000 on 157 epidural/facet injections. Furthermore, our review found more than £920,000 estimated expenditure on 294 tonsillectomies in the South Eastern Trust and over £278,000 on 261 epidural/facet injections. The South Eastern Trust also recorded an estimated more than £4.3 million expenditure on 2,179 benign skin lesions. Trusts told us that due to limitations in data collection methods, this figure is likely to also include malignant skin lesions too which, if excluded, would reduce the estimated costs.

Figure 2: Summary of Key Facts

Over £20 million: The amount estimated to have been spent on restricted procedures in a single year

Almost £6 million: The amount estimated to have been spent on tonsillectomies in 2023-24

Close to 12,000: The number of procedures, restricted by the EUR policy, performed in 2023-24

Over 40 per day: The average rate restricted procedures were carried out

Each regional health Trust is estimated to have spent £millions on restricted procedures in 2023-24

There is a need for greater oversight of the EUR policy

Trusts have not been monitoring compliance with the EUR policy

20. Trusts are accountable for their healthcare professionals who do not comply with the EUR policy. The policy states that Trusts “need to ensure arrangements are in place to monitor referrals and activity” relating to restricted procedures. In correspondence to Trusts, SPPG emphasised the importance of Trusts taking forward the implementation of the updated EUR policy. In May 2023 correspondence to Trust Chief Executives, SPPG said: “It is the SPPG’s expectation that proportionate implementation arrangements will be established.”

21. However, this review has found monitoring arrangements which should ensure compliance with the EUR policy by medical staff across all regional Trusts in NI are not adequate. The Belfast, South Eastern and Western Trusts confirmed they have no specific arrangements in place to monitor referrals received or decisions taken relating to procedures in the EUR policy, beyond the normal processes for advising clinicians regarding the requirement for adherence to the policy. The Southern Trust failed to provide any information in this regard. Meanwhile, the Northern Trust outlined that it had sought assurance from Directors, who had responsibility over procedures relevant to EUR, that the Trust was complying with the policy. However, this still falls short of the arrangements outlined within the policy to monitor referrals received or decisions taken relating to EUR procedures.

22. Given this, our review has found no evidence that Trusts can provide assurance that their clinicians have been complying with the terms of the EUR policy when carrying out restricted procedures.

23. In recent years, the DoH has undertaken significant work to implement the Encompass programme. The Encompass programme is key to supporting digital transformation and modernisation in the health service. Aimed at improving system-wide IT, Encompass involves developing a single, real time and up-to date digital care record for every patient in Northern Ireland. It is the largest digital health initiative ever undertaken in this jurisdiction. We note the substantial investment in time and resources the DoH and Trusts have allocated to the roll-out of this project. The Department has told us this has prevented Trusts from putting in place monitoring arrangements for the EUR policy.

SPPG’s oversight of the EUR policy has not been sufficient

24. The EUR policy states that SPPG should have established a monitoring framework to ensure Trust compliance with the conditions of the policy. However, SPPG has had no such framework in place during the one-year period analysed in this report. SPPG has placed a heavy reliance on consultants and GPs adhering to the EUR policy. Given restricted procedures have been carried out on a considerable scale, with notable associated costs and inadequate Trust monitoring, SPPG’s approach has been insufficient.

25. SPPG confirmed that when Trusts identify deviation from the EUR policy by their healthcare professionals, it’s incumbent upon them to inform SPPG of this noncompliance with the policy. However, SPPG could highlight no occasion when this occurred during the one-year period assessed. This puts an even greater onus on SPPG to take proactive steps to provide proper oversight of the extent of Trusts’ compliance with the EUR policy. This is so assurance can be provided regarding medical staff’s adherence to the policy. However, such steps have not been taken by SPPG to date. When issued, the stated purpose of the EUR policy was to promote the effective use of resources across the health care system. Despite this, SPPG has also been unable to identify if any improved use of financial resources have been made as a result of the October 2022 EUR policy.

Value for Money conclusion

26. This review has found a lack of evidence to demonstrate compliance with the EUR policy by Trusts in NI. There is currently a lack of oversight by Trusts and SPPG alongside inadequate arrangements to ensure compliance with the policy. Without this, there is no assurance that the almost £21.8 million spent by Trusts on restricted procedures in 2023-24 was spent in accordance with the EUR policy. Given these circumstances, this review has found there to be substantial concerns that a lack of recorded evidence regarding adherence to the EUR policy could mean the health service’s resources are not being allocated appropriately or effectively by Northern Ireland’s five regional Trusts. To date, the 2022 update of the EUR policy has not resulted in good value for money being achieved. This must be addressed as a matter of priority.

Recommendation 1

Within the next 12 months, Northern Ireland’s five regional Trusts must introduce appropriate, proportionate arrangements to monitor activity and referrals relating to restricted procedures outlined in the Effective Use of Resources policy. These arrangements must be robust enough to ensure relevant staff have awareness of and are complying with the policy. Efforts should be made to incorporate this into the Encompass programme if feasible.

Recommendation 2

Within the next 12 months, the Department of Health’s Strategic Planning and Performance Group must introduce a proportionate monitoring framework to ensure each regional Trust is complying with the Effective Use of Resources policy. This framework must be robust enough to identify whether Trusts are complying with the policy.

Recommendation 3

The Department of Health should conduct a formal review of the Effective Use of Resources policy every 24 months. This should include an assessment of the commissioning criteria in the policy, taking account of approaches applied elsewhere in the UK and internationally to identify if the current contents of the policy continue to be appropriate and follow best standards. This formal review of the EUR policy should also include an assessment of the extent to which the policy has been adhered to and resulted in the health service’s resources being allocated appropriately and effectively by Northern Ireland’s five regional Trusts.

Appendix 1: List of procedures in the EUR policy

Appendix 2: EUR policy costing information (supplied by SPPG)

Source: SPPG