Evidence Based Interventions programme (EBI) Frequently Asked Questions PUBLICATION OF THE EVIDENCE-BASED INTERVENTIONS POLICY: RESPONSE TO THE PUBLIC CONSULTATION AND NEXT STEPS 1 What is the aim of the EBI programme and who has been involved? The aim of the EBI programme is to reduce harm and reduce unnecessary interventions, by ensuring that interventions routinely available on the NHS are evidence-based and appropriate. We have partnered with NHS Clinical Commissioners, the Academy of Royal Medical Colleges, NHS Improvement and National Institute for Health and Care Excellence to develop the proposals. 2 What is the purpose of the publication? During the Summer and Autumn, we consulted on clinical recommendations for 17 interventions with the intention of producing statutory commissioning guidance outlining when the interventions should be commissioned or offered. We also consulted on system changes to support implementation of the statutory guidance. The Evidence-Based Interventions policy provides an overview of the consultation responses, the changes we have made to our proposals in response and the finalised commissioning guidance for the 17 interventions. 3 How can people access the document? There are a number of ways you can access the document: Via the following link: https://www.england.nhs.uk/evidence-based-interventions/. Request an alternative format via the email address below: england.ebinterventions@nhs.net. THE INTERVENTIONS 4 Which interventions are included in the clinical criteria commissioning guidance? We have produced guidance on the following four interventions that should no longer be routinely commissioned or offered because they do not work or have been superseded by a safer alternative. However, on those rare circumstances where they may be appropriate, they can be offered if accompanied by a successful Individual Funding Request: Snoring Surgery (in the absence of Obstructive Sleep Apnoea) Dilatation and curettage for heavy menstrual bleeding in women Knee arthroscopy for patients with osteoarthritis Injections for nonspecific low back pain without sciatica
We have produced guidance on a further thirteen interventions that should only be commissioned or offered when specific clinical criteria are met (as they have only been shown to be appropriate in certain circumstances): Breast reduction Removal of benign skin lesions Grommets for Glue Ear in Children Tonsillectomy for recurrent tonsillitis Haemorrhoid surgery Hysterectomy for heavy menstrual bleeding Chalazia removal Arthroscopic shoulder decompression for subacromial shoulder pain Carpal tunnel syndrome release Dupuytren s contracture release Ganglion excision Trigger finger release Varicose vein surgery 5 Will all seventeen interventions be completely stopped? No. Our guidance states that the following four procedures should not be routinely offered as they are proven not to work in the vast majority of cases: snoring surgery (in the absence of Obstructive Sleep Apnoea), dilatation and curettage for heavy menstrual bleeding in women, knee arthroscopy for patients with osteoarthritis and injections for nonspecific low back pain without sciatica. In rare cases where a patient and their clinician can demonstrate exceptionality, these procedures can be accessed with an Individual Funding Request. The clinician will need to demonstrate that the patient is different in some way from all other patients with the condition AND they can provide the evidence for why this individual might benefit more from the procedure than other patients. In such exceptional cases an Individual Funding Request would be submitted to their CCG on behalf of the patient. The 13 procedures listed above would only be offered by the NHS in circumstances in line with research and evidence based criteria. Whilst CCGs need to ensure compliance with the guidance, we agree that they should have discretion as to how they do this. However, where there are concerns about achieving the desired clinical change and proposed activity reduction goals we encourage the use of other measures, such as prior approval. In considering the use of prior approval, we propose local areas also consider category 2 interventions be monitored through regular audits and engagement with clinicians and, if needed, be reinforced through financial levers.
6 Who should be responsible for making these decisions? We will not mandate who should be responsible for seeking approval (IFR or prior approval) other than to suggest it should be the treating clinician. Local commissioners and providers need to agree the most suitable approach in their area for each condition. We expect local systems, where appropriate, to enable referrals to a specialist for an opinion. 7 How were these seventeen interventions chosen? We initially compiled a long list of interventions with no or limited clinical effectiveness, based on clinical evidence and research including NICE guidelines, Choosing Wisely recommendations and academic studies. We prioritised those interventions that we could test our approach on and implement relatively quickly on a large scale. We focused on surgical interventions commissioned by CCGs, where there was high variability in the application of clinical guidelines. We worked with the relevant Royal Colleges, specialist societies and clinicians and some patients to refine the list, ensuring there was clinical consensus and buy-in. We also worked closely with CCGs through NHS Clinical Commissioners and patient representative groups like Healthwatch to test the proposals and understand their priorities. 8 How was the clinical criteria guidance refined for the seventeen interventions chosen? We have worked closely with the Royal Colleges and specialist societies throughout the consultation period to refine our clinical criteria taking on board the latest evidence and professional opinion of the relevant specialties. We have also taken on board the views of clinicians, commissioners and patients that have contributed to the consultation. The guidance reflects NICE, NICE accredited guidance and the latest guidance from the relevant specialist societies. 9 What happens if I have been referred for one of the seventeen interventions? Only four of the interventions should not be routinely commissioned, 13 interventions are still appropriate in certain circumstances which patients should be referred for. However, if you have any concerns you want clarifying please follow up with your GP or surgeon who will be able to answer your questions and provide you with any relevant information. 10 What about people who have recently had one of the seventeen interventions? If someone has received one of the seventeen interventions recently, there is no need for concern. But patients should talk to their GP if they are worried.
11 Why are you only focussing on seventeen interventions? By having a relatively narrow focus on a few interventions initially, rather than pursuing all possible opportunities at once we can encourage success. One of the reasons similar initiatives have failed in the past is because they aimed too wide too soon. However, we intend to make this a much wider, on-going programme, subject to making sufficient progress in this phase. We will consult on further interventions in phase two, which will be launched in the new year. We will keep the list under periodic review as the evidence base grows in future years. Phase two will also include specialised services, which are commissioned by NHS England. GENERAL QUESTIONS 12 Is this rationing? No. The aim of the programme is to: i. Reduce avoidable harm to patients. With surgical interventions, there is always a risk of complications. Weighing the risks and benefits of appropriate treatments should be co-produced with patients. ii. Save precious professional time, when the NHS is severely short of staff professionals should offer appropriate and effective treatment to patients. iii. Help clinicians maintain their professional practice and keep up to date with the changing evidence base and best practice. iv. Create headroom for innovation. If we want to accelerate the adoption of new, proven innovations, we need to reduce the number of inappropriate interventions. This allows innovation in prescribing and technology to improve patients ability to self-care and live with long term conditions. v. Maximise value and avoid waste. Inappropriate care is poor value for the taxpayer. Resources should be focused on effective and appropriate NHS services The time and resources saved will all be reinvested in patient care, so that we can ensure we spend the NHS to the very best effect. 13 What savings will be made by reducing these interventions? The main reason for introducing this programme is to prevent avoidable harm to patients by ensuring they receive appropriate care, free up clinical time and capacity as well as to reduce variation across the country. Overall, we are aiming to achieve a reduction in activity of 128,038 spells by April 2020, rather than a financial saving.
14 How would any released capacity be redistributed? We expect CCGs and providers to work collaboratively on implementing these changes and agreeing how any released capacity is deployed for the benefit of patients. 15 What progress do you expect to see? Pace is a core design principle of the programme. We expect more appropriate use of the 17 interventions and have established clear, quantified national and local goals based on analysis of unwarranted variation across the country for CCGs, STPs and providers. Overall, we are aiming to achieve a reduction in activity of 128,038 spells by April 2020. A reduction of 17,650 for the 4 interventions we are proposing should no longer be commissioned, and by 110,388 for the 13 interventions that should only be commissioned if the criteria are met. 16 How will you ensure change is delivered? Previous attempts to reduce the commissioning of inappropriate interventions on the basis of clinical evidence have faltered through lack of sustained national and local drive and the absence of formalised levers to support implementation. This programme has focused on introducing national levers including statutory commissioning guidance that CCGs should have regard for, changes to the national tariff, introduction of local activity targets, dashboard with performance data CCGs can access and aligning the guidance with the Care Quality Commissions inspection methodology to support and encourage the changes required to implement the guidance. NHS England / Improvements regional teams will also follow up progress with CCGs and providers to encourage them to achieve the local activity targets. 17 What if local systems are going further than the proposals set out in this document? Some local systems have already developed and implemented plans to address the issues set out in this document, engaging and consulting local clinicians, providers and their local populations. We do not intend to reverse legitimate local decision-making, however CCGs will need to be able to demonstrate that they have had regard to the new national guidance. 18 What if you have a query about the evidence used to substantiate our guidance? The evidence has been reviewed by our NHS England s National Clinical Directors, NICE, AoMRC, Royal Colleges and specialist societies and is accurate to the best of our current knowledge. However, we understand that research and advancements in medicine continues, therefore any queries will be considered and managed as is appropriate. Any queries should be sent to: england.ebinterventions@nhs.net
19 Is the data you are using robust? We have been open and transparent about the data we have used, including the codes in our public consultation as well as our response document. We have worked closely with clinicians, our demonstrator community and local coding experts to review and refine the data and codes to ensure they are robust. 20 Who have you engaged with? We held a number of engagement events across the country. We worked with the Health and Wellbeing Alliance, Healthwatch England, the NHS Youth Forum and Voluntary Sector and Community Enterprise to engage with patients, carers and the public via a series of webinars events. NHS Clinical Commissioners also ran a series of webinar events to engage with clinical commissioners; the Academy of Medical Royal Colleges hosted an event for clinicians, CCGs and patients (and in partnership with other national partners in the programme); and we worked with The Patients Association to run a focus group with patients. Responses were received from a wide spectrum of individuals and organisations, including: clinicians, voluntary organisations, patient representative groups, national NHS representative groups, local NHS Trusts and Foundation Trusts, CCGs, Royal Colleges and specialist societies, and individual patients and members of the public. 21 Is this ineffective treatment? These interventions are not clinically ineffective in all cases. However, they are inappropriate in certain circumstances which is why we have developed clinical criteria for 13 interventions and have the option of an Individual Funding Request for four interventions. 22 When should the guidance take effect from? To ensure that patients have access to the most appropriate treatments as soon as possible, CCGs will be expected to start to have due regard for the guidance as of the date of publication (28 November). Changes to reimbursement of the 17 interventions will come into effect on 1 April 2019 and will apply to all patients added to waiting lists after the statutory consultation on the National Tariff Payment System for 2019/20 is published (expected to be 17 January 2019). This will give NHS trusts and GPs time to change clinical practice before 17 January 2019 while also ensuring that we act quickly so that patients are not subject to inappropriate interventions.