ADHERENCE TO EVIDENCE BASED MEDICINE -
To receive a report from Vince McCabe, Director of Commissioning Enfield Clinical Commissioning Group (CCG) on the results of the consultation
Dr Jahan Mahmoodi (Medical Director, Enfield CCG) introduced this report which set out proposals to implement AEBM for some procedures/ treatments in Enfield.
He highlighted the following:
- Enfield CCG is a statutory body responsible for deciding which health services should be purchased for the people of Enfield and for ensuring that there is value for money
- There is evidence that some procedures offered by the NHS have limited or no benefits for patients. It was therefore decided, especially in light of the financial deficit, to look at a number of procedures to determine whether there was evidence that procedures were offering clinical benefit.
- Initially 149 procedures were looked at under the programme. The programme was led by local GP’s together with a wider group of clinicians. Any clinical decision was to be evidence based. Eventually there were 13 procedures which were identified for review.
- These procedures were put forward for a pre- consultation phase with various groups including the Health and Wellbeing Board, the Health Scrutiny Panel, and Enfield Healthwatch. The CCG aimed to involve as many members of the public as possible as well as representative bodies, professional bodies, providers and clinicians in the consultation which commenced on 1 March 2017 and ended on 30 June 2017.
- Members of the public and clinicians were able to access and review the evidence that the CCG’ had used and submit comments.
- An independent consultation report was produced looking at the findings from the consultation.
- Following this it was decided that 11 procedures should go forward for change. Of the comments received, 76% were about hearing aids also a large number about weight management outcomes re knee ops. It was decided to take both these procedures out of the proposed list.
- All clinical committees have looked at the evidence that the change in the 11 procedures would improve outcomes, they decided that this would also be value for money. The decisions/conclusions have been made by clinicians – not ‘number crunchers’.
- There would be a total decommissioning of homeopathy. Treatments would be provided only where there would be better outcomes. However if a person is in pain along the process they would always be able to go to referral.
- The Equality Impact Assessment had been carried out and ratified.
- The CCG is implementing the changes as soon as possible. Referrals are being returned back to doctors with additional information for them to inform discussions with patients.
The following questions/ issues were raised
Q: Councillor Abdullahi asked if it was the case that a large number of responses received were from people outside the borough?
A: DrMahmoodi answered that the vast majority of people who had responded were concerned about hearing aids, many were under the misapprehension that they would no longer be able to obtain hearing aids although this was not the case.
Q: Councillor Pearce said that as the other 4 boroughs of the North Central London region would be implementing changes by the end of 2018 would it not be better for us all to change at the same time, to ensure consistency throughout the area?
A: The process has been clinically led and is evidence based and the other boroughs would be proceeding with this.
A concern was raised that 90% of the time spent during the consultation discussions related to hearing aids. By the time it was decided to remove hearing aids from the list of procedures for change there was no further discussion about the other procedures. There may be worries about the other procedures selected for review that have not been voiced.
It was answered that the CCG had responded to public opinion about hearing aids. The decisions made were – clinically led, evidence based and were to optimise outcomes.
Q: Councillor Abdullahi questioned what would happen if the consultation carried out by the other North Central London region boroughs brought to light different findings from Enfield?
A: It is unlikely that this would happen because the decisions made would be – clinically led, evidence based and were to optimise outcomes as for Enfield.
Q: Councillor Pite referred to the removal of the procedure relating to hearing aids from the list of procedures for change - which appears to be due to public demand rather than ‘evidence led’ criteria? What happens if there is a huge outcry about the change in procedure for gallstones in the future – would it not be better to wait 6 – 8 months until after the other boroughs consultation?
A: Further evidence had been received relating to hearing loss procedures which concurred with public demands. It was the evidence that had changed and therefore it was correct that the hearing aid procedure be removed from the list of measures for change.
Councillor Pite spoke of her concerns that the public outcry regarding hearing aids may have been linked to the third sector -due to commercial reasons. She said she was concerned about what would happen if there was another public outcry regarding a procedure. She thought there may be issues in the future as a result of joint commissioning, where there is a potential for mismatch. She thought it would be safer to wait until the other North Central London region boroughs were on board.
Dr Mahmoodi said it had been important for the CCG to clarify process undertaken. They had discharged their legal requirements and shown how they had come to their decisions. Hospital Trusts change their procedures without consulting the public, the CCG have instead, shown how they have applied latest evidence to support the changes made.
Financial savings in proceeding with changes now rather than waiting until July/Aug 2018 is expected to be approximately £300K.
Councillor Abdullahi spoke of the knee replacement procedure and asked about the change in criteria.
It was explained that in order to undertake knee operations it is essential for surgery/ rehabilitation that people are able to lose weight, however we do not yet have the weight management service in place. It will take approximately a year before this happens and therefore a further review of knee replacement thresholds will take place at a later date.
It was asked if the changes would mean that it was possible to have a procedure in one borough but not in another.
An answer was given that it is inevitable that thresholds may be in one place before another, the aim is to standardise the service to improve outcomes.
Councillor Pearce asked for clarification about the changes to hospital procedures that she understands is happening.
It was answered that the Royal Free were currently reviewing 140 of their pathways, ensuring evidence based clinical excellence. They will not have to consult.
Q: Does this mean that at the Royal Free there will be different thresholds applied depending on the area you are coming from?
A: It will be aligned to the primary care service for example someone having a vasectomy would have this under local anaesthetic as here this is considered to be safest process.
It was explained that some people may have had a procedure undertaken in the past for example a gallstone removed which had not been painful at the time but following the procedure, this had resulted in the area becoming painful for the person involved. The aim would now be for doctors to discuss with their patients the benefits and risks involved and for them to decide whether the benefit outweighs the risk involved.
A member of the public referred to the consultation and said she spoke of concerns regarding hearing aid and also about bunions. She thought the responses received, regarding hearing aids, was more pronounced because it was thought this was more life changing. However further consultations would probably result in more comments regarding bunions.
It was answered that the decisions were made not as a result of the number comments received but about the evidence base.
A member to the public referred to knee surgery, he said
“NICE (National Institute for Health & Care Excellence) give a period of 3 months before referral, however, the CCG have set down a period of 6 months. The CCG advocates a ‘pain questionnaire’ whereas there is evidence that a pain questionnaire could disadvantage age, sex, people with obesity. You appear to advocate longer times for knee surgery however there is evidence (a New Zealand paper) that the longer people wait for surgery then the cost is eventually higher than for those who wait a shorter period. Your guidelines for referral are contradictory to those set down by NICE and detrimental to Enfield’s residents”.
Another member of the public spoke of problems where pain makes exercise very difficult although this may be necessary for losing weight before surgery undertaken.
Dr Mahmoodi said they would look at criteria for knee procedures but were not looking at including this procedure for now.
Valerie Dinsmore of Healthwatch said she thought the consultation could have been better and she was concerned that procedures would be different with other boroughs. She stressed that any negative impacts should be reported back because she is concerned that something may have been missed so need to ensure review of procedures and quality impacts.
Members noted the proposals to implement Adherence to Evidence Based Medicine for some procedures/ treatments in Enfield.
Cllr Abdullahi said the Panel would confirm their view in writing that any alteration to treatment thresholds should be implemented simultaneously across the North London Sector, not in isolation within Enfield.
Dr Mo Abedi, Mark Eaton, and Dr Jahan Mahmoodi were thanked for their report and left the meeting at this point.