Please click here to view the full Hip and Knee Replacement Commissioning Statement.

Commissioning Position

NHS Vale of York CCG does NOT routinely commission referral to secondary care for hip or knee replacement for patients whose BMI is 35 or above.

Exceptions to this threshold:

• Revision hip surgery which is clinically urgent AND where delay could lead to significant deterioration/acute hospital admission. Includes infection, recurrent dislocations, impending peri-prosthetic fracture, gross implant loosening or implant migration.
• Revision knee surgery which is clinically urgent AND where delay could lead to significant deterioration/acute hospital admission. Includes infection, impending peri-prosthetic fracture, gross implant loosening/migration, severe ligamentous instability.
• Primary hip or knee surgery which is clinically urgent because there is rapidly progressive or severe bone loss that would render reconstruction more complex.
• Orthopaedic procedures for chronic infection

Please note: As part of the Prevention and Better Health strategy, patients with a BMI range of 30 to 35 will be covered by the Optimising Outcomes from All Elective Surgery Commissioning Statement  also note that any patient who is a current smoker will also be covered by this statement, regardless of their BMI.

Funding will ONLY be considered where criteria are met (see section 3). The clinician needs to ensure that the patient fulfils all the criteria and provides evidence of any of the clinical indications before they are referred to secondary care.

All other cases need to be referred for consideration by the Individual Funding request panel (IFR). For further information see IFR policies and guidance (including the referral form)

To submit an application to the CCG's Individual Funding Request Panel, please click here for further information.

In line with NICE CG177 Care and Management in Osteoarthritis³, patients should be offered advice on the following core treatments. (All conservative options should have been tried for at least 3 months).

1. Non pharmacological management⁴

• Agree individualised self-management strategies. Ensure that positive behavioural changes, such as paced activity / exercise, weight loss, use of suitable footwear and, are appropriately targeted
• Activity and exercise should be encouraged, irrespective of age, comorbidity, pain severity or disability. Exercise should include local muscle strengthening and general aerobic fitness.
• All patients must have taken part in regular tier 2 exercise, with support as available from any appropriate service eg local authority exercise trainers, NHS services where available or private gyms and personal coaches
• All patients must have undertaken a programme of physiotherapy, including manipulation and stretching as an adjunct to core treatments.
• Interventions to achieve weight loss must be offered if the person is overweight or obese (see NICE CG 43⁵).
• People with osteoarthritis who have biomechanical joint pain or instability should be considered for assessment for bracing/joint supports/insoles. Assistive devices (e.g. walking sticks) should be considered for people who have specific problems with activities of daily living. Referral to occupational therapy or podiatry may be appropriate
• TENS should be considered as option for pain relief
• DO NOT offer glucosamine or chondroitin products, or acupuncture, for the management of osteoarthritis

2. Pharmacological management

Arthritic pain is chronic nociceptive pain and drug management is covered in the RSS pathway guidance for pain relief.

This includes:

• Oral analgesia (eg regular paracetamol, cocodamol)
• Topical NSAIDs
• Oral NSAIDs eg ibuprofen 400mg tds or naproxen 500mg bd, with PPI cover.

At least three different types should be tried. Diclofenac and Cox2 inhibitors are not recommended because of the increased cardiovascular risk

• Intra-articular corticosteroid injections can be considered as an adjunct to core treatments, if appropriate, for the relief of moderate to severe pain in people with osteoarthritis³

3. Before any referral for surgery, patients also have to meet the following criteria:

• Experiencing moderate-to-severe persistent pain not adequately relieved by an extended course of non-surgical management. Pain is at a level at which it interferes with activities of daily living e.g. washing, dressing, lifestyle and sleep

AND

• Troubled by clinically significant functional limitation resulting in diminished quality of life AND
• Patients with a BMI range that is >30 but <35 meet the criteria covered by the Optimising Outcomes from All Electrive Surgery commissioning statement² AND
• The patient has been a non-smoker for at least 8 weeks

AND

• Evidence that regular paced tier 2 activity/exercise has been undertaken, with physiotherapy support if appropriate

AND

• A simple x-ray to confirm diagnosis has been carried out

AND

• Evidence that PROMS data have been explained and discussed
• Evidence that the patient has had their options discussed via a shared decision-making tool⁶

Patient Information

Further information for patients can be found the following link:

Prevention

4. Referring Clinician

Therefore the referring clinician must:

• Ensure patients are signposted to the most appropriate support required for their lifestyle changes
• Ensure that patients are advised to seek review by their GP or other appropriate health care professional should their condition change during the period for lifestyle changes
• Ensure patients who continue to smoke and are not able to reduce their BMI must be allowed to access clinically appropriate elective care after specified periods of time.
• Ensure patients who receive interventions contrary to this policy statement may still be able to access support post procedure to improve their lifestyles to minimise any disadvantage to their health.
• Vulnerable patients / patients with mental illness, learning disabilities or cognitive impairment will need to be clinically assessed to ensure that where they may be able to benefit from opportunities to improve lifestyle that are offered. (Please note that deferring elective interventions may be appropriate for some vulnerable patients based on clinical assessment of their ability to benefit from an opportunity to stop smoking/reduce their BMI/improve pre-operative fitness.) 

5. The MSK service must refer all requests via the RSS and demonstrate that

• Patients with clinically urgent need do not experience avoidable delay
• The recommended hierarchy of management within NICE CG177 Care and Management in Osteoarthritis has been followed: non-pharmacological treatments first, then drugs, for at least 3 months
• Adherence to the Optimising Outcomes from All Electice Surgery commissiong statement² for those patients withing a BMI range that is >30 but <35 
• Confirmation that patients have been made aware of the options available as an alternative to surgery and the risks associated with surgery, and have considered the PROMs data and used shared decision-making tools⁶ during the patient care pathway
• Patients’ fitness for surgery has been properly assessed and this is evidenced AND
• Ensure that patients with significant co-morbidities [systemic or local] have appropriate investigations and treatment to optimise their condition before referral

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