Low clinical value treatments: the future?

With the NHS needing to achieve £20 bn of efficiency savings by 2015, against a background of increasing demand for services and during a time of significant reorganisation, it is important that both NHS Trusts and PCTs plan and implement service modernisation to deliver efficient, high-quality services as funding growth slows down. A recent Health Briefing undertaken by the Audit Commission takes an in-depth look at how Primary Care Trusts (PCTs) are currently spending on low clinical value surgical treatments and how some are working to reduce costs in this area. Analysis undertaken as part of the report Reducing spending on low clinical value treatments: Health Briefing, April 2011 has shown that some PCTs have reduced expenditure on low clinical value treatments and it is estimated that a reduction in PCT spending of between £179 m and £441 m is achievable. From the PCTs visited while compiling the report it would appear that for every person in a PCT’s population an annual reduction in spending of £10 is possible. Nationally, this would suggest an annual reduction in spending of about £500 m, although hospitals would not make the same saving, the report does say that this reduction would free up capacity and money to undertake treatments of higher clinical value. The QIPP initiative works at a national, regional and local level to support clinical teams and NHS organisations to improve the quality of care they deliver. Part of this initiative is the “Right Care workstream”. Commenting on this, Sir Muir Grey, the QIPP Right Care lead, said: “Providers and clinical networks need to learn how to find value from within their existing budgets by stopping low clinical value interventions or procedures that are still routinely undertaken in the NHS, demonstrating both the clinical rationale and also showing the cost; promoting the universal application of high-value activities and releasing the resource.”1 As part of the QIPP programme, most PCTs and their strategic health authorities (SHAs) are looking at reducing their spending on “low clinical value treatments”, which refers to treatments considered to be clinically ineffective or not cost-effective. Other terms used by PCTs include “low value procedures”, “procedures of low limited clinical value’ or “low priority treatments”. In November 2010 Atlas of Variation in Healthcare2 was published to help remove unwarranted variation to increase value and improve quality. It makes reference to low clinical value treatments and highlights the issue that some patients are receiving treatment that some clinicians would consider unnecessary and of no added value and that there is an opportunity cost to providing low clinical value treatments. The money could be better spent on other types of treatment, either for people with the same condition, or to meet unmet needs in another group of patients.

Identifying low-value treatments

The report highlights the fact that there is no single national list of low value treatments and many PCTs have developed their own approaches and lists. While there is evidence that some treatments are not clinically effective, for others there is still a lack of evidence regarding their clinical effectiveness. Certain treatments may be effective for particular patients, but not for others. Therefore, some PCTs have grouped their lists of ineffective treatments into those that they refuse to pay for and those where patients must satisfy specific thresholds to ensure that only the right patients gets the right treatment. Some PCTs have been leading the way in producing treatment lists. Croydon PCT, for example, started putting together a list in 2005/6 and has been developing this ever since. However, there is still a great deal of inconsistency when it comes to identifying exactly what merits an ineffective treatment. To identify the estimated spending on low clinical value treatments the report used the list of 34 low priority treatments produced by Croydon PCT, which has wide acceptance among commissioners. Treatments on the Croydon list fall into five categories (For the full list see panel):