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Statement on hernia policy in Kent and Medway

User AvatarPosted by Daniel Harper at 17/07/2018 11:58:10

The Kent and Medway clinical commissioning groups (CCGs) strive to provide patients with high quality, cost-effective and compassionate care.

Over the years it has emerged that not all treatments routinely offered by the NHS are effective or good value for money. We have to ensure we spend the money available to us to achieve maximum benefit for our population.

Therefore, we have a thorough and meticulous process, led by doctors and other health professionals, to review the evidence for specific treatments, and put in place criteria if appropriate.

The policy on hernia surgery, including criteria for the circumstances under which patients should be routinely referred for surgery, was agreed through this process and reviewed in 2015.

Clinicians undertaking the review considered national guidance, professional society guidelines, the baseline position (with respect to activity, costs and expenditure), other CCGs’ policies, evidence of safety, clinical- and cost-effectiveness and the views of local experts. They took into account 2013 guidance on hernias from the Royal College of Surgeons of England, the Association of Surgeons of Great Britain and Ireland, and The British Hernia Society. Their review also looked at the outcomes of clinical trials, and patients’ own reports of their experience. They found insufficient evidence that changing the policy would improve quality of life.

We appreciate that this will be disappointing to some patients but the NHS has a duty to make sure that all patients get the best support and treatment available and that NHS money is spent on items and procedures which are clinically effective and bring clear improvements to patients. We will consider any new evidence as part of a policy review in due course.

For guidance

Kent and Medway clinical commissioning groups’ policy on access to elective hernia repair in adults has been in place since the formation of the CCGs in 2013.

It states that surgical repair is not routinely funded for asymptomatic or mildly symptomatic inguinal hernias in adults. Adults should be referred for surgical assessment if theydemonstrate pain or discomfort significantly interfering with activities of daily living AND meet at least one of the following:

  • A history of incarceration of, or real difficulty reducing, the hernia
  • An inguino-scrotal hernia
  • Increase in size month to month.

This policy was reviewed by the Kent and Medway Policy Recommendation and Guidance Committee (PRGC) in 2015.

The PRGC is responsible for determining clinical commissioning policy recommendations and, in particular, whether drugs, devices or treatments should be funded by the NHS in Kent and Medway, on the basis of whether they are proven to work well and offer good value for money to the NHS.

The PRGC is composed of primary and secondary care clinicians, pharmacists, a lay member, representatives from CCGs and a public health representative from across Kent and Medway.

Evidence considered by the PRGC included data on patient-reported outcomes (2014/15) whichindicated that quality of life is likely to worsen for 17 to 42 per cent and remain unchanged  for 20 to 32 per cent of English patients undergoing surgical repair of groin hernia.

Several large randomised controlled trials indicate that there is no clear benefit of immediate surgery over watchful waiting and vice versa in terms of pain, physical function and complication rates in minimally symptomatic patients. Up to eight per cent of inguinal hernia repair patients may be left with persistent/ chronic pain following surgery.

There is, however, no blanket ban on elective inguinal hernia repair or any of the other healthcare interventions covered by the Kent and Medway policy statements. There is an established mechanism for dealing with individual funding requests (IFRs), in cases where interventions are not routinely funded or a patient does not fulfil the defined eligibility criteria. Clinicians can make individual funding requests on behalf of individual patients.