BKS Response to the NHS Evidence-Based Interventions Programme Consultation, December 2018

Background

The UK Biological Knee Society is an academic study group established by a group of specialist knee surgeons from the UK with a specific interest in the very latest and best possible surgical options and techniques for knee reconstruction. It is dedicated to the study, evaluation and promotion of the very best surgical options for patients with damaged knees who are too young for artificial joint replacement surgery.

Statement on NHS England’s Evidence-Based Interventions Programme

The UK Biological Knee Society believes that patients in the United Kingdom, whether in the National Health Service or the Private Sector, should have access to high quality healthcare for the management of traumatic and degenerative conditions in the knee.

We believe that in order to achieve this, patients must have access to experienced and informed specialists providing evidence-based practice in this field, who are supported by their healthcare organisations. Patients should also be given an opportunity to benefit from innovative technologies within a suitable clinical governance framework.

We believe that this goal has been significantly undermined by some of the recent misinformed and ill-conceived guidelines that have been published by bodies that do not represent the opinions of specialist knee surgeons in the UK. Some of these blanket guidelines based on limited evidence of moderate quality are inadequate when considering the management of often complex conditions in a heterogenous group of patients with differing demands and aspirations.

These ‘guidelines’ are in effect simply being used as a tool to ration patients’ access to appropriate healthcare, both in the NHS and via certain insurers in the Private sector, effectively for their financial gain but directly against the best interests of some patients. They have also led to the undermining of the type of professional opinion that can only be provided from a proper face-to-face assessment by an experienced consultant orthopaedic surgeon.

Currently, decision-making for patients within the NHS is often devolved to ‘over the phone’ assessments, physiotherapy triage clinics and musculoskeletal physicians. Increasingly within the Private Healthcare Sector, we are beginning to see insurance companies interfering with patient referrals, with patients having to talk to clerks in a call centre who are vetting their cases. These kinds of people are not qualified knee surgeons and they do not have the breadth of experience or expertise needed to make fully-informed choices in conjunction with the patient.

‘Arthritis’ and ‘knee arthroscopy’ are often used as ‘catch-all’ terms. The former, however, is a complex, varied and evolving disease process that affects the knee, and the latter simply a mechanism by which the knee is accessed to provide a number of established and novel therapies, including articular cartilage surgery, meniscal cartilage surgery, ligament repair, reconstruction and augmentation. These are the actual procedures, using ‘knee arthroscopy’ simply as the method of accessing the joint.

At no stage do the BKS wish to defend poor practice, unnecessary surgery or indiscriminate use of arthroscopic techniques where the clinical situation does not warrant it; however, the current climate where ‘knee arthroscopy’ is being used as a sweeping generic term that is being inappropriately demonised is having an adverse effect on patient care.

The UK is already falling behind in this area, with a number of potential therapies for cartilage damage no longer available in this country. Companies have come to realise that the UK is not a market to invest in as innovation is constantly stifled. It is our belief that UK patients are being put at a disadvantage when compared to their counterparts in the developed world as a result of the current climate.

Summary

• ‘Knee arthroscopy’ is nothing more than just a method for looking into a knee joint with a ‘camera’. It tells you nothing about why a patient might need surgery or what the actual surgical procedure inside the knee might actually be.
• The practice of patient referrals being diverted and patient care being interfered with by individuals who are not suitably qualified is to be deplored.
• Guidelines issued by non-experts have the propensity to be misleading and even dangerous, and should not be used as tools to ration healthcare and to deny patients access to appropriate treatments that they might benefit from.
• The decision as to whether any individual patient might potentially need knee arthroscopic surgery is a decision that should only ever be made between the patient themselves and a fully-qualified experienced knee surgeon, after a proper clinical assessment, which must include a hands-on clinical examination, a review of all relevant imaging and a face-to-face in-depth discussion between the patient and their specialist surgeon.

Posted 2nd December 2018