how to implement procedures of limited clinical value

We would like your thoughts on ” procedures of limited clinical value”

 Updated in light of today’s BMJ article on knee surgery…….

I am frequently asked this question. I have participated in this area on many occasions over the years. It crops up each time there is a squeeze on money.

The below is my attempt to provide an answer on a question of how to do this, learning from my past mistakes.


As money becomes tighter and tighter we all think harder and harder about “where and how to make cuts”. One of the recurring themes is so called “procedures of limited clinical value”. This often comes with other names (the Croydon List, operations with limited clinical effectiveness), and the actual “list” varies.


There is a crossover into the answer for a similar question – “how to transform planned care”.




Before you start

1          don’t focus only on the list, focus on the how

2          Be realistic about why you are in this area and what will be achieved in financial terms

3          Be wary of the potential for collateral damage



How to implement –

If you are going to do it – here is my reflection on a “how to” guide.

1          What procedures will you focus on

2          sort your data on activity. here do we stand – CCG compared to similar, practice compared to proactive

3          develop your policies and pathways

NICE, SIGN, Royal College where it exists

Agree with surgeons.

Don’t be under any illusions that “writing a pathway will solve the problem”

What may happen in general practice- the onus this places on the GP

Pathways and alternative approaches –

Policing policies and NICE guidance

4          Referral management schemes, services and systems. Be mindful what the evidence says.

  1. Comms and engagement questions

6          The issue of supply induced demand

7          Concluding points
Before you start

1          don’t focus only on the list, focus on the how

This sounds an attractive way of achieving “savings” and a low hanging fruit. I am far from convinced, having worked on this area a number of times.


Take great care – each time I have participated in this, it seems a sure-fire route to hack a lot of GPs and surgeons off and not save much cash. Often in the past PH has been the fall guy for implementing, this time it will be General Practice.


Each time this concept of PCLV (which also goes also by a number of other names) is raised – Im always assured “ahhh but it will be different this time”….. and Im never convinced.


Be careful with terms. The term “procedures of limited clinical value” is highly contested, and often deeply divisive. Patients and clinicians may define “value” in entirely different ways.


The provenance usually can be traced back to an entity known as “the Croydon List”.

This is the (infamous) list of procedures with allegedly limited clinical value.


Each time this comes up I fear we over focus on “lists of low value stuff” and “clinical thresholds” and not think about the broader objectives and importantly the “how”. The “list” is the easy bit. However once you have a list, from a commissioner perspective at least this leads to micro management (that most commissioners don’t have the time or expertise for) and also doesn’t / cant reflect the day to day worldview of a clinician – be that a GP or a surgeon.




2          Be realistic about why you are in this area and what will be achieved in financial terms

What does the evidence tell us


Black – JPH – restrictions cant be justified on the basis of value for money.

Complex study of linked procedure volume and PROM data. Be mindful of equity impact.


Schwartz – 2.7% of total spend is in “low value” procedures, raising a question of how much money can REALLY be saved?

This is a US study, thus treat with appropriate caution. There are some important and generalisable lessons for the UK:

  • Be (very) mindful of the (serious) limitations of administrative data.
  • Much “low value” care is actually low cost care
  • Services detected by more sensitive versions of measures affected 42% of beneficiaries and constituted 2.7% of overall annual spending.
  • Services detected by more specific versions of measures affected 25% of beneficiaries and constituted 0.6% of overall spending.


Wilson – doi:10.1136/bmjqs-2015-004518. Brilliant piece in this area. Illuistrates the difficulty


the notion that 20%–30% of healthcare is unnecessary and/or harmful offers an attractive and intuitively simple solution.

Low-hanging fruit is simple in concept and morally defensible, but will require an unprecedented level of change.


Complexity of change

  • The complexity of any large-scale change can be quantified
  • pervasiveness (how much of the system does it affect?) – see the Schwartz paper – A study of low-value tests and surgical procedures among US Medicare patients4 identified low-value care identified in 42% of a medicre pop (USA – important context), 2.7% of overall spending or 25% of pop and 0.6% of total spending using more specific measures.
  • depth (how different is the new model to current ways of thinking and doing?)
  • apparently easy targets can require substantial culture change
  • size of variation (how widely spread is the change across geographical boundaries, organisations or distinct groups of people). Variability of “low value” care.


Patient Cultural issues

people—patients—may not want to forego low-value care. – healthcare is traditionally an entitlement or a privilege. More care is better.




Clinician cultural issues

  • Lists derived by clinically led processes, (eg choosing wisely) often critizised on two grounds – 1) some professionals are better at identifying other people’s opportunities for change rather than affecting their own practice or income, 2) the lists are often of marginal importance and avoid the really big issues (income and livelihood)
  • How many clinicians will drive a process that sees their expertise less valued, their workload reduced and their livelihoods threatened?
  • Implementing



  • None of these problems is insurmountable, but they illustrate the complexity of applying a simple principle in practice.
  • Success will require planned and coordinated change right across the system.
  • Changing incentives, information systems and the shape of services will all be needed.
  • So, will major cultural shifts.
  • If low-value care is to be eliminated then value rather than cost, profit, affordability or entitlement must be the accepted currency in which healthcare is judged by its providers and users.


The Evaluation of the USA Choosing Wisely programme is instructive on the limitations of “lists”




3          Be wary of the potential for collateral damage

Tread carefully. The potential to alienate clinicians is high, and the likelihood of significant cash realising gains is low.

Sorting out the arrangements for both corporate and clinical governance of implementing a programme such as this is paramount.

How to implement –

If you are going to do it – here is my reflection on a “how to” guide.

1          What procedures will you focus on

    • The US and Canadian Choosing Wisely stuff is a decent place to start

  • NICE do not do and optimised recommendations


  • Perhaps look at the top procedures by volume or cost done in last year at local trust….always a good starting point
  • Or fast growers….
  • And check off against NICE recommendations – especially look at IPG, and within that where there is an IPG recommendation where it says “only with special arrangements”
  • the infamous Croydon List – the (so called) procedures of limited clinical value – and I use that term advisedly.


Minor skin lesions carry out in general practice minor surgery. Or not at all. Often the path of least resistance however is to “simply whip it off”. Might this exacerbate expectations?
Knee arthroscopy – therapeutic


Mosely (NEJM) and a host of other studies (BMJ June 15) have told us no better than placebo. Care re coding creep into diagnostic washout.
Knee arthroscopy – diagnostic This one is tricky.
Primary hip replacement


NICE is clear on this

Not exactly “low value”(!)

Knee replacement As above.
Hip and Knee revisions
Carpal tunnel Less invasive – physio and OT management in all. Splinting service?
Spinal X Ray (low back pain)


Might as well add MRI into this. Suggest no spinal imaging unless from tier 2 or 3 type service. Wont be popular.
Trigger Finger About how the pathway is managed. Lots of policies out there.
Ganglions ditto
Spinal surgery Now NHSE?
Spinal injections See my separate note on this
Nasal diathermy Cant see this being high volume
Grommet insertion SIGN criteria. Maybe scope for audit of surgery against indications.
Tonsillectomy / adenoidectomy SIGN criteria. Maybe scope for audit of surgery against indications.
Sinus X Ray
Bone anchored hearing aids. NHSE now?
Cataract surgery Thresholds. Unintended consequences?

RCOpth Commissioning guidance recently published

Blepheroplasty Wrap up with cosmetic policy. Don’t know volume, but not insignificant. Many policies out there
Wisdom teeth extraction
D+C and hysteroscopy for heavy menstrual bleeding ?coding issues rather than clinical practice?
Female Genital Prolapse/Stress incontinence Female Genital Prolapse/Stress incontinence
Hysterectomy for menorrhagia More cost effective treatments first. This is an effective procedure.
General surgery  
Inguinal umbilical and femoral hernias
Anal procedures Multiple indications.
Vasectomy under GA Should be v few patients
Reversal of sterilisation Arguably shouldn’t be done. Maybe issues around documentation in initial consent. Cropped up in IFR panels from time to time.
Circumcision on non clinical ground Should be zero. Many legit clinical indications however.
Varicose Vein procedures Cheaper alternatives – sclerotherapy and or laser?
Cosmetic surgery Manage through strict policies.
Cancelled procedures  

2          sort your data on activity. here do we stand – CCG compared to similar, practice compared to proactive

where does the procedure rate per capita lie compared to similar populations.

of note is the RCS Procedures Explorer Tool which gives far better data than the routine contracting stuff.


If doing an analysis of variation per capita across all units – tread carefully with interpretation:

  • There isn’t a “right” rate of referral.
  • We don’t know if the benchmark (usually) average is too low or high.
  • Age structures within practice or other factors may make a difference – things that are beyond a GPs control.


How are people getting in – may influence referral rate interpretation.

Is there direct referral to ENT from audiology. In some places 30-40% of children referred for grommet insertion is from community audiology.

Is there direct referral to Opth from optom for eg cataract

Is there direct referral from ESP to O&T.


3          develop your policies and pathways

hard to move away from SIGN, NICE or Royal College etc where it exists.

Royal College and similar policies – there’s a bit of fox and chicken coup here…. but……they are pretty good clinically speaking.

RCS commissioning centre –

RCS proposed commissioning policies –

Have you been to see the surgeons to hammer this out, procedure by procedure. Specialty by specialty.

Is there any audit of procedure against (commissioner) agreed indications.


Don’t be under any illusions that “writing a pathway will solve the problem”

See the Hamilton piece on arthroscopy. BMJ 2015;351:h4720. Illuistreates the complexity and difficulty of acheiveing change, even then the evidence is clear.

Similarly the US Choosing Wisely evaluation is instructive about overfocus on just writing a list.


What may happen in general practice- the onus this places on the GP

everyone will say yes of course, but my patient is different.

The onus is thus on the GP or whomever sees a patient first to be clear and realistic about what will / wont, can / cant happen down the line

Are GPs happy about gate keeping being done by optom, ESP, audiology.

The trust position is very likely to be “if it comes in we will treat”.


Pathways and alternative approaches – You may need to consider for EACH procedure on your list.

  • Pathways that have stop sight, or pathways where there alternatives to referral to hospital.
  • Alternative non hospital management – either procedure undertaken as part of general practice minor surgery etc or no procedure and alternative management.
  • Triage that isn’t just triage but where there is active management of patients – both clinically and down trading their expectations.
  • No referral till less costly (and or more effective) interventions exhausted – referral against stricter criteria.
  • Use of shared decisions and self care – good evidence. Cochrane review highlighted they DO change decisions, economic evidence is lacking. Lots of anectode.
  • Use of lifestyle – loose some weight and you might have less knee pain. Stop smoking and you may get more benefit from the drugs etc


Policing policies and NICE guidance

Basic options often quoted are:

  • Clinical Threshold Service where clinicians receive all referral forms and they only authorise surgery when patients meet the policy criteria.
  • compliance audit at the trust on a quarterly basis to assess compliance and if not compliant the trusts will not be paid. The policies and the audit are part of the contract agreed by both parties.





4          Referral management schemes, services and systems. Be mindful what the evidence says.

All CCGs already have a “referral management system”; its called General Practice – very trained clinical brains.


Many CCGs might consider investment in “GP referral management systems” / “threshold management systems” and similar.

Tread carefully here – potential for brute force administrative approaches to fail spectacularly. More effort towards audit, feedback and education. Though this is a slow drip approach.

The evidence any form of service over and above this make ANY difference is highly debateable at very best, and they add cost. As above – each time it crops up Im assured “it will be different this time”.

There is a decent evidence review on “managing demand in primary care” from Sheffield University, and a number of highly pertinent Cochrane reviews on this matter.

Read it, understand it, act accordingly.

There IS scope, significant scope, for more nuanced approaches say involving audit, feedback and education – both one to one academic detailing for a practice and wider mass education events. This is largely untested evidence wise in THIS context, but plenty of evidence from the wider QI literature.


Some references

  • Faulkner  2003 – BJGP. overview of types of referral management . BJGP 2003, 53, 878-884
  • Faulkner   2003  – Cochrane review referral management . this is the Cochrane collab review based on the 2003 BJGP paper
  • Ringberg,  – BJGP 2014; DOI: 10.3399/bjgp14X680521 – Cultural reasons that have explanatory power in referral rates may vary. “referral to reassure – maybe when medically less necessary – may reflect acquiescence towards patients”

  • Cox – BJGP  June 2013 –  –  Referral management scheme didn’t change OP attendance. More expensive than internal peer review.
  • Sheffield Uni -evidence review. I think this then got turned into an RCGP toolkit. Very helpful. some papers coming out of this are
  • Blank 2013 BJGP – Don’t just focus on primary care. There is no magic bullet.

Blank et al highlights the complexity of this, and a lack of a neat single answer.

What is the evidence on interventions to manage referral from primary to specialist non-emergency care. Health Serv Deliv Res 2015;3(24)


Key points

  • complexity of the referral process and multiple elements that will impact on intervention outcomes.
  • multitude of assumptions that are made between interventions and demand management outcomes and that successful referral outcomes are highly dependent on the individuals involved in the referral and also the context in which the referral is taking place.
  • in order to tackle demand management of primary-care services, the focus cannot be on primary care alone – a whole-systems approach is needed as the introduction of interventions in primary care is often just the starting point of the referral process
  • The findings suggested that, although individual-level interventions may be popular, the stronger evidence relates only to peer-review and feedback interventions.
  • Process change interventions appeared to be more effective when the change resulted in the specialist being provided with more or better quality information about the patient.
  • System changes, including the community provision of specialist services by GPs, outreach provision by specialists and the return of inappropriate referrals, appeared to have evidence of effect.
  • The international evidence suggests that individual peer-review/feedback interventions, and some process change and system change interventions, may be effective and applicable in the UK.
  • The review, however, highlighted the role of local factors such as waiting times, access to specialists and workload, which may influence the success of any intervention. It is likely that local differences between specialties, UK demographic variation and elements that the review identified relating to individual patients and practitioners will have a stronger impact on the effectiveness and applicability of the interventions identified.
  • Possible exceptions to this – the addition or removal of gatekeeping systems and changes to health-care payment systems.
  • It might take more fundamental revision of existing NHS management and procedures to make these types of changes within the UK.
  • However, the review identified few studies evaluating these systems, with evidence of their effectiveness in managing demand conflicting




  1. Comms and engagement questions

Is the hospital on board – surgeons and corporate. Clinical and corporate position is likely to be “if we see the referral we will act according to clinician judgment”. Unlikely that referrals that “get in” will be returned if they don’t meet the agreed indications (for a number of good reasons).

Thus onus will be on GPs to manage. Are GPs on board with this, is there the support of the wide GP body. Are patient organizations on board?

Have you sorted out the lines you will give to GPs to help them have potentially difficult conversations.

Have you sorted out the public comms line?

Has there been engagement with local politicians if patients denied care their neighbour had last year complain to their elected representative.


If the hospital has 12 Orthopod salaries to pay in my hospital with catchment of 400,000….it is going to have to pay their salaries. The best way to do this is through activity. If I only had 6 orthopod salaries to pay, then I may be inclined to have a lower activity level.


So if the CCG works with their GPs to implement threshold based policy that in effect take x% of procedures out of the system, and the provider trust still has y orthopod salaries to pay for the incentive is on the chief exec and her business managers to find other ways to make ends meet organisationally speaking. There is talk of trusts “trading their way out of deficit”. This all doesn’t seem a very joined up and integrated solution.


The area of secondary care spending that seems to be going up fastest is OP and elective care. See the Kings Fund “NHS in Numbers”. There is plenty of UK and US evidence on supply induced demand.


Van Dijk ( considered the question from a primary care perspective. As investment in “primary care” increases, there doesn’t seem to be a reduction in overall referral volume, confounding the often set out hypothesis.





7          Concluding points

I recommend against this approach to saving money.

I have consistently had this view over many years.

It is a difficult and thankless task and the evidence that is achieves a great deal of financial gain is almost non existent.


I have tried to reflect on what I have learned by participating in this area on a number of occasions.


Frequently in the past we have failed to focus on WHY we are doing what we are doing, WHAT we want to achieve and HOW. We have also massively under focus on culture and incentives.


It might be more beneficial to strategically as a PAYER and either set price for procedure, for bundle of care or total volume of care for a population of patients – and hold people to that price with contracting method. Make the clinicians feel the need to look for value and transfer the responsibility to them. 

Alternative contracting models may help. Alot of effort though

(And sometimes having alternatives, sometimes just saying no)


Views in this world are highly polarised and I accept there will be others with diametrically opposed views to this …. many are holding on (strongly) to the belief that “procedures of limited clinical value” will save lots of cash, the evidence seems against this view. Colla set out a useful overview or strategies (Strategies for Low Value Care NEJM 371;14  October 2, 2014). The table is very interesting


I hope this helps. Im sorry it is rather downbeat, but I hope it provides you with some food for thought.


Postcript July 2016

July 29th BMJ article on knee surgery for degenerative meniscal tear.

And the withering editorial
It’s not a question of the evidence.
The best way to implement PCLV is through standard data led QI approaches and through manipulation of £ paid to reflect value

Eg for knee arthroscopic surgery make the tariff equivalent to physiotherapist cost and let patient decide though shared decision making whether they want to see a surgeon or a physio




June 2015








OCPS coding

NB – this is an old list of OCPS codes from when I last worked in this area (2011)

Coding practice may have changed, coding architecture may have changed since this time.

Adenoidectomy. E201 Hysterectomy for Menorrhagia. Q071-075. Q078, Q079, Q081-083, Q088, Q089.
Aesthetic surgery – Breast. B301-303, B308, B309, B311-314, B356 Incisional and Ventral Hernias. T251-253, T258, T259, T261-264, T268, T269, T271-T274, T278, T279.
Aesthetic surgery – ENT. D033, D038, D039, D062, E025-29, E094 Inguinal Umbilical and Femoral Hernias. T201-T204. T208, T209, T211-T214, t218, T219, T221-223.
Aesthetic surgery – Ophthalmology. C131-134, C181-186, C188-189 Jaw replacement. V118, V119, V171-173, V178, V203, V209, V218, V219, V139, V142-144, V148, V161-163, V168, V169, V198, V199, V071, V078, V079.
Aesthetic surgery – Plastics. S011-S014. S018-S022. S028,SO29, S031, S032, S211, S212, S332, S333 Knee arthroscopy – diagnostic. W871-879.
Anal Procedures. H511-H512, H518-524, H528, H529, H531-H533, H538, H539, H558, H559, h569, H482. Knee arthroscopy – therapeutic. W821-829, W831-839, W841-849, W851, W852, W858, W859,
Arm Lift. S033. Knees. W401, W408, W409, W411, W419, W421, W428, W429, W431, W438, W439, W411, W448, W449, W451, W458, W459, W521, W528, W529, W531, W538, W539, W541, W548, W549, W581, W588, W589.
Back Pain: Injections and Infusion. V333, V335, V336, V371-374, v378-379, 381-384, V388, V389, V221, V241, V251, V253, V231, V261, V391-395, V398, V399 Minor Skin Lesions. J33-J37 (HRG codes used)
Bariatric Surgery. G301-G309 Orthodontics. F142-144. F148, F149.
Bilateral Hips. (HRG codes used) H01 Other Hernia Procedures. F76, F77. (HRG codes used)
Bone anchored hearing aids. D131-139. Other Joint Prosthetics. W431, W432, W438, W439, W441-443, W448, W449, W451, W452, W458, W459, W521, W522, W528, W529.
Cancelled Procedures. S22 (HRG code used) Primary Hip. H80, H81. (HRG codes used)
Carpal Tunnel. A651, A658, A659 Reversal of sterilisation N181, Q29, Q37
Cataract Surgery. B13 (HRG code used) Sexual Transformation. X151-159
Circumcision. N303 Snoring. F323, F324.
Cochlear Implants, D241, D242 Spinal (lower back) surgery thresholds. V251-256, V258, V259, V261-266, V268, V269, V281, V282, V288, V289, V331-339, V341-349, V358, V359, V382-385, V393-397.
D+C and hysteroscopy for heavy menstrual bleeding. Q 103, Q108, Q109, Q181, Q188, Q189. Spinal Cord Stimulation. A438.
Dilation and Curettage. Q103, Q108, Q109 Thigh Lift. S032
Dupuytrens Contracture. T541, T548, T549, t521, T522, t528, T529. TMJ joint replacement. V201-209.
Elective Cardiac Ablation, K571, K572, K579 Tonsillectomy. E201, E208, E209, F341, F342, F344-346, F348, F349, F361, F368, F369,
Female Genital Prolapse/stress incontinence (non-surgical) M13 (HRG code used) Trigger Finger. T705, T708, T709, T718, T719, T728, T729, T748, T749, T652, T658, T659, T691, T698, T699.
Female Genital Prolapse/Stress incontinence (Surgical) M531

M538, M539, P219, P221-223

P228, P229, P231-234

P238, P239, P241, P243, P244, P248

P249, P251

Varicose Veins. L832, L851, L852, L853, L858, L859, L871-879, L918, L919, L931-933,
Ganglions. T591-599. T601-609. Vasectomy. N171, N172, N178, N179
Grommets. D151, D158, D159, D202, D203, D208, D209, D288, D289. Wisdom Teeth Extraction. F091, F093, F099
Hip and Knee Revisions.

(HRG codes used) H05-07, H71, H72.





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