Access to procedures of limited clinical value in the National Health Service in England: a comparative policy analysis
File(s)
Accepted version
Author(s)
Smyth, Jamie
Ogier, Anna
Christopher, Tweedie
Jain, Vageesh
Type
Journal Article
Abstract
Objectives: To systematically quantify the variation in access to criteria-based procedures across England's National Health Service (NHS).
Design: A cross-sectional comparative policy analysis.
Setting: The NHS in England
Participants: The analysis included publicly available commissioning policies from all 42 ICBs. From an initial 175 procedures identified across policies, 163 were included in the final analysis.
Primary and secondary outcome measures:
1. Primary: The Restriction Index (RI), calculable only for procedures mentioned by at least 20% of ICBs (≥9/42), was defined as the proportion of ICBs restricting a procedure to Individual Funding Request (IFR) status, scored from 0 (consistently funded with criteria) to 1 (consistently restricted to exceptional circumstances).
2. Secondary: The Commissioning Variability Index (CVI) was an entropy-based measure quantifying the level of policy inconsistency across ICBs (including IFR, funded with criteria, and not mentioned in policies) on a scale of 0% (perfect consistency) to 100% (maximum variability).
Results: Analysis of 3,242 explicit commissioning decisions for 163 procedures revealed substantial variation across ICBs. The median RI was 0.1 (IQR 0.00-0.68), with 36.7% (n=40) consistently funded and 5.5% (n=6) consistently restricted. The median CVI was 50%, with only 18.4% (n=30) of procedures showing high consistency across policies (CVI ≤20%). Procedures with the highest variability in access included those related to aesthetics, musculoskeletal, and ENT. Regionally, the proportion of procedures restricted to IFR ranged from 26.9% in the North East and Yorkshire to 40.7% in the North West. No significant correlation was found between procedure cost and the RI (Spearman's ρ=0.04, p=0.75).
Conclusions: There has been a longstanding history of restricting access to certain clinical procedures in the NHS. Yet there remains a lack of consensus in commissioning policies for many of these procedures. These findings highlight an urgent need for greater standardisation in policy development to ensure equitable, evidence-based care and to reduce unwarranted variation.
Design: A cross-sectional comparative policy analysis.
Setting: The NHS in England
Participants: The analysis included publicly available commissioning policies from all 42 ICBs. From an initial 175 procedures identified across policies, 163 were included in the final analysis.
Primary and secondary outcome measures:
1. Primary: The Restriction Index (RI), calculable only for procedures mentioned by at least 20% of ICBs (≥9/42), was defined as the proportion of ICBs restricting a procedure to Individual Funding Request (IFR) status, scored from 0 (consistently funded with criteria) to 1 (consistently restricted to exceptional circumstances).
2. Secondary: The Commissioning Variability Index (CVI) was an entropy-based measure quantifying the level of policy inconsistency across ICBs (including IFR, funded with criteria, and not mentioned in policies) on a scale of 0% (perfect consistency) to 100% (maximum variability).
Results: Analysis of 3,242 explicit commissioning decisions for 163 procedures revealed substantial variation across ICBs. The median RI was 0.1 (IQR 0.00-0.68), with 36.7% (n=40) consistently funded and 5.5% (n=6) consistently restricted. The median CVI was 50%, with only 18.4% (n=30) of procedures showing high consistency across policies (CVI ≤20%). Procedures with the highest variability in access included those related to aesthetics, musculoskeletal, and ENT. Regionally, the proportion of procedures restricted to IFR ranged from 26.9% in the North East and Yorkshire to 40.7% in the North West. No significant correlation was found between procedure cost and the RI (Spearman's ρ=0.04, p=0.75).
Conclusions: There has been a longstanding history of restricting access to certain clinical procedures in the NHS. Yet there remains a lack of consensus in commissioning policies for many of these procedures. These findings highlight an urgent need for greater standardisation in policy development to ensure equitable, evidence-based care and to reduce unwarranted variation.
Date Acceptance
2026-10-06
Citation
BMJ Open
ISSN
2044-6055
Publisher
BMJ Publishing Group
Journal / Book Title
BMJ Open
Copyright Statement
Subject to copyright. This paper is embargoed until publication. Once published the Version of Record (VoR) will be available on immediate open access.