Value based clinical commissioning of elective surgical care: from low to high value?


This report on Phase 1 of work by the QIPP Right Care Team looks at emerging views of commissioners and surgeons on the issue of commissioning policies on “low value” procedures. The studies were commissioned by Professor Sir Bruce Keogh, NHS medical director.


Recent years have seen the emergence of several listings of procedures deemed to be “limited effectiveness”, “low value” or requiring a “threshold”. These vary, bringing the risk of inequitable patterns of service delivery by postcode. Further, there has been widespread concern from professional bodies that attention to the underpinning evidence base for inclusion has been insufficiently robust. The inclusion of procedures such as cataracts or arthroplasty, with well established evidence of effectiveness, has helped to fuel the debate.

The approach

This paper from the Right Care team draws on discussions held between clinicians and commissioners in two SHAs (London and East Midlands), on expert opinion and projects which held consensus meetings.


This interim report makes recommendations on the effective commissioning of elective surgical procedures for consideration by the NHS Operations Board. It considers:

  •  Value base clinical commissioning of elective surgical care
  • Emerging views on underpinning principles
  • Right Care elective surgery project summary templates


  • There should be a change in terminology to reflect a more holistic approach: ‘value based’ or ‘effective clinical commissioning’ is proposed
  •  Limited lists should be abandoned.
  •  The NHS Commissioning Board needs to clarify how it will develop high‐level commissioning guidance for GP consortia, based on common, nationally produced guidance and evidence
  •  NHS Commissioning Board to support the development of commissioning guidance for elective surgical care pathways through a partnership between NICE and the surgical speciality associations which engages with all relevant stakeholders
  •  The authors propose a structure for commissioning guidance
  •  Evidence of effectiveness or cost effectiveness should be sought for new and existing procedures.  NHS R&D should play a central role where evidence is lacking
  •  The team proposes to publish a ‘Procedures Explorer’ giving information on variation in clinical activity and outcome at population, provider and GP practice or consultant level.
  •  There should be a review of existing patient and clinician facing information, including effective shared decision‐making tools
  •  The NHS Commissioning Board should consider the role for clinical senates and networks in advising and peer reviewing CCGs and providers
  •  There is a need to support research into the value that populations derive from the implementation of high value care pathways and specific rates of intervention
  •  Programme budgeting offers a useful framework for considering improvements in outcomes against available resource


Suleman, M. (ed) Value Based Clinical Commissioning of Elective Surgical Care: Emerging Views of Commissioners & Surgeons and Production of High Value Care Pathways (PDF) QIPP Right Care Team, November 2011.

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