Hernia rationing: an assessment of commissioning guidelines

Hernias are a common surgical condition. Most guidelines recommend repair in almost all cases. NHS Devon clinical commissioning group (CCG) guidelines restrict the commissioning of hernia repair. The aim of this study was to follow up a cohort of patients referred for hernia repair to assess the impact of commissioning guidelines on clinical outcomes.Methods All patients referred to a single UK surgeon with an abdominal wall hernia over a 12-month period were followed up to determine whether CCG criteria were initially met. If they were not, time to any subsequent surgical intervention was recorded.Results After exclusions, 106 patients referred for abdominal wall hernia repair were followed up. Of these, 53 (49%) fulfilled commissioning guidelines for surgical repair. Thirty-one patients (23%) who had an indication for surgical repair did not fulfil commissioning criteria. This group was followed up for a median of 1,112 days (range: 962–1,287 days). Twelve patients (39%) required an operation within 900 days with one of these (3%) requiring emergency repair. These 12 patients waited a mean of 232 days before being accepted for surgery.Conclusions A large number of patients who did not initially meet NHS Devon CCG’s criteria ultimately required surgery. Three per cent of this ‘watch and wait’ group required emergency repair. NHS Devon CCG guidelines do not effectively identify patients who can be managed safely without surgical hernia repair. The incidence of emergency repair in this group should inform the prioritisation of hernia repairs when restarting elective services that have been halted because of the COVID-19 pandemic.