The British Orthopaedic Association (BOA), the body that represents the professional interests of orthopaedic surgeons across the UK, has today published a report reviewing current practices and outcomes of NHS hospitals providing orthopaedic surgery in England, to identify and quantify variation in clinical outcomes, processes, patient experience, patient pathways, network arrangements, financial impacts and waiting times.
The report Getting It Right First Time (GIRFT) builds on Professor Tim Briggs’ original research in 2012 which suggested ways in which extensive savings and improvements could be made in elective orthopaedics by hospitals to ensure continuing high quality care and access for patients within the financial constraints of the NHS.
England funded the GIRFT pilot as a national professional pilot across England. The project was hosted on behalf of the BOA, at the Royal National Orthopaedic Hospital (RNOH) in Stanmore.
The GIRFT team, led by Tim Briggs during his year as BOA President, developed a clinically-led approach to reviewing the total pathway of adult elective orthopaedics and spinal activity, and considered all efficiencies including clinically unsupported variations of practice in terms of device and procedure selection, price benchmarking, infection rates, quality outcomes and litigation costs.
The pilot has identified significant variations in practice and outcomes in terms of device and procedure selection, clinical costs, infection rates, readmission rates, and litigation rates. For example, long term deep infection rates for hip and knee replacement vary between 0.2% and 5% and statistics show an average return to theatre as a result of complications of between 0% and 7%. During conversations with trusts it also came to light that there appears to be a similar range of variation in the prices paid for hip and knee implants above and beyond what could be clinically justified.
It also clearly demonstrated that there is significant scope to tackle many of these variations and drive short, medium and longer- term improvements in quality of delivery (through adopting best practice), reducing supplier costs (for example of implants) and thereby generating savings. Another important observation is that there is often no formal consensus as to what constitutes best practice in areas of activity where there is no NICE or formal guidance from the BOA or other professional sub-specialty association. This also provides a significant opportunity to drive quality and efficiency.
The GIRFT team summarises their measurable impacts for orthopaedics as follows:
Short Term Reductions in
• Prostheses costs
• Loan kit costs
• Readmission rates
• Length of stay
• Surgical site infection
Medium Term Reductions in
• National variation for procedures
• Outliers in national registries
• Infection/complication rates
Long Term Reductions in
• Revision Surgery
• Litigation numbers and rates
As well as its immediate impact, the project is intended to have a long term positive impact on service. This work has gathered overwhelming support from clinicians across the NHS, as this is being driven clinically with the work taking place peer to peer.
The GIRFT team conducted deep dive visits to 120 Trusts comprising of some 205 hospitals that provide elective care to understand first-hand the differing practices and challenges to identifying realistic and achievable efficiency opportunities. The team has travelled 17,241 miles, met 1649 surgeons, 414 managers plus over 2063 personnel. the total adult orthopaedic and spinal activity for the 120 trusts in the year that the data was reviewed totalled over 488,371 cases. Professor Briggs commented, “Our approach has enabled us to take a consolidated view of all the available data and metrics relating to each trust’s clinical and financial performance and to then engage with each management team and group of clinicians to use this evidence to reflect on variation in clinical practice, management approach and variation in prosthesis selection.”
Colin Howie, current President of the BOA added, “Clinicians enthusiastically embraced this opportunity to benchmark themselves nationally and explore how clinical evidence is considered and informs their practice. This highly detailed approach has helped us to develop an extensive understanding of the links between practice, outcome and cost drivers. In turn this has provided solutions that will address the variations, drive efficiency, spread best practice and support network development. This is an excellent example of front line clinicians taking responsibility for their service and will result in substantial improvements for our patients and the quality of the life-changing healthcare that we deliver.”
Colin Howie also noted the valuable review the Chartered Society of Physiotherapy had undertaken of rehabilitation services for knee replacement and hip fractures across the country, included as a chapter within the report, commenting that "we have been delighted to collaborate with the CSP on this aspect of the project and welcome their thoughtful and thorough approach to this important issue."