Trust implements a programme to remove variations in orthopaedic services by creating awareness of best practices, resulting in a reduction in orthopaedic litigation claims

During the GIRFT pilot in elective orthopaedics Professor Briggs visited 140 providers to review all their available data to reflect on variation in clinical practice, management approach and procurement. This uncovered huge variations in practice and outcomes.

Trusts implementing the recommendations have reported enhanced value and quality including a reduction in litigation; surgeons stopping low volume work; greater price transparency; and the reversal trend favouring inappropriate hip fixation in older patients. The team are of the view that the task is so huge that providers and clinicians need this approach to help them identify what can and must be done.

Challenges

1.Orthopaedic services are struggling to meet growing demand and the expectations of patients and commissioners. It is difficult for many providers to meet acceptable waiting times and deal with cost pressures whilst maintaining clinical standards. It is recognised that both patient experience and staff morale could be improved, but that it is hard to balance what the specialty feels is best practice (such as provision of ring-fenced ‘clean’ beds and laminar flow theatres to minimise infection) in the face of wider financial and efficiency pressures.

2.The GIRFT data analysis has highlighted unexplainable variation across the whole of the orthopaedic pathway. In many cases, the variation found was unexpectedly large, and could not be explained by differences in obvious drivers of demand, such as age or incidence of osteoarthritis. Reducing variation where it is unwarranted: in who receives care, how services are provided, the tools and techniques used, and in the quality of outcomes, is recognised as fundamental to improving quality and reducing costs.

3.The cumulative effect of many of these variations is a greatly increased proportion of orthopaedic activity becoming ‘rework’, providing remedies to issues that are largely avoidable or that arise much sooner than would be the case if best practice were adopted. The impact on clinical outcome, patient experience, capacity and above all cost is very significant.

4.Visits to providers by the GIRFT team identified several recurring themes contributing to the variation. Several of these are amenable to easily implemented changes that promise to bring about significant improvements. The key theme is that much clinical decision-making could be improved through greater awareness of best practice. Decisions about clinical practice were often not consistent or fully evidence based. There was a lack of clinical leadership in local policy decisions, made harder by poor use of information to inform choices. This was compounded by the lack of easily accessible and widely disseminated information and visibility about what is really happening.

Actions

1.The original Getting It Right First Time (GIRFT) pilot in elective orthopaedics was funded by the medical directorate of the Department of Health and NHS England and was undertaken by Professor Tim Briggs and his team based at the Royal National Orthopaedic Hospital in conjunction with the British Orthopaedic Association (BOA). It marked an important landmark for the National Health Service (NHS) and the orthopaedic specialty in particular in that it was clinically led, professionally supported, centrally funded project, run from a provider based team.

2.Professor Briggs and his team visited almost every Trust in England as part of the pilot (over 140 Trusts including over 200 hospital sites) and spoken to members of both the orthopaedic and management teams. It is clear that there is a need to look beyond tariff reduction or rationing and to work to identify the many ‘fixable’ variations that are being identified by the GIRFT programme. It is the incremental effect of a mass of improvements that typifies the GIRFT approach and the team are of the view that the task is so huge that providers and clinicians need this external, but ultimately sympathetic and evidence based, approach to help them identify what can and must be done to tackle unwanted variations in outcomes and needless variations in cost.

3.Key features of the approach included: a consolidated view of all available data and metrics pertaining to each provider’s clinical and financial performance at a service line/individual specialty level; a peer to peer review by a leading clinician, using data as evidence to reflect on variation in clinical practice, management approach and variations in procurement e.g. prosthesis selection; the ability to benchmark providers nationally and explore how clinical evidence is considered and informs practice; and a highly detailed approach facilitating an extensive understanding of the links between practice, outcome and cost drivers, which in turn enabled a series of recommendations to be developed benefitting quality of care and finances of both providers and commissioners.

4.The creation of a set of national recommendations that have been embraced by the British Orthopaedic Association, been adopted by NHSI and are now gradually being supported centrally across Health service.

Results

1.Notes - Note re attribution - The GIRFT programme cannot, of course, claim that all positive change in any metric is solely due to its influence as there are many national and local efforts that will also be impacting total hospital and health sector efficiency and quality in orthopaedic surgery and within individual Trusts. However, clinical behaviour is clearly changing in a number of areas where GIRFT has had a particular focus.

Note re methodology - GIRFT has created an initial methodology for assessing the impact it has had to date. It is important to bear in mind that change is slow, and the accumulation of marginal change may take some time to reach a point where it is ‘significant’ and measurable. This is considering both meanings of the word significant: statistically so and in terms of real world worthwhile impact on NHS finances or patient care. The approach GIRFT has taken is to reduce the direct costs of providing an orthopaedic intervention.

For instance, selecting a less costly implant or negotiating a lower procurement price, reduces the spend required for the intervention. This will not increase capacity, however, until the savings are reinvested. In contrast, more efficient theatre utilisation or bed use (decreased length of stay) will increase capacity and reduce average case costs but will not directly reduce spend. Income may increase if the provider uses the additional capacity to treat more patients and help meet waiting time targets.

Cost savings benefit the provider and may turn around a loss-making service, for example a case study from North Bristol Trust reports that hip replacement surgery was transformed from a loss of 22% to a profit of 8% in less than 12 months. Eventually, over time, widespread cost savings will drive down the NHS Reference Cost, and as a result NHS National Tariff rates will be reduced. As a result, the provider’s income will fall, but savings will accrue to the commissioner.

2.There is emerging evidence of change in NHS provision of orthopaedic surgery with clear quantitative impact including: a step change in the method of fixation for primary hip replacement in the over 65 year old cohort with a jump from just under 45% of activity to over 55% between 2012/13 and 2013/14, reversing a long term trend - this alone is worth an estimated £4.4 million per year; reductions in length of stay for primary hip and knee replacements of half a day, creating over 50,000 bed days in released capacity; the initial 71 trusts who have responded to the DH Survey so far indicate direct savings of between £20 and £30 million with an additional £15-20 million of savings in 2015/6; and a fall in orthopaedic litigation claims from 1758 in 2013/14 to 1505 in 2015/16.

3.The Trust responses to the DH Survey also provided qualitative information on the changes in service provision the GIRFT programme is encouraging: a move towards ring-fenced elective orthopaedic beds and a consolidation of activity to facilitate where geographically appropriate; greater scrutiny of the charges applied for ‘loan kit’; early evidence of greater price awareness and sensitivity amongst surgeons; 75% of the trusts who have replied report renegotiation and rationalisation of their implant stock; moves to address appropriate surgeon level minimum volumes; and networks forming to concentrate complex casemix in the right environment for best outcome. It is recognised that obtaining more formal evidence of impact will require longer term and more detailed study.

4.The GIRFT programme was then commissioned and funded by the Department of Health to review eleven further surgical specialties and Professor Briggs was appointed as the National Director for Clinical Quality and Efficiency in the Department of Health to lead the programme. He recruited national clinical leads for each specialty to head up the projects using the GIRFT methodology and approach. The programme is directly linked into the work done by Lord Carter on NHS Productivity and Efficiency and has been informing the development of the Model Hospital programme in clinical areas.

5.Most recently the GIRFT programme has entered a partnership with NHS Improvement and is working alongside the new Operational Productivity Directorate to roll the GIRFT methodology out to a further 19 clinical areas including further surgical specialties, medical specialties and clinical support service areas.

Value

The DH circulated a questionnaire to providers asking 16 questions, this was returned by 71 Trusts. Highlights include: savings of between £20m and £30m with an additional £15-20m of savings forecast in 2015/6. Extrapolating this to 142 Trusts would potentially see savings in the region of £40m-£60m and a further £30m-£40m over the next year. These savings will in the long run inform tariff.

Detailed example - the total procedure cost for cemented hip implants is £600 cheaper on average than for uncemented and there is no evidence that uncemented implants are better in the short or long term for patients over 65-70 years old. There is however evidence that if they do need revision the procedure is much more complex, higher cost and more likely to have clinical complications. The risk of peri-prosthetic fracture is also higher. Therefore, the GIRFT programme has recommended cemented fixation for this patient cohort. Data shows that the proportion cemented fixation has jumped by over 10% between 2012/13 and 2013/14, reversing a long term trend. Based on the price differential between methods and all associated costs (implant, theatre time, cement etc.) this is an estimated saving of £4.4 +/- £0.6 million per year.

In detail

Orthopaedic services share the same challenges as other parts of healthcare in the UK. Rising demand and costs, limited capacity, the desire to improve outcomes, safety and patient experience, and the need to work to very tight budgets are common to all specialties. In response, the GIRFT programme was developed to address these challenges without the need for radical change or additional investment, but by concentrating on making the best use of currently available staff, skills, tools, techniques and facilities to achieve significant and sustainable benefits. The principles underpinning GIRFT are that it is clinically led, and develops a consensus based on sound evidence, using comprehensive and reliable data to understand issues, prioritise areas for action, and to drive and monitor change.

Furthermore, the principles and methods used mean that the approach used by GIRFT is not confined to orthopaedics. The opportunities identified and approaches proven here are widely applicable and are now being rolled out to a total of 30 specialties and clinical support areas in partnership with NHS Improvement. GIRFT concentrates on eliminating undesirable variation through agreement on and standardisation of best practice with the priority to improve quality and drive reductions in poor clinical and cost outcomes, and patient and staff experience. The concept that ‘high quality first time’ costs less in the long run is well evidenced in healthcare and GIRFT is a way to achieve this.

Getting It Right First Time has six underpinning principles:

• Do the right thing

• Make sure you have the right patient

• Do it the right way

• Deliver care in the right setting

• Do it well

• Combine and coordinate efforts

The pilot study

The Pilot involved examining the data and creating indicators to measure performance. In addition, the team set out to speak to orthopaedic units across the country in order to gather the qualitative aspects that complement the quantitative analysis. In total, 220 hospitals across 144 acute trusts were visited by clinical leaders, with a unique dataset on orthopaedic care and outcomes. 1,634 consultants, 400 senior managers were met during these peer-to-peer reviews.

Pricing letter

Professor Briggs wrote to all orthopaedic departments in June 2015, following the August 2013 Department of Health publication ‘Better Procurement, Better Value, Better Care’ and established the National NHS Procurement Efficiency Programme. Under the GIRFT principles of ensuring quality is maintained or improved, the price ranges for certain hip and knee replacements were provided to the reader. The aim being to empower clinicians in re-evaluating their prosthesis selection, taking into account the improved transparency that the GIRFT team has facilitated and published.

Questionnaire

In January 2016 the Department of Health circulated a questionnaire to 142 Orthopaedic centres asking 16 short questions that aimed to gather otherwise invisible but crucial data on variation in cost, process and outcomes, in order to get an early indication of the impact of the programme to date. 50% completed and returned this (71 Trusts) and they indicated direct savings of between £20 million and £30 million in total to date (with an additional £15-20 million of savings forecast in the next 12 months). Extrapolating this to 142 Trusts would potentially see savings to date in the region of £40-£60 million and a further £30-£40 million over the next twelve months.

British Orthopaedic Association Guidance

In February 2016 the British Orthopaedic Association (BOA) published guidance to its membership to help Trauma & Orthopaedic Surgeons and departments assess their practice and ensure that they are compliant with GIRFT principles. The guidance is a framework for units and surgeons, individually and collectively, to examine their own practice and respond to and address any issues that might arise, so facilitating high quality local governance, aiding effective appraisal and optimising local care delivery. GIRFT as a health economics programme GIRFT has proven to be successful in attaining marginal quality gains via the promotion of best practice standards in orthopaedic decision-making. GIRFT has also been successful at delivering effective marginal efficiency gains through procurement rationalisation, bed day consumption through reduced length of stay and reductions in costly readmissions.

GIRFT, from the health economics viewpoint, is a successful programme to improve the efficiency and improve quality. The programme delivers efficiency gains and utility gains. GIRFT was developed to address unwarranted variations in the quality of clinical outcomes. However, they have arrived at a de facto health economic solution as well. The idiosyncratic forces that operate in health care economies, mean that marginal gains can be reversed if we do not maintain control and improve. The way to ensure that this progress continues, is to improve the quality of data collection, analysis and distribution so that the GIRFT programme continues to provide detailed intelligence of increasing value to Trusts.

GIRFT – The Future

The next steps of the GIRFT project are to continue to refine the methodology in orthopaedics and continuing to roll it out to a wider audience, which will enable improvements in the quality of care, and efficiency savings to be scaled up dramatically. The programme has been successful as it has brought both the right data and the right people together on an increasingly large scale. Now that GIRFT has attracted the necessary momentum and interest, the next steps are therefore to address the inequalities we have identified.

We have called this the GIRFT Charter:

•To improve the quality of patient outcomes

•To improve patient experience

•To enhance safety

•To address unacceptable variation in practice and outcome

•To challenge unacceptable and wasteful practice

•To identify and disseminate best practice

•To provide hands-on clinical consultancy and intervention to effect rapid change

In order to do this, GIRFT must be supported by:

•Ramping up the reliability and consistency of NHS data

•Driving behaviours towards best practice and supporting Trusts adequately with further site visits

•Improving clinical coding

•Taking control and improving the efficiency of NHS procurement by rationalising implant choice and inventory

•Promoting the processes identified by GIRFT by introducing best practice tariffs

•Supporting NHS innovation as a driver of a Vanguard project

•NHS scalability and potential reach