Tim Briggs, National Director of Quality and Efficiency, Department of Health, and Consultant Orthopaedic Surgeon at Royal National Orthopaedic Hospital NHS Trust, discusses how hospitals can improve care, reduce unwanted variation and deliver better value.
This presentation was recorded at our conference, How changes in clinical practice can deliver better value, on 22 June 2016.
So we’ve all in this room got a massive problem, and I’m going to use musculoskeletal because I’m an orthopaedic Surgeon at the Royal National Orthopaedic Hospital. I'm still a frontline clinician and in orthopaedics we have a massive problem. We’ve got a great population that’s ageing, we’re living longer with increasing BMI, we’re going to need increasing demand. And we’re big players in the provider game in that we’re 33% of the surgical workforce and 25% rising to 26^ now of all surgical interventions in the provider sector is due to trauma and orthopaedic surgeons.
Now the great thing is we want to keep people active, we want to keep people independent and therefore if you look at the National Joint Registry that was set up in 2003 and look at the number of hip and knee replacements that were registered in 2004 it was 47,000, fast-track that forward to 2014 and in one year alone it’s now over 200,000 joint replacements in year. And then if you look on the right side of the screen there the increasing numbers of hip and knee revisions as these joints wear out, therefore there is an increasing financial burden to treat these because they are expensive procedures.
Now the elephant in the room is we’ve all got the same problem, and the healthcare systems around the world are struggling with just as much as we are. How are they going to maintain healthcare for their populations with this massive world debt of over $58 trillion? And we know what we’ve got in terms of the NHS settlement but we know that by 2020 we’ll be running the NHS on about 7% of GDP whereas currently it’s 8.6%. So we have to do something differently. If we don’t we’re going to see what you see on this slide.
On the left hand side is England, the areas in red are where there is a reduction in hip and knee replacement despite the fact we’ve got a population that’s ageing and on the right side is we’re now beginning to hear from some CCGs again about hip and knee replacements being of limited clinical value, which is absolutely crazy because if a hip and knee replacement lasts you 15 years it works out about £7.50 a week which is cheaper than lots of x-rays, lots of physiotherapy etc. and anti-inflammatories.
So we’ve got to find another way if we’re going to succeed. So as professionals in healthcare and in the provider side we can no longer bury our heads in the sand, we’ve got to think, because if we don’t the person that’s affected more than anybody else is that lady in the bed, not the younger people around there, it’s the elderly patient in the bed and often they don’t have the voice that they should have to get timely and effective care.
So if you look at London, because this is where I work, we’ve got an annual health budget of about £16b, we spend £1b on primary care, £2b on mental health and £13b on providers which is where I work and if we are the major cost, which we are, then we as clinicians have to make the changes to our practice that is going to influence outcome and allow us to continue.
So I ask you, how do we justify this? So those who are non-medical, on the left hand side is a hip and it’s a 65-year-old patient who’s got an arthritic hip. Just to the right of that is what’s called a cemented hip replacement, the cost to the NHS is about £650. The surgeon, however, chose to use the components on the right hand side of the slide and that is a very expensive implant, a cost of £5,000 and yet there is no evidence to show that that £5,000 produces a better outcome or increased survivorship for the patient on the left who had a cemented implant which is £650.
Likewise, this is a patient with arthritis of the knee, and on the left side is what we call a half a knee replacement and in the first three years that has already been revised twice. And then on the right hand side they’ve used the same implant a year previously and already we now see that there is arthritis on the other side so that needs revising. So how on earth can we put up with revision rates of half knee replacements within ten years are something like 16% whereas in a total knee replacement are only 3%, because the added cost on the revisions.
So I wrote this report and Chris was kind enough to reference it in his introduction and it was all about, in orthopaedics, improving the quality of care, re-empowering clinicians to do the job well and I felt that that would improve safety, reduce complications by improving outcome. And so the Secretary of State and Bruch Keogh kindly gave me a grant of £200,000 and on the basis of that report we then looked at elective orthopaedics as a national pilot. I recruited a team of six who have been absolutely brilliant, and we collected twelve sets of data for every single trust in England and then we got that data set together, it had never been put into one document before, and then we sent it out to every single trust and after they had received their document I and two or three others went to visit all those hospitals.
So the project began in May 2013 and the report was published in March 2015 and I have visited, if you include Wales, Northern Ireland and Scotland now, and I did part of Western Ireland yesterday and on Monday, I have personal visited 258 hospitals to see clinicians, discuss their data and when you discuss a data set in a non-confrontational way because it is a peer to peer clinical review, the actual solutions because obvious. So what do I mean? So Jeremy Hunt mentioned about infection rates. Well this is ten hospitals in a major city and we had all the ten trusts in the same room at the same time. And if you look at their deep infection rate for hip and knee replacement you can see it varies from 0.19% to 4.49%. Elsewhere around the country we saw hospitals where the infection rate was 5% and in one hospital in London for a period of three months it was 15%. Okay? No-one in this room or their family would go to a hospital to have their joint replaced in a hospital that has a high infection rate.
Now if we go to improve and we can quite easily, and reduce the infection rate across the country to 0.2% then you would save, at a stroke, the NHS every year £250m to £300m, £1.5b over five years and that would allow you to an extra 60,000 joint replacements if that’s what you chose to do with the money at no added cost.
This is a funnel plot which shows patients who are aged 60, who have an arthroscopy where you put a telescope in the knee, and then they have a knee replacement within one year. So you could say why on earth are you doing the arthroscopy? Now each of those little round blobs there is a trust in England and look at the variation in practice there. And look at the variations in those trusts which are two and three standing deviations above the mean. Why are we doing that? And then when you compare us to Scotland, for patients who are having telescopes put in the knee, arthroscopies in the age 60 to 74-year-old, why is ours over 200 per 100,000 population and in Scotland it is now just above 95? Why is there that difference? And we’ve got to address it.
We also found low volumes of surgeons doing low volumes and low numbers. So the number of surgeons that we found in England doing less than eleven hip revisions a year was 61%. And again I would suggest to people in this room that no-one would go and have their hip revised by a surgeon doing such a low volume. But the added cost to that is if you’re doing low volumes you then have loan kit costs because the hospital gets in the kit because you don’t do it very often and you pay full market value for the prosthesis and we found on average in England trusts paying £200,000 plus a year for loan kits and 30% of those loan kits weren't used, but some trusts were paying over £760,000. Dead money and money that goes back to the implant companies, so something we have to do something about.
And then when you look at half knee replacements which I showed you earlier, we found that 75% of surgeons were doing less than ten of those a year, and do you know what the commonest number was around the country? It was one. And the second commonest number was two and the third commonest number was three. And really that is unacceptable practice. And then when you look at revision knee replacements which are very expensive and complicated 81% of surgeons doing less than ten a year. So clearly we’ve got to do something to change clinical behaviour in clinical practice because not only does that not produce the best outcome for the patient it’s also the most expensive way to do things.
And it’s not just in hip and knee replacements, this is the same ten trusts in the North of England, 46 elbow replacements being done by those ten trusts, look at that, 31 elbow replacements done in one hospital and then the rest done in small numbers in the others. Since we’ve been there all those elbow replacements now are done in the big hospital and the other surgeons who still want to do it move to that hospital in order to do that surgery.
We’ve now got to start using the evidence base, and we’ve got a lot of evidence now through the National Joint Registry that certainly in patients over 70 hip replacements, cemented hip replacement is probably the most clinically effective, will outlast the patient and actually is the cheapest. But actually what we’ve seen is a trend of going to the un-cemented route, thinking it’s nice and shiny, the implant companies drive it and it’s about three times the cost compared to a cemented hip replacement.
So again this is Manchester, and other trusts around the country and yellow is un-cemented, blue there is cemented and why do we have in one trust 98% of the hip replacements are cemented, in another trust only 4%? Why is there that difference? We need to change that variation. And we do it by the National Joint Registry assessing outcomes and seeing where trusts are on the funnel plot to see whether they are outliers or they’re producing best value and best quality, reduced complications.
Now in spinal surgery I have to say I think it’s like the wild west out there, and I'm going to give you an example. So let’s go to Teesside where I’ve been to, there’s North Tees and South Tees, North Tees has a capital population of 226,000. South Tees has a population of 523,000 and there’s that river isn’t there in between. Well I have to tell you that river might as well be 600 miles wide, because of the differences in practice across that river. So if you look at North and South Tees and you look at their analysis for spines, why is North Tees with half the population doing three times as many facet joint injections, why is it doing three times as many injections into the joint and then when you come to fusions why is it doing twice the number of fusions with only half the population? And that was the question we posed to both trusts either side of the river. And what’s happened now as a result they never really shared that data and now they’re working together in MDT and you will see significant change of practice I believe in terms of what happens in terms of back surgery.
So let’s move to London. There was a national spinal registry that was mandated by CCGs that surgeons should input it in their data for the last five years. Do you know something? Only 15% of the data has been inputted. So why have we got this huge variation across London? And we need to look at the centres that are doing high volumes but we also need to look at the centres that are doing low volumes and suggest should those centres actually be doing that sort of work?
Now Chris talked about litigation. Litigation is going through the roof and it’s frankly going to be unsustainable. So the potential liability in 2010 for the NHS was £15.5b, by 2013 had risen to over £23b and in 2011/2012 the NHSLA paid out £863m and in 2012/2013 £1.2b. Now if you look at what are my speciality we are now more than 50% of all claims, if you strip out obs and gynae. So in 2003/2004 we paid out £39m in one year, 2011 and 2012 we paid out £187m in one year and we looked at the four causes and we looked at the 28 causes and the top four are judgment, tissue damage, procedure and unsatisfactory outcome. They are all totally preventable. But what was interesting is trusts never discuss this data between the clinicians and the management and so what we did with the 2011/2012 data we drilled it down to what we called an orthopaedic spell. So anybody going to hospital for an orthopaedic procedure what was the cost around the country for the litigations coming out of that? And it worked out at about £54.42
So we then, as an example, I’ll give you Manchester again. The top trust wouldn’t let me show you their data so you can read into that what you will, but if you look down the group it varied on that year £36 to £134. We went to some trusts where it was zero, but some trusts where it was over £150 for every orthopaedic procedure and in those trusts they didn’t realise it but it was a recurring theme. And so they were poor the year before, they were poor the year after and it was a theme that was not discussed with the clinicians and not discussed across the clinicians and the management board. And now part of the dashboard that we’re developing will become part of that, because we’ve got to drive those costs down.
Now let’s just look at costs of implants, okay? And this is a graph which shows types of implants and if you look on the left hand side that pinky-red and that is a metal on poly, which is a very good implant, it also happens to be the cheapest. So we found Basingstoke had the best value of the implant, so they use what’s called a 10 A rated implant which is very good and they pay for that implant £438. But we went to other hospitals where the mesne price was £1,000 and we went to one hospital where it was over £4,000. Well how is that unacceptable and why on earth do we have that huge variation?
And this is a trust, when it comes to complex revisions, that is doing low volume so they’re doing 84 revision hips a year, they’ve got 15 surgeons, so a third of them are doing less than five a year and you don’t need to see the actual detail but that shows they’ve got seven different types of implants, they’re paying full market value for it, loan kits, it’s just crazy and everybody is winning, the only people that are winning are the actual implant companies. And when you come back to spines, my god, I talk about the wild west, it is unbelievable.
So you can buy a screw that you can put into a back and it can be £32, but you can also buy a screw for £600. You can look at a rod to stabilise the back at £672, but you can also pay £1,000 and we spent £100m on this sort of surgery with spinal instrumentation and actually if you said to me, “Where’s the evidence for long term ethicacy for patient outcomes?” the data is pretty poor when you compare it to un-instrumented fusions. And it is again something that we are going to definitely address.
Another theme that we found, and I think it’s very important to say this, is loss of morale and disengagement through all the trusts I went to. A top down approach will not work, it is not working, you get complete disengagement by the orthopaedic and all the clinical staff, they do the minimum, they won't do the extra and actually then outcomes are affected. And so what we’ve got to do is I call it shoulder to shoulder, I played a lot of rugby when I was younger, I played against some horrible people I have to tell you in Wales and France and if you didn’t stick together you were in for a very very uncomfortable afternoon. And that says things very mildly. So we’ve got to start working shoulder to shoulder if we are going to solve this problem.
The other big issue is we’ve got 129,000 beds and everybody told me wherever we went, “Tim our beds are blocked, 30% of patients are ready to go but we don’t have anywhere to put them” and so I’m working with Patrick Carter, I'm looking at a model of step-down beds to try and increase the discharge rate that we can get patients out of hospital allowing us to increase the number of patients that we can put through in our trust.
So what did the pilot show me? It showed that there was huge variation out there, in practice outcomes, and I have to say as an orthopaedic surgeon working at a hospital that’s rated in the top three in the world I assumed everybody was doing what I was doing, and I would echo what Jeremy Hunt said and Mike Richards says, the variation out there is unbelievable and it’s something that we do have to address and we have the scope I believe to tackle that and actually many of the answers are already out there but where there is no consensus about what’s best practice we have to provide it.
So let me just tell you about the £200,000 I was given and what’s it done, just by spending that £200,000. We’re already seeing a reduction in length of stay after knee replacement, with an increase in the number of patients from 2013 to 2015 discharged within four days. We’re already seeing a reduction in the length of stay for primary hip replacement so that was 2012 and 2013 and you can see how the graph has shifted. But what’s interesting is there are some hospitals that have done absolutely nothing. So what we’re going to do, we’ve sent them out their second lot of data and I’m going to visit the bottom 25% and then marry them up with the top 25% so we get the synergy of improving across the piste.
And I’m pleased to say we’re seeing an increase in a fixation trend of cemented in the over 65s and a reduction in un-cemented and that now is gathering pace because we’re out there telling the surgeons they’ve got to use the evidence to do that. And we’re seeing an overall reduction in complication rates of 30 days’ re-admission rates in all orthopaedics. So what’s that done, spending that £200,000? We’re seeing a reduction in length of stay, use of cemented implants, ring-fence beds where the surgeons have a ring-fence to reduce the infection rate, reduction of loan kits and just reducing the cost of hip and knee replacement irrespective of shoulders, elbows, ankles, and spinal implants, reduction in arthroscopy rates and low volume surgery. So I now have some really good evidence that by improving quality, reduction in complications, that £200,000 has already saved between £60m and £90m. And that is just scratching the surface.
So we’re now in the implementation phase and to do that you’ve got to have your professional association behind you, which we do, and the BOA has now put out some implementation guidance for GIRFT and it is going to change orthopaedic practice in the provider side absolutely. So I want to be able to say when a GP or CCG buys hip replacements or knee or shoulders, elbows, ankles, from any trust in the country it’s best quality, best value and low complications, and I think we will get there. And the answer has got to be hub and spokes where you define the units, you define your numbers, you want gold standard, you want low infection rates, robust audit and review outcomes, and that’s what we will see and I’m pleased, and the guy here is from Leicester because Leicester is a great example. They had surgeons on three hospitals they’re now on one site, seven theatres, 33 consultants, three wards, morale through the ceiling, complications through the floor, productivity up, efficiency up and actually much better training for their trainees. And really this support, the five year forward view about improving the clinical outcomes and the key to delivering this is the orthopaedic dashboard. And so we’ve had a lot of conversations with the CQC, we know their five categories, we’ve added another one, does it make best value of a resource, and we now have up on the model hospital portal the first orthopaedic dashboard for every single trust in England, we’re going to get the orthopaedic trust to actually refresh that every six months and then once that’s up and running every three months and then we’re going to share that data for trusts to be able to look at other trusts and on-one wants to be in the bottom 25% and then what I want to do in the future is let patients see it and CCG see it. And it allows you to put in what you want in terms of what you expect out of the outcome and this is about responsive care and then most importantly it allows you to look at the variation chart and if you’re in the red there, which this hospital is, the round blob, you’re standard deviations the wrong side of the mean.
And so the CQC will be able to look at lots of data and look to where the trusts really are not performing and where they need to improve. And so in terms of effective care, this will actually drive the agenda.
So this has gained huge amount of attraction as you can imagine amongst politicians in DH and I’m now working with Tim Evans who’s speaking later on and we’ve now got the go-ahead to drive this same model using the same girth methodology into all the surgical specialities and now into all the medical specialties and I have a meeting on Thursday at DH in terms of the funding which has been promised and will come. So my team is going to grow from five to about 120, we are going to take each individual specialty, we’ve appointed already ten national clinical leads for the other surgical specialties, the ones in red they will be appointed over the next two to three months, they will get the methodology, they will get all the evidence and they will be going out to see every individual trust to have this peer to peer clinical review and drive the agenda. And it has the full support of NHSI, Carter’s report says the solutions of the GIRFT groups must be implemented in its totality and therefore we have a mandate, Tim and I, to drive this agenda and once you’ve got that right you can then look at your productivity and further efficiency gains. But at the moment we’ve got to sort that out.
So what I would say is we’ve got a big problem, we all understand ageing population and no money, so we’ve got to make sure we accumulate and follow the evidence transparency, and it’s not just evidence here, it’s the world evidence, we’ve got to change behaviour of clinicians and that is already happening, we’ve got to re-empower clinicians, give them the right environment, the tools to do the job and we’ve got to reduce the variation in practice and complex cases are not for everybody. So appropriate selection of patient right procedure, implants, outcome and cost and reduce complications such as infection as we’re doing and we’ve got to contain and reduce litigation.
If we do that then we are making a massive stride to make sure the tax payer is getting best value for money and patients are getting the best care.
Thank you very much indeed.