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(Elective) hips don't lie


Our recent report illustrated how financial pressures in the health system are having a very different impact in four different service areas. Whereas genito-urinary medicine and district nursing services have seen an impact on access to, and quality of, their services, neonatal and elective hip replacement services were not affected to the same extent by the same pressures. However, for elective hip replacement services, despite having much to celebrate it appears the impact of financial pressures is beginning to show.

National data shows that the number of elective hip replacements increased by 90 per cent between 2000/1 and 2015/16. While some of this growth can be attributed to population increase, the growth in the rate of elective hip procedures is far higher than the rate of population growth in the elderly, who are the main recipients of such surgery. There have also been dramatic improvements in elective waiting times (for all patients), with average waits reducing by about nine weeks since 2007. All of which suggests an expanding service treating more patients.

It is also a very successful procedure, with 96 per cent of patients reporting an improvement in their condition following surgery, and an article in The Lancet called hip replacement ‘the operation of the century’.

However, there are signs that the expansion in hip replacement services may be slowing. The number of elective hip procedures decreased in 2015/16 by 1 per cent compared to 2014/15. This was the second time in three years that activity was lower than the year before.

This isn’t due to reduced demand; the number of patients waiting for treatment has grown each year since 2012/13. At the same time, average waiting times for trauma and orthopaedics – which includes elective hip replacements – were a week longer in December 2016 compared to December 2015. This means there are more patients needing treatment and they are waiting longer to receive it.

Why is this happening? Elective hip replacements are provided in acute hospitals, where bed-occupancy rates have been running high for the past year: a result of rising emergency admissions together with growing delays in discharging patients. One way to ease this capacity problem has been to delay (or simply cancel) elective activity.

At the same time commissioners have been looking at how they can manage demand for hip replacement services (as they have for all services). While some local areas have used capacity in the private sector to help meet waiting times targets, others are looking at more fundamental changes to manage demand.

Some areas are looking at changing how they contract elective hip replacement services. There is evidence that some commissioners are changing their fee-for-service contracts to fixed budgets, while other commissioners are looking to implement prime-provider contract models, an integrated delivery model. There is some uncertainty about whether this is happening to improve patient pathways or to shift financial risk from the commissioner to their providers.

Some areas are using referral management to manage patient demand. Though not new, the use of referral criteria – sometimes based upon an individual’s weight and whether they smoke – has been expanding. This has sparked debate at the highest levels about how clinically based these referral criteria are and to what extent they should be used in future.

While recent debate has focused on increases in waiting times and referral thresholds, it’s worth reflecting that we are only able to have these debates because there is so much data available for elective services; all acute hospital activity is recorded in Hospital Episode Statistics that are routinely reported by NHS Digital, while elective hip replacements are part of the 18-week waiting times data recorded by NHS England and form part of the Department of Health’s Mandate.

Commissioners have a responsibility to make their referral criteria for acute care publicly available, meaning we can keep track of how many are doing so. This was not the case for the other service areas we studied, where a lack of data meant that we were unable to do similar analyses. The plethora of data makes it difficult to enforce significant cuts on elective hip replacement services.

There has been much to celebrate for people accessing elective hip replacement services over the past 15 years, but progress looks uncertain for the foreseeable future as operational pressures on hospitals remain and priorities change.

Whatever direction elective hip replacement services take over the next decade, we will have the data available to show us. At the end of the next decade, I’d like to be able to do the same for a wider range of services.