Press Release - Hip replacements: an update
17 July 2003
NHS patients receiving hip replacements have received an
improved service over the last three years, according to a report
today from the National Audit Office. But it will take time for
developments to take full effect and more remains to be done to
ensure improved quality of care to patients. This includes making
sure that surgeons use replacement hips that meet the National
Institute for Clinical Excellence benchmark, and reducing the time
patients stay in hospital.
In April 2000 the NAO published its first report on hip
replacements, over 43,000 of which are performed in the NHS each
year. This highlighted significant variations in performance across
the NHS and noted the need to spread good practice more widely for
the benefit of patients. Twenty recommendations were made for
improving the service provided to patients requiring hip
replacement. The Public Accounts Committee subsequently reported on
the subject and made its own recommendations for improvement.
The effectiveness of replacement hips remains a central issue.
For many of the hip replacement prostheses on the market, there is
no evidence that they are effective over the long term. Todays
report by head of the NAO Sir John Bourn points out that 90 per
cent of consultants use prostheses which comply with standards set
by the National Institute for Clinical Excellence - but is critical
of the remaining ten per cent who have no adequate evidence of
effectiveness for the prostheses they use. The establishment of a
National Joint Registry is welcomed by the report and should
provide valuable information on choice of replacement across the
country.
Incentives are offered by prosthesis manufacturers to trusts and
to consultants to use new versions. The report expresses concern
that such incentives to trusts may unduly influence their
purchasing decisions. Some two-thirds of incentives accepted by
consultants mainly overseas trips for training - were not properly
registered, and 40 per cent of the 24 consultants who accepted
overseas trips did not go through an approval process.
Todays report shows that the percentage of consultants who
consider that a quarter or more of their referrals from GPs are
inappropriate has increased over the last three years from six to
ten per cent, imposing an unnecessary burden on patients and the
NHS. But the average wait for a hip replacement following an
outpatient appointment is eight months substantially better than
the NHS target of a maximum of 12 months. Concern is expressed,
however, that one in ten consultants decide on the priority of
their patients for hip replacements mainly on the basis of the need
to meet waiting time targets - rather than on clinical urgency.
Patient length of stay in hospital has decreased significantly over
the last three years; but the report suggests that it could be
shortened further, partly through the greater use of integrated
care pathways. The result could be more patients receiving
treatment.
The April 2000 NAO report concluded that some consultants may
not carry out enough hip replacement operations to maintain their
expertise and ensure that the outcomes of surgery are the best
possible. The low volume of hip operations by some surgeons remains
a concern, with some ten per cent still carrying out ten or fewer
operations each year.
Among the NAOs recommendations are that the Department of Health
draw up templates for an integrated care pathway for hip
replacement. Chief Executives of acute trusts should develop
protocols to ensure consultants use prostheses that conform to the
National Institute for Clinical Excellence guidelines, monitor
length of stay for patients, evaluate the risks involved with
consultants who carry out few hip replacements, and put in place
arrangements to verify that all consultants comply with NHS
guidance on commercial sponsorship. The Commission for Health
Improvement should ensure that it examines levels of compliance
with National Institute for Clinical Excellence guidelines and
whether trusts maintain and monitor registers for commercial
sponsorship.
Sir John Bourn said today:
"Since my last report on hip replacements three years
ago, the NHS has improved its procedures thereby providing better
quality of care for patients. There is still further progress to be
made, however, including the spreading of good practice, to ensure
that the service provided by the NHS is as good as
possible.
"Hip replacement is one of the most common and effective
major surgical procedures. But there are some question marks over
how hospitals are managing the process, not least to ensure that
the replacement hip used has a satisfactory track record. Strong
leadership within hospitals is the key to ensuring that these risks
are managed effectively for the benefit of patients."
Notes for Editors
- Integrated care pathways map out a patients journey
while in hospital. They can have significant benefits for both the
patient and NHS.
- Press notices and reports are available from the date of
publication on the NAO website at www.nao.org.uk. Hard copies can
be obtained from The Stationery Office on 0845 702 3474.
- The Comptroller and Auditor General, Sir John Bourn, is the
head of the National Audit Office which employs some 800 staff. He
and the NAO are totally independent of Government. He certifies the
accounts of all Government departments and a wide range of other
public sector bodies; and he has statutory authority to report to
Parliament on the economy, efficiency and effectiveness with which
departments and other bodies have used their resources.
Press Notice 53/03
All enquiries to Barry Lester, NAO Press Office:
Tel: 020 7798 7937
Mobile: 07748 181692