Press Release - Hip replacements: getting it right first
time
19 April 2000
Sir John Bourn, head of the National Audit Office, reported to
Parliament today that many NHS trusts and orthopaedic consultants
apply good practice in the way that they handle total hip
replacements. However, there are significant variations in
performance, and there is need for good practice to be spread more
widely for the benefit of patients. There is also a need to address
the lack of evidence of long term effectiveness for some hip
prostheses in use, and weaknesses in the process for introducing
new prostheses.
NHS performs over 30,000 total hip replacements each year. They
are generally highly effective, reducing pain and increasing
mobility, at a total cost to the NHS of some £140million a year.
Most patients are implanted with one of a small number of
established designs and can expect their new hip to work
effectively for some ten to fifteen years. However, there are over
60 different hip prostheses available, and evidence of long term
effectiveness is not available for all those in current use.
Moreover, while current procedures for approving hip prostheses
ensure that they are safe, these procedures cannot ensure their
long term effectiveness.
Most patients requiring a hip replacement receive an excellent
service from the NHS. Nonetheless there are widespread variations
in such areas as the follow-up of patients after their operation,
and the supervision of surgery. Pressure of work and lack of funds
are the main reasons given by consultants for why only a quarter
follow up patients after hip surgery for life, though more than
half believe this should be done. In addition, eight percent of
orthopaedic consultants perform less than 10 primary replacements a
year, and 71 per cent perform less than 10 revisions a year. In the
National Audit Office’s view this may be insufficient to ensure
outcomes of hip surgery are maximised, particularly in revision
surgery.
NHS trusts spent £53 million on the purchase of prostheses in
1998-99. Many have taken initiatives to reduce purchasing costs,
but there is scope for NHS trust to do more to reduce costs. This
could save £7 million a year in total, though the potential for
savings at individual trusts will vary significantly. Many trusts
and consultants believe that length of stay for patients could be
reduced from the current average of 11 days, though most trusts
have no plans to do so. A reduction of between 2 and 6 days could
save NHS trustsbetween £15.5 and £46.5 million each year, though
this does not take account of any additional costs to the overall
health systemresulting from early discharge, such as community and
social care.
In the light of these findings, based in part on major surveys
of orthopaedic consultants and NHS trusts, Sir John makes 20
recommendations for improving the service provided to patients who
require total hip replacements. In particular:
- the NHS Executive and the Medical Devices Agency should take
further action to ensure the effectiveness of new hip prostheses.
In particular we recommend that consideration be given to requiring
that hip prostheses are subject to appropriate trials before they
enter general use in the NHS;
- trusts should consider restricting the prostheses used to those
with long term evidence of effectiveness, in line with the recent
recommendations by the National Institute for Clinical
Excellence;
- the NHS Executive in consultation with National Institute for
Clinical Excellence and the British Orthopaedic Association, should
explore whether consultants should perform a minimum number of
primary and revision hip replacements to maintain their expertise,
and consider issuing guidance;
- trusts should review the scope for improving their prosthesis
purchasing procedures to save costs, while maintaining quality
standards;
- trusts should ensure that where operations are carried out by
non-consultant grades without consultant supervision, there are
effective risk management assessments and procedures in place;
and
- trusts should take steps to prevent unnecessary length of stay
in hospital.
Sir John said today:
"Hip replacement surgery is a procedure that
successfully improves the lives of tens of thousands of people each
year. However, the current process for introducing new hip
prostheses into the NHS cannot always ensure long term
effectiveness, and if a hip prosthesis performs poorly, it can have
serious consequences for the patient. We have also found variations
in practice between NHS trusts and between orthopaedic consultants
on a range of issues such as the purchase of hip prostheses,
supervision of surgery, length of patient stay in hospital, and
follow-up after operation. In these and other areas, all trusts and
consultants need to follow good practice for the benefit of
patients. My Report also contains a list of 19 questions patients
can ask in connection with their hip replacement."
Notes for Editors
Press notices and reports are available from the date of
publication on the NAO website at http://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 employing some 750 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 29/00
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