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.