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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.

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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.

"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."

Sir John Bourn


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