Royal National Orthopaedic Hospital delivering service improvement for the NHS, including the Getting It Right First Time programme

The Getting It Right First Time (GIRFT) programme supports improvements in clinical efficiency for aims to support improvements in clinical efficiency for 35 workstreams, 12 of which are surgical, 19 of which are medical and the remainder of which are cross-cutting. Both the GIRFT and the Clinically-Led Quality and Efficiency programmes report to the NHS Procurement and Efficiency Board within NHS Improvement. It is funded by the Department of Health, and this funding is currently in place. The GIRFT Team consists of employees of the Royal National Orthopaedic Hospital (RNOH), who are the sole data controller who also processes data for the purposes described within this Agreement. Neil Wilson Associated Ltd were previously listed as a data processor but they are no longer processing the data provided under this Agreement.

The GIRFT methodology include two main features: (1) peer-to-peer meetings between a clinical lead and clinicians and senior managers from acute NHS hospitals to review clinical practice and surgical performance; (2) these meetings are supported by a broad selection of clinical, quality, cost and performance metrics. The metrics are used not to judge, but to encourage further investigation and understanding of clinical practice and the service delivered by hospitals.

Hospital Episode Statistics (HES) data will be used to calculate some of the metrics that are used to support the peer-to-peer discussions. The HES data will be used to calculate a range of activity and quality metrics for the 11 surgical and 24 medical specialties at hospital and Clinical Commissioning Group (CCG) summary level. The calculated metrics (along with metrics calculated using other data sources) will be used to populate several GIRFT output products. Both individual year values and trend values will be reported in these products.

Hospital and CCG summary level values will be reported in hospital, regional and national data packs and reports (GIRFT output products). The GIRFT metrics calculated from HES data will be published publicly in the Model Hospitals dashboard (the web-based dashboard developed by the Clinically-Led Quality and Efficiency programme and sitting within NHS Improvement) with small numbers suppressed in line with the HES Analysis Guide.

The metrics will also be used to support research relating to issues arising from the GIRFT programme – such as reduced disability leading to faster return to work, reductions in surgical site infections, and increases to ward-based critical care thereby reducing the cost of critical care overall. Analysis and evaluation based on HES data may be submitted for peer-review publications, with small numbers suppressed in line with the HES Analysis Guide.

HES data will also be used to benchmark coding quality. Information about the ICD10 (International Classification of Diseases) and OPCS (UK clinical coding) code combinations used to identify specific procedures will be examined and reported back to Acute Trusts. This analysis may include small numbers when reported to Trusts. Only activity in procedure or patient groups defined by ICD10 or OPCS codes will be returned – no person identifiable or data fields will be included.

The GIRFT Team will include small numbers in products reported direct to Trusts because one major issue that the GIRFT programme aims to address is Trusts who are delivering small volumes of complex surgical procedures. If a surgeon, and particularly if a Trust, is delivering small volumes of a specific complex surgical procedure then this is likely to be less safe for patients. Clinical outcomes for surgeons delivering small volumes are likely to be worse than for surgeons delivering larger volumes.

The GIRFT output products contains a wide range of metrics, some of which are calculated using HES data.

HES data are processed in the following way:

• FCE (Finished Consultant Episode) records will be grouped to spells using the Local Payment Grouper software (www.hscic.gov.uk/article/3938/HRG4-201415-Payment-Grouper);

• National Tariff Payment System rules will be applied to the data (note: this will include linking the Inpatient HES dataset to the Critical Care HES dataset to ensure the correct calculation of excess bed day national tariffs);

• National and indicative tariffs will be applied to spells, including all National tariff adjustments;

• Various performance metrics will be calculated at Acute Trust and CCG level, and trend values will be calculated using HES data from different financial years

The performance metrics will relate to:

• Original surgical specialties - orthopaedic surgery, spinal surgery, cardiothoracic surgery, ENT, general surgery, gynaecology, neurosurgery, oral and maxillofacial surgery, paediatric surgery, urology, and vascular surgery.

• New medical & surgical specialties - dentistry, breast surgery, plastic surgery & burns, general medicine, emergency medicine, intensive care, imaging &radiology, cardiology, geriatric medicine, outpatients, respiratory, dermatology, neurology, rheumatology, gastroenterology, diabetes, endocrinology, pathology, renal services, paeadiatric medicine, oncology, trauma, mental health and independent sector.

HES data processing will occur at two sites, Royal National Orthopaedic Hospital (RNOH) and NA Wilson Associates (NAW), The processing activities described above will occur at both these sites.

For clarity, the following is a description of the current activities (at December 2018) undertaken by the various organisations listed in this application:

. RNOH - data controller, storage location, processor and processing location. Analyse HES data for inclusion in GIRFT outputs as described above.

. Iron Mountain - storage location. Backup storage site for RNOH.

HES data will never be linked with any other data (except the HES inpatient to HES critical care linkage discussed above).

Hospital and CCG aggregate level values will be reported in hospital, regional and national reports and data packs. Research related to the GIRFT programme using HES data may be submitted for peer-review publications. The GIRFT programme will publish metric values on the NHS Improvement Model Hospitals on-line dashboard. Aggregate hospital-level values with small number supression may be released to other organisations as described below.

With reference to these outputs, the following should be noted:

• No patient-level values will ever be published

• All data processors are aware of and will ensure that small numbers are suppressed in line with the HES Analysis Guide. All outputs, except for hospital datapacks, will only every contain aggregate values with small number supression

• Hospital data packs will only be released to the NHS Trust from which the data originated. Under an agreement between GIRFT and NHS Digital, we may publish small numbers in these datapacks.

• Data processors will never release data other than in the publications described above. To be clear, data will never be used for sales or marketing purposes.

The GIRFT Team request the right to share small numbers with the Trust to whom the data relates. This is not data containing patient identifiers, but is small activity numbers for a patient or procedure group (i.e. for a hospital they may deliver 3 endoscopic resection procedures for bowel cancer). One of the major patient safety issues that GIRFT wishes to address is to prevent Trusts from delivering small volumes of complex procedures. If a surgeon, or a Trust, is delivering small volumes of complex procedures then the outcome for patients is likely to be poorer than for surgeons or Trusts delivering larger volumes. When small volumes are delivered, the Programme's clinical leads recommend that this service be stopped within a Trust. The GIRFT Team have explicit permission from NHS Digital to share small numbers with the Trust to whom the data relates under a strict data sharing protocol.

For the creation of the GIRFT output products or publications, it may be necessary to share summary level values with other organisations (only aggregated with small numbers supressed in line with the HES Analysis Guide). Below are the purposes for which GIRFT may be required to share summary level data:

• GIRFT works with various clinical associations and NHS national organisations to ensure that the quality metrics in the output products are the most appropriate for the GIRFT programme and the calculation methodology is the same for both organisations. GIRFT may share summary level values with organisations such as clinical association (e.g. British Orthopaedic Association, Association of Coloproctology of Great Britain and Ireland), national quality programmes (e.g. the National Spinal Taskforce, Arthritis Research UK, NEQOS (North East Quality Observatory System)), NHS England (e.g. Specialised Services Clinical Reference Groups, Quality Surveillance team), and other NHS organisations (e.g. RightCare) for this purpose.

• GIRFT is required to report to the NHS Procurement and Efficiency Board (NHS Improvement) and the Department of Health. GIRFT may need to share summary level values with this Board for this purpose.

• The national reports may include maps to show geographic distribution of access and performance. GIRFT may share summary level values to organisations who can produce these maps for us (e.g. SHAPE (Strategic Health Asset Planning and Evaluation; Public Health England, North West Commissioning Support Unit)).

It is likely that GIRFT will be working jointly with RightCare to produce some STP level products. GIRFT may need to share summary level HES data (with small numbers suppressed in line with the HES Analysis Guide) for inclusion in these products.

The hospital, regional and national datapacks and reports for the 11 surgical and 24 medical specialties are expected to be published during 2019 and 2020, approximately one specialty per month. In addition, refreshed versions of previously published hospital and regional reports may be published during 2019 and 2020. Similarly, GIRFT plan to publish national recommendation reports for each specialty during 2019 and 2020 - about 1 every month.

The GIRFT programme may undertake research related to clinical quality issues that are identfied in the hospital, regional and national datapacks and reports. This research may include analysis of HES data and may be released in peer-reviewed publications on an ad hoc basis (possibly starting during 2019).

Publication of metric values on the Model Hospital dashboard and the Specialist Orthopaedic Alliance dashboard commenced with orthopaedic surgery metrics in December 2016. A rolling timetable for publication of metric values for other specialties (perhaps one specialty per month) is planned during 2019 and 2020.

Reports for specialties that include economic modelling and detail about clinical coding are expected during 2019 and 2020. These are likely to be internal NHS documents.

An opportunity assessment of the GIRFT orthopaedics pilot identified £400 million of efficiency savings per annum, representing nearly 4% of total orthopaedic pathway cost and in excess of 7% musculoskeletal orthopaedic pathway cost. These savings relate to the opportunity to tackle variation in surgical practice across England. In particular to drive short, medium and longer-term improvements in quality of delivery (through adopting best practice), lower supplier costs (for example of implants) and lower readmission, re-operation and litigation rates.

It is recognised that the same scope for efficiency may not exist for all specialties, but drawing on the experience of the GIRFT pilot project and other clinical insights, a conservative 3% annual saving opportunity was assessed to be achievable through the application of GIRFT principles. A comparison of the headline potential savings for the 3-year delivery programme is shown in the table below:

3 year Delivery Programme

Total programme costs £60 million

Annual savings based on 3% efficiencies (once programme fully implemented) £1.4bn

Cumulative savings over 3 years based on 3% efficiencies £3.86bn

Number of clinical pathways 31

Return on Investment in first full year of savings realisation 404:1

It is anticipated that the annual saving should commence approximately one year after implementation of GIRFT recommendations for each specialty, approximately two years after publication of hospital datapacks. A breakdown of the expected annual savings by the specialty areas is illustrated below:

. Clinical Pathway; Annual savings target; Description

. Orthopaedics and spinal surgery; £400 million; Very significant savings have been identified outside of the immediate surgical spend. Growth last year of 6.35% also makes this an important target.

. Cardiothoracic surgery: £124million ; 7.8% growth last year and high readmission (7.6%) and reoperation (8.8%) rates.

. General surgery; £98million; Elective general surgery grew by 5.9% last year and readmission rates are high.

. Neurosurgery; £91million; 19.8% growth and high readmission 13.3% and reoperation 5.4% rates.

. Oral & Maxillofacial surgery; £73million; Relatively high cost specialty.

. Urology & Renal; £69million; Readmission rates of 7.5% for elective and 20.4% for non-elective. Reoperation rates of 5.1% for elective and 6.3% for non-elective. 30.1% growth in non-elective.

. ENT; £68 million; 3.9% readmission rate and relatively high cost specialty.

. Gynaecology; £26million; High volume specialty but with low growth last year and moderate readmissions.

. Paediatric surgery; £20million; Relatively high readmission rate of 5.5%.

. Vascular surgery; £17million; Very high growth last year of 15.6% and high readmission rate of 6.6%.

. Total surgery; £986 million per annum recurring

The evidence that these potential opportunities are achievable relies on evaluation of the GIRFT orthopaedic pilot programme. This programme gathered information during peer-to-peer meetings that demonstrated where implementation of good practice is already driving efficiency savings, and also examples where abandoning best practice has had the opposite effect. Some of these examples are listed below.

Wound infection

Many studies demonstrate that ring-fenced beds have a significant impact on the incidence of wound infection and this has been one of the principle lines of enquiry for the GIRFT pilot. The GIRFT team visited hospitals where the primary hip and knee replacement deep wound infection rates varied between 0.5% and 4%, with one Trust for a short period having a rate of 15%. Three Trusts cited examples of infection rates escalating from 0.5% to 4% following the loss of ring- fenced elective orthopaedic beds. At one hospital, there was a particularly extreme example, where the loss of the orthopaedic ring-fenced beds in the face of winter bed pressures led to a 40% increase in infections.

Deep wound infection is traumatic and devastating for the individual patients, and is estimated conservatively to cost the NHS an additional £50k per patient (studies have quoted a range of between £50k and £100k). If a cost of £100k per patient is accepted then this equates to an extra £1,000 for each orthopaedic arthroplasty procedure to cover the costs of readmission, reoperation and medication for infected patients. At the national level, if Trusts achieved a 1% deep infection rate, this would equate to transforming the lives of 6,000 patients per year and saving the NHS £300m per year – a saving of £1.5 billion over five years.

Procurement

Many of the orthopaedic teams that the GIRFT team met were unaware of their loan kit and prosthesis expenditure, or their rates of cemented vs un-cemented hip fixation. Loan kit - Trusts were encouraged to adopt a best practice methodology developed by GIRFT that could achieve a 90% reduction in loan kit costs within two years. With an average annual spend per hospital of £200,000, a saving of £108 million over the next five years is possible. Cost of implants - The NJR (National Joint Registry) procurement pilot demonstrated that adoption of the GIRFT procurement recommendations and a review of the NHS Supply Chain to reduce the large price variations that currently exist between Trusts could realise potential saving of £40 million per year. This equates to £200 million over five years. Fixation type - Published evidence indicates that a cemented fixation for hip replacement surgery is preferable in most over 65 year old patients – few patients require revision, and the prostheses are significantly less expensive. If all English hospitals delivered cemented hip replacement surgery to 75% of patients over 65 years, approximately £16 million per annum could be saved. These saving would increase in future years because the lower revision rate would lead to fewer readmissions.

Litigation

A review of information released from the NHSLA (NHS Litigation Authority) databank by the GIRFT team identified a rapid rise in litigation claims in orthopaedic surgery. The GIRFT team is undertaking more detailed analysis, in association with leading law firms involved with orthopaedic clinical negligence, with a view to developing procedure specific guidelines to improve patient care and safety. The available data indicates a potential to reduce the cost of litigation claims for orthopaedic surgery by £50 million per annum. It has not been possible yet to assess the potential savings for other specialties.

Since the GIRFT programme began, changes in clinical practice have taken place within hospitals. As an example, for orthopaedic surgery services, GIRFT have measured reductions in length of stay, reductions in readmission rates, reductions in litigation in orthopaedics (bucking the trend for other specialties), and reductions in number of centres carrying out low volume of interventions. There are similar examples of changes in neurosurgery, paediatric surgery, and cardiothoracic surgery.

One specific example for vascular Abdominal Aortic Aneurysm (AAA) surgery – when AAA surgery is performed in centres of excellence you get a significantly reduced mortality rate and reduced length of stay. In low volume (non centre of excellence) centres mortality can be as high as 25%.

In addition to the improvements in clinical quality from the changes described, the GIRFT Team have measured the financial opportunity that has been realised as a result of the GIRFT programme. The GIRFT Team's current estimate is that this value was over £70 million in 2016/17, over £280 million in 2017/18, and over £240 million in Quarters 1 and 2 of 2018/19. The realised financial opportunity from the reduction in litigation costs for orthopaedic surgery alone over the last three years is estimated at over £79 million.