UCL researchers have found significant improvements in orthopaedic care for patients requiring hip and knee surgery through the NHS in the last ten years.
The study evaluated the impact of Getting it Right First Time (GIRFT), a National NHS Improvement Programme which started in 2012. The programme was established by a senior surgeon to focus on orthopaedic care, such as knee surgery and now operates over 40 specialities.
GIRFT operates at both local (NHS provider Trusts) and national levels, recognising the importance of both system-level leadership and local leadership in Trusts for driving change.
The findings were published in BMJ Open.
Analysing orthopaedic care in the NHS
The researchers analysed data from over 700,000 patients who underwent hip or knee surgery at 126 NHS Trusts between April 2009 and March 2018 and interviewed over 50 staff.
The team employed a mixed methods approach to conducting a comprehensive analysis of the impacts of GIRFT in orthopaedics from different perspectives and at both national and local levels. This included a statistical analysis of linked national datasets to measure the impact of processes and outcomes of hip and knee surgery care, an economic analysis, and qualitative methods to understand staff perceptions of GIRFT’s impact.
They studied eight different aspects of NHS orthopaedic care that the programme identified as needing improvement, including the use of uncemented hip implants in over 65s and knee arthroscopy, a type of keyhole knee surgery. The former has been found to lead to higher revision rates, and the latter has shown to be ineffective.
Substantial improvements in hip and knee surgery
The researchers found substantial improvements in the last ten years. When comparing 2009-2012 and 2015-2018, the number of uncemented hip implants in over 65s reduced by 29% and the knee arthroscopy before knee replacement surgery dropped by 58%.
The main role of the GIRFT orthopaedic programme to host ‘deep dive’ visits to individual NHS trusts by the national programme team. Before the visit, each Trust received a bespoke ‘datapack’, which brought together different data sources. The packs described the Trust’s performance across 100 variables including direct patient care, use of evidence-based procedures, costs, ways of working, and procurement.
The researchers also conducted 50 interviews with NHS staff, including orthopaedic surgeons and managers, across six hospital sites. GIRFT had contributed to them making a range of improvements at three different levels: changes to individual patient care; changes to ways of working at Trust-level; and greater regional co-operation between Trusts. For example, changes included use of different joint implants during hip and knee surgery and improved collaborative working within Trusts and across regions.
The team found that this programme has had a positive impact on orthopaedic care. GIRFT datapacks provided Trusts with the vital information they required to support change; however, researchers did not have access to data needed to examine some of the broader GIRFT target measures, such as reducing litigation and procurement costs. It is clear that the processes and outcomes of orthopaedic care have generally improved.
Co-investigator, Professor Rosalind Raine (UCL Institute of Epidemiology & Health and Director of NIHR ARC North Thames), said: “This research clearly demonstrates that a range of activities offered by different initiatives are needed to achieve change and the difficulty in achieving improvements without broader system change.”
Rob Hurd, Chief Executive, North West London Integrated Care System and former Chief Executive, Royal National Orthopaedic Hospital said: “The overall improvements in the quality of orthopaedic care and the wider economic benefits during the period of this study are impressive. Professor Briggs and the GIRFT team are to be commended for inviting a level of academic rigour to be applied to the GIRFT improvement methodology that is not always applied elsewhere in the NHS.
“Achieving systemic and sustained improvement in health services and outcomes is complex and the variables are immense. Improvement can only be achieved through a set of conditions to which GIRFT principles of being clinically led, evidence-based measurement focus and transparency across pathways and over appropriate longevity, must play a significant part.”
