GIRFT is delivered in partnership with the RNOH and the Operational Productivity Directorate of NHS Improvement

Getting It Right First TimeAn Update for the National Orthopaedic Alliance

Monday 5th February 2018Rob Hurd, CEO RNOH and GIRFT Joint SRO

Introducing GIRFT

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• Led by frontline clinicians who are

expert in the areas they are reviewing

• Innovative use of data sets to

identify unwarranted variations in the

way services are delivered

• Peer to peer engagement helping

clinicians and managers to identify

and deliver changes that will improve

care and deliver efficiencies.

• Support across trusts, CCGs and

STPs to drive locally designed

improvements and to share best

practice across the country

A clinically led programme implementing recommendations

locally and nationally across 35 clinical specialties to reduce

unwarranted variation, improve the quality of patient outcomes

and deliver operational productivity improvements that

translate into resource savings of £240-420m in 17-18 and

c.£1.4bn p.a. by 20-21 (c.£3-4bn cumulative 17-21).

Programme Objective

• Reduction in average length of stay and increased same day admission

for elective surgery

• Reduction in post-op infection/complications and readmission

• Clear policy guidelines for a basket of major treatments & improved

selection of surgical implants

• Standardisation of what is meant by best practice & discussion on

appropriate levels of clinical autonomy

• Improved surgical success rates by consolidating complex cases among

high-volume surgeons

• Improved patient pathways for mental health patients

• Improved provision of out of hours imaging for emergency cases

• Reduction in surgery that has poor proof of efficacy

• Strengthened ‘front door’ with senior surgical input to reduce

unnecessary emergency admissions.

Clinical Improvements

From pilot to national programme

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• Delivery strategy agreed and

governance in place

• Collaboration agreements

with national and local

partners being delivered

• Regional implementation

support network being put

into place

• Benefits measurement &

tracking approach in place

• Implementation until March

2021 with more specialties

(oncology, paediatric

medicine) to be added

subject to business case

29 1000Clinical work

streams are

already underway

Clinical Lead

visits already

completed6

Remaining work streams

will kick off in waves

between Nov 17 - Mar 18

Wave Workstream Start Date

Data packs to trusts

Workstreams Total

1 2012 Received Orthopaedics 1

2 Jan 2015 Received General surgery, Spinal, Vascular,

Neurosurgery 5

3 Jan 2016 Received

Urology, Cardiothoracic, Paediatric surgery,

Ophthalmology, ENT, Oral & Maxillofacial,

Obstetrics & Gynaecology

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4 May 2017 Mar 2018 Emergency medicine 13

5 July 2017 May 2018 Dentistry, Breast surgery, Diabetes,

Endocrinology 17

6 Sep 2017 Jul 2018 Cardiology, Imaging & Radiology, Intensive &

Critical Care, Anaesthetics & Perioperative, 21

7 Nov 2017 Sep 2018 Renal, Acute & General medicine, Stroke 24

8 Jan 2018 Nov 2018 Neurology, Geriatrics, Respiratory,

Dermatology 28

9 Mar 2018 Jan 2019 Rheumatology, Pathology, Outpatients 31

10 May 2018 Mar 2019 Gastroenterology 32

11 Summer 2018 (tbc)

tbc Trauma Surgery, Plastic surgery & burns,

Mental health 35

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Recent clinical progress• General Surgery National Report identified:

- A total opportunity for £160m savings annually

- £32m from improving enhanced recovery to shorten length of stay

- The need to overhaul quality and capture of clinical data

- The need to overcome barriers to reducing unwarranted variation e.g. best practice vs clinical autonomy

- That consultant-led assessments in EDs could cut admissions by 30%, improving EDs’ sustainability and

…….freeing up bed capacity.

- Cost savings of 59% for a basket of typical surgical supplies.

• Vascular Surgery National Report released to trusts last week. It recommends round-the-clock availability of

early diagnostics, decision-making expertise and intervention critical to the successful treatment of vascular

conditions, by establishing ‘hub and spoke’ vascular surgery networks. The report also recommends treating every

vascular surgery case as ‘urgent’, which would substantially reduce the risks associated with blocked arteries such

as sudden death, strokes, restricted movement and amputations.

• Implementing GIRFT surgical site infection audit findings from Feb 2018 across 13 specialties will improve

patient outcomes and deliver significant savings (e.g. £1.5bn over 5 years potential in orthopaedics alone)

• Litigation data across surgical specialties shared with trusts in Dec 17, with work on spreading best practice to

follow, which will help drive patient care improvements leading to reduction of litigation costs

• Evidence that pilot to reconfigure orthopaedic services in Gloucestershire NHS Trust across hot and cold sites is

yielding improved patient outcomes and staff morale, and productivity gains; pilot to be extended to other trusts

• GIRFT to deliver Sir Norman William’s vision for the National Clinical Improvement Programme (NCIP) initiative.

GIRFT Implementation• The responsibility for designing and implementing any changes derived from GIRFT

recommendations lies with trusts and their partners in each local health economy.

• Each trust should have a board-level GIRFT clinical champion (normally Medical

Director), and each clinical workstream will have a designated GIRFT lead. Important that

CEOs and Directors of Finance are closely involved in leading a whole trust effort.

• GIRFT plays several roles:

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Clinical Leads advise trusts on designing an appropriate response to the unwarranted variations

seen in GIRFT data packs and help trusts to benchmark their performance against their peers

Regional Hubs assist & encourage trusts and their local partners with implementation of Clinical

Lead recommendations, ensuring a joined up approach with other NHS support partners

GIRFT National Team and Regional Hubs ensure GIRFT is placed in the wider context by working

with trusts and Clinical Leads to map unintended consequences to GIRFT recommendations

(including financial ones) and ensure that effective mitigations are designed into implementation.

Regional Hubs & GIRFT Analytics Team ensure that the national programme can measure

progress and demonstrate how GIRFT is having an impact on improving the quality of patient care,

leading to operational efficiencies and resource savings.

GIRFT Going Forward

• Mental Health

• Paediatrics

• Responsible innovation – medical devices

• AQPs – Orthopaedics, General surgery, ENT, Gynaecology,

Gastroenterology and Cardiology

• General Practice – GIRFT Pilot Hammersmith and Hounslow

GIRFT is delivered in partnership with the RNOH and the Operational Productivity Directorate of NHS Improvement

GIRFT in MSK and associated workstreams

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GIRFT in Orthopaedics• The orthopaedic data packs have

been refreshed twice since Tim Briggs first visited all providers in England.

• Tim is now undertaking revisits to all trusts and 80 trusts have had at least one revisit and a number have had up to four visits.

• Tim is working directly with a number of providers of specific projects including:

• The implementation of a hot/cold site split at Gloucestershire Hospitals.

• Support for reorganisation of elective orthopaedics at Barts.

• The early stages of a hot/cold site split at Kings.

• Similar conversations are underway with East Kent and North Lincolnshire and Goole.

• In terms of implementation the following is underway:

• Collaboration with BESS (led by Jonathan Reese) and the BOA to fund and co-produce guidance, a patient leaflet regarding the appropriate exercise regime for patients with sub-acromial pain to avoid unnecessary referrals and surgery. This will be reviewed in light of the recent Oxford led NIHR funded research into the efficacy of this surgery.

• Collaboration with Professor Andy Price and BASK to develop guidance on arthroscopy. This will be published with Oxford.

• Discussions with the tariff team at NHSI regarding the inclusion of the use of un-cemented hip fixation in patients over 70. Thresholds are under discussion.

GIRFT in Spinal Surgery• All visits bar one have now been completed.

• The national report is being written and is scheduled for distribution to trusts in the summer.

• The process of updating all the spinal data is underway and once the national report is complete revisits will be booked to all providers. The new reports will include extended paediatric data.

• Spinal procurement is under specific scrutiny with NHSI and the PPIB tool providers and this will be included in the national report and refreshed data packs.

• Options for mandating compliance with the BSR are being explored and in the interim compliance with the registry has gone up by over 25%.

• The spinal lead Mike Hutton is working closely with the Spinal CRG to seek to align their work.

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Related workstreams

• The programme is advertising for adult and paediatric trauma leads.

• A review of anaesthetics and perioperative medicine is now

underway in collaboration with the Royal College of Anaesthetists.

• A review of rheumatology services will begin in 2018 and will be led

by a former president of the British Society of Rheumatologists.

• A cross cutting report looking at care for inflammatory conditions and

coordinating across the rheumatology, gastroenterology and

dermatology workstreams is planned.

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GIRFT is delivered in partnership with the RNOH and the Operational Productivity Directorate of NHS Improvement

Variation

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Unwarranted Variations Identified

Cemented: £650

Uncemented:

£5,300

No evidence that

uncemented hip

provides better

outcome for over

70s

Lower back

pain

surgery

costs

>£100m per

annum with

little

evidence of

efficacy

-£1,000

£1,000

£3,000

£5,000

£7,000

Obstetric litigation cost per birth (5 years)

N = 135, Range = £55 - £6896

England average £1398Litigation: huge variation between trusts in averages:

• General surgery: £17 - £477

• Urology: £4 - £117

• Vascular: £1 - £6,353

• Obs & Gynae: £55 - £6,896

Significant unwarranted variations seen in practice and outcomes, but scope identified to tackle many of

these variations, and great appetite found among clinicians and managers to do so.

0.19% - 4.49%

Variation in hip & knee deep

infection rate within one city. If

all trusts got to 0.19% this

would save the NHS £2-300m

p.a, enough for 60,000

replacements

Oral cancer surgery 90 day return rate: 8 to 80%

Post tonsillectomy return rate: 4 to 25%

80% spinal surgeons not aware of own infection rates

Procurement variation - analysis re implantable cardiac defibrillators

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Urology – variation in cystectomy outcome measures

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General Surgery – variation in the proportion of patients undergoing pre-operative short or long course radiotherapy (%) 2012/13

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There are vast differences between

trusts in the use of pre-operative

radiotherapy for patients with rectal

cancer. In some trusts, no patients

received radiotherapy; in others,

over 80% did. The trust in which

radiotherapy was most commonly

offered was also one of the trusts

performing the most surgery;

conversely, two trusts which

provided similarly high volumes of

surgery offered fewer than 5% of

patients pre-operative radiotherapy.

In short, there is no clear pattern -

suggesting complete disagreement

on the optimal pathway both within

the general surgery community and

the wider multidisciplinary team.

General Surgery – variation in the proportion of patients who have a stoma present 18 months after surgical resection for rectal cancer (%) - 1 April 2010 to 31 March 2013

Variation in stoma rates at

18 months in colorectal

cancer have been identified

at between 0% and 78%

retaining a stoma post-

surgery for colorectal

cancer. This is against best

practice in most cases and

anecdotal evidence (to be

supported by data in due

course) suggests that this

leads to increased litigation.

This data means that

48.86% of patients still have

a stoma 18 months after

surgery.

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Cardiothoracic Surgery – variation in the cost of delivering blood perfusion during heart bypass procedures 2014/15

The cost of blood products for perfusion during heart bypass procedures vary from £500 to £2,500 per operation. A model of the potential savings this offers is described below:

Estimation data source: 2015 National Cardiac Benchmarking Collaborative Annual data report

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Vascular Surgery - variation in number of procedures undertaken per operating theatre for all NHS provider organisations in England – 01-Apr-2016 to 30-Jun-2016

For the NHS in general, the trend observed with activity per operating theatre is fairly clear cut: the more operating theatres a provider has, the lower the procedure throughput tends to be. In the most basic economic terms of resource allocation, those trusts with a scarcity of operating theatre resource tend to use these most efficiently, as would be expected. However, the distribution could tell a more complex story, with demand and supply not falling at equilibrium; implying that some providers may have too many theatres, while others have too few. Another hypothesis may be that the data may highlight huge disparities in theatre management and efficiency.

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Cranial Neurosurgery – variation in % admitted for further cranial procedures within one year following a shunt procedure 2012/13 and 2013/14

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Cranial Neurosurgery – variation in number of patients returning for another neurosurgical procedure within 1 year follow surgery for primary cranial tumour – 2014/15

Re operation rates in neuro surgery within 1 year vary between 5% and 17% requiring a further procedure within one year post surgery for a malignant cranial tumour.

Estimation data source: 2012/13 to 2014/15 HES – cost calculated using national tariff

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General Surgery – variation in adult surgery litigation costs per admission in England

Between 2011/12 and 2015/16, the NHS received 5,367 claims related to general surgery, resulting in estimated

settlement costs of £585 million. In 2015/16, general surgery accounted for 9% of all clinical negligence claims and 3% of costs. Only orthopaedic surgery, casualty/A&E and obstetrics and gynaecology contributed more claims.

The average cost of litigation per general surgical spell nationally was £88.23; regionally, this varied from £17.32

to £476.67.

The most common causes for claims are ‘judgement/timing’ (2,809 claims, 52.34%), ‘unsatisfactory outcome to

surgery’ (1,078 claims, 20.09%) and ‘interpretation of results/clinical’ (984 claims, 18.34%). In total, 5% related to

issues of consent yet this is probably the area around which most litigation related discussion has focused in recent

years.

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ENT Surgery – paediatric tonsillectomy % readmitted within 30 days 2012/13 – 2013/14

Following a tonsillectomy the rate of emergency readmission within 30 days varies from 3.68% to 24.77%.

Estimation data source: 2012/13 to 2014/15 HES –cost calculated using national tariff

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Oral & maxillofacial Surgery – return for another oral & maxillofacial procedure within 90 days following surgery for head and neck cancer for –2014/15

Following oral and maxillofacial cancer surgery the rate of return for another

procedures within 90 days varies from 8.33% to 80.56%.

Estimation data source: 2012/13 to 2014/15 HES – cost calculated using

national tariff.

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Paediatric surgery – emergency readmission within 30 following hypospadias repair – 2013/14 – 2015/16

Hypospadias repair is surgery to correct a defect in the opening of the penis that is present at birth. The urethra does not end at the tip of the penis. Instead, it ends on the underside of the penis.

Complications in hypospadias surgery are higher than other reconstructive procedures. The incidence of complications can be reduced if proper preventive measures are taken.

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Thank You

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