Committee of Public Accounts

Press Notice No. 17 of Session 2003-04, dated 5 May 2004


Mr Edward Leigh MP, Chairman of the Committee of Public Accounts, said today he still has concerns about whether patients are always getting the best results they could from hip replacement surgery, and pressed the Department of Health and the NHS to issue a full list of effective hip prostheses and research how many operations need to be undertaken by surgeons annually to maintain their skills.

Mr Leigh was speaking as the Committee published its 17th Report of this Session, which examined elective hip replacement in the NHS, including the progress made in the last three years in implementing the Committee's previous recommendations. Hip replacements are one of the most common and most effective major surgical procedures performed in the NHS. Over 43,000 are carried out each year, bringing mobility and relief from pain. The way in which the hip replacement pathway of care for patients is managed and organised has implications for the economic, efficient and effective use of the resources of NHS acute trusts, and above all for the quality of care provided to the patient. Since the Committee last reported, there have been a number of key developments including the launch of a National Joint Registry, and the publication of guidelines by the National Institute for Clinical Excellence (NICE) on the evidence of effectiveness required for hip prostheses used in the NHS.

The Committee found that around 1 in 10 of consultants use hip prostheses for which there is inadequate evidence of effectiveness. Innovation can bring benefits for patients, but there need to be strict safeguards for new models with little or no track record. The NHS Purchasing & Supply Agency should issue a full list of prostheses which meet the NICE standard as soon as possible.

To get the most value from the new National Joint Registry, it needs to be comprehensive. Currently only around half of NHS hip and knee replacement operations are recorded. The Department should identify the best means of encouraging wider participation, which might involve making data submission by NHS trusts mandatory, and implement it without delay.

Around 40% of trusts are offered incentives to introduce new prostheses, and around 1 in 10 of consultants had accepted incentives from hip prosthesis manufacturers. Departmental guidance sets out rules to ensure that incentives are transparent, properly authorised and do not impact adversely on patient care. Such incentives have the potential to distort clinical judgement and to prejudice the value for money of procurement decisions. The Department should explore with suppliers how these incentives might be phased out.

Patients should receive their hip replacement from a surgeon who has the experience and knowledge gained by carrying out the operation frequently. About half of consultants undertaking primary hip replacements do so less than the equivalent of once a week, and a significant proportion may gain insufficient experience to maximise their skills and knowledge. We recommend that the Department of Health considers as a matter of urgency advising patients as to the advantages of seeking a surgeon who regularly undertakes a number of operations a week.

The Department should obtain a good understanding of the relationship between numbers of operations carried out by individual surgeons and their outcomes. It should then set minimum annual numbers of primary and revision hip replacements to be undertaken by surgeons who work in the NHS.

Too many referrals from General Practitioners for hip replacement turn out to be inappropriate. Trusts should give feedback to individual GPs on their referral patterns.

Primary hip replacements cost from £2,266 to £7,456. The Department should establish the reasons for the wide variation in costs, including whether costs are recorded accurately, and the scope for greater efficiencies.

The roll-out of Treatment Centres risks a mismatch between the need for and provision of additional capacity in the NHS. To mitigate that risk, the Department should take stock of the establishment of Treatment Centres to date, and apply the lessons in rolling out the next tranche.

Despite our predecessors' recommendation that standards should be set for follow up of hip patients after surgery, such standards are still not in place. The Department should implement that recommendation and agree standards with the British Orthopaedic Association without further delay.

Although use of care pathways brings significant benefits for patients, only 50% of trusts use them for hip replacement cases. Use of care pathways by trusts, general practitioners and others involved in patient care should be universal for routine hip replacement work and pathways should be based on established templates to ensure consistency of good practice.

Mr Leigh said today:

"Although there have been some welcome developments since the Committee's previous report, I still have concerns about whether patients are always getting the best results they could from hip replacement surgery in the NHS.

It is welcome that there is now guidance in place on the evidence of effectiveness needed for the hip prostheses used and that, following the Committee's recommendation, the National Joint Registry has been set up. But 1 in 10 consultants are still using hip prostheses which we cannot be confident about and half of consultants do less than one operation a week.

The NHS Purchasing and Supply Agency needs to issue a full list of prostheses that meet the published standards as soon as possible. And the Department of Health must research how many operations need to be undertaken annually by surgeons to maintain their skills and ensure good clinical outcomes are achieved."

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