NHS Digital Data Release Register - reformatted

Royal National Orthopaedic Hospital NHS Trust

Project 1 — DARS-NIC-14440-Q2G4W

Opt outs honoured: N

Sensitive: Non Sensitive

When: 2017/03 — 2017/05.

Repeats: One-Off

Legal basis: Health and Social Care Act 2012

Categories: Anonymised - ICO code compliant


  • Hospital Episode Statistics Admitted Patient Care
  • Hospital Episode Statistics Critical Care


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 2% 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 £2.45mn Annual savings based on 2% efficiencies (once programme fully implemented) £0.99bn Savings over 5 years based on 2% efficiencies £3.86bn Number of clinical pathways 10 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 reports. A breakdown of the expected annual savings by the specialty areas is illustrated below: Clinical Pathway Annual savings target @ 2% (surgery only) Notes Orthopaedics and spinal surgery £400 million Very significant savings have also been identified outside of the immediate surgical spend. Growth last year of 6.35% also makes this an important target. Cardiothoracic £124million 7.76% growth last year and high readmission 7.61% and reoperation 8.8% rates. General surgery £98million Elective general surgery grew by 5.93% last year and readmission rates are high. Neurosurgery £91million 19.77% growth and high readmission 13.31% and reoperation 5.44% rates. Oral & Maxillofacial £73million Relatively high cost specialty. Urology & Renal £69million 7.51% for elective and 20.36% for non-elective for readmission and 5.13% for elective and 6.31% for non-elective for reoperation. 30.14% growth in non-elective. ENT £68 million 3.95% readmissions and relatively high cost specialty. Gynaecology £26million High volume specialty but with low growth last year and moderate readmissions. Paediatric surgery £20million Relatively high readmissions at 5.51%. Vascular £17million Very high growth last year of 15.59% and high readmissions at 6.6%. Total £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.


Hospital and CCG summary level values will be taken from the GIRFT performance dashboard and reported in hospital, regional and national reports and data packs. Analysis and evaluation based on HES data may be submitted for peer-review publications. The GIRFT programme will publish metric values from the performance dashboard on the NHS Improvement Model Hospitals on-line dashboard. Summary level values may be released to other organisations as described below. With reference to these publications, the following should be noted: • No patient-level values will ever be published • All data processors are aware of and will adhere to small number suppression requirements in HES analysis guidance • Hospital data packs will only be released to the NHS Trust from which the data originated (under the agreed GIRFT-NHS Digital process). • Data owners/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. For the creation of the performance dashboard or publications, it may be necessary to share summary level values with other organisations (aggregated data with small numbers supressed). 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 performance dashboard 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. We 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 from the performance dashboard 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)). There are two other organisations with whom we may need to share HES data: . The main tables and graphs for some of the hospital, regional and national reports will be produced by Methods Analytics. GIRFT may need to share summary level values from the performance dashboard with this organisation for this purpose. This will need to include hospital or CCG values without small number suppression where these data are for hospital data packs. We are aware that Methods Analytics has agreement with NHS Digital that they can work with and report unsuppressed small numbers for the GIRFT programme only. . 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 number suppression) for inclusion in these products The hospital, regional and national datapacks and reports for the 10 surgical and 19 medical specialties are expected to be published during 2016, 2017 and 2018, approximately one surgical specialty per month. In addition, refreshed versions of previously published hospital and regional reports may be published during 2017 and 2018. The only new hospital data pack publication that has been planned so far is for cardiothoracic surgery, in March 2017. Refresh versions of the existing orthopaedic surgery, general surgery and urology hospital data packs are planned for early 2017. National reports for general surgery, urology, neurosurgery and vascular surgery are likely to be published during the next 6 months. Evaluation is likely to occur on a regular basis (to meet the timescale for NHS Procurement and Efficiency Board meetings), with a major annual report and other ad hoc reports as required. From the analysis for these Board meetings, peer-reviewed publications will be produced on an ad hoc basis (possibly starting during 2017/18). Publication of metric values on the Model Hospital dashboard commenced with orthopaedic surgery metrics in December 2016. A rolling timetable for publication of metric values for other specialties (perhaps one specialty area per month) is planned during 2017. Reports for orthopaedic surgery that include economic modelling and detail about clinical coding are expected during 2017. These are likely to be internal NHS documents, and will only include aggregated activity values.


The GIRFT performance dashboard contains a wide range of metrics, some of which are calculated using HES data. For the dashboard, 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 • Performance metrics will be stored in the GIRFT performance dashboard (see outputs section for publication details) The performance metrics included in the performance dashboard will relate to: • Original surgical specialties - orthopaedics and 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. HES data processing to populate the performance dashboard will occur at two sites (see data flow diagram below). These sites have different roles: • RNOH and NA Wilson Associates calculate hospital and CCG level values for inclusion within the GIRFT performance dashboard; • CLAHRC statistically analyses a selected group of metrics for the purpose of evaluating the success of the GIRFT programme. CLAHRC will use both HES pseudonymised patient-level HES data and hospital and CCG level values from the performance dashboard for its work. HES data will never be linked with any other data (except the HES inpatient to HES critical care linkage discussed above). Processing HES data for the evaluation and macroeconomic modelling work will include controlling for factors such as age and sex patients, and variations in individual pathways. This is only possible with pseudonymised patient level data. The Specialist Orthopaedic Alliance (SOA; the organisation that originally hosted the GIRFT programme) used 2011/12 HES inpatient data to populate the SOA orthopaedic and spinal performance dashboard (Application reference RU738). This data has since been deleted in compliance with a HSCIC data destruction certificate. The SOA subsequently updated the SOA orthopaedic and spinal performance dashboard using the 2012/13 and 2013/14 HES data provided by application NIC-275445-L6X9T. The GIRFT programme applied for 2014/15 HES data under application NIC-393384-L9Z2J. The approval was subsequently changed (NIC-14440-Q2G4W) to allow access to the HES data for Methods Analytics (who undertook some analysis of HES data for the GIRFT programme).


The Getting It Right First Time (GIRFT) programme has been extended from a pilot (for orthopaedic surgical activity only) to a programme supporting improvements in clinical efficiency for 10 surgical and 19 medical specialties. Both the GIRFT and the Clinically-Led Quality and Efficiency programmes now report to the NHS Procurement and Efficiency Board within NHS Improvement. 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. The requested 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 10 surgical and 19 medical specialties at hospital and CCG summary level. The calculated metrics will be stored in the GIRFT performance dashboard (along with metrics calculated using other data sources). The dashboard will hold data for individual years and trend data. Hospital and CCG summary level values will be taken from this dashboard and reported in hospital, regional and national data packs and reports. The GIRFT metrics calculated from HES data will be published publically in the Model Hospitals dashboard (the web-based dashboard developed by the Clinically-Led Quality and Efficiency programme and sitting within NHS Improvement) adhering to small number suppression requirements in HES analysis guidance). As part of the GIRFT programme, we are also undertaking research to evaluate and assess the GIRFT methodology. The analysis will help inform improvements in the GIRFT methodology and will model how those improvements in outcomes translate into broader macroeconomic benefits – such as reduced disability leading to faster return to work, less reliance on health and care services, and less expenditure on social security benefits. Analysis and evaluation based on HES data may be submitted for peer-review publications. HES data will also be used to benchmark coding quality. Information about the ICD10 and OPCS code combinations used to identify specific procedures will be examined and reported back to Acute Trusts. This analysis may include record-level reporting to Trusts; however, only ICD10 and OPCS coding will be returned - no person identifiable or date fields will be included.