By: 30 May 2015
Timing critical for patients needing a knee or hip replacement

Winning the lottery

The Medical Technology Group’s latest report suggests that timing is more critical than ever for determining how quickly patients needing a knee or hip replacement will receive treatment

The ‘time of year’ lottery faced by patients needing a knee or hip replacement on the NHS became worse in 2014, data from the Medical Technology Group has revealed. The Group’s report ‘Hip and knee replacements: combating patient lotteries’ suggests that timing is more critical than ever in determining how soon patients receive treatment.
There is also dramatic regional variation, with knee operations falling by 33 per cent in London compared with a drop of just 2.5 per cent in the North East.
The report has also revealed for the first time that the number of hip and knee replacements on the NHS in England has fallen dramatically from March to April almost every year from 2004 to 2013,  implying that NHS Trusts’ financial calendars are driving patients’ access to therapy.

The national picture
Government data suggest that shortly before Christmas may be the best time of year to be referred for hip or knee joint replacement.
Between March and April last year, hip operations fell by 13 per cent and knee operations by 17 per cent in England, implying that the financial calendar rather than patient need is still a huge factor in determining when patients are treated. The last ten years saw an average of 498 fewer hip replacement procedures and 641 fewer knee replacement procedures in April than in March.
Given that the average wait for a hip or knee replacement is 15 weeks, and March is the busiest month for hip and knee replacements, patients are better starting the 15-week wait for a new knee or hip at the end of December in time for a March operation. The number of procedures performed in April is dramatically lower – patients who narrowly miss an operation in March have the longest wait.
Like a postcode lottery, this ‘time of year’ lottery means patient outcomes are radically different depending on when in the year joint replacement surgery is needed.
The March–April drop coincides with the end of the financial year on 31 March, implying that financial calendars for NHS Trusts could be driving patients’ access to surgery. In the public sector, organisations forecasting that they may underspend at the end of the financial year are incentivised to spend up to their delegated limit and will conduct additional activity at the end of the financial year. This financial-calendar-led allocation of procedures is highly unlikely to be the best model through which to fund equitable and consistent healthcare, being based around short-term funding, rather than what is best for the patient.

Patients denied access to treatment by restrictive criteria
The last decade has seen a 92 per cent increase in the number of hip and knee joint replacement operations performed, from 72,006 to 138,281 [4]. This is a reflection of greater patient need, driven in part by demographics. However, Freedom of Information requests to Acute Trusts from the Medical Technology Group have confirmed suspicions that commissioners are imposing more restrictive conditions. Thirty-three out of 67 trusts (49 per cent) answered Yes to the question: Are your commissioners applying more stringent conditions before referring patients to your Trust? [2].
This is troubling for all patients in need of joint replacement surgery, particularly in light of evidence that hip and knee procedures score highest in the latest patient-reported outcome measures report. This shows that hip and knee procedures have the best overall improvements for patient outcomes and that those Trusts which perform a greater number of hip and knee joint replacements have better clinical results.

Higher volumes of knee replacement surgery result in higher patient-reported outcomes
An increased frequency of hip or knee replacements by definition increases the quantity of patients helped. It also appears to improve the quality, with higher-volume knee surgeons achieving better outcomes. The number of knee procedures performed by different Trusts in 2011/12 was compared with the Oxford Knee Score – a patient-reported outcome measure that tracks whether patients felt better, worse or unchanged following the operation [3]. The comparison clearly showed a positive relationship between the number of procedures performed by a Trust and the percentage of patients reporting that their condition had improved following the procedure. Although results were strongest for the Oxford Knee Score, the relationship holds true across two other PROMs measures evaluated: EQ-5D and EQ VAS.

How to improve patient outcomes
Eighty-five trusts responded to the question: Does the trust have in place strategies to improve patient outcomes from arthroplasty? Of these, 62 trusts (73 per cent) answered Yes. Having such strategies formalised is a clear sign of good outcomes across a number of measures. Trusts that said No had waiting times an average of a week longer, and much higher rates of surgical site infection [4].

Waiting times
Freedom of Information requests found average waiting times for hip and knee replacements to be 102 days (14.6 weeks) in 2012 [5].
There was a sharp increase in waiting times in 2011 compared with 2010, they then fell back to around their 2010 levels. This would appear to be the consequence of the Government scrapping the 18-week target for the gap between seeing a GP and the beginning of treatment in June 2010 [6], and reinstating it less than a year later the following June [7].

Timely intervention
The point about waiting times is important as timely intervention produces better outcomes for patients. A number of studies have highlighted the benefits of timely intervention.

Timely intervention removes pain and restores mobility while delay leads to worse patient outcomes
Research by the Royal College of Surgeons shows the effects of increased waiting times on the Harris hip score [8] of those waiting for total hip replacement [9]. The study, which looked into the hip score of patients at the time of listing for an operation and again immediately pre-operatively, found that the scores decreased in positive correlation with the length of wait. The mean decrease in score was 8.9 points, which could approximate to a change from ‘moderate pain’ to ‘marked pain’ (10 points difference) or ‘slight limp’ to ‘unable to work’ (8 points difference).

Better outcomes for patients, the NHS and welfare spend
A study by the British Medical Journal in response to Primary Care Trusts introducing eligibility criteria restricting total knee replacement (TKR) to patients with low Oxford Knee Scores [10] in order to reduce costs, found that TKR is “highly cost-effective for most current patients” [11]. Scandinavian research which looked into the effect of waiting time on health outcomes and service utilisation found that although a longer waiting time did not result in poorer HRQOL at the time of admission, there was likely to be higher costs of waiting by people who wait simply because they use those services for a longer period. The research also found that the most common services used while waiting were rehabilitation and informal care, including unpaid care provided by relatives, neighbours and volunteers. Furthermore, in addition to the physical dimensions of health, patients suffer from restrictions in psychological well-being such as depression, distress and reduced vitality.

Positive impact on family life and psychological wellbeing
Delaying access to hip and knee replacements and other orthopaedic operations can affect the outcomes of surgery, with evidence that patients are less mobile and suffer more pain if their operation is delayed or denied.
A report by the Work Foundation highlighted that 31 per cent of women and 42 per cent of men receiving artificial hips are of working age. Over 30 per cent of men and women had a knee replacement before they were 65 years old [12]. The benefits of early access to treatment include:
•    Improved well-being, better quality of life/independence, able to return to productivity and participate in family life, psychological benefits.
•    Reduced absenteeism, improved productivity, improved performance (engaged and integrated workforce), savings on recruitment of temporary workers.
•    Benefits of welfare system (disability payments avoided, increased tax revenue), economic growth (more people in work), engagement in the community, increased consumption.

The postcode lottery for knee and hip procedures
Thirty-three NHS Trusts have reported that their commissioners are applying more stringent conditions before referring patients to them.
Waiting times for hip and knee procedures vary by region by as much as a month. In 2012, patients in London waited an average of 30 days (34 per cent) longer for hip operations than patients in the East Midlands – and 28 days (31 per cent) longer for knee operations.
For the absolute number of knee procedures performed, the North West is the highest. But, per capita, the North East and Wales are notably higher. London and the East of England are bottom of the league for performing hip procedures.
London comes bottom again for number of hip procedures carried out per head, with the North East again top. In absolute numbers, the North West is again highest.

As the NHS seeks to make efficiencies and meet the so-called ‘Nicholson Challenge’ – of £20 billion in productivity savings by 2015 – it is important that clinically proven and cost-effective interventions such as hip and knee replacement are viewed as an investment and are utilised to drive efficiency within the NHS. As the new NHS emerges, everything must be done to encourage efficient commissioning that realises this challenge for the benefits to the patient, the economy and society.
NHS organisations must ensure that access to hip and knee joint replacements is equitable and based on clinical need and patient benefit, working towards reducing unwarranted variation and unlocking the clinical, societal and economic benefits of early intervention.
The Medical Technology Group recommends the following:
Clinical Commissioning Groups should discontinue the practice of imposing more restrictive conditions before referring patients – trusts which perform more operations also have better patient-reported outcomes.
Patients should not be stopped from getting surgery due to their age, weight or other characteristics as per NICE Clinical Guideline 59 – Osteoarthritis.
Trusts should aim to ensure greater equity of access throughout the year.
All Trusts should have strategies in place to improve patient outcomes from joint replacement surgery.
The Best Practice Tariff for hip and knee joint replacement should be extended to include the length of wait between referral and treatment as a qualifying criterion.

The report
‘Hip and knee replacements: combating patient lotteries’ is the first in a series of reports from the Medical Technology Group, aimed at highlighting areas of medical treatment where access to the best available treatments are limited – either nationally or in particular areas of the country.
At the heart of ensuring this is improving equity of access, and tackling rationing by Trusts or Clinical Commissioning Groups.
The focus of this report is hip and knee joint replacements, of which there were almost 140,000 in 2012 [1] – making them among the most frequently undertaken medical interventions. The report uses data from the National Joint Registry, from recently released Patient Reported Outcome Measures and from Freedom of Information requests to Acute Trusts in England and Wales to recommend policies for improving patient outcomes.

Data from the National Joint Registry, NJR Centre, at (accessed 27 October 2013)
Freedom of Information request by the Medical Technology Group to Acute Trusts, 5 August 2013
118 Trusts for which both were available. Sources: National Joint Registry and Finalised Patient Reported Outcome Measures (PROMs) in England – April 2011 to March 2012
Freedom of Information request by the Medical Technology Group to Acute Trusts, 5 August 2013 xii
See ‘Targets on NHS waiting times scrapped’, Financial Times, Nicholas Timmins, 21 June 2010, at 11df-a0f5-00144feabdc0,Authorised=false.html?_i_location=http%3A %2F 00144feabdc0.html%3Fsiteedition%3Duk&siteedition=uk&_i_referer=#axzz2ijpujBBs (Accessed on 28 October 2013)
See ‘Targets on NHS waiting times revived’, Financial Times, Nicholas Timmins, 7 June 2011, at 9668-00144feab49a,Authorised=false.html? 00144feab49a.html%3Fsiteedition%3Duk&siteedition=uk&_i_referer=#axzz2ijpujBBs (accessed on 28 October 2013)
Harris hip scores measure a range of factors including pain, joint function, range of motion, and absence of deformity.
Royal College of Surgeons, Change in Harris hip score in patients on the waiting list for total hip replacements (2003)
The OKS is a patient self-completion containing 12 questions on activities of daily living.
Dakin et al, Rationing of total knee replacement: a cost-effectiveness analysis on a large trial data set, British Medical Journal, 2 (2012), at
‘Introducing Decision Aids At Group Health Was Linked To Sharply Lower Hip And Knee Surgery Rates And Costs’, David Arterburn, Robert Wellman, Emily Westbrook, Carolyn Rutter, Tyler Ross, David McCulloch, Matthew Handley and Charles Jung, HealthAffairs, September 2012 vol. 31 no. 9 2094-2104, at (accessed on 28 October 2013)