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 meas