ECC0004

1. Versus Arthritis is the charity formed by Arthritis Research UK and Arthritis Care joining together. We work alongside volunteers, healthcare professionals, researchers and friends to do everything we can to push back against arthritis. Together, we develop breakthrough treatments, campaign for arthritis to be a priority and provide support. Our remit covers all musculoskeletal conditions which affect the joints, bones and muscles including osteoarthritis, rheumatoid arthritis, back pain and osteoporosis.[2]

2. Arthritis and related musculoskeletal conditions affect 17.8 million people in the UK and are the single biggest cause of pain and disability in the UK. Cumulatively, the healthcare costs of osteoarthritis and rheumatoid arthritis will reach £118.6 billion over the next decade.[3] Musculoskeletal conditions account for a fifth of all sickness absence and result in the loss of around 30.8 million working days to the UK economy each year.[4]

3. This submission responds to the four core areas of the inquiry resulting from the National Audit Office report published in March 2019.[5] This will include consideration of:

• Why are the Department and NHS England not meeting waiting time standards? What is the impact on patients?
• What are the factors affecting waiting time performance?
• How can NHS England and NHS Improvement better understand increasing demand and capacity constraints?
• How can NHS England improve waiting times performance as part of the NHS Long Term Plan?

4. Summary points:

• There is declining performance against waiting times for orthopaedic procedures that may be caused in part by increased clinical need for joint replacements due to changes in population health.
• Patient outcomes from joint replacement surgery worsen after six months of waiting for treatment, highlighting the importance of a maximum waiting time to incentivise performance.
• Overall, targets for elective surgery have contributed to a fall in waiting times since their introduction.  People with arthritis experience significant pain whilst waiting for joint replacements and value having an assurance that treatment will be delivered in a timely manner.
• Waiting time performance could be improved with better productivity – NHS Improvement’s recent report suggests that 57,000 more orthopaedic procedures could be delivered through greater efficiency.
• Patient rights to start consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions are set out in the Handbook to NHS Constitution.  It is essential that a public-facing commitment about when a person with arthritis can expect to receive planned surgery is maintained.
• There is room for innovation within existing waiting times targets to improve how performance is measured.  However, a recommendation by NHS England to replace the current maximum waiting times target may well negatively affect patient outcomes.
• Data is collected for a number of procedure categories for surgery but this needs to be broken down further for joint replacements to provide a greater understanding of performance against waiting times.
• Although the NHS is under financial pressure, the needs of people with arthritis cannot be overlooked.  NHS England’s Clinically-led Review of NHS Access Standards offers an opportunity to improve waiting times performance and to ensure that providers are held accountable for delivering timely orthopaedic elective surgery.
• There is an opportunity for better engagement with patient groups and patients in the next stage of the Review to understand their experience of waiting for treatment.

Context on musculoskeletal conditions and elective surgery

5. Osteoarthritis is the most common form of arthritis affecting 8.75 million people over 45 years of age in the UK.  Physical activity is a recommended core treatment for osteoarthritis.   However, for with people with severe osteoarthritis, joint replacement surgery is recommended by the National Institute for Health and Care Excellence (NICE) and is clinically and cost effective, restoring mobility and reducing pain for many.

6. NICE recognises that joint replacement operations are clinically and cost effective.[6] Patient Reported Outcome Measures for hip and knee operations are routinely collected.

7. Academic evidence (see sections 24-27 below) indicates that patient outcomes can be affected by the length of time people wait for joint replacement surgery. Waiting can occur both before people seek help as well as throughout their treatment pathway.

8. The National Joint Registry records that in 2017, there were 105,306 hip replacements (a 3.6% increase from 2016), 112,836 knee replacements (a 2.8% increase from 2016) and 7,525 shoulder replacements (an increase of 8% from 2016).

9. A significant majority of first time (primary) joint replacements were carried out in patients with osteoarthritis: 90% of primary hip replacements, 98% of primary knee replacements and 54% of primary shoulder replacements.

10. On a national level, data on treatment pathways are reported as ‘Trauma & Orthopedics’ by NHS-England. It is not possible on the basis of current routine data to look at elective joint replacement pathways alone.

11. Current commitments to elective surgery, which apply to joint replacements and are set out in the Handbook to the NHS Constitution are[7]:

• Patients have the right to start consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions;
• Patients waiting for a diagnostic test should have been waiting fewer than six weeks from referral;
• All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons should be offered another binding date within 28 days, or the patient’s treatment to be funded at the time and hospital of the patient’s choice.

Why are the Department and NHS England not meeting waiting time standards? What is the impact on patients?

12. Despite some fluctuation over the last two years, data from the Trauma & Orthopaedics category of waiting times dataset shows a clear pattern of declining performance against the target of 92% within 18 weeks from referral to treatment since 2016.  The number of patients waiting longer than 18 weeks from referral for Trauma & Orthopaedic surgery has almost doubled in that period.[8]

Number of patients not receiving treatment within 18 weeks of referral

13. One of the factors behind the increase in the number of patients waiting longer than 18 weeks may be an increase in need for joint replacement surgery.  The National Joint Registry Annual Report 2018 highlights an increase in the number of common joint replacements carried out in 2017 compared to the previous year:[9]

14. The increasing number of joint replacement surgeries reflects the growing disease burden of osteoarthritis in England.[10] This disease burden in turn reflects wider demographic and health trends, including an ageing population, increased physical inactivity and higher levels of obesity.

15. However, it is not inevitable that demand for joint replacement surgery will continue to rise.  The NHS Long Term Plan envisages an increase in primary care-based interventions that can support people to improve their own musculoskeletal health including through participation in evidence-based structured community rehabilitation programmes such as ESCAPE-Pain. [11]

16. Rather than proceed to joint replacement surgery, many people with osteoarthritis will choose prevention interventions, if they are supported to explore these as part of a shared decision-making process.

17. The NHS Long-Term Plan outlined a vision where more people benefit from personalised care, one component of which is shared decision making between patients and clinicians. NHS England should ensure that systems and training are in place to ensure these conversations are consistently carried out to a high standard supported by appropriate decision-making tools.

18. For some, this shift towards shared-decision making and participation in prevention interventions such as ESCAPE pain may reduce their need for joint replacement surgery.

Impact on patients

19. For people with severe osteoarthritis, hip and knee joint replacement surgery are clinically and cost-effective operations, which can give people their mobility back and can enable freedom from pain. Delaying access to joint replacement surgery for those who need it can lead to deterioration in health and worse overall outcomes, ultimately costing the health and care system more.

20. Whilst the current targets for elective surgery allow the NHS to build some picture of how long a person is waiting from the point of referral, it does not capture the “hidden wait” that occurs from when a patient first experiences pain in their joints to first presenting to a healthcare professional.  This means that for many patients, effectively the waiting time for joint replacements will be longer than the 18-week minimum standard (without taking into account possible delays for prehab and surgery).

21. The pain, impact on mobility and disruption of delaying or denying an operation, can have a significant impact on someone’s life, including their ability to work and care for family members.

22. This was highlighted in a report published by Versus Arthritis in 2013, which explored the rights of patients with arthritis in accessing joint replacements.  We heard from patients the impact and burden of pain they experienced whilst waiting for an operation, especially those due for knee replacements.  Consequently, the date of the operation, once fixed, became a day that people needing a joint replacement were planning their lives around when this would take place.[12]

23. Evidence collated by Harry Burns for the review of targets and indicators for health and social care in Scotland reflects this point.[13]  The report highlighted a range of academic studies that explored the relationship between the length of time waiting for joint replacement and clinical outcomes. 

24. One study completed by Garbuz found that waiting for joint replacements for longer than six months ‘was linked to a 50% decrease in functional outcome’ and ‘that delaying treatment may result in deterioration that may not be recoverable after surgery.’ [14] Additional studies in the review showed that ’each additional month waiting for treatment was associated with an 8% decrease in the odds of better than expected functional outcome.’

25. Furthermore, the review found that functional capacity gain was poorer for patients who waited longer the six months for surgery, and that patients on extended waiting times had increased pain and disability compared to those with shorter waits.

26. The studies featured in the Burns Review give us evidence on the likely timeframes that make surgery most effective, and an evidence base that demonstrates outcomes deteriorate after this point.

What are the factors affecting waiting time performance?

27. Besides increasing disease burden and demand for surgery (see 11 above) there are at least two factors affecting waiting times performance: capacity and productivity:

Capacity

28. The National Audit Office’s recent report on elective treatment places a strong emphasis on capacity as being the main factor behind providers not meeting existing waiting times.[15] 

29. In addition, NHS Improvement’s recent report with Deloitte on productivity in elective care argued that strengthening demand and capacity planning could help ensure there is sufficient bed capacity for the elective workload in hospitals.[16]

Productivity

30. Recent evidence from NHS Improvement suggests that greater efficiency within the NHS could also allow more procedures to take place, reducing the amount of time that patients have to wait.[17]

31. NHS Improvement and Deloitte published a report in early 2019, which argued that greater productivity in the NHS would have allowed for 57,000 more orthopaedic procedures.[18]

32. The report noted that of the 89 trusts that submitted orthopaedic data comprising the report’s evidence, 29% had an in-session productivity opportunity of more than 20% through the elective sessions that were delivered across the 12-month period. 

33. In the distribution of “downtime” on operating lists that could have completed additional cases, early finish accounted for 50.5%, late start 20.1% and “intercase downtime” (29.4%).

34. Recommended actions in the report included developing improvement plans, determining productivity measures at procedure level and sharing best practice at speciality and procedure level from Trusts that achieve consistently strong theatre productivity.

35. This evidence resembles the conclusions of Getting It Right First Time (GIRFT)’s review of adult elective orthopaedic services in England in 2015, which noted in its Executive Summary that there were “undesirable variations in practice.”  The review highlighted data which showed that 23.7% of surgeons performing hip replacements, and 16.1% of surgeons performing knee replacements undertook 10 or fewer procedures per annum, suggesting substantial room for improvement in productivity. [19]

36. GIRFT also noted substantial evidence in the literature indicating that surgeons undertaking low volumes of specific activities may well result in less favourable outcomes as well as increased costs.  There is evidence of a failure to follow the evidence of the National Joint Registry (NJR) and other registries in decision making around implant choice, especially in those aged over 68 years.

37. A number of solutions were identified by GIRFT for professionals, providers, managers and commissioners who all have a role in improving outcomes in adult elective orthopaedics.  Learning from best practice is critical to ensuring that less patients are waiting in pain for joint replacements that can improve their pain, mobility and independence.

38. NHS Improvement’s report highlights that despite the capacity and demand challenges faced by providers, greater efficiencies could ensure that more patients can access orthopaedic surgery, including hip and knee replacements, in a timeframe where the procedure is most likely to be clinically effective.[20]

How can NHS England and NHS Improvement better understand increasing demand and capacity constraints?

39. Data from the Trauma & Orthopaedics category only provides a limited picture of access to surgery.  NHS England should publish data on procedure categories within Orthopaedics (in particular hip, knee and shoulder replacements where there is significant volume of surgery conducted each year) to improve understanding of waiting times performance.

How can NHS England improve waiting times performance as part of the NHS Long Term Plan?

40. The interim Clinically-led Review of NHS Access Standards was published in March 2019 by NHS England to outline proposals around current targets for elective and cancer care.[21] 

41. In the interim Review, NHS England acknowledged that targets had helped reduce waiting times for elective surgery in England: “Efforts to reduce waiting lists over the last decade have been supported by the national target of 18 weeks.” [22]

42. The maximum waiting time target from referral to treatment for elective surgery has helped to hold healthcare providers to account for delivering treatment and provides patients with rights to access treatment at a time when it will be clinically effective.  Existing rights under the NHS Constitution also allow patients to access an alternative provider when surgery cannot be delivered within 18 weeks.

43. We welcome the use of penalties for providers if they do not deliver elective surgery within 52 weeks within the NHS Long-Term Plan, but as stated above it is important that accountability is strengthened as existing waiting times targets are reviewed.

44. Within the interim Clinically-led Review of NHS Access Standards, NHS England highlights a couple of discrepancies within the existing waiting time standards for elective care that need to be addressed.

• No account is given currently to how long beyond 18 weeks someone has waited – performance is rated the same at 19 or 49 weeks;
• The current target can be “misleading” to patients who may believe the majority of people wait as long as 18 weeks for treatment.

45. NHS England has proposed exploring the following standards for elective care as part of the interim Review:

• Maximum wait of six weeks from referral to test, for diagnostic test
• Defined number of maximum weeks wait for incomplete pathways, with a percentage threshold OR average wait target for incomplete pathways
• 26-week patient choice offer (supporting measure)
• 52-week treatment guarantee (supporting measure)

46. We are supportive of NHS England’s intention to better understand the performance of providers who deliver surgery between 18–52 weeks and how this will be measured, addressing the issue raised in section 45.

47. However, it is vital that a public-facing commitment on elective surgery is retained as part of the Review process.  We are consulting with people with arthritis to understand their priorities around waiting times for joint replacements.

48. Evidence from the studies identified in the Burns Review suggest that patient outcomes gradually worsen the longer they have to wait for treatment, so it is important that this is reflected in the way performance is measured after 18 weeks.

49. We are also concerned that the proposals for elective care access standards include a weakening of patient rights to an alternative provider if treatment cannot be provided within maximum waiting times.  The proposal in the interim Clinically-led Review of NHS Access Standards is to allow for patient choice of an alternative provider if treatment is not delivered within 26 weeks.

50. This would suggest a watering down of the current access standard in the Handbook to the NHS Constitution states: “You have the right to start your consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions…  If this is not possible, the CCG or NHSE… must take all reasonable steps to offer a suitable alternative provider, or if there is more than one, a range of suitable alternative providers, that would be able to see or treat you more quickly than the provider to which you were referred.” [23]

51. It is also unclear at this stage what the rationale is behind selecting 26 weeks as the cut-off point when patients will be able to request/access an alternative provider if the NHS cannot deliver surgery within the recommended time-frame.

52. We look forward to participating in the working groups being set up by NHS England to provide patient voice and experience as these standards are tested, piloted and evaluated.  There is room for innovation within existing waiting times targets to improve how performance is measured. 

53. However, It is essential that a public-facing commitment about when a person with arthritis can expect to receive planned surgery is maintained.

April 2019

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