Routine orthopaedic procedures are more complex than ever before in the NHS

September 18th, 2023. Go to post.

Introduction

A decade of Staffing shortages, low bed capacity and a devastating 2-year pandemic has culminated in an unprecedented backlog of elective procedures for the NHS with over 7 million patients currently waiting for care in England1.

As a response to these growing waitlists, the NHS conceived the national high-volume low-complexity (HVLC) programme during the COVID-19 pandemic. This programme has worked to standardise pathways, introduce surgical hubs, and improve theatre productivity to increase the throughput of trusts performing routine procedures. It has long been suspected however, that routine procedures in the NHS are not as low complexity as they were before the pandemic2. This is in part due to increasing prevalence of long-term illnesses3, an ageing population4, and the degradation of patient health whilst waiting for surgery2.

As part of our work supporting the GIRFT HVLC programme, we have worked with surgeons to identify patient characteristics that have statistical relationships with the cost of high-volume orthopaedic surgery procedures. These include clinical diagnoses, such as cancer or diabetes in patient records, procedural features, such as the emergency admissions prior to surgery, or patient demographics, such as age and deprivation. Using Machine Learning approaches, we can quantify the impact of these features and develop an indicator of clinical complexity in routine procedures. Our work brings light on the poorly understood impact of increasing patient complexity and is the first step towards mitigating and tackling the increased burden being felt by surgical specialties in England.

Methodology

To quantify patient complexity, 2 key data sources have been used.

  1. Hospital Episode Statistics (HES), a detailed dataset containing clinical, demographic, and patient information.
  2. Patient Level Information and Costing Systems (PLICS), a dataset relaying the cost of hospital admissions in England.

By linking these two sources, we have been able to create statistical models that uncover the relationship between clinically relevant patient features and the cost of a procedure. Specifically, we have worked with Orthopaedic surgeons to select 22 drivers of operation cost which are shown in Figure 1.

Figure 1. Features used to estimate clinical cost from HES data.

HES/PLICS data from 2018-19 was used to extract these features and train procedure specific linear regression models that estimate procedure cost. Using these models, we can track the estimated cost that is driven by the clinical characteristics of the patient over time which is a pertinent indicator of patient complexity.

Findings

The expected costs have been calculated for 3 major HVLC orthopaedic procedures in Figure 2. They clearly show that since the COVID pandemic, patients have been more complex and resource intensive than ever before. Analysis of patients has revealed this increase is primarily driven by increased frailty, as there is a 30% increase in patients with a severe frailty score, as well as a 10% increase in the average number of significant ICD-10 codes. Worryingly, this increase shows no sign of reversing as of March 2023, suggesting that this trend is potentially here to stay.

This work reveals several far-reaching implications for the NHS, most notably that routine procedures are likely to drain resources more rapidly than ever before. Unless hospitals are paid accurately to reflect these changes, there will be a reduction on how much can be spent on staffing and other resources which further damages patient care. We have compiled a set of key recommendations that aim to mitigate the knock-on effects of complexity increase.

  1. Increased cost and resourcing requirements should be reflected when creating activity plans. This will affect trust, care system and specialty managers with limited budget.
  2. Tariffs should be regularly updated to reflect the ever-changing patient case mix that is seen by hospitals. The tariffs should also be sensitive to demographic features of patients, such as age and deprivation, as we have found that these are important drivers of surgery cost.
  3. Programmes should focus on increasing the general health of patients before elective admission. We have shown that the increased expected costs of hip replacements alone amount to over £13 million pounds per year for the NHS. If programmes, such as the PREP-WELL project by the health foundation5, can demonstrate that they are able to reduce clinical complexity, there is large potential for savings.
  4. National programmes that track surgical outcomes, such as Model Hospital and the National Consultant Information Programme, should adjust performance metrics to account for changing patient case mixes. This will enable increased buy in from clinicians who have been most directly affected by increased complexity.

References

  1. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis ↩︎
  2. https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(21)00001-1/fulltext ↩︎
  3. https://www.ons.gov.uk/employmentandlabourmarket/peoplenotinwork/economicinactivity/articles/risingillhealthandeconomicinactivitybecauseoflongtermsicknessuk/2019to2023 ↩︎
  4. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/ageing/articles/profileoftheolderpopulationlivinginenglandandwalesin2021andchangessince2011/2023-04-03#:~:text=2.,from%2016.4%25%20to%2018.6%25 ↩︎
  5. https://www.health.org.uk/improvement-projects/preparing-for-surgery-the-community-pre-habilitation-and-wellbeing-project-the#:~:text=Following%20an%20initial%20health%20evaluation,week%20programme%20prior%20to%20surgery ↩︎


Improving Cancer Outcomes – Why ICSs Must Tackle Health Inequalities

June 1st, 2023. Go to post.

There is a recurrent emphasis on the need for Integrated Care Systems (ICSs) to address health inequalities, as highlighted by media outlets, conferences, and reports.

Addressing these disparities is a monumental task, especially for the newly established ICSs, which have been tasked with not only establishing new governance and strategies but also tackling an elective backlog and long-standing health concerns like health inequalities.

One crucial area of focus, particularly in relation to the Core20Plus5 mandates, is cancer, as we are aware of inequalities in access impacting diagnosis and survival rates. The ambitious objective set out by the NHS Long Term Plan is to diagnose 75% of cancers at Stage 1 or 2 by 2028.

Lung cancer, where 64% of patients receive a diagnosis at stage 3 or 4, is an excellent example that underscores both challenges and opportunities for ICSs.

Why avoiding emergency diagnoses is key

We examined publicly available data on lung cancer care. Patients referred by a GP are more likely to be diagnosed at an early stage than those in emergency settings.

This relationship can be seen by comparing NHS clinical commissioning groups (CCGs), where a 10% increase in GP diagnoses is associated with a 3% increase in early diagnoses (stages 1 and 2), when adjusting for confounding factors, as shown in Figure 1.

Figure 1. Source PHE 2018

Since patients are over 3 times more likely to survive more than 5 years when diagnosed at stage 1 compared to stage 3[i], detecting cases via referrals from primary care has a direct impact on lowering lung cancer mortality rates associated with a late-stage diagnosis.

Diagnosis RouteStage 1Stage 2Stage 3Stage 4
Primary Care21%10%25%44%
Emergency Department10%5%14%72%
Ohter28%10%20%42%

Table 1. Source NCRAS 2015-16

Reducing variation in primary care referral rates

The challenge, however, lies in the unequal volumes of lung cancer referrals made in primary care, which vary dramatically across NHS regions. We have used Public Health England data and machine learning approaches to uncover the relationship between the number of GP referrals and the percentage of all lung cancer cases diagnosed from these referrals.

As seen in Figure 2, there is a clear positive relationship between the volume of referrals from primary care and early diagnosis, which is particularly strong for areas with low referral volumes.

It follows that if GPs with low referring rates could be supported increase referral volumes, there will be a high impact in driving earlier diagnosis and improving survival rates. This means that increasing referral rates would be very material for the NHS and its patients. In fact, if all ICSs were able to bring all the lowest referring GP services in line with the bottom quartile, as shown in Figure 3, we would expect 700 extra early diagnoses and 100 lives saved per year across the country.

Figure 2. Source PHE, 2018
Figure 3. Source PHE, 2016

How these findings turn into practical implications for ICSs

Variation in urgent suspected cancer referrals and early diagnosis rates is likely a combination of both GP organisation/behaviour and broader patient behaviour. For the former, it is well known that there are pressures on GP numbers and overall workload, which will impact access locally.

Nonetheless, there will be opportunities for ICSs to surface data on variation in cancer referral rates and work with practices to understand variation and support where necessary.

ICSs can also lead improvements by understanding how their local population, demographic and health system factors are influencing access. Although this highlights the complexity of the challenge, it also offers multiple sources of opportunity for systems.

In our experience, some of the key actions for ICSs to address the above are:

  • Involve primary care networks (PCNs) and cancer alliances early into conversations about improving cancer detection – we are currently working with a cancer alliance on data-driven research to better understand the drivers of variation in the detection rate and the most effective interventions for addressing them.
  • Provide practices and PCNs with tools to better understand their local population and their health needs (see here for a population health management dashboard we developed for Surrey Heartlands).
  • Plan adequately for workforce, particularly in primary care, to make sure there is enough capacity to boost referrals and avoid workforce overwhelm. Given the falling numbers of full-time equivalent GPs, this is a priority area for ICSs and nationally.
  • Assess secondary care diagnostic capacity, including modelling demand and capacity and promote system-wide initiatives such as new community diagnostic centres, implementing rapid diagnostic services and supporting mutual aid between trust, as we have discussed previously.

As the landscape of healthcare continues to evolve, ICSs have a crucial role to play. The responsibility lies with them to implement innovative strategies, utilise data-driven research, and ensure a robust primary care workforce.
With a concerted effort towards these goals, ICSs have the potential to significantly influence early cancer detection rates and, ultimately, patient survival.


[i] Characteristics of patients with missing information on stage: a population-based study of patients diagnosed with a colon, lung or breast cancer in England in 2013. C Girolam and others BMC Cancer (2018). Volume 18, Page 492



Tom is a Senior Analyst at Edge Health with experience working with senior clinicians and leading risk adjustment projects. He has a special interest in machine learning applications for healthcare data and analysis.