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

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.

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 ↩︎