Getting it right first time in spinal surgery

Getting it right first time in spinal surgery

The Getting It Right First Time programme recently published its national report on spinal services, authored by Mike Hutton, consultant spine surgeon at the Royal Devon & Exeter Hospital. We take a closer look at the recommendations…

Replacing short-term pain relief injections with long-term physical and psychological rehabilitation programmes could help tens of thousands more patients cope with debilitating back pain, according to the national report on spinal surgery from Getting It Right First Time (GIRFT).

Lower back or radicular pain is the primary cause of disability in the UK. It affects one-third of the population at any one time, and 84 per cent of people in their lifetime.

The GIRFT report found that, despite NICE guidance, a significant number of patients are still receiving facet joint injections to block pain, which have limited clinical value. On average between 2015 and 2018, almost 6 per cent of patients with back pain received three or more facet joint injections in a year, at a cost to the NHS of £10.5m.

Reinvesting this money in longer-term physical and psychological rehabilitation programmes close to patients’ homes – in line with the National Low Back and Radicular Pathway – is one of the key recommendations outlined in the report. 

This is the eighth specialty report from the Getting It Right First Time programme and it focuses on spinal emergency conditions (spinal cord injury and spinal infection), as well as the management of common conditions like sciatica. In 2017/18, the NHS carried out 52,523 surgical procedures on the spine. 

A series of 22 recommendations bring opportunities to improve the patient experience through earlier discharge from hospital, reducing cancelled operations and ensuring trusts are equipped to deliver the best care in the most timely manner. It is estimated the recommendations could deliver cost efficiencies of up to £27m.  

The report’s author, Mike Hutton, is a consultant spine surgeon at the Royal Devon & Exeter Hospital, as well as an elected member of the executive of the British Association of Spine Surgeons as the audit and British Spine Registry lead, and the spinal lead for the Department of Health clinically led quality and efficiency programme.

His GIRFT review took him to 127 spinal units across England, to meet with his peers and discuss the issues facing the specialty.

He said: “During my visits, I have been repeatedly struck by the passionate commitment of the clinical staff towards the NHS as a force for good in society. The majority of units expressed pride in their work, a sense of ownership of their unit and a loyalty to the communities they service.

“They do so, however, under significant increasing demand on their services and financial constraints.

“I am excited to put forward the recommendations in this report. I firmly believe they offer the potential to achieve significant improvements in patient care and to create significant financial opportunities.”

Among the other key recommendations in the report is the support of referral without delay to 24-hour MRI scanning in the hospital of presentation for patients with suspected cauda equina syndrome, to help prevent the possible limb paralysis and permanent loss of bowel and bladder function if it is not treated quickly. There are more than 8,000 suspected CES cases every year in England. Trusts are urged to follow Society of British Neurological Surgeons (SBNS) and British Association of Spine Surgeons (BASS) standards on the management of patients with suspected CES, reviewing their policies for out-of-hours on-call radiology to help facilitate around-the-clock MRI scanning. GIRFT has pledged to work with trusts, local infrastructure and networks on finding solutions to enable that to happen.

The report also recommends changes to the referral pathway of paediatric spinal deformity patients to enable children to be treated close to home where appropriate, but at a centre with the shortest waiting time. Data shows many patients receiving paediatric spinal deformity surgery currently face long waiting times and have a relatively high risk of their surgery being cancelled. There are opportunities to reduce the risk of cancellation, which could include preferentially scheduling surgery during the summer (school holiday) months for cases requiring paediatric high dependency/intensive care units, enhanced ward recovery for cases of adolescent idiopathic scoliosis and directing referrals to centres with shorter waiting times and low cancellation rates.

Another section of the report focuses on the better recording of implants, their costs and their effectiveness. Purchase Price Index and Benchmark Tool (PPIB) data suggests £42m a year is spent on implants in spinal surgery, yet most trusts do not understand the cost of the implants they are procuring or whether they are offering best value for the NHS, let alone the best outcomes for patients. Some trusts, for example, pay £150 each for polyaxial pedicle screws, while others spend £650, even though there is little demonstrable peer-reviewed evidence to suggest one type is better than another. If the NHS in England were to follow the French model and move to a nationally set figure of around £200 each for these screws, it is estimated the saving could be around £4.6m.

The GIRFT report recommends that all surgical interventions are logged on the British Spine Registry (BSR) going forwards, with best practice tariffs for providers that comply. This will enable clinicians and procurement managers to better judge whether certain brands of implants justify their price. The report also recommends the introduction of the Beyond Compliance programme for the specialty to further strengthen surveillance. 

Patients with a spinal cord injury (SCI) will also benefit from a recommendation for 24-hour cover at major trauma centres to enable the swift decompression and stabilisation of patients with a fractured or dislocated spine. Nationally, the median time from injury to surgery is one day, but the GIRFT data showed 33 per cent of patients are waiting for two days or more. Trauma centres are asked to review out-of-hours cover and rotas to ensure patients are operated on as quickly as possible.

The GIRFT spinal services report is the latest since the programme’s initial orthopaedic surgery pilot, published in 2015 by Professor Tim Briggs. The recommendations in this latest report are endorsed by the UK Spine Societies Board (UKSSB), the British Association of Spinal Surgeons (BASS), the Society of British Neurological Surgeons (SBNS), the British Orthopaedic Association (BOA) and the National Backpain Pathway Clinical Network (NBP-CN). They will be implemented in partnership with NHS Improvement and NHS England, as well as directly with hospital trusts and Sustainability and Transformation Partnerships. 

Patrick Statham, chair of the UKSSB, said: “The many visits that have been made to individual trusts have provided new insights and have been a powerful stimulus for improvements in patient care. 

“Bringing these insights together in this national report shows where progress has already been made, gives examples of organisations that are leading the way in driving further improvements, and gives focus to areas where more work is needed.”

Health Minister Stephen Hammond added his support, saying: “This is a significant step forward in the way the NHS cares for people living with spinal conditions, focusing on rehabilitation rather than just relief to improve patient experience and lead to better treatment outcomes.

“These clinically-endorsed recommendations could have a major beneficial impact on the quality of life for tens of thousands of patients a year. This reflects a wider drive in the NHS Long Term Plan to reduce variation in treatment and deliver exceptional patient care at the best price for our taxpayers.”

Kathy McLean, Executive Medical Director and Chief Operating Officer at NHS Improvement, said: “As the Long Term Plan states, we are committed to supporting NHS trusts to learn from one another and to make changes that will both benefit patients and free up funds that can be invested back into frontline care. 

“The recommendations in this report are based on what clinical teams have found to work most effectively in managing lower back pain, and so we encourage trusts to review their own practice without delay as this could improve the lives of thousands of people across the country.”

Copies of the GIRFT spinal services report are available at www.gettingitrightfirsttime.co.uk

What is GIRFT?

GIRFT is a national programme created and led by consultant surgeon Professor Tim Briggs, who ran a pilot programme in orthopaedic surgery which helped to save £30m in the first year and a further £20m in the second year. By 2021, it is expected the GIRFT programme will have created opportunities to improve patient care nationwide while also saving up to £1.4bn annually. Professor Briggs is GIRFT Chair and National Director of Clinical Improvement for the NHS.

The GIRFT programme works with frontline clinicians to help improve the quality of care within the NHS by identifying and reducing unwarranted variations in service and practice. It is a partnership between the NHS Royal National Orthopaedic Hospital Trust (RNOH) and the Operational Productivity Directorate of NHS Improvement (NHSI).

GIRFT methodology analyses hospital data looking for unwarranted variations; differences between trusts in areas such as effective procedures, waiting times, length of stay, infection rates, procurement costs and patient pathways. GIRFT then recommends changes to reduce variations and improve the effectiveness of care.

Q&A with Mike Hutton

SSN: Tell us a bit about your background/career.

MH: I qualified from Charing Cross and Westminster Medical School in 1995 and, after my house jobs, became a professional rugby player for two years until a broken leg ended that career. I returned to medicine on a Basic Surgical Rotation at St George’s Hospital in Wandsworth from 1998 to 2000, then undertook my specialist orthopaedic training on the Cambridge rotation. Initially I wanted to be a sports injury orthopaedic surgeon but was hooked having worked with the Ipswich Spine Surgeons and the neurosurgeons in Cambridge.

I undertook a travelling spinal surgical fellowship at the Royal National Orthopaedic Hospital, Harbour View Hospital, Seattle, USA and Vancouver General Hospital, Canada.

In 2007, I was appointed as a spinal surgeon at the Royal Devon & Exeter Hospital.

SSN: Why did you want to carry out this GIRFT review?

MH: I witnessed what Professor Tim Briggs achieved with the original orthopaedic pilot and felt that spinal services were also likely to have significant unwarranted variation in their delivery. With the pressures facing the NHS, I felt the project was a way in which I could really make a difference to patient care on a grander scale than I could deliver as just a local clinician.

I also saw the opportunity to visit spinal units around the country as a chance to learn what clinicians and their management teams were doing that was good for patients, and to apply that to my own service.

SSN: What has been the most surprising thing you’ve learned in your visits?

MH: I expected there would be some variation in the delivery of spinal services, but I was extremely surprised by the scale of the variation – things like the repeated use of facet joint injections for back pain, the costs of polyaxial screws ranging from £150 to £650 and the huge cost of litigation in spinal-related cases, which is estimated at £100m per year when the NHS England budget for spinal surgery delivery is £300m. Totally unsustainable!

SSN: What are your main hopes in publishing this report?

MH: My main hope is that the 22 recommendations of the report are actioned and implemented by the various stakeholders. If they are, I believe the care of patients with both emergency and elective spine problems in England will be significantly improved. Hopefully this will play a part in preserving a healthcare service free at the point of delivery for future generations.

The 22 recommendations from the GIRFT spinal services national report 

  1. CCGs and trusts to agree local plans to implement and adhere to the National Back & Radicular Pain Pathway.
  2. Mandatory use of National Neuromodulation Registry for Spinal Cord Stimulators.
  3. Trusts to follow SBNS and BASS guidance on the management of patients with suspected cauda equina syndrome, including urgent referral by a senior decision-maker to a 24-hour MRI scanning service performed locally in the hospital of presentation, ensuring no delay. Radiologists must prioritise these patients in light of the syndrome’s severity and the time-critical nature of effective treatment.
  4. Spinal hubs (a spinal hospital with 24/7 spinal consultant on-call) to implement electronic emergency referral systems, that allow effective two-way communication between and within trusts.
  5. All major trauma centres to have 24/7 ability to stabilise and decompress patients with fractured and/or dislocated spines.
  6. Additional SCI beds, including ventilation beds, to be funded in the system.
  7. Develop a standardised mobilisation protocol for patients with a SCI, based on international recognised practice, and improve recording and monitoring of outcomes through the National Spinal Cord Injuries Database.
  8. All providers, including AQPs, to be part of a Regional Spinal Network. Clinicians, including allied health care practitioners, to actively engage in their Regional Spinal Networks.
  9. Review the list of trusts that are designated specialist spinal surgery centres and that non-specialist trusts are not remunerated for undertaking specialist work. Specialist top-ups phased out and tariff restructured so that specialist centres are appropriately remunerated for the specialist activity they undertake and are not incentivised to perform non-specialist work.
  10. Review of minimum surgeon and provider volumes for a range of rare spinal conditions and complex spinal surgeries, including adult spinal thoracolumbar degenerative deformity surgery and paediatric spinal deformity surgery.  Spinal societies asked to make recommendations.
  11. BASS to review NICE guidance and recommendations on the appropriate use of vertebroplasty and kyphoplasty and timing of intervention.
  12. The BSS and the Spinal Services CRG asked to define criteria in the 16-18 age group that should be treated as a paediatric case.
  13. CCGs to ensure that all primary care referrals for paediatric deformity surgery go through their local paediatric deformity unit. A central paediatric deformity referral management tool is used to ensure that cases go to the correct geographical centre with appropriate skill sets and shorter waiting times.
  14. Spinal Services CRG (NHSE) asked to review service specification for Type I and Type II Paediatric Scoliosis Surgery.
  15. SBNS, BASS and BSS asked to collate and disseminate evidence on best practice in reducing hospital length of stay and supporting early discharge.
  16. All spinal surgical interventions to be recorded on the British Spine Registry.
  17. Implement a range of specific measures to ensure that spinal surgery implants are introduced and adopted in line with emerging evidence and best practice, and that comprehensive data is collected to support appropriate dissemination.
  18. Mandatory requirement for trusts to participate in Public Health England’s surveillance of SSI post-spinal surgery.
  19. Training across the spinal specialties and within trusts to be strengthened by funding the Spinal Training Interface Groups and reviewing the ongoing training provided by trusts in relation to spinal services.
  20. Urgently implement measures to reduce litigation costs by applying GIRFT’s five-point plan, adopting best-practice consenting processes, and adhering to guidance on the management of suspected CES.
  21. Instigate pricing transparency in procurement for spinal surgery and use the resulting insight to deliver more cost-effective procurement.
  22. Industry to publish details of financial and non-financial support they provide directly or indirectly to individuals or units.
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