There is an ongoing drive for greater transparency within the NHS to improve standards and safety, and reinforce trust in doctors and surgeons. As part of this, under the 'Everyone Counts' initiative, NHS England has asked thirteen surgical and medical specialties, including orthopaedics, to share their data publically.
This is the second year that orthopaedics has published this information and the refreshed and additional information in Surgeon and Hospital Profile is in response to this request. It is intended to empower patients by giving them accurate data about the orthopaedic surgery care provided in England.
NJR's Surgeon and Hospital Profile allows patients, their friends, family and carers to view surgeon specific data and make comparisons between hospitals in their local area. This is intended to help patients find information to help them make decisions about their care and their surgery.
The NHS England initiative is encouraging joint replacement patients to seek out this information in advance of surgery so that they are able to discuss it with the surgeon and get a full picture of his or her practice in the context of the care delivered by the whole healthcare team at the hospital.
Hip, knee, ankle, elbow and shoulder joint replacements have become common and highly successful operations that bring many patients improved mobility and relief from pain. More than 200,000 of these operations take place in England, Wales and Northern Ireland every year. It is a procedure with very low mortality.
There is limited data available on which to make international comparisons, but the limited evidence we have suggests that this surgery is as safe here as in any other country. The fact that England, Wales and Northern Ireland have an established National Joint Registry to monitor the quality of joint replacement implants, hospitals and surgeons is a mark of quality and a commitment to improving care at all times for the benefit of patients.
A wide range of implants can be used in the joint replacement operations that are carried out. This is where the NJR helps, monitoring the performance of these implants as well as the effectiveness of different types of surgery. The overall aim is to improve clinical standards and outcomes for the benefit of patients, surgeons, healthcare professionals and the wider orthopaedic community.
The National Joint Registry (NJR) for England, Wales and Northern Ireland collects information on hip, knee, ankle, elbow and shoulder joint replacement surgery and monitors the performance of joint replacement implants, hospitals and surgeons. It was set up in 2002 by the Department of Health and Welsh Government. Northern Ireland joined in 2013.
NJR mission statement:
'The purpose of the National Joint Registry for England, Wales and Northern Ireland is to collect high quality and relevant data about joint replacement surgery in order to provide an early warning of issues relating to patient safety. In a continuous drive to improve the quality of outcomes and ensure the quality and cost effectiveness of joint replacement surgery, the NJR will monitor and report on outcomes, and support and enable related research.'
In 2008, the management of the NJR was transferred from the Department of Health to the Healthcare Quality Improvement Partnership (HQIP), a consortium comprising the Academy of Medical Royal Colleges, the Royal College of Nursing and patient organisation, National Voices. More information about HQIP can be found at www.hqip.org.uk
Patients receiving joint replacement surgery are invited by their hospital to consent for their personal details to be recorded in the NJR (name, address, NHS number/national patient ID). The hospital will then upload details of patients receiving joint replacement surgery through an electronic data capture system, which includes details of the patient, the operation, the surgeon and the implants used.
If the patient receives any future revision surgery (where the implanted joint is replaced due to loss of function for example), these records are linked in order to measure the time between the first-time or primary surgery and the revision operation.
Patients should always be given additional information before they consent via the NJR Patient Consent Form. Please click here to read the NJRs Patient Information Leaflet.Other nationally collected data sets are then linked to the NJR data in order to measure other outcomes, including death following surgery within 30 days and 90 days.
The data represents that data entered by each hospital into the NJR. Whilst the NJR takes steps to prevent errors, by validation at the point of data entry, it is possible for data entry errors to occur.
The accuracy and validity of the data relies heavily on the diligence of Trusts and surgeons entering all primary and revision operations. It is the responsibility of the surgeon, hospital team and Trust/Local Health Board/Provider to make sure that all cases are registered and accurate. It is mandatory for cases to registered, termed as ‘compliance’ with the NJR. The NJR measures and monitors the proportion of cases recorded and compares this to the expected number of cases (from other data sources). This is termed ‘compliance’ with the Registry.
The NJR encourages and supports all hospitals in achieving full compliance through its NJR Regional Coordinators. Compliance with the NJR is measured at a national-level and hospital-level. Nationally, compliance with the registry in 2013/14 was 99.6%. However, at a hospital-level, a greater variation is shown.
The NJR does not currently have a way of cross-checking hospitals in Northern Ireland and the independent sector to ensure all of the relevant procedures are submitted. This is why there are no compliance figures relating to these hospitals.
The compliance rate is presented for each hospital in England and Wales (at Trust-/Local Health Board-level) as part of this information found in Surgeon and Hospital Profile. It is benchmarked against 85% as the minimum expectation for submission aligned to other healthcare requirements (Best Practice Tariff). However, the NJR defines the best practice for hospitals as being 95% data submission and above.
Surgeons are advised to regularly check to ensure data held by NJR are accurate. Surgeons who do not already have a username and password can find out how to register for the service on the NJR website. Surgeons have been specifically invited to review and check their individual data prior to this publication.
Consultant surgeons who have undertaken one or more hip, knee, ankle, elbow or shoulder procedures between 1 April 2015 and 31 March 2016 are listed on the website, under the hospitals in which they are reported as working.
However, only those surgeons who have carried out one or more NHS-England funded procedures as Consultant in charge in that time are automatically included under the NHS England initiative and have their profiles available to view.Consultant surgeons whose current practice is only in Wales, Northern Ireland or the private sector are not automatically included but may choose to opt in to their data being published. Surgeons who wish to opt-in can do so through the NJR Clinician Feedback system.
Yes, only Consultants in charge are included for publication. All joint replacement procedures are overseen by a Consultant in charge and they have responsibility for the care the patient receives. However, the Consultant in charge of the operation is not necessarily the operating surgeon.
For surgeons who have undertaken both private and NHS-funded practice (including NHS 'Choose and Book' in a private practice setting) between April 2015 and March 2016, their total practice as 'Consultant in charge' will be included in the analysis. All the hospitals in which they work will be listed. The volumes of NHS and private practice will not be disclosed; only a total volume will be published.
Consultants who solely work in private practice with no NHS-funded patients are not in scope for this initiative. However, they are able to opt-in to publication of their data if they wish through the NJR Clinician Feedback system.
Practice profiles show the total number and type of procedures overseen by the Consultant in charge for the period 1 April 2015 to 31 March 2016 (12 month profile) and 1 April 2013 to 31 March 2016 (36 month profile), as recorded in the NJR. Procedures are attributed to a surgeon where the surgeon is the Consultant in Charge of the operation but not necessarily the operating surgeon.
Procedures recorded against a surgeon may have been undertaken in any of the hospitals in which the surgeon has practised, and includes both NHS- and privately-funded activity. This means that patients are looking at the total practice for the surgeon in the time periods presented.
Activity is also shown alongside the national average (mean) number of procedures of each type undertaken over the same time periods.
This graph shows data on the proportion of patients who die within 90-days of first-time (primary) joint replacement surgery in the form of a Funnel Plot. A Funnel Plot analysis means that each surgeon and each hospital can be compared after important risk adjustments are made for patient characteristics that affect outcomes of surgery, for example, age group and general health prior to surgery (excluding the joint problem being addressed).
Each surgeon (or if you are reviewing hospital data, each hospital) is represented by a blue dot on the graph. Multiple surgeons (or hospitals) may report the same mortality ratio and therefore appear on the same dot. On each profile, the surgeon or hospital you are reviewing will be highlighted as a black triangle. All those under the top red line have a mortality rate in line with expectation.
Progression along the horizontal (x) axis means that the surgeon or hospital has done more operations and/or operations on patients that are at a higher risk of death such as older or elderly patients. Progression along the vertical (y) axis means the surgeon or hospital has had more deaths. Those surgeons or hospital that appear above the top red line have a higher than expected mortality rate. Those on the central (green) horizontal line have had exactly the expected number of deaths taking into account the types of patients they operate on and number of operations. Hospitals either side of the central green line but below the upper red line have had a level of mortality that is within the expected range.
All the orthopaedic surgeons and hospitals analysed in Surgeon and Hospital Profile have outcomes in line with the expected mortality rate, as they are all below the top red line.
Outcome indicators (mortality and revision) are 'risk adjusted' to take account of the fact that different surgeons may operate on higher-risk or lower-risk patients (e.g. because of the overall health condition of the patient population they work with). Risk adjustment allows surgeon and hospital data to be adjusted to show what the outcome would have been had each surgeon operated on the average patient. Case-mix adjustment is not precise and some differences in rates may be the result of random events.
The role of the NJR Surgeon Outliers Sub-committee is to ensure that, at the earliest stage, concerns about potential outlier performance of hospitals and surgeons is highlighted and communicated to those concerned, to trigger an internal audit of surgeon practice. The NJR Surgeon Outliers Sub-committee has been carrying out this role since 2008.
It is important to emphasise that the identification of a potential outlier surgeon does not mean that a surgeon's performance is poor as many other contributing factors may have influence, for example, the type of patient the surgeon operates on and incomplete provision of data to the National Joint Registry. All or a combination of these factors have been seen to contribute to potential outlier performance being identified in some cases.
All the orthopaedic surgeons analysed in Surgeon and Hospital Profile have outcomes in line with the expected mortality rate, as they are all below the top red line.
The information on the surgeons has been presented as a 'funnel plot', which we feel is the best way to portray this information. Deaths following orthopaedic surgery are a rare event. One surgeon may have a death in his or her first 10 patients while another has 90 patients and only one death - their mortality rates would look very different, but the surgeon with 10 patients may have 80 more cases with no more deaths. It is important that the presentation of this information reflects this. We also do not feel that it is helpful to patients to portray one surgeon as being better than another, when there are many factors that can influence mortality, particularly health and other factors of the patient.
We would emphasise that no surgeons have been found to be outliers in this analysis, and as such all the surgeons' outcomes are in line with expectations.
If you are already undergoing treatment or have surgery booked in the near future, we suggest you talk to your surgeon about this. He or she can talk to you about their data, and they can explain more about their expertise and any factors that may have influenced their data.
You can also talk to your GP, and you can ask to be referred to a different surgeon if you continue to be concerned.
Yes, ask for more information. Your GP and/or your healthcare team at the hospital should be able to provide further information as to the numbers and results of procedures carried out locally. Importantly, this might include local context for example, additional information on the specific types of procedures or the types of patients that are treated.
The hospital will be aware of the results shown through this service and receive regular, detailed information on their data that is held and analysed by the NJR. Using these results, the hospital will normally start a period of review to identify the reasons why it may have been identified as outside the expected range of performance. Sometimes this may be a result of not providing the NJR with all of the relevant information for the analysis.
Statistics should not, on their own, be taken as a guide to the standards of a hospital and the care you would receive. However, if you have any doubts or questions, speak with your GP, your surgeon and healthcare team at the hospital.
Note on hospital revision rate information
It is important to note that the data shown is a snapshot in time of the relative performance of this hospital. A hospital’s results may fluctuate over time and get progressively better or worse, reflecting the types of procedures they carry out and/or the types of patients that they treat among other, local factors including whether the hospital is providing a full and accurate submission of data to the NJR.
For the revision and mortality information, it is also important to note that more recent changes in practice at hospitals may not be reflected in the results because of the longer five and ten year time periods covered and/or insufficient reporting of first-time and revision operation information to the NJR.
NJR Public and patient guides are also available which include further FAQs about the NJR and a summary of the most recent joint replacement information by joint type. This includes more information about revision rates for different implant types for example:
The same information can also be found in an alternative format through NHS Choices at: www.nhs.uk/Service-Search/performance/Consultants.
Surgeons wishing to check their data can do so through the NJR Clinician Feedback System. Surgeons who do not already have a username and password can find out how to register for the service on the NJR websiteYou can contact the NJR Centre using the following methods:
Telephone: 0845 345 9991
Email: email@example.comMore information for surgeons on this initiative can be found on the British Orthopaedic Association's website: https://www.boa.ac.uk/PP/Pages/Publication-of-Surgeon-Outcomes.aspx