Watchdog attacks hip surgery

Not all hip joints are of proven value

Patients may be suffering unnecessarily because doctors are using unproven artificial joints in hip replacements, says a government report.

The National Audit Office, while praising the way many NHS trusts and orthopaedic consultants carry out hip replacement surgery, also warns of "significant variations" in standards across the country.

The government has responded by announcing the creation of a national register of hip replacements in England.

This will allow monitoring of the various types of hip replacement over the long-term.

Health minister John Hutton said: "We want to concentrate on using the best equipment that is available, and to make sure there is better follow-up once somebody has had an operation."

The NHS performs more than 30,000 total hip replacements each year designed to reduce pain and increase mobility.

Most patients are implanted with one of a small number of established designs and can expect their new hip to work effectively for up to 15 years.

The current process for introducing new hip prostheses into the NHS cannot always ensure long term effectiveness

Sir John Bourn, National Audit Office

However, there are more than 60 different types available, and evidence of long-term effectiveness is not available for all those in current use.

Sir John Bourn, NAO head, said: "Hip replacement surgery is a procedure that successfully improves the lives of tens of thousands of people each year.

"However, the current process for introducing new hip prostheses into the NHS cannot always ensure long-term effectiveness, and if a hip prosthesis performs poorly, it can have serious consequences for the patient."

Follow-up worry

The NAO found variations in the supervision of surgery, and in the way patients were followed up after their operation.

More than half of consultants surveyed said patients should receive life-long follow-up, but only a quarter said that they actually offered such a service.

They blamed the discrepancy on pressure of work and lack of funds.

The public can be reasonably reassured that hip replacement is a highly effective operation

Hugh Phillips, president, British Orthopaedic Association

The NAO was also concerned that some orthopaedic consultants carry out too few operations to keep their skills sharp.

It was found that 8% of orthopaedic consultants perform fewer than 10 primary replacements a year, and 71% perform fewer than 10 revisions a year.

In some cases, it was also found that patients were staying in hospital too long after surgery. Cancelled surgery and delays in starting hip operations also waste 200 hours of theatre time each week, according to the report.

The NAO has drawn up a list of 20 recommendations to improve the service for patients. These include:

• trials for new types of artificial hips before they enter general NHS use
• only those with proven long-term effectiveness should be used
• possible introduction of a minimum number of operations per consultant per year to ensure expertise is maintained
• trusts should review purchasing arrangements to minimise costs while maintaining quality standards
• action to prevent unnecessary length of stay in hospital

Hugh Phillips, president of the British Orthopaedic Association, said a register of hip replacements was needed so that effective clinical audit could be carried out.

"This report has raised concerns, but the public can be reasonably reassured that hip replacement is a highly effective operation, and along with coronary artery bypass and cataract removal, is one of the top three most effective operations available to the public."

The NAO report follows the issuing of guidance to all orthopaedic consultants in England and Wales on hip replacements earlier this month by the National Institute for Clinical Excellence (NICE).

NICE said that only artificial joints that had a failure rate of 1% or less per year for the first 10 years should be used on patients.