'What does a good Spinal Service look like?' Find out with the latest GIRFT Report

Published 19 February 2019

The GIRFT programme led by Professor Tim Briggs is designed to improve healthcare practices, techniques and processes for the benefit of patients. The latest report looks at spinal services offered in the NHS in England. NHS Resolution data shows these services are now creating more claims than ever costing £100m per year.

Mr Mike Hutton, Consultant Spinal Surgeon, and his GIRFT team conducted a comprehensive review of current service which he says needs to 'catch up' with other surgical specialties on new technologies, collation of data and learning from incidents. High quality care was identified but significant geographical variations exist. The Report makes 22 recommendations to reduce variation and improve patient outcomes and value for money.

Read on to consider the impact of the Spinal Services GIRFT Programme National Speciality Report.

What does a good spinal service look like?

The first issue Mike Hutton's team considered was 'what a good spinal service looks like'. The answer was a good clinically led service working collaboratively with its management and a service focusing on the holistic patient journey, starting with initial diagnosis and aiming for the best possible outcome for that patient in the most cost-effective way. The service should be supported by robust governance with clinicians meeting regularly both locally and on a wider geographic scale to discuss clinical issues. An exemplar service will offer transparency on complications and provide comprehensive outcomes data.

What did they find?

The GIRFT team found pockets of high quality care around the country alongside great variation. Following 127 site visits and collation of all findings they looked at areas for improvement and shared examples of good practice for other trusts to learn from. Findings were linked to 22 recommendations offering practical solutions to improve the spinal service in England. Two key examples are:

• To minimise variation the GIRFT team promote universal adoption of the National Back and Radicular pain pathway which is an end-based pathway using spinal triage (specialist trained physios) which would require future investment to increase numbers of these professionals. Coordination of care allows for significant enhancement of the patient experience and cost savings by cross team working.
  
  
• As well as more common spinal conditions the report considered the rare, more devastating conditions including Cauda Equina Syndrome, Spinal Cord Injury, Spinal Infection and Spinal trauma looking specifically at the crucial importance of rapid MRI scanning and noting the problems created by the lack of available radiographers to perform out-of-hours scanning. This has been tackled by way of re-training and use of current on-call rotas.

The nitty gritty - Problem areas, exemplar practice and solutions

The further findings were wide ranging and we pick out the highlights with improvement recommendations:

• Wide variation in the management of lower back pain and radicular pain with some units using treatment of low clinical value (e.g. facet joint injections) at inappropriate time periods and with a lack of adherence to established guidance at a cost impact of around £17.2m per year. Further, significant variation in the use of Spinal Cord Stimulators at an estimated cost of £6m in 2017/18. The GIRFT team called for collection of data to measure clinical impact and inform future guidance.
  
  
• Lack of adherence to Cauda Equina Syndrome (CES) protocols and evidence of non-emergency and non-surgical patients taking up acute beds for long periods of time. The principal reason for patients with suspected CES not receiving emergency MRI scans (which are essential to dictate whether surgery is required) was a lack of out of hours radiographer cover. Recommendations were made to adhere to SBNS and BASS guidance[i] in order to deliver timely access to MRI locally, removing the need for costly and potentially risky referrals between trusts.
  
  To try and reduce the number of inappropriate emergency admissions examples were provided of best practice around the country including an on-call system used in Sheffield which provides significant operational benefits by improving and increasing bed availability.
  
  One of the largest issues related to the location of care and coordination of care between providers. The team saw examples of patients being managed in the wrong place and inefficient transfers in terms of both timely patient care and cost. The team advocated establishment of further, (up to 14), Regional Spinal Networks (RSNs) to coordinate the delivery of services across geographies. Each would be responsible for delivery of spinal services regionally and for reviewing and tracking success. All providers, even those Independent Sector providers, should be part of a RSN. Extremely helpful examples are provided of existing Networks which are working effectively now in different parts of the country.
  
  
• Specialist Trusts (who are funded as such) providing non-specialist treatment and non-specialist Trusts performing complex spinal surgery with variance in both volume and remuneration. Only providers equipped with appropriate skills and expertise should deliver specialist surgical services. The designation process requires review and following this non-specialist trusts would be prohibited from undertaking activity designated as specialist, with a review of minimal thresholds for high complex cases.
  
  
• Variation in treatment of osteoporotic fractures, i.e. (kyphoplasty and vertebroplasty) despite little evidence to indicate a difference of outcome yet there being a 4-fold difference in cost. New Guidance was recommended to provide for appropriate use and timing of these interventions.
  
  
• Long waits and high rates of cancellations for paediatric spinal surgery which could be improved by use of a referral management tool to ensure preferential scheduling, with specialist skills and shorter waiting times. Examples were given of a model to combat this used in Norfolk and Norwich which, when in place, allowed the equivalent of 10 weeks surgery to be completed in 5 days (within school hols) by a specialist team improving both efficiency and outcomes. Recommendations were also made in relation to young adults (18+) with specialist centres for treatment to ensure smooth transitions from paediatric to adult care.
  
  
• A need for wide-spread adoption of New Care Models seeing local providers and health systems work together to improve patient care.
  
  
• To speed up the uptake of new technologies, collation of data and learning to inform future practice. Data can be used to identify financial inefficiencies and reduce surgical infections. One recommendation was that all future spinal surgery is recorded on the British Spine Register for collection and outcome tracking. Variation in training was identified and noted as an opportunity to improve consistency, quality and patient outcome.
  
  
• The vast variation between NHS care and Independent Sector Providers and the need for more consistency and coordination was also highlighted. ISPs are significant contributors to spinal care in England accounting for approximately 9% of total volume, hence the need for them to be included in the Regional Specialist Networks.
  
  
• Litigation;
  
  The high cost of spinal surgery cases to the NHS is well over £100m per year and greater than ever before. The GIRFT team found that many units have little knowledge of the claims against them and therefore the opportunity to learn and inform future practice is limited. The most common causes of claims in spinal surgery between 2012/13 and 2016/17 were noted as:
  
  - Judgement/timing (52.4%)
  - Interpretation of results / clinical picture 26.1%
  - Unsatisfactory outcome to surgery (19.6%)
  - Failure to warn / misinformed consent (8.1%)
  - Never events / wrong site surgery / retained instruments (2.7%)
  
  The GIRFT team recognised that the issue of consent in spinal cases plays a large part in many of these claims, and indeed, a much greater percentage than the specific 8.1% as listed. Further, that many of these claims were avoidable by adherence to an adequate consent process in which an informed patient was involved in shared decision making. The BASS three legged stool consent model was recommended with consent being given in 'consent clinics' 2 to 4 weeks pre-surgery.
  
  CES claims were also highlighted as common and expensive claims in spinal services. Again practitioners were referred to the BASS Guidance, which provides specific guidance for diagnosis in suspected CES cases as well as timely MRI and specialist transfer.
  
  
• To achieve greater transparency in procurement with both pricing (i.e. use of the GIRFT categorisation pricing) and heavier clinical involvement to save costs.

How we can help?

Whilst lengthy, the Report provides an extremely digestible summary of the range of spinal services currently on offer in England with achievable recommendations for streamlining the service and achieving economies of scale to improve both the patient journey and crucially the clinical outcome. At the same time, it allows for cost savings to occur through a more joined-up way of working. Whilst some of the recommendations may take a level of reorganisation on both a regional and national basis before the benefits can be seen, the examples of good practice allow for changes which can be put in place now.

Our team of legal healthcare experts can advise providers across the health sector on the full range of issues that these recommendations raise and assist with the necessary response to implementation. Please don't hesitate to get in touch.

[i] SBN and BASS - Society of British Neurological Surgeons and British Association of Spine Surgeons Guidance