The BOA works in close collaboration with the Department of Health at a senior and influential level on a number of strategic issues. For example, in recent years it has engaged with the Department of Health (DH) in relation to clinical leadership, the European Working Time Regulations and clinical audits.
Through our liaisons with the DH we aim to have influence over Tariffs, Payment by Results, the Enhanced Recovery Programme, Workforce Planning, Patient Reported Outcomes Measures (PROMS), the implementation of Liberating the NHS and other latest policy changes.
The BOA also carries out an Annual Census of orthopaedic surgeons while maintaining an extensive manpower database. This helps to support our negotiations with the Department of Health in relation to workforce planning and manpower levels. The census is regarded by the DH Review Team as best practice and is highly valued in this respect.
The government's intention to overhaul the entire healthcare system has been sending shockwaves through the Department of Health and NHS. The BOA seeks to take advantage of this by advancing imaginative and creative solutions that deliver better quality treatment and outcomes for out patients, are more efficient and offer clear value for money.
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The Healthcare Quality Improvement Partnership (HQIP) and the National Joint Registry (NJR)
The Healthcare Quality Improvement Partnership (HQIP) was established in April 2008 to promote quality in healthcare, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. It is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices (formerly the Long-term Conditions Alliance).
HQIP sees clinical audit as one essential tool in a much broader range of activity to improve quality in healthcare. HQIP believes that clinical audit is a quality improvement methodology to be used alongside a range of other techniques under the broader Quality Improvement banner. HQIP will promote any improvement methodology that has proven effectiveness and appropriateness.
HQIP believe that building both national and local level partnerships between clinicians, clinical teams, managers and patients is at the heart of this. Supporting local staff, fostering active dissemination of information and implementing quality improvement initiatives is key – this way will ensure that quality measurement is the engine which drives improvement.
The National Joint Registry (NJR) was established in 2002 to improve patient care by finding out more about hip and knee joint replacement implants and surgery, carried out in both the NHS and independent healthcare sector in England and Wales.
Data collection began in April 2003 and the registry now holds over one million records, and more records about certain procedure types than any other registry in the world. As a result of the increasing volume and quality of data it is possible to make accurate analysis available to all stakeholders and contribute significantly to good practice and patient safety.
Aims of the NJR:
In establishing the NJR, a clear set of aims were defined. These aims have remained constant and continue to be met with varying degrees of success, either by the NJR alone or through its work with key stakeholders and partners. To date, work has largely focused on improving data coverage and data quality. The latest Strategic Plan can be downloaded at:
www.njrcentre.org.uk
The main aims of the registry are to:
•Ensure patients obtain the best clinical care during and following their joint replacement operation.
•Improve surgical practice through identification of best practice.
•Highlight in real time any brand of prosthesis showing high failure rates, and allow prompt removal from the market, if necessary.
•Improve evidence-based purchasing of joint replacement implants for orthopaedic units/hospitals.
•Improve patient awareness of hip and knee joint replacement outcomes.
•Provide patients, clinicians, healthcare providers and commissioners, regulators and implant suppliers with evidence of which are the best performing implants.
Organisation of the NJR:
NJR Centre
The NJR Centre manages the development and running of the NJR database for all data collection and analysis. It is managed by Northgate Information Solutions (UK) Ltd under contract with the Healthcare Quality improvement Partnership, (and previously with the Department of Health).
NJR Steering Committee
The NJR Steering Committee oversee the work programme of the NJR Centre and performance manage its delivery. With a lay Chair, membership includes representatives of the surgical profession (BOA, BHS and BASK), patient groups, orthopaedic implant suppliers, public health/epidemiology, NHS purchasing and supply agency, Medicines and Healthcare products Regulatory Agency, NHS Trust Management, Independent Healthcare Sector, and the Welsh Assembly Government.
HQIP supports the work of the steering committee, including the implementation of its strategic plans and development work on its behalf. HQIP manages the levy payment collections and holds the budget of the steering committee. The Development team in HQIP, led by Elaine Young, supports the NJR.
Regional Clinical Coordinators Network
Regional Clinical Coordinators are consultant orthopaedic surgeons who act as NJR local ‘champions' to ensure that the benefits of the NJR are understood and encourage compliance with NJR data requirements.
Levy
The NJR is self financing and funded through a levy raised on the sale of hip and knee replacement implants. The rate of levy is set by the NJR Steering Committee in consultation with the Department of Health.
Participation
Arms length/ other bodies
The National Institute for Health and Clinical Excellence (NICE)
The National Institute for Health and Clinical Excellence (NICE) provides guidance, sets quality standards and manages a national database to improve people's health and prevent and treat ill health. For more detail, go to: www.nice.org.uk
NICE’s principal outputs are:
Guidance
NICE makes recommendations to the NHS on:
• New and existing medicines, treatments and procedures treating and caring for people with specific diseases and conditions.
• NICE makes recommendations to the NHS, local authorities and other organisations in the public, private, voluntary and community sectors on how to improve people's health and prevent illness and disease.
NHS Evidence
NHS Evidence is one of the most significant resources to be developed in recent years, providing everyone working across health and social care with easy access to a wealth of quality information and best practice so that every care decision made can be based on the best possible evidence -
http://www.evidence.nhs.uk/.
Quality standards
NICE is developing and defining the standards of healthcare that people can expect to receive. These standards will indicate when a clinical treatment (or set of clinical procedures) is considered highly effective, cost effective and safe, as well as being viewed as a positive experience by patients:
http://www.nice.org.uk/aboutnice/qualitystandards/qualitystandards.jsp.
Quality and outcomes framework (QOF)
NICE oversees the development of indicators used to show that GPs should be rewarded for providing good quality clinical care and for helping to improve people's health. These indicators are part of the quality and outcomes framework (QOF), a voluntary incentive scheme for GP practices in the UK:
http://www.nice.org.uk/aboutnice/qof/qof.jspFellows and scholars programme
Scientific advice consultancy service
How NICE works
NICE works with experts from the NHS, local authorities and others in the public, private, voluntary and community sectors - as well as patients and carers. NICE aims to make independent decisions in an open, transparent way, based on the best available evidence and including input from experts and interested parties.
The BOA works extensively with NICE on the formulation of clinical guidance and quality standards. We are publication partners with NICE for the VTE Quality Standard. Our lead Council member for NICE is Professor Roger Atkins.
The BOA President meets periodically with the NICE Chair to discuss trauma and orthopaedic issues, and we engage with the NICE Chief Executive through ARMA.
NICE at BOA Congress 2011
At the BOA 2011 Congress in Dublin, Bruce Campbell, Chair of NICE Interventional Procedures and Medical Technologies Advisory Committee made a power point presentation to delegates. A copy of this presentation can be viewed here:
NICE Congress Presentation.pptThe Medicines and Health products Regulatory Agency (MHRA)
The MHRA’s aims are:
Protecting public health through regulation, with acceptable benefit-risk profiles for medicines and devices.
Promoting public health by helping people who use these products to understand their risks and benefits.
Improving public health by encouraging and facilitating developments in products that will benefit people.
Its strategic objectives are to:
Safeguard public health through our primary role in ensuring that the products we regulate meet required standards, that they work and are acceptably safe.
Carry out our communication role through the provision of accurate, timely and authoritative information to healthcare professionals, patients and the public.
Support research, ensuring through the application of Better Regulation principles that regulation does not stifle innovation.
Influence the shape of the future regulatory framework through use of our effective European and International relationships.
Run an organisation with a skilled and equipped workforce that is fit for the future.
Its main activities are:
Assessing the safety, quality and efficacy of medicines, and authorising their sale or supply in the UK for human use.
Overseeing the UK Notified Bodies that audit medical device manufacturers.
Operating post-marketing surveillance and other systems for reporting, investigating and monitoring adverse reactions to medicines and adverse incidents involving medical devices and taking any necessary action to safeguard public health, for example through safety warnings, removing or restricting the availability of products or improving designs.
Operating a proactive compliance programme for medical devices.
Operating a quality surveillance system to sample and test medicines and to address quality defects, monitoring the safety and quality of imported unlicensed medicines and investigating Internet sales and potential counterfeiting of medicines.
Regulating clinical trials of medicines and medical devices.
Monitoring and ensuring compliance with statutory obligations relating to medicines and medical devices through inspection, taking enforcement action where necessary; promoting good practice in the safe use of medicines and medical devices.
Managing the General Practice Research Database (GPRD) and the British Pharmacopoeia (BP) and contributing to the development of performance standards for medical devices; offering scientific, technical and regulatory advice on medicines and medical devices.
Providing the public and professions with authoritative information to enable informed dialogue on treatment choices.
The BOA engages with the MHRA through a variety of routes and initiatives including Expert Working Groups (for example, Metal on Metal Hip Replacements) and a focus on innovation (for example, the elaboration of a better joined up approach to the introduction to market of orthopaedic implants).
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Orthopaedic Device Evaluation Panel (ODEP)
ODEP is a subset of the NHS Supply Chain - http://www.supplychain.nhs.uk/odep/. The BOA and British Hip Society (BHS – one of our specialist societies) are represented on the panel.
For 10 year benchmark products ODEP place products in one of 4 categories:
For products that fall below NICE’s 10 year benchmark, ODEP in consultation with industry, MHRA, BOA, BHS and RCS has chosen to look at evidence at 3, 5, 7 years. Each level is split into 3 categories:
Products that are yet to meet NICE’s 3 year entry benchmark have been listed as ‘pre-entry’ so that surgeons may see what is currently undergoing clinical evaluation.
The National Hip Fracture Data Base (NHFD)
The NHFD is a joint venture of the British Geriatrics Society and the British Orthopaedic Association, and is designed to facilitate improvements in the quality and cost effectiveness of hip fracture care.
The NHFD is intended to focus attention on hip fracture both locally and nationally, benchmark its care across the country, and use continuous comparative data to create a drive for sustained improvements in clinical standards and cost effectiveness.
Delivering good care for patients with hip fracture is challenging and involves many health professionals including nurses, surgeons, anaesthetists, geriatricians and rehabilitation staff. The quality of that care varies considerably across the country. The combination of care standards, in the form of the
BOA BGS Bluebook - on the care of patients with fragility fractures, and Audit (NHFD), will encourage fracture units to develop the interdisciplinary services for rehabilitation and secondary prevention necessary to improve matters for this group of patients.
For more information on the detection and management of outlier fracture units click
here.National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
NCEPOD's purpose is to assist in maintaining and improving standards of medical and surgical care for the benefit of the public by reviewing the management of patients, by undertaking confidential surveys and research, and by maintaining and improving the quality of patient care and by publishing and generally making available the results of such activities.
NCEPOD is independent of the Department of Health and the professional associations. It is both a charity and a company limited by guarantee.
NCEPOD has a board of directors that are referred to as the NCEPOD Trustees. This board oversees the charitable and corporate governance of the organisation.
In addition we also have the NCEPOD Steering Group. Members are nominated representatives of the various medical Royal Colleges and Associations and lay representation. There are also five observers on the group from the National Patient Safety Agency (NPSA), the Coroners Society, the Institute of Healthcare Management, the Scottish Audit of Surgical Mortality and The Institute for Health and Clinical Excellence. This board ensures the clinical integrity of the work that NCEPOD undertakes. Details can be found at:
http://www.ncepod.org.uk/staff.htm
NCEPOD is mainly funded by the Department of Health and the remainder of funds are provided by the Health and Social Service Executive Northern Ireland, the offshore islands and the Independent sector.
Chief Medical Officer (CMO) for Wales
Dr Tony Jewell is the Chief Medical Officer for Wales, and Director of the Department for Public Health and Health Professions.
The Chief Medical Officer (CMO) provides independent professional advice and guidance to the First Minister and other Welsh Government ministers, and to officials in the National Assembly for Wales on health and healthcare matters.
The CMO:
•Leads public health policy and programmes, working across all National Assembly policy departments and with a wide range of external partners, with the aim of improving health and reducing health inequalities;
•Leads the clinical contribution in Wales to improving the quality of healthcare and patient outcomes;
•Leads the medical profession in Wales, having key roles in medical regulation, education and training, standards and performance;
•Maintains appropriate UK and international links, working with other UK Chief Medical Officers, government departments and organisations.
Dr Tony Jewell took up his appointment as Chief Medical Officer for Wales in April 2006. Dr Jewell was previously Clinical Director and Director of Public Health in the Norfolk, Suffolk and Cambridgeshire Strategic Health Authority. He was a family doctor ('general practitioner' or GP) in inner London for 10 years before training in public health in East Anglia. He has worked in the Department of Health and is past President of the UK
Association of Directors of Public Health.
The BOA President meets periodically with the CMO to discuss trauma and orthopaedic issues.
National Specialist Advisory Group for Trauma and Orthopaedics
The Welsh Assembly Government is advised on trauma and orthopaedic issues by a National Specialist Advisory Group [obtain objectives from Declan O’Doherty please – he provided it for a recent Council meeting I seem to recall]
For detail on the organisation of NHS Wales visit:
Department of Health Central
Right Care
Right Care is one of thirteen national workstreams in the Department of Health's Quality Innovation Productivity and Prevention Programme (QIPP). Right Care is an enabling programme focused on increasing value and improving quality through addressing variation in the provision of healthcare, promoting the use of health investment tools - such as programme budgeting - and through sustainable systems and population planning.
The BOA engages at senior level with Right Care on the commissioning of elective orthopaedic services.
Right Care's stated aim is transformation through enhanced value. It acts to stimulate clinicians and commissioners to work together to increase the value derived from health investment in their populations. It does this by designing and promoting tools to analyse and understand variation in health expenditure and outcomes, through local pilots and by knowledge transfer. Full details – including the NHS Atlas of Variation - can be found at:
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National Clinical Directors
BOA Council member Professor Keith Willet is the Department of Health’s National Clinical Director for Trauma and has been instrumental in revitalising the focus on musculoskeletal trauma in England. For a full list of the National Clinical Directors go to:
Enhanced Recovery Programme
Enhanced recovery, often referred to as rapid recovery, is a new, evidence-based model of care that creates fitter patients who recover faster from major surgery. It is the modern way for treating patients where day surgery is not appropriate. Patients are fitter sooner and ready to go home earlier with reduced complications. The model of care is safe and effective, ensuring patients are partners in their care - focusing on less invasive surgical techniques, pain relief and the management of fluids and diet, which help patients to recover better post-operatively with no additional burden on primary or social care. The Enhanced Recovery Programme is undertaken in partnership with the NHS Institute for Innovation and Improvement, NHS Improvement, the NHS Cancer Action Team and the Department of Health. A senior BOA member sits on the enhanced Recovery Programme Board.
Payment by Results and Best Practice Tariff
The aim of Payment by Results (PbR) is to provide a transparent, rules-based system for paying trusts. It will reward efficiency, support patient choice and diversity and encourage activity for sustainable waiting time reductions. Payment will be linked to activity and adjusted for casemix. Importantly, this system will ensure a fair and consistent basis for hospital funding rather than being reliant principally on historic budgets and the negotiating skills of individual managers.
Full details of Payment by Results and guide go to:
Best Practice Tariffs represent one of the enablers for the NHS to improve quality, by reducing unexplained variation and universalising best practice. With best practice defined as care, that is both clinical and cost-effective, these tariffs will also help the NHS deliver the productivity gains required to meet the tough financial challenges ahead. The aim is to have tariffs that are structured and priced appropriately both to incentivise and adequately reimburse for the costs of high quality care.
There is no one definition of what best practice looks like. A specific model will be developed for each of the service areas, each tailored to the characteristics of clinical best practice in that area and the availability, quality and flow
The best practice tariff for fragility fractures of the hip can be found at:
The BOA is fully involved in the setting of Payment by Results and Tariffs through membership of the relevant Department of Health Expert Working Group.
Patient Reported Outcomes Measures (PROMs)
A more rounded way of measuring treatment outcomes.
What are PROMs?
Patient Reported Outcome Measures (PROMs) measure quality from the patient perspective. Initially covering four clinical procedures, PROMs calculate the health gain after surgical treatment using pre and post operative surveys.
The four procedures are
•Hip replacements
•Knee replacements
•Hernia
•Varicose veins
From 1 April 2009, all providers of NHS-funded care have been required to collect PROMs for these four clinical areas.
PROMs are measures of a patient's health status or health-related quality of life. They are typically short, self-completed questionnaires, which measure the patients' health status or health related quality of life at a single point in time. The health status information collected from patients by way of PROMs questionnaires before and after an intervention provides an indication of the outcomes or quality of care delivered to NHS Patients.
Who is responsible for delivering PROMs?
PROMs are co-ordinated by the Department of Health. A senior member of the BOA sits on the PROMS Board. A number of organisations are involved in the collection, processing and analysis and reporting of PROMs data, including Providers, PCT Commissioners, The NHS Information Centre and contractors.
For Department of Health guidance materials for NHS providers and details of other organisations' roles in PROMs go to:
For information for patients, including a video clip and frequently asked questions go to:
What is happening now?
The Department of Health has reviewed the current PROMs publication through a consultation survey and an operational assessment, to identify the most effective way to release this data. Following this, the Department of Health has decided to change the frequency of the PROMs publication and the period that it covers.
Between April 2010 and August 2010 PROMs data was published on a monthly basis and considered data from pre-operative questionnaires only. Between September 2010 and July 2011 the Department of Health continued to publish data on a monthly basis, but also included the analysis of data from post-operative questionnaires. During these periods, data was reported cumulatively, that is, each month saw a further month of data added to the dataset.
Finalised PROMs figures
In August 2011 the first annual refresh of PROMs data was published. This finalised the data for PROMs pre-operative questionnaires completed in the period April 2009 to March 2010 and any associated post-operative questionnaires that had been returned.
The finalised Patient Reported Outcome Measures (PROMs) in England - April 2009 to March 2010 can be found at:
From August 2011 on, data will be spilt by financial year to enable comparison. Provisional data for each financial year will continue to increase in size until the next annual refresh covering the period April 2010 to March 2011.
Centre for Workforce Intelligence
The Centre for Workforce Intelligence is the national authority (commissioned by the Department of Health) on workforce planning and development, providing advice and information to the NHS and social care system. For full details go to:
The BOA works closely with the Centre – principally through our Honorary Workforce Liaison Officer, Gavin Bowyer, who co-ordinates the production of our annual T&O workforce census.
To read the BOA's response to the CfWI's Consultation on the Shape of the Medical Workforce please click on the link below:
The Centre’s mission is to become the primary source of workforce intelligence for health and social care. It seeks to produce quality intelligence to inform better workforce planning, in order to improve people's lives by providing an easily accessible route to NHS and social care planners, clinicians and commissioners seeking workforce planning and development expertise to improve NHS and social care services.•Supporting long-term and strategic scenario planning for the whole health and social care workforce, based on research, evidence and analysis, in order to build strong leadership and capability in workforce planning.
The Centre’s brochure can be viewed at:
The Centre focuses on three key strategic areas:
1. Providing workforce intelligence to the health and social care system to enable it to make better decisions. This intelligence spans the 'here and now' through thought leadership about the workforce in 10-20 years time. Delivering robust and timely intelligence: The Centre is the primary source of workforce intelligence in health and social care.•Sharing good practice and innovation through an expanded and validated body of knowledge.
2. Providing leadership within the system, helping senior leaders to drive workforce planning, strengthening the influence of workforce planners, and connecting different parts of the system.
• Strengthening leadership in workforce planning: Senior leaders in health and social care are driving workforce planning that is integrated with service and financial planning.
• Promoting long-range planning: Organisations are taking a longer-term view of workforce planning.
3. Providing the support, resources and best practice to improve the effectiveness of workforce planning at local, regional and national levels.
- Improving skills and resources so that organisations have the skills and resources they need to plan and develop their workforce.
- Matching the workforce to patient needs through a focus on improved service delivery, productivity and quality of care.
Medical Director for NHS England
Sir Bruce Keogh is Medical Director of the National Health Service in England. He is responsible for the quality framework, clinical policy and strategy and postgraduate education of doctors, dentists and pharmacists and postgraduate training of clinical scientists. He is also responsible for the medicines supply chain in to the UK, including policy around the pharmaceutical industry, drug pricing, prescriptions and the role of pharmacy. He oversees the work programme of the National Institute for Health and Clinical Excellence (NICE) and the National Patient Safety Agency (NPSA). He was a British Heart Foundation Senior Lecturer and consultant cardiothoracic surgeon at the Hammersmi
th Hospital in London before moving to the Queen Elizabeth Hospital in Birmingham, where he became associate medical director for clinical governance and the cardiac surgical service lead. In 2004 he was appointed Professor of Cardiac Surgery at University College London and Director of Surgery at the Heart Hospital. He has been president of the Society for Cardiothoracic Surgery in Great Britain and Ireland, Secretary General of the European Association for Cardio-Thoracic Surgery and president of the Cardiothoracic Section of the Royal Society of Medicine. He remains International Director of the US Society of Thoracic Surgeons. He has served as a Commissioner on the Commission for Health Improvement (CHI) and the Healthcare Commission and was knighted for services to medicine in 2003.
The BOA maintains a close engagement with Sir Bruce’s office, principally through the Department of Health’s Director for Clinical Strategies, Mary Newman.
For more information on the senior Department of Health team:
Chief Medical Officer for Scotland
Sir Harry Burns MPH FRSC(Glas) FRCP(Ed) FFPH
The Chief Medical Officer (CMO) is the Scottish Government's principal medical adviser and is also Head of the Scottish Medical Civil Service. The post covers every aspect of health in Scotland. Sir Harry is keen to encourage the assets based approach to people's health which focuses on behaviours and influences and also the social factors which impact people's health and wellbeing, especially in their early lives. He took up post as Chief Medical Officer for Scotland in September 2005.
The BOA President meets with the CMO for Scotland periodically to discuss trauma and orthopaedic issues
Deputy Chief Medical Officer
Dr Aileen Keel CBE MBChB FRCP FRCPath MFPH
Appointed Senior Medical Officer to the then Scottish Office Department of Health in 1992. Deputy Chief Medical Officer since 1999. Honorary consultant in haematology at Edinburgh Royal Infirmary. Longstanding interest in the influence of lifestyle risk factors on health and champion of the Health Promoting Health Service in Scotland. Currently chair of the Scottish Cancer Taskforce.
Scottish Committee for Orthopaedics and Trauma (SCOT)
The Scottish Committee for Orthopaedics and Trauma (SCOT). SCOT is a committee of elected orthopaedic surgeons from each of the regions in Scotland, plus the clinical directors of each of the orthopaedic departments in Scotland (the chairman of which sits on the British Orthopaedic Association council). For full details go to:
The Scottish Arthroplasty Project steering committee is made up of three orthopaedic nominees, one of whom must chair, a medical director, ISD members including a public health consultant (who is the "Caldicott Guardian" for data security) and two patient representatives.
Representatives are elected for three years with an option to renew this term only once. The chair must be a practicing orthopaedic surgeon whose data appears in the report.
Scottish Arthroplasty Project
The Scottish Arthroplasty Project (SAP) was established in 1999 with the following aims.
•To instigate change through continual feedback.
•To set individual results in a local and national context.
•To use outcomes which the public could identify with (death, dislocation, infection, DVT/PE and re-operation).
The SAP is an administrative dataset derived from the Scottish Morbidity Record (SMR01). Each individual in Scotland has a unique Community Health Index number (CHI) used in all patient episodes. All NHS hospitals in Scotland submit an SMR01 return for every patient episode. As well as the patient demographics, this record contains information about the dates of admission and discharge, surgeon, diagnosis, operation and up to five other co-morbid events relating to that admission. Any subsequent admission (or transfer) is similarly coded. These records are submitted to and linked by the Information and Statistics Division centrally (ISD) using the patient's unique identifier. The patient's journey and history can be tracked before and after the index procedure. Thus reporting co-morbidities, complication rates and ensuring patient confidentiality (all data is professionally encrypted).
The data is submitted by the local hospital and "owned" by the local hospital that has to undertake any corrections to the dataset and resubmit it to ISD. Quarterly listings are sent to consultants to verify and amend the data.
The data and the clinical content of the annual report are managed by the Scottish Arthroplasty Project Steering Committee, which is overseen by the Scottish Committee for Orthopaedics and Trauma (SCOT).