BOA Response to the Atlas of Variation 2015

25 Sep 2015

The BOA welcomes the release of The Atlas of Variation 2015 and recognises the extent of variation it highlights for hip replacement surgery. This variation warrants further investigation to ensure patients are given the right treatment, in the right place, at the right time so as to maximise patient outcomes and efficiency in the NHS. Any such investigation should acknowledge that:

  • Procedures such as Hip and Knee Replacement are highly cost effective, with a QALY cost of £1372 for Total Hip Replacement and £2101 for Total Knee Replacement.1  This represents between 15-20 times the value of many interventions that NICE would support as cost-effective. It follows that reducing rates of these procedures may undermine moves to increase value in the NHS.
  • Low or high rates of surgery do not alone indicate under or overprovision: the reasons for variation are multifactorial and it is not clear what the optimum intervention rate is. However, a severe austerity programme has been in place for some years and low rates of intervention probably represent rationing rather than optimal patient care.
  • Patients with osteoarthritic hips, whose joint replacement surgery is unduly delayed, for example by six months to a year, will not regain the same degree of function as they otherwise would have.
  • There is very little variation in EQ-5D health gain following hip or knee replacement between CCGs. This implies that variation in surgery rates is unlikely to have an impact on patient outcomes for those who undergo surgery.2
  • Given these points the BOA recommends that commissioners identifying high or low rates of orthopaedic interventions in their areas seek clinical guidance from local surgeons, the BOA and the wider MDT to examine this data in the context of a review of relevant care pathways. To assist with this process the BOA has developed a suite of Commissioning Guidance Documents and is building a network of Regional Advisers and Clinical Champions to provide support to CCGs as they work to improve patient care.

1 Jenkins PJ, Clement ND, Hamilton DF, Gaston P, Patton JT, Howie CR.
(2013) “Predicting the cost-effectiveness of total hip and knee replacement: a health economic analysis”. Bone and Joint Journal Jan, 95-B(1):115-21 . Available at:

2 Health and Social Care Information Centre (2015) PROMS Score Comparison April 2013 to March 2014,finalised data


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