An ambitious redesign of total joint replacement services could lead to a massive level of savings without the loss of capacity at the same time. Sg2 vice president Meghan Robb outlines the potential.

Care pathway optimisation for total joint replacement allows hospitals to offset likely loss of income incurred by the new best practice tariff, and offers commissioners significant cost savings. It also provides an opportunity to create capacity within the NHS without added investment.

Sg2’s primary hip and knee forecast, published in the latest HSJ Change Forecast, shows that total joint replacement pathway optimisation can save the NHS £664m over the next 10 years.  

This equates to more than 1,664,903 bed days saved over the 10-year period. This, in spite of an 18 per cent demand growth fuelled by an ageing population, shows that improved total joint replacement pathways can create 13 per cent bed day capacity without added investment.  

This provides an opportunity for cross-organisational cooperation to better manage care across the continuum and to achieve these savings to the mutual benefit of providers and commissioners.

Conversely, if no immediate action is taken to address the forecast increase in referrals and bed days, the financial impact on local providers is likely to sting as the new best practice tariff for elective primary total hip and knee replacements introduced in the payment by results 2011-12 draft guidance starts to bite.


The potential bed day capacity increase over the next 10 years without added investment

This best practice tariff is designed to incentivise high quality, cost effective care via a tariff reduction of £232 per spell, which equates to an average four per cent reduction in total joint replacement payment and a one year reduction in revenue upwards of £400,000 for some trusts.

As England’s average length of stay for this surgery is variable among providers and is higher than in many comparable health economies, care pathway optimisation should present a path to both improved quality and efficiency and, for many, an achievable option for offsetting the impact of best practice tariff-induced income reductions.

Optimising the care pathway

While the 2011-12 best practice tariff changes necessitate immediate financial review of joint replacement services, it is critical to note that this tariff design is based on available clinical and service delivery evidence. It should follow that not only is the type of high quality, efficient joint replacement care incentivised by this tariff possible, it exists within today’s NHS.

The following seven improvement steps are a guide for pathway optimisation, and offer a template for achieving the opportunity in the face of growing financial pressures:

  1. Quantify the income loss the 2011-12 best practice tariff presents to your organisation, as well as the opportunity your organisation has to offset this loss by reducing length of stay while improving both quality and patient experience. Look at forecasts to calculate specific opportunity, and to generate financial and capacity scenarios for planning purposes.
  2. Build a case for change that will motivate both the organisation and necessary partners. Use care utilisation forecasts to put pathway optimisation outcomes in context of the performance of your peers. Consider the economic and capacity impacts that length of stay reductions can have when charting the local health economy’s near term course for quality, innovation productivity and prevention programme targets.
  3. Next, plan an action strategy, including who to involve, what steps to take, timelines for success and likely impact. Use implementation indicators such as cost, time, culture and impact at each stage of the care pathway redesign initiative.
  4. Explore the key aspects of an integrated total joint replacement service as described in the 2011-12 best practice tariff, including pre-operative assessment together with patient education, planning and preparation before admission; structured peri- and post-operative care as well as pain relief management; early supervised mobilisation and safe discharge; and access to post-discharge support together with clinical advice and outreach rehabilitation.
  5. Keep in mind that to gain maximum impact a myriad of improvement options should be included, although the emphasis given to each can vary depending on local requirements and facilities. This multidimensional approach necessitates complex change management oversight.Ongoing change management can be aided by understanding target metrics that mark progress and be used when course correction is needed. Use metrics that reinforce a societal, local economy and national economy case for change. Communicating target metrics and progress among all parties involved in programme redesign efforts is critical for success.
  6. Learn from others to create a strong foundation for sound decision making and to understand the application of pathway redesign concepts within the NHS and across other international health economies. Consider the operational insights, management strategies, and lessons learned both at home and abroad. Sg2 works with health systems around the world and we see parallel schemes and programmes that should be replicable in the NHS, resonating with local initiatives.
  7. Finally, plan ahead for ongoing programme audits as a means to demonstrate value both to the patient and your stakeholders, and to sustain an optimised programme. Planned programme audits should include metrics tracked across multiple facets of the revised care pathway. Data on length of stay variation provides a good starting point to assess current processes.

Incorporating patient experience measures (including clinical outcomes, return to normal rate, and patient reported outcome measures), readmission and revision rates and compliance measures with specific facets of the pathway will ensure length of stay reductions are not gained by reductions in care quality. 

A well thought through and appropriately implemented multidimensional optimisation initiative should improve all these metrics.

These seven steps are gleaned from work undertaken in the NHS and abroad to create an action oriented guide for proactive change to the total joint replacement continuum. Addressing this service is a necessity in the new financial environment of the 2011-12 best practice tariff, but also represents a clear and achievable path to delivering a quality primary hip and knee replacement service within available resources to meet the growing demands of an ageing population. 

Change Forecast

All sources referenced here, including the supporting data, improvement guides, evidence, NHS and international case studies are available at

Change Forecast is a quarterly feature, developed in association with Sg2, providing detailed insight on what the future looks like for each organisation for a specific disease area, along with best practice case studies and guidance on how to capitalise on the opportunity.

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