• Delays to spinal surgery lead to £23m being paid a year in compensation
  • Time-critical cauda equina treatment delayed by workforce shortage, GIRFT report says
  • Some units “reluctant” to interrupt elective scans for late night CE admission

An “unacceptable” postcode lottery is leading to tens of millions being spent compensating patients left disabled by delayed treatment, a government report has found.

The Getting It Right First Time report into spinal surgery warned delays in carrying out an MRI scan for patients suffering cauda equina could leave them with paralysis, incontinence and impaired sexual function.

The NHS spends roughly £100m a year on clinical negligence payments for spinal patients, 23 per cent of which relate to cauda equina, which is when a bundle of nerves at the base of the spine get compressed.

The report published today said standards set by the professional associations were “not currently being met, with potentially life-changing impacts on patients”. 

The report continued: “This is unacceptable. Evidence collected during visits indicates that the principal reason for patients with suspected CE not receiving timely MRI scans is a lack of out-of-hours radiography support in referring units. Even though MRIs are switched on out-of-hours, in many instances a radiographer may not be available to operate the scanner.”

The GIRFT team visited 127 spinal units across England.

Davies & Partners medical law specialists said the “industry accepted norm” for compensation was between £600,000 and £800,000.

The firm said: “In around half of [CE] cases, the die is cast within the first four to six hours.”

GIRFT staff observed “a reluctance to interrupt elective scanning lists with emergency cases”, but said some trusts countered this by staffing machines from 7.30am so that people brought in late at night and needing an urgent assessment could be seen sooner.

Among the report’s 22 recommendations was “all major trauma centres to have 24/7 ability to stabilise and decompress patients with fractured and/or dislocated spines”. Mike Hutton, the surgeon who led the review, told HSJ his estimate was that roughly 20 per cent of units did not hit that standard.

Mr Hutton said: “I am imploring hospitals to get their capacity up for providing emergency MRI scans as quickly as possible”.

In response to the report, the Royal College of Radiologists said most district general hospitals did not have the staffing to deliver 24/7 MRI scanning.

Vice president for clinical radiology at the college, Caroline Rubin, said: “Ideally, there would be 24/7 imaging and neurosurgery expertise available to deal with these critical cases in any hospital, but that would require extra funding and NHS staff capacity.”

Dr Rubin continued: “To mitigate a patient ‘postcode lottery’, hospitals will have to form ‘hub and spoke’ emergency networks.

“Neighbouring hospitals will need to have clear assessment and transfer protocols in place to ensure suspected CE cases can be transferred to a hospital that has capacity to deliver a 24/7 MRI service, scanned and potentially taken straight to surgery.”

The GIRFT report looked at spinal surgery across the NHS, on which roughly £300m is spent a year.

It found 40 of the 127 units reviewed were designated specialist, but warned: “The data suggest a significant amount of specialised spinal surgery is being undertaken by trusts that are not designated as specialised. We also found inconsistencies in how trusts are remunerated for specialist activity.”

The report recommended the designated trusts be reviewed to make sure non-specialists were not encouraged to do work beyond their capabilities, while specialists were incentivised to do work that could go elsewhere.

Asked about why this was, Mr Hutton said the service had not acted on earlier reports about spinal surgery provision.

He said the GIRFT process had already seen progress made and that the implementation team would be working to hold providers to the recommendations.

A key recommendation was the mandatory use of a registry for spinal cord stimulators, devices which are used to suppress back pain.

Another is that clinical commissioning groups refer all paediatric deformity surgery through their local paediatric deformity unit, “to ensure cases go to the correct geographical centre with appropriate skill sets and shorter waiting times”.

Asked by HSJ, Mr Hutton said he did not know why referrals were sent to the wrong place but that a central paediatric deformity referral management system should solve the problem.

The data collected by the team showed a wide variation in the amount of facet joint injections CCGs paid for to counter lower back pain, despite National Institute for Health and Care Excellence guidance to the contrary. The report said this accounted for £10.5m in spend that could be put to more effective use on a rehabilitation programme.

Mr Hutton said the CCGs that paid for more of this work often lacked a nearby specialist unit.

HSJ also revealed today that an unpublished NHS England internal review discovered spinal patients had suffered “avoidable harm” due to “wholly unacceptable” delays to their treatment.