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Written on 15th August 2017 by Susan Brown

GIRFT (Getting It Right First Time) has recently published its National Speciality Report into General Surgery, one of a series of 34 clinical speciality audits which will be carried out over the next two years.

The report forms part of the GIRFT Programme set up by Professor Tim Briggs, National Director of Clinical Quality and Efficiency at NHS Improvement and Consultant Orthopaedic Surgeon at the Royal National Orthopaedic Hospital NHS Trust.

The GIRFT Programme arose after Professor Briggs decided to take action to investigate and “fix many of the issues” that his colleagues in orthopaedics experienced, to ensure better care and outcomes for NHS patients. So, in 2012, Professor Briggs carried out his own review of orthopaedic surgery. His small team of specialists undertook a pilot audit, examining NHS data from a variety of sources, visiting over 200 trusts and meeting with over 2000 surgeons and their staff. In peer-to-peer conversation they reviewed their data, discussing and trying to understand the variation in orthopaedic patient outcomes, procurement costs and litigation rates between trusts, sharing best practice and working together to design workable solutions.

His pilot report, named Getting It Right First Time, highlighted the impact of variations in practice. For example, some hospitals had individual surgeons performing very small numbers of complex surgical procedures each year, a practice which renders the procedure less safe in that surgeon’s hands and more costly to the NHS in terms of equipment costs and claims. Some trusts had out of hours MRI scanning provision for emergency conditions, such as cauda equina but others didn’t.

Other expensive variations included infection rates (which ranged from 0.2% to 4.5%, with one hospital’s as high as 15%). Average litigation costs per patient treated also varied amongst units. Another issue arose from differences in procurement costs, with individual surgeons’ preferences and manufacturers’ sales promotions leading to a growing trend for exponentially more expensive hip replacement joints, to quote one example, whereas evidence suggested that patients had better outcomes, reduced complications and readmission rates with the cheaper procedure.

In short, Professor Briggs’ orthopaedic pilot demonstrated that a frontline clinician-led, shoulder-to-shoulder peer support programme which analysed variations in practice and worked closely with clinicians within the trusts to share best practice and develop locally workable solutions, not only improved patient safety, patient outcomes, but also improved morale and reduced cost.

GIRFT won the approval of the Department of Health and is now overseen by NHS Improvement, with support from the Royal Colleges, NICE and other professional bodies. Led by “Clinical Leads”, who are all respected, frontline clinicians and experts in their particular specialism, GIRFT is now being rolled out over 34 clinical specialties, with reports into vascular surgery, cranial neurosurgery, spinal surgery, cardiothoracic surgery and obstetrics and gynaecology amongst those expected during 2017 and 2018.

Aims of the GIRFT Programme include:

  • Improved patient outcomes
  • Improved patient experience
  • Improved patient safety
  • Reduced complications and readmissions
  • Reduced length of hospital stay
  • Reduced litigation claims and costs
  • Reduced procurement costs (equipment)
  • Re-empowered clinicians and increased morale
  • Increased workforce productivity and reduced locum costs
  • Improvement in NHS trust balance sheets
  • Savings in taxpayers’ money

The GIRFT Programme includes the following stages:

  • A national report on each clinical area
  • A national report on litigation
  • A national report on clinically driven effective hospital management
  • A report and model approach to procurement
  • A GIRFT Implementation Plan for each NHS Trust
  • Hubs to be set up with Clinical and Project Delivery Leads to disseminate best practice and support NHS trusts with implementation and delivery. Additional resources will be provided for trusts requiring intensive support.

Recommended GIRFT changes will work on individual and team levels to apply best clinical practice and reduce unwarranted variation.

At trust and national level, GIRFT will involve tactical and strategic changes to service provision (such as, ensuring that complex operations are performed in centres of excellence by experienced surgeons). At national level, GIRFT will work with Royal Colleges, NICE and other national professional associations, NHS England and NHS Improvement and NHS bodies, such as the Care Quality Commission and National Clinical Audit Programme, to provide a streamlined and complementary approach. Work will continue after initial implementation to ensure that the changes and benefits are sustained.

Professor Briggs emphasises that the success of Getting It Right First Time depends upon the embodiment of an ethos of shoulder-to-shoulder, peer-to-peer, clinical review in which clinicians are able to meet, talk through their challenges and review their data in a non-confrontational way.  He says that top-down managerial pressure on clinicians to change their practices doesn’t work and reduces morale. In a GIRFT, shoulder-to-shoulder, peer-to-peer non-confrontational environment, he says solutions become obvious.

Will it work?

The indications to date are encouraging. Professor Briggs’ pilot GIRFT programme in orthopaedic surgery cost only £200,000 and has helped save over £50 million in two years, with a reduction in litigation claims and costs from £215 million to £138 million.

At Boyes Turner we welcome any initiative which will bring about genuine improvements in patient care, outcomes and experience. Here, we see another heartening example of top level medical professionals taking fearless action to face up to what’s really going wrong and working together to restore all that’s good about the NHS for patients, clinicians and taxpayers alike.

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