1. Getting It Right First Time Seamless Surgery Connect - 23 March Michael Horrocks, GIRFT Clinical Lead Vascular Surgery & Clinical Ambassador SW Hub Liz Lingard, GIRFT Hub Director, North East, North Cumbria & Yorkshire

2. GIRFT First principles
GETTING IT RIGHT FIRST TIME – reducing variation, improving patient outcomes
Aiming to deliver operational productivity improvements that translate into resource savings of £ m in and c.£1.4bn p.a. by (c.£3-4bn cumulative ).
Programme is led by frontline clinicians who are expert in the areas they are reviewing
Supported by Secretary of State for Health, Royal Colleges and professional societies
Peer to peer engagement helping clinicians and managers identify and deliver changes that will improve care and deliver efficiencies.
Innovative use of data sets to identify unwarranted variations in the way services are delivered
Regional hubs will support trusts, CCGs and STPs to drive locally designed improvements

3. Unwarranted Variations Identified
Significant unwarranted variations seen in practice and outcomes, but scope identified to tackle many of these variations, and great appetite found among clinicians and managers to do so.
0.19% %
Lower back pain surgery costs >£100m per annum with little evidence of efficacy
Variation in hip & knee deep infection rate within one city. If all trusts got to 0.19% this could save the NHS up to £2-300m p.a, enough for 60,000 replacements
Cemented: £650 Uncemented: £5,300
No evidence that hip on right provides better outcome for over 70s
England average £1398
Litigation: huge variation between trusts in averages:
General surgery: £17 - £477
Urology: £4 - £117
Vascular: £1 - £6,353
Obs & Gynae: £55 - £6,896

4. GIRFT Orthopaedics Pilot: impact to date
c.£50m
50,000
£4.4m
75%
estimated savings over two years and improved quality of care
estimated savings p.a, from increased use of cemented hip replacements for patients aged over 65 – reducing readmissions
of trusts have renegotiated the costs of implant stock and reduced use of expensive ‘loan kit’
estimated beds freed up annually by reduced length of stay for hip & knee operations
Litigation cases
1,600
1,350
Litigation cost
£215m
£138m
Pricing Letter
BOA used GIRFT principles in best practice guidance
A pricing letter provides transparency of procurement costs to all trusts
Litigation costs have reduced by 36% in 3 years

6. From pilot to national programme
1000+ 28
Clinical work streams are already underway
Clinical Lead visits already completed 7
Remaining work streams will all start by summer 2018
Wave
Workstream
Start Date
Data packs to trusts
Workstreams
Total 1
2012
Received
Orthopaedics 2
Jan 2015
General surgery, Spinal, Vascular, Neurosurgery 5 3
Jan 2016
Urology, Cardiothoracic, Paediatric surgery, Ophthalmology, ENT, Oral & Maxillofacial, Obstetrics & Gynaecology 12 4
May 2017
Mar 2018
Emergency medicine 13
July 2017
May 2018
Dentistry, Breast surgery, Diabetes, Endocrinology 17 6
Sep 2017
Jul 2018
Cardiology, Imaging & Radiology, Intensive & Critical Care, Anaesthetics & Perioperative, 21 7
Nov 2017
Sep 2018
Renal, Acute & General medicine, Stroke 24 8
Jan 2018
Nov 2018
Neurology, Geriatrics, Respiratory, Dermatology 28 9
Jan 2019
Rheumatology, Pathology, Outpatients 31 10
Mar 2019
Gastroenterology 32 11
Summer 2018 (tbc)
tbc
Trauma Surgery, Plastic surgery & burns, Mental health 35
Delivery strategy agreed and governance in place
Collaboration agreements with national and local partners being delivered
Regional implementation support network in place
Benefits measurement & tracking approach in place
3 national reports published, with 9 more to come in 2018
Implementation until March 2021 with more specialties (oncology, paediatric medicine) to be added

7. Cross-cutting clinical projects
GIRFT is delivering a number of cross cutting projects:
GIRFT Clinical Leads are coming together to work in clinical service lines when beneficial for exploiting opportunities or joining up services across specialty boundaries:
Litigation
Procurement
& Technology
Patient
Safety
Strategic
Service
Change
Medicines
Optimisation
Frailty
Coding
Anaesthetics
Perioperative
Pathology
services
ED & Acute
Admissions
Brain
conditions
Outpatients
Diagnostic
services
Critical &
Intensive
Care

8. General Surgery National Report (August 2017)
General Surgery National Report (published in August 2017) identified:
The need to overhaul quality and capture of clinical data and overcome barriers to addressing variation.
That consultant-led assessments in Emergency Departments (EDs) could cut admissions by 30%, improving EDs’ sustainability and freeing up bed capacity.
Cost savings of 59% for a basket of typical surgical supplies.
A total opportunity for £160m savings annually including £32m from improving enhanced recovery to shorten length of stay 8

9. Vascular Surgery National Report (February 2018)
70 trusts in England conduct vascular surgery and many of these already collaborate within a local network. However, there is no standard model.
A nationwide, vascular surgery “hub and spoke” network of specialist units treating every vascular surgery case as “urgent” could stop over 100 deaths and reduce disability by substantially reducing the risks associated with blocked arteries such as sudden death, strokes, restricted movement, and amputations.
Regional specialist vascular surgery hubs within networks would ensure round-the-clock availability of early diagnostics & specialist interventions to improve surgical outcomes.
Improved NHS productivity resulting from fewer strokes, and reduced emergency readmissions, returns to theatre, and length of stay would save between £7.6m (€8.58m; $10.5m) and £16m, and there would be an opportunity to save a further £6.5m through improved procurement. 9

10. GIRFT implementation model is up and running
The responsibility for designing and implementing any changes derived from GIRFT recommendations lies with trusts and their partners in each local health economy.
Each trust has a board-level GIRFT clinical champion (normally Medical Director), and each clinical workstream will have a designated GIRFT lead.
Over 80% of GIRFT staff are trust facing. Nearly 40% are clinicians. They support each trust and their local partners to improve clinical outcomes by:
Clinical Leads, as national leaders in their field, advise trusts on how to reduce any unwarranted variations seen in their GIRFT data packs and help to benchmark their performance against their peers.
Clinical Leads drive improvement nationally by writing a GIRFT National Report on their specialty, through working closely with NHSE Clinical Directors, and by feeding into wider national improvement initiatives.
Regional Hubs support trusts in delivering the Clinical Leads’ recommendations by:
Helping them to assess and overcome the local and national barriers to delivery including in mitigating unintended negative consequences.
Working closely with NHSI regions to ensure prioritisation of GIRFT delivery takes account of the wider context within each trust and is joined up with local and regional improvement initiatives.
Working closely with Op Prod teams to ensure a joined up approach to trusts on clinical quality and productivity improvements.
Joining up with RightCare/NHSE to ensure joined up support to STP level improvements

11. GIRFT-NHSI Regions Collaboration
GIRFT Hubs working alongside NHSI regions and Op Prod on NHSI Top 15 trusts
Joined up planning beginning on GIRFT national report delivery
GIRFT ‘Trust on a page’ dashboard available from late spring 2018
GIRFT Analytics Portal training for NHSI staff from April
Hubs have fed opportunities into trust CIP planning
Joint trust meetings already happening in the North

12. GIRFT Implementation: regional hubs7
GIRFT Hubs with clinical and project delivery leads who will support trusts, commissioners, STPs and ACCs to:
Build and deliver implementation plans reflecting:
The variations highlighted in trusts’ data packs
The improvement priorities discussed in Clinical Lead visits
The recommendations set out in each National Report
Provide concentrated
additional resources
and disseminate best
practice
Name
Hub Area
Ruth Tyrrell
North West
Ian Donnelly
West Midlands
Liz Lingard
North East, North Cumbria & Yorkshire
Eiri Jones
South West
Michael Dickson
South East
Karen Hansed
East Midlands
Graham Lomax
London

13. North East, North Cumbria & Yorkshire Hub Implementation Team
Hub Director
Liz Lingard
3/10/2017
Clinical Ambassador Mr Mark Lansdowne
(88 days)
March 2018 TBC
Clinical Ambassador
Dr Jean Macleod
(88 days)
27/02/2018
Implementation Managers
Jennifer Wilkie
8/01/2018
Aimee Robson
05/03/2018
Terese Phillips 05/03/2018
Helen Biggs
16/04/2018
Jacqueline Calydon 16/04/2018
Helen Ridley 16/04/2018
Michael Lydon 30/4/2018
NENCY Hub Base
Waterfront 4, Newburn, Riverside
Newcastle upon Tyne, NE15 8NY
Business Intelligence
Manager
Vacant
Communications Manager
Vacant
Hub Administrator
Paula Kew
15/01/2018

14. Being a GIRFT clinical Lead
Michael Horrocks

15. Themes to be investigated by GIRFT
Organisation of the service
Staffing/ Activity levels (lists, outpatients etc.)
Time from Referral, Assessment to Surgery (definitive treatment)
Lengths of stay and delayed discharge
Complications: Mortality, Return to theatre, complications (infection)
Readmissions, particularly within 30 days
Skills/Deskilling
Post surgery destination
Friends and Family Test
Data
Procurement
Litigation costs

16. Reported numbers of Vascular Surgeons and Interventional Radiologists by provider - Oct-2015

17. Provision of weekend elective vascular surgery reported by providers and provider type Oct-2015

18. Proportion of all AAA procedures that are repaired by EVAR by provider and provider type 01-Apr-2014 to 31-Mar-2015

19. Proportion of Aneurysms repaired by EVAR
Proportion of all unruptured (elective) AAA procedures that are repaired by EVAR by provider and provider type 01-Apr-2014 to 31-Mar-2015
(x2 variation)   
Proportion of all ruptured (emergency) AAA procedures that are repaired by EVAR by provider and provider type 01-Apr-2014 to 31-Mar-2015
(x10 variation)

20. Proportion of patients readmitted in an emergency within 30 days for any reason following an AAA procedure by provider and provider type: initial admission 01-Apr-2012 to 31-Dec-2014
Open procedure
EVAR procedure

21. In-hospital  mortality following any AAA repair procedure by provider and provider type 01-Jan-2015 to 31-Dec-2015
(x10 variation)

22. Proportion of patients receiving a CEA procedure of any type within 7 days of referral to a Vascular service by provider and provider type 01-Jan-2014 to 31-Dec-2014
(x6 variation)

23. Median days from assessment to surgery for CEA repair by provider and provider type 01-Jan-2014 to 31-Dec-2014
(5-30 days variation)

24. Proportions of post-surgical destination ward type post CEA procedure by provider 01-Jan-2014 to 31-Dec-2014

25. Adjusted in-hospital mortality or stroke rate of patients undergoing a CEA procedure during the inpatient spell of the procedure by provider and provider type 01-Jan-2014 to 31-Dec-2014   
(x10 variation)

26. Activity counts of lower limb revascularisation procedures by procedure type, provider and provider type 01-Apr-2014 to 31-Mar-2015

27. Average length of stay for elective lower limb bypass procedures by provider and provider type 01-Apr-2014 to 31-Mar-2015
Diabetic
Non-diabetic

28. - twice as long if admitted as an emergency
Average length of stay for elective lower limb bypass procedures by provider and provider type 01-Apr-2014 to 31-Mar-2015
- twice as long if admitted as an emergency
Diabetic
Non-diabetic

29. Recommendations Engage of profession with management
Fully develop the Network Structure (for Vascular)
Develop as an Urgent Specialty with fast through flow
Engage with Spoke hospitals, clinicians and managers
Ensure all patients have same priorities
Share pathways and timelines with other teams
Adequate staffing and facilities
Consider 7 day operating with cases fed into facilities
Arrange angioplasties to reflect the urgency and facilities

30. Continued Full pre-admission work-up Prehabilitation where possible
Early discharge planning
Identify likely re-admitters (frailty score)
Early medical contact post-op
Phone contact for worried patients
Review your litigation cases and learn from them

31. Local Issues Hubs, how many and where Combining teams
Particular geographical problems
Ensuring spokes are on board
Shared pre-op work-up
Accept post-op transfers
Ensure links for referrals and MDT’s
Regular reviews of data and outcomes

32. Questions Mike Horrocks GIRFT Vascular Clinical Lead
Mike Horrocks
 GIRFT Vascular Clinical Lead
GIRFT Clinical Ambassador for South West Hub  E M
Liz Lingard
 North East, North Cumbria & Yorkshire Hub Director  E M