Getting It Right First Time (GIRFT) is a national programme, created and led by consultant orthopaedic surgeon Professor Tim Briggs, working with frontline clinicians to identify and reduce unwarranted variations in service delivery and clinical practice. The clinicians involved with the GIRFT programme are all specialists in the area they are reviewing. Currently 35 surgical and medical specialties are being reviewed. The aim is to improve the quality of medical and clinical care within the NHS through deeper insight of performance, informed by data analysis across a range of metrics.
GIRFT methodology identifies changes that will help improve care and patient outcomes. The programme delivers individual trust-level data packs and a national report with a set of recommendations for each specialty it reviews, aimed at improving quality of care and also reducing expenditure on complications, litigation, procurement and unproven treatment.
It is a partnership between the Royal National Orthopaedic Hospital NHS Trust (RNOH), which hosted the pilot orthopaedic programme, and the Operational Productivity Directorate of NHS Improvement (NHSI).
The expansion of GIRFT was made possible by £60m of funding from the Department of Health, announced by the Health Secretary Jeremy Hunt, in November 2016.
The GIRFT programme is one of NHS Improvement’s workstreams, under the Operational Productivity directorate, designed to improve NHS productivity and efficiency in response to the Lord Carter Review.
Funding is currently in place for reviews of 35 clinical specialties – 25 are already underway and the remaining ten will begin in waves between November 2017 and March 2018.
The twin outcomes/objectives, agreed by the Health Secretary, are to improve outcomes for patients whilst saving the NHS up to £1.4bn per year by 2020/21, and between £240m to £420m in 2017/18.
The GIRFT Process
This involves a six-stage implementation pathway:
Phase 1 – preparation
The specialty reviews are led by clinicians who are experts in their field and understand the disciplines and services they are reviewing. They examine trust data looking for unwarranted variations; differences between trusts in areas such as effective procedures, length of hospital stay, infection rates and costs. GIRFT analyses data from multiple data sources, including Hospital Episode Statistics, NHS Litigation Authority, and relevant data streams for each clinical area, including registry and professional body data.
Phase 2 – data pack distribution
A bespoke data pack is produced for each trust delivering the specialty under review. This helps clinicians and managers understand what the variations are, what needs to be done to address them and explore the challenges they face. In the event that trusts receive their packs some time ahead of a clinical lead visit, GIRFT Regional Hubs will support trusts in interpreting their datasets and help to build implementation plans and begin to deliver on reducing unwarranted variation.
Phase 3 – clinical lead visits
In order to validate and explore the data, the GIRFT clinical lead undertakes a number of ‘deep dive’ visits to present the trust report and discuss the data with the hospital team. GIRFT hub teams and trusts incorporate recommendations into implementation plans.
Phase 4 – national report publication
The emerging trends from the visits to trusts and analysis of datasets enable the lead clinician to develop a national report with key recommendations based on the findings. Where appropriate, these national recommendations are added to trust implementation plans. Further recommendations will follow as the programme moves into review refresh phase and as the available data increases.
Phase 5 – data refresh
The core GIRFT data will be updated on an annual basis to enable trusts to monitor progress and, where necessary, reprioritise implementation efforts. The GIRFT analytics team refresh and re-issue the trust data packs, and the specialty clinical leads revisit trusts.
Phase 6 – implementation complete and transition to business as usual
The GIRFT Regional Hub teams support trusts to complete actions in the implementation plans and transition improvements into business as usual. Throughout this process, hub teams also look at priorities and solutions across local health economies working closely with regional teams from:
- NHS Improvement
- NHS England and the RightCare programme
- Clinical Commissioning Groups (CCGs)
- Sustainability and Transformation Partnerships (STPs)
The speciality reviews are undertaken as part of a rolling programme, with the last currently funded workstreams beginning in March 2018. The specialty reviews can take between 6 months for the smaller workstreams and up to 24 months for the larger workstream reviews to be completed.
After all the reviews have been completed, the GIRFT clinical leads oversee the creation of national reports into their specialty which provide detailed evidence of the benefits that proposed improvements can bring. An implementation phase then follows in sequence for each specialty (see: six-stage implementation pathway).
It is anticipated that the average workstream will take 36 months to go from initiation to incorporating improvements into trusts’ business as usual approach. Based on a March 2018 start date for the final wave, all workstreams are projected to have completed transition to business as usual across trusts by March 2021 although it is possible delivery will extend further into 2021 depending on the pace of implementation by trusts.
There are 35 specialties being reviewed (visit www.gettingitrightfirsttime.co.uk) with more specialties (oncology, paediatric medicine) to be added subject to Department of Health business case approval.
There are more than 40 clinical leads and senior advisors involved in the GIRFT programme. They are specialists in their field and lead the reviews into the medical and surgical specialties which form the workstreams of the GIRFT programme. The majority of the clinicians joining GIRFT are recruited to the programme in conjunction with their specialty’s Royal College or professional society.
As part of the implementation phase, locally based GIRFT Regional Hub teams work closely with trusts. The hubs will include local clinicians in the role of GIRFT Ambassadors.
Across the programme, more than 800 ‘deep dive’ visits to 150 trusts have taken place. Clinical specialty visits are ongoing and all hospitals in England will be approached to take part in the GIRFT review. The visits are specialty focused, which means several units/ centres/ service teams at each NHS trust will be involved in the review process at any one time.
Hospitals are required to measure their performance in many ways and gather information about a range of factors. The GIRFT clinical leads oversee the creation of an insight-driven data pack on their specialty which combines publicly available information including Hospital Episode Statistics (HES), relevant registry or professional body data, and the results of a questionnaire issued to the trust being reviewed. This data report looks at a wide range of factors, from length of stay to patient mortality, and individual service costs through to overall budgets.
Where the data indicates the trust may be underperforming in some way, this is explored in more detail with the GIRFT clinical leads to consider the potential changes to practice. Likewise, where the data indicates a trust is outperforming its peers, the clinical leads seek to understand what the trust is doing differently and how its approach could be adopted by others to improve performance across the NHS.
Recommendations will vary according to the priorities of the specialty. The ‘deep dive’ meetings with clinicians and trust managers as part of the initial review process enable staff to explore improvements that make the best use of currently available staff, skills, tools, techniques and facilities to achieve significant and sustainable benefits.
The clinical leads liaise with the Royal College/ professional societies relevant to the specialty to review the data and findings, and to develop recommendations that fulfil improvements for a range of partners, including: clinicians, trusts, commissioners, Sustainability and Transformation Partnerships (STPs), professional bodies, and national public bodies.
GIRFT staff will support trusts at every stage. Liaison with clinical teams at the review stage involves providing some data and completing a questionnaire, and this is followed by a meeting with a further revisit to the trust per specialty review to present the data packs and the findings. These meetings are usually around two hours, and led by the relevant GIRFT clinical lead.
Trusts participating in the GIRFT programme will need to commit time for consultants, clinicians, and nurses from the relevant specialty, the operational managers, and senior executive directors including the Medical Director and Chief Executive to attend review meetings at which the GIRFT clinical lead presents the findings. It is an opportunity to provide more context around unwarranted variations that have been identified and to open up a discussion around any challenges the trusts face.
Part of the role of the GIRFT hub teams is to ensure ongoing collaboration with local partners, including regional teams from NHS Improvement, NHS England and RightCare, to dovetail our approaches and where appropriate to streamline visits. A key aim is to ensure that GIRFT priorities are mainstreamed into local improvement plans, and joint partner visits will be arranged where appropriate to reduce the burden on trusts.
Seven GIRFT Regional Hubs support project delivery leads to work with GIRFT clinical leads and trusts on implementation plans. The hubs provide in-depth and on-going support to trusts to interpret their datasets and start delivering on unwarranted variations in advance of their clinical lead visits.
The hub teams assist in the delivery of agreed improvements, tracking progress and prioritising support where needed. GIRFT Ambassadors and implementation managers work closely with trust clinical teams and CCGs, and other NHS programmes including NHS RightCare and Sustainability and Transformation Partnerships (STPs), seeking to improve patient outcomes and deliver efficiencies across local health economies.
The GIRFT hub teams collaborate closely with colleagues in other NHS bodies at a regional level to dovetail approaches and maintain a joint strategic overview of priorities and solutions for local health economies. The GIRFT implementation plans are developed in collaboration with other NHS partners working to deliver service change and improvements, including NHS Improvement Regional Teams, NHS England and the RightCare programme.
Involvement of STPs and CCGs early in implementation is important to deliver opportunities that go beyond secondary care, require co-operation across providers or otherwise involve larger scale strategic change.
The GIRFT programme provides trusts with specialty-level data packs to support clinical lead visits and implementation plans. Some indicators from the datapacks will be uploaded to NHS Improvement’s Model Hospital portal, which will be the gateway for accessing GIRFT information for trusts. Currently commissioners can only access GIRFT information direct from their local trust. GIRFT and NHSI are working with trusts to review policies for sharing data such that direct sharing with commissioners may be possible in the future. All decisions to share trust data with local commissioners are currently left to the discretion of individual trusts. Also, GIRFT is working more closely with NHS RightCare such that some GIRFT clinical metrics may be included within information provided by NHS RightCare.
The purpose of the data packs presented to trusts at the review stage is to provide insight to help inform clinical decision-making. The information within each pack focuses on a single clinical specialty. For information governance reasons, these packs cannot be routinely shared by GIRFT outside of the trust they apply to. However, where the data and insight raises a need for a trust and its clinical teams to work with commissioner colleagues, the GIRFT programme would encourage trusts to share their data packs and/or the information within it as they feel appropriate.
In order to support regional plans, GIRFT will produce data resources for the wider health systems. Alongside trust-level implementation reports and national specialty reports, GIRFT will produce reports for each of the 44 STP areas. These will report information about the trusts in the STP, they will not include information categorised by CCG. GIRFT is also working closely with NHS RightCare to deliver complementary sets of data and analysis collated at STP footprint level for the series of Commissioning for Value packs and tools developed by the RightCare programme to support CCGs and STPs.
GIRFT is supported within Next Steps on the NHS Five Year Forward View and the Use of Resources Framework. In addition, the programme works with NHS bodies and programmes to explore opportunities to further support change, ensure alignment and reduce duplication. We also work with professional bodies and NICE to explore whether clinical guidance may support implementation. The programme may also identify wider lessons for NHS policy, which we will discuss with all relevant stakeholders as they arise.
We believe that trusts will recognise the value of the GIRFT programme in providing an extensive (free of charge), nationally endorsed and clinically supported review of their key metrics and the national context. It is supported by detailed plans to implement changes that will improve productivity, efficiency and outcomes for patients.
This, and the improvements that are made as a result, are considered within NHS Improvement’s Use of Resources assessments. These assessments gauge how well trusts are using their resources in line with the Carter Review. The Use of Resources assessments help NHS Improvement identify potential support needs at a trust under the Single Oversight Framework (SOF), and to deliver support accordingly.
It is recognised that redesigning services across multiple providers or healthcare sites to drive improvement across a health economy can create costs for individual providers although the net financial impact should be positive across the whole local health economy. For individual trusts, such costs should also be offset by the savings created through delivery of GIRFT recommendations. The programme is exploring solutions and will support providers to navigate this issue via its regional hubs.
GIRFT is a support offer to trusts which is jointly overseen by NHS Improvement and the Royal National Orthopaedic Hospital NHS Trust (RNOH). The programme is led by front line clinicians who conduct peer to peer conversations across all trusts to determine what action should be taken to reduce unwarranted variations. The approach is individual to each trust and the focus is granular and clinically sensitive. In this way, GIRFT is a support vehicle for local change led by local clinicians and managers.
Sometimes GIRFT will identify opportunities to improve referral pathways. We are currently establishing our regional hubs which will work closely with CCGs, GP consortia, STPs and other local support teams such as RightCare to support improvements as required across the whole pathway.
GIRFT is supporting trusts with data-driven insight into where changes and improvements can be made across a range of specialties to deliver real benefits in patient care, reducing complications and raising quality. Recommendations adopted following publication of the GIRFT orthopaedic national report have helped to free up to 50,000 beds annually by reducing length of stay for hip and knee operations. Trusts have also moved towards more ring-fenced orthopaedic beds, reducing cross infection and enabling patients to return home sooner.
Further opportunities to enhance patients’ experience of care and improve patient outcomes while delivering tangible savings to trusts were highlighted in the GIRFT general surgery national report published in August 2017. Its recommendations include suggestions that could reduce length of stay, reduce post-surgical infections and prevent unnecessary readmissions. Our ambition is that trusts, working with GIRFT and in collaboration with local STP and NHS RightCare programmes, will reap the benefits over time as changes are embedded.
We cannot afford to lose traction on the gains made by trusts through the GIRFT programme. GIRFT will work with partners to make sure we sustain improvements by:
- Ensuring transition to ‘business as usual’ is completed for all trusts.
- Helping clinical leaders at trusts to drive a culture of continuous quality improvement locally linked to professional training and revalidation programmes, so that outliers strive to match best performers over time.
- Seeking to replicate the National Orthopaedic Alliance Vanguard model in other specialties as vehicles for maintaining the GIRFT approach over the long term.
- Working across specialties, building networks to deliver longer-lasting gains than can be achieved within each specialty alone.
- Launching campaigns for model approaches, and ensuring that GIRFT recommendations are incorporated into future iterations of best practice guidance and regulation.
Benefits measurement and tracking change
GIRFT tracks progress against implementation plans for individual specialties within a hospital, which is aggregated to a trust-wide plan and then informs our national monitoring. These plans measure implementation of recommendations, which is linked to quality indicators and savings opportunities. GIRFT regional hubs will use this tracking to prioritise support to trusts.
GIRFT measures quality improvement first and foremost. We identify quality improvement in key outcomes or practices, and ascribe a savings value to those quality improvements. Each national specialty report includes a detailed ‘impact statement’, setting out the potential quality improvements based on the clinical lead’s findings and recommendations, and a potential associated cost/resource saving.
Trusts can use GIRFT to identify savings opportunities within their CIP returns, even if these are already included In the GIRFT implementation plan. GIRFT tracks trust-level savings in order to aggregate them nationally and provide an overall projection of potential quality improvement and cost savings as evidence to support the GIRFT business plan.
GIRFT has already helped trusts save millions of pounds in orthopaedics alone, following the review in which Professor Briggs visited over 200 sites undertaking orthopaedic surgery. In a survey carried out by the NHS, more than 70 trusts responded and reported total savings of between £20m and £30m for 2014/15 as a result of adopting GIRFT’s recommendations. If extrapolated across the 140 trusts visited, these savings would increase to an estimated £40m to £60m. Furthermore, the trusts that responded forecast a further £15m to £20m of savings for 2015/16, estimated at £30m to £40m if replicated across all the orthopaedic trusts.
The original orthopaedics report included a raft of recommendations, many of which have been adopted by orthopaedic providers and have delivered real benefits:
- The recommendation to adopt cemented hip replacements for patients aged over 65 has led to a 10% increase in the use of this method, saving an estimated £4.4m p.a.
- Reduced length of stay for hip and knee operations has freed up 50,000 beds annually.
- Trusts have moved to more ring-fenced orthopaedic beds, reducing cross infection.
- Greater awareness of costs has led to reduced use of expensive “loan kit”.
- Litigation claims are down 36% from 1,758 (£215m) in 2013/14 to 1,350 (£138m) in 2015/16.
- A GIRFT “Pricing Letter”, providing transparency of the prices different orthopaedic trusts pay for
prosthesis, is now used by consultants selecting implants.
- In 2016 the British Orthopaedic Association used GIRFT principles in published guidance to
ensure best practice amongst its members.
GIRFT’s first priority is to improve the quality of outcomes for patients and our savings come from making quality improvements, whether by reducing complications or increasing use of the most appropriate treatments. These savings can then be reinvested to further improve patient care.
GIRFT monitors patient outcomes through its data packs which are produced from trust data and presented to clinical teams at the ‘deep dive’ specialty meetings, subsequent re-visits and via the GIRFT regional hubs. We use this data to help trusts identify where improvements can be made to patient care and what GIRFT can do to help trusts implement change.
National reports and their findings
Two national reports have been published:
- Orthopaedics (pilot) – in 2013 with a refresh in March 2015
- General Surgery – August 2017
Further reports are in the pipeline with vascular surgery, cranial neurosurgery and urology expected to be in the next tranche of publications over the next few months. The national reports are co-badged with the relevant Royal College and/or professional society. GIRFT is also working with these bodies and NICE on best practice guidance and definitive treatment positions.
Poor data quality
Poor or inconsistent recording of data across trusts inhibits understanding of treatment decisions. Improving data quality is a key requirement of being able to track and improve patient outcomes effectively. Clinicians and managers are often surprised by the variation between them and their peers. GIRFT recommends helping trusts to meet data completeness through the use of mandated national audit providers.
The GIRFT reviews have highlighted issues with the both the accuracy of the data collected and the way it is recorded using different codes for diagnosis and the procedures or treatment carried out by the hospital. Only by improving data quality will trusts know how well they are treating patients and how they can improve patient treatment and care.
Variation in procurement costs
Variation in procurement is seen as an NHS-wide issue and there are ongoing initiatives such as the Purchasing Price Index and Benchmark programme. The GIRFT reviews have found that there are often significant variations in the costs individual trusts pay for the same or similar items. In August 2017, the GIRFT General Surgery National Report found that prices paid for common surgical instruments and consumables varied by up to 59% higher for some trusts, and that price variation appears to be a result of factors such as a surgeon’s preference for particular surgical instrumentation, and choice based on clinical opinion that it will provide a better patient outcome. GIRFT recommends actions to bring pricing transparency and greater consistency in procurement.
Wide variation in respect of patient treatment options and pathways
Evidence suggests there is wide variation across trusts and CCG areas on the optimal patient pathway for a particular treatment. For example, the GIRFT General Surgery Report reported that patients with rectal cancer undergoing pre-operative radiotherapy varies from less than 10% in some trusts to over 80% in others. It found that care is optimised in the management of complex disease through the involvement of different specialties via multi-disciplinary team working (MDTs), but suggested that there may be disagreement among clinicians on the optimal pathway despite use of MDTs to help oversee decisions on treatment pathways.
Improved data quality and data collection will be key in supporting clinicians and commissioners in their decision making. GIRFT recommends improving the accuracy of coding; the quality of data collection; and improving the completeness of national audit programmes.
Wide variation in litigation costs
Data provided by NHS Resolution shows significant growth and variation in litigation costs between trusts. GIRFT is encouraging trusts to review incidents and complaints to identify the underlying causes of claims. Reviewing incidents and complaints and making changes in clinical practice from lessons learned will improve the quality of care and reduce the cost of claims for trusts.
This is a result of a combination of factors: there are different approaches to the patient pathway within different trusts; there is a variation in demand for different procedures; there are issues around the quality of data collection within trusts; and there are gaps in data capture for national audits. This impacts on decision-making, benchmarking and learning, with clinicians and managers unaware of how they perform against their peers.