Regarding the importance of understanding the journey along the referral pathway towards joint replacement surgery for patients with comorbidities, the majority of the professionals reported that the system needed to be improved to better manage patients with comorbidities across the system. As one intermediate care professional explained:
“…it’s a hole in the NHS provision, if they could get better at stopping patients with long-term conditions crashing and burning, if they could commission something that would help support them so they stayed on a good functional level, all our jobs would be easier” (ICP, Interview 8).
This quote underlines that while there was an understanding of a need to improve the system for patients with comorbidities the professionals do not know how best to achieve this improvement and whose responsibility it is to make it happen. It also highlights that the professionals perceive managing patients with comorbidities as challenging. This appears to be exemplified in the two major themes that emerged from the data: differences in approaches to managing comorbidities and the professional’s view on whose role and responsibility it is to prepare patients for joint replacement surgery.
Managing comorbidities
The presence of comorbidities did not preclude the referral or selection of patients for joint replacement. All the professionals indicated that diabetes, chronic obstructive pulmonary disease (COPD) and heart disease were the most common comorbidities which they often found challenging to manage. Each professional group, however, concentrated on different aspects of comorbidity. This different focus influenced how each group of professionals approached the management of patients with comorbidities. GPs focused on the long-term complex care of the patient’s conditions, intermediate care professionals focused on the patients’ eligibility for surgical consultation, and orthopaedic surgeons on the short-term risks of the surgical procedure.
GPs spoke about the complexity of the long-term management of patients’ comorbidities alongside their hip or knee pain. This is perhaps unsurprising as GPs are responsible for the management of the patients before and after surgery. The majority of GPs described their initial assessment of patients presenting with hip or knee pain as being not just about evaluating the risks of the surgery but also about the impact of the comorbidities on the patient’s daily life and the long-term benefits of the hip or knee replacement in terms of improvements in quality of life, pain and disability. One GP explained that he did not think in terms of specific comorbidity categories as one could assume that patients presenting with hip or knee pain were from an age group in which comorbidities were very common (GP, Interview 1). Similarly, several GPs reported general ‘frailty’ in elderly patients as a reason to be concerned about ‘fitness for surgery’ but these GPs seemed to be primarily concerned about the patients’ ability to recover from such an invasive surgery (GP, Interview 3).
GPs reported also having to manage the complexity of ‘multimorbidity’, given the impact different comorbid conditions can have on each other. As one GP described it, core management of joint pain focuses on improving mobility and people with comorbidities struggle even more with mobility. Similarly, the joint pain makes it more difficult for patients to deal with their comorbidities. For some GPs, this complexity did have an impact on the care they believed they could provide in the lead up to joint replacement. For example, as one GP said:
“If someone’s got severe COPD then offering them physiotherapy may not be an option, the exercise class may not be good enough so there will be comorbidity that will limit what you can and can’t offer in all spectrums, so whether that is medication, exercises, even surgical fitness, you know, all of these come into mind and have to be detailed at the time of consultation.” (GP, Interview 9).
In contrast, intermediate care professionals, reported focusing the impact that comorbidity has on the patients’ suitability for surgical consultation and the likelihood of patients being selected by surgeons for surgery. Patients, if not sent directly by the GP for orthopaedic consultation, were referred to an intermediate service to be further assessed. The intermediate care professionals reported that, while the presence of comorbidities did not prevent the referral of patients for orthopaedic consultation, a key aspect of their management of patients was the decision about the likely impact that comorbidities have on the risks and benefits of the surgery. As one intermediate care professional explained:
“I had a patient who had osteoarthritis knee but they’d had a coronary artery bypass graft, they’d had a stroke, they had high blood pressure, they actually hadn’t tried much physiotherapy so we went down the conservative route first, but looking at all of those things and their age, would a surgeon actually want to put them on the operating table for fear that with all of that they might not wake up again. So that’s sort of weighing up the pros and cons of ‘are you going to benefit from this or is there no point in us actually doing the surgery’.” (ICP, Interview 15).
All intermediate care professionals described risk in terms of the risks of the surgical intervention itself. This may partly reflect the fact that intermediate care professionals reported working more closely with surgeons.
Orthopaedic surgeons focused on the risk comorbidities posed to the surgical procedure itself and the immediate postoperative recovery. Despite this focus on the procedure and postoperative period, they indicated that the presence of comorbidity did not preclude the selection of patients with comorbidities for hip or knee replacement. Orthopaedic surgeons often talked about assessing risks as necessary to avoid the risk of ‘death on the table’ (Surgeon, Interview 6). This risk of death was primarily linked to the impact of comorbidities on anaesthetic risk.
Some surgeons also spoke about what they described as needing to assess the benefits, which they defined as the likelihood of a successful surgery without postoperative complications. Surgeons reported that the likelihood of complications such as cardiac complications was important to consider in the effective management of resources for patients with comorbidities. Patients with multiple comorbidities were labelled as ‘complex patients’ who therefore needed high-dependency beds in case of complications. One surgeon reported that getting a high-dependency bed was challenging. As a result, surgeons explained that in managing patients with comorbidities they had to think not only of the risks of the actual surgical procedure but also the immediate post-operative risks and the logistics of providing care for these ‘complex ‘patients. As one surgeon describes:
“Last week I did a patient and […] this patient had been put on a list over a year ago and we’d delayed her on three successive occasions, mainly because they needed high-dependency bed...” (Surgeon, Interview 5).
Roles and responsibilities
Across the professionals, the theme of roles and responsibilities was central to the discussion about referring and selecting patients for replacement surgery. Differences between professionals groups emerged in how professionals perceived their roles and responsibilities in supporting patients in their preparation for surgery.
GPs indicated that it was not their responsibility to support patients in their preparation for joint replacement by addressing their comorbidities prior to surgery, as they were not clinical orthopaedic experts. They explained therefore that they could not make final decisions on appropriateness for surgery for patients with comorbidities. One GP described the role of GPs more succinctly indicating that it was about “intervening in modifiable long term risks” (GP, Interview 11) rather than the short-term risks related to surgery. Another GP reported:
“I don’t really feel that I’m referring someone for surgery in that kind of way. I kind of more feel like I’m referring them to a specialist who can help them in a special way which might involve surgery. So I don’t, I’m not really in that kind of mindset of this person is going for surgery and I need to be for sure that they’re ready for it” (GP, Interview 3).
Some GPs mentioned that it was not their role to make a decision about appropriateness for surgery. Others admitted they were not sufficiently informed about what constitutes appropriateness for surgery and therefore let the surgeons make this decision. In addition, some GPs explained that the complexity of the referral system was a barrier to being confidently able to refer and manage patients with comorbidities in preparation for joint replacement surgery.
Intermediate care professionals did not consider it their responsibility to support patients with comorbidities in their preparation for joint replacement surgery. In general, these professionals all suggested that their role was to triage patients referred to them from GPs and not to give an accurate diagnosis or consider fitness for surgery. Again, like GPs, they assigned the role of ‘expert’ to the orthopaedic surgeons. One interviewee explained: “I’m not a surgeon, I’m not the expert” (ICP, Interview 15). There was an agreement amongst all intermediate care professionals that their role was very technical and was to ensure that surgeons were sent only those patients who were ‘appropriate’. An appropriate referral was defined as a patient who had tried all non-surgical treatment options and had undergone all investigative tests. All intermediate care professionals suggested that it was important to achieve high ‘conversion rates’, that is, the rate of consultations with the surgeon resulting in a surgical intervention, so that they did not waste a surgeon’s time. Several intermediate care professionals reported that they worked alongside surgeons to improve this conversion rate with the aim of reducing waiting times. They also believed that their role, and the reason intermediate services were introduced, was to relieve the pressure on GPs who were not ‘experts’ either. One intermediate care professional stated:
“GPs are fantastic, the 13% of their case load is musculoskeletal (MSK) dysfunction and they’re not specialists in MSK, so a lot of the time these patients would be more appropriate to come to us in that we are a cheaper service and our tariff is less but we can give just as good care, but we don’t do the surgery.” (ICP, Interview 16).
Orthopaedic surgeons defined their role as the ‘expert’ who made the decision about the most appropriate surgical option but were not responsible for supporting patients in their preparation for surgery. One surgeon explained that ideally surgeons would receive only appropriate referrals of patients who needed surgery and were prepared for surgery. At the pre-assessment clinic, surgeons reported that further investigative tests could be ordered if necessary. The majority of surgeons, however, agreed that it was the GP’s main role and responsibility to support patients with comorbidities in their preparation for joint replacement by addressing their comorbidities prior to referral. In order for patients with comorbidities to be prepared for surgery, surgeons explained they needed to be ‘optimised’ – their comorbidities had to be under control. One surgeon reported it was about “managing those long-term conditions so they don’t delay surgery” (Surgeon, Interview 5). As he explained, operations were often cancelled due to patients not being ‘optimised’:
“This week we cancelled a patient on a day surgery, in fact we’d seen her two weeks ago, she had high blood pressure, cancelled her on day surgery, she… hadn’t started on blood pressure medication, sent her back to her GP, “Can you start on medication,”…, a month later she comes back her blood pressure’s even higher than it was the first time around” (Surgeon, Interview 5).
When patients with comorbidities are assessed by a surgeon and deemed unprepared for surgery the majority of surgeons explained that in most cases they refer patients back to GPs. One surgeon explained there was an incentive to discharge patients as hospitals were penalised if they did not meet the 18-week target from referral to surgery. More than half of the surgeons suggested, however, that GPs may not make re-referrals and patients therefore may be ‘lost to the system’. As a result, these surgeons took it upon themselves to refer patients for further investigations or to other secondary care specialists. They described this as a measure to reduce the waiting time for patients. One surgeon said:
“I’ll keep them under my review, I won’t discharge them, I’ll bring them back after a few months because I don’t want them getting lost, forgotten about. If I’m not sure, it’s borderline then I might refer to my anaesthetist and ask them their opinion and then they can decide, they may just say yes, that’s fine, just order a few more tests or they may say, yes, I think they need to see a cardiologist for example.” (Surgeon, Interview 20).
Some GPs and intermediate care professionals reported that patients also had a role in preparing themselves for surgery and this explained why some patients referred back to GPs were not re-referred. They reported that patients were not able to change their lifestyle, to improve their ability to manage their comorbidities, to be prepared for surgery and as a result were never re-referred and never receive the hip or knee replacement. According to one GP:
“I regard that as basically saying you can’t have the operation because people like her have got to their weight over the course of their life, … most people have very high BMIs so you’re talking about them having to lose some life-changing amount of weight and they don’t do it, so I regard that as just saying no, I’m not going to do your surgery….” (GP, Interview 11).