4. Mrs N complains the Trust delayed her double hip replacement in 2020. She says the delay was caused by the Trust’s physiotherapist incorrectly referring her for investigations of her spine on 24 January.
5. Mrs N says she could not live a normal life because she was in a lot of pain with severely restricted mobility. She says she felt let down and had no choice but to have her hips replaced privately. She wants the Trust to reimburse her for the cost of the hip replacements.
6. Mrs N’s GP referred her to the Trust’s orthopaedic services on 5 December 2019. The referral included Mrs N’s history of pain and stated she had mild osteoarthritic changes (osteoarthritis is a condition that causes joints to become painful and stiff). It stated Mrs N had been seen by the community physiotherapist who thought the issue may be lumbar stenosis (a condition where a narrowing of the spinal canal in the lower back can cause pain or weakness in the legs).
7. The referral noted the main reason for the referral was, ‘lumbar stenosis. For spinal ESP [extended scope practitioner]’. ESPs are physiotherapists who work closely with consultants in specialist areas.
8. The referral went to the hip and knee orthopaedic triage service. When Mrs N had the 24 January 2020 appointment, the physiotherapist thought the referral related to spinal issues and referred her to spinal services.
9. Mrs N had appointments and investigations with spinal practitioners over the next eight months. The orthopaedic spinal practitioner reviewed Mrs N in September 2020 and noted a slight change of symptoms. He decided her pain was due to degenerative hips and referred her to the hip team.
10. The hip and knee triage physiotherapist wrote to Mrs N’s GP in November 2020 and said she was on the outpatient waiting list for the hip team.
11. Mrs N explained the problem was so bad she could not walk or lead a normal life. On 9 December Mrs N’s GP referred her for private total hip replacement. She had the hip replacements in January and April of 2021.
16. Mrs N told us she thinks she should have been sent for imaging (scans) in January 2020. She said she had a hip not a spine issue and this is what she was referred for.
17. The physiotherapist who saw Mrs N on 24 January reviewed the referral and noted the GP had referred her for a spinal problem, so referred her to the spinal clinic instead. The physiotherapist did not do an assessment or investigation.
18. Our physiotherapist adviser told us each musculoskeletal assessment service has its own way of assessing patients for triage. Some take a general approach, where each patient will be assessed at the first point and then referred to the relevant specialist service. Some have a more restricted process, where each specialism will do its own triage.
19. They explained there is no fixed approach and no requirement for one method rather than the other. The Trust seems to have used the second approach.
20. As the referral was clearly marked by the GP as being for the spinal service, the actions of the physiotherapist were in line with the HCPC guidance that says:
‘You must keep within your scope of practice by only practising in the areas you have appropriate knowledge, skills and experience for’ and ‘You must refer a service user to another practitioner if the care, treatment or other services they need are beyond your scope of practice.’
21. Mrs N said she thinks the physiotherapist should have ordered imaging at the first appointment to find the cause of her symptoms. Our physiotherapy adviser confirmed that as the physiotherapist did not examine or assess Mrs N, but sent a referral there was no need for them to request imaging.
22. Our orthopaedic adviser agreed it was in line with guidance for the Trust to investigate possible spinal issues at this early stage. They explained it was not clear what was causing Mrs N’s symptoms and the BOA guidance says referrals for hip replacement are mostly only in cases where, ‘other non-operative treatment will have failed or proved to be futile’.
23. We looked to see if there were any failings that led to delays in Mrs N’s treatment pathway from this point on.
24. The NHS RTT guidance says an 18-week clock for referral to treatment should start from the time a patient is referred, to the point they start their first complete treatment, or a clinical decision is made that stops the clock.
25. We recognise Mrs N was seen outside of this 18-week period. We cannot say this was due to any failings by the Trust because this was the situation at that time across the whole NHS.
26. NHS England issued guidance that postponed all non-urgent elective (planned in advance, not emergency) operations from 15 April 2020, for a period of at least three months. This action also led to increased waiting times that were outside the control of individual trusts.
27. Our orthopaedic adviser said in this context Mrs N was seen within a reasonable amount of time.
28. The spinal practitioner acted in line with the GMC guidance to, ‘promptly provide or arrange suitable advice, investigations or treatment where necessary’ by organising imaging. Unfortunately, the COVID-19 pandemic affected the time it took to organise imaging. There is nothing in the records to show the time taken for this imaging was due to failings on the part of the Trust.
29. When the spinal practitioner got the imaging back they made a referral for Mrs N to have physiotherapy. This is in line with the GMC guidance to, ‘refer a patient to another practitioner when this serves the patient’s needs’. And, the BOA guidance says that non-operative treatment would need to have failed or proved to be ineffective before other surgical solutions are considered. Our orthopaedic adviser said this was appropriate action, considering the imaging showed ‘moderate degenerative features’.
30. The spinal practitioner saw Mrs N again in September and referred her back to the hip team after a slight change in her symptoms. Our orthopaedic adviser told us this was the correct action in line with the GMC guidance to:
‘adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient promptly provide or arrange suitable advice, investigations or treatment where necessary refer a patient to another practitioner when this serves the patient’s needs.’
31. Mrs N was then put on the waiting list for an outpatient appointment. We recognise this process took some months and understand how much this delay was affecting Mrs N. There is again no evidence that the delay was due to any failings on the part of the Trust. These delays were common in all NHS trusts and waiting time was further affected by the COVID-19 pandemic.
32. We considered whether the Trust should have fast tracked Mrs N for a hip replacement. The British Hip Society issued advisory guidelines for prioritisation in hip surgery, to be used alongside other guidance. This gives a long list of conditions that should be considered as a priority for immediate treatment, or treatment within three months. This includes conditions like fractures, infections and malignant bone tumours. Mrs N did not fall into any of the priority categories. For these reasons we find it was in line with guidance for her treatment not to be prioritised.
33. Mrs N then decided to have private treatment. We can see her first operation was completed before she had the orthopaedic consultation on 10 March 2021. She was put on the waiting list with the aim of having surgery within three months. She told the Trust on 18 April that she would be arranging for the second hip replacement to be done privately.
34. It is unfortunate Mrs N had to wait a long time to see a consultant hip surgeon. This was outside the expected 18 week wait. We found this was due to resource issues and delays caused by the COVID-19 pandemic, not failings by the Trust. The treatment pathway including the referral for spinal investigations in January 2020, was in line with guidance.
35. We do not underestimate how much pain Mrs N experienced because of her medical condition. We did not find that the Trust did anything wrong so we are not making any recommendations for the Trust to reimburse the cost of her private treatment.
1. We have considered Mrs N’s complaint about the Trust’s actions when it received a referral to its orthopaedic department from the GP.
2. We found the physiotherapist’s actions were in line with relevant guidance when it referred Mrs N for spinal investigations. We can see Mrs N did have to wait a long time before the Trust decided to put her on the waiting list for surgery. We recognise how much pain Mrs N was in and the frustration this caused her. But we did not find this waiting time was due to the Trust’s failings. We do not uphold the complaint.
3. We are sorry to hear about the circumstances that led to Mrs N bringing her complaint to us. We hope this report gives an answer to her unresolved concerns.