Delay in injections
17. Mr A complains the Trust delayed in giving him injections to manage his pain. This was despite the Trust expediting his appointment as per his GP’s request.
18. The Trust explained when it lists patients for surgery, they are allocated a clinical priority code. It said it booked patients based on clinical urgency with code one being the most urgent, and code four being routine. The Trust listed Mr A as code four in October 2023. The Trust updated this to code three in January 2024 following a letter from Mr A’s GP.
19. The NHS Constitution sets out that patients should wait no longer than 18 weeks from referral for non-urgent conditions. If this is not possible, the NHS must take all reasonable steps to offer a range of suitable alternative providers.
20. The Trust explained to Mr A that due to the long-standing effects of the COVID-19 pandemic, and many patients waiting for surgery, it was unable to able Mr A his injections in a timely manner.
21. The Trust’s guidance sets out the steps it is taking to address the waiting list. It provides estimated timelines for inviting patients to register their request to move provider, should they wish to take up the offer. The guidance categories patients into different cohorts:
• Cohort one – patients waiting over 40 weeks (from end of October 2023) • Cohort two – patients waiting over 32 weeks (from start of December) • Cohort three – patients waiting over 26 weeks (from start of March 2024) • Cohort four – patients waiting over 22 weeks (from start of June).
22. The Trust’s guidance explains that it would adjust the timelines for cohorts two, three, four following the delivery of inviting patients in cohort one. In other words, once the Trust was aware of how many patients it could offer the move to a different provider, and the time this would take, then the other timelines may move.
23. The Trust listed Mr A for bilateral steroid injections at the end of October 2023 as a routine appointment. In January 2024, Mr A’s GP wrote to the Trust to ask it to expedite Mr A’s appointment as per his request. The Trust upgraded Mr A’s appointment as a priority (appointment within three months from upgrade) near the end of January.
24. The consultant involved in Mr A’s care also wrote to the Trust’s admissions department in June to ask it to give Mr A an appointment in the next few weeks (Mr A underwent his injections in July). We are therefore satisfied the Trust expedited Mr A’s appointment.
25. If we take the 18-week treatment timeframe, Mr A should have had his injection by the beginning of March 2024. After this point, as per the NHS constitution, the Trust must take all reasonable steps to offer an alternative provider. For example, a local private provider, or a different NHS Trust. This is dependent on local arrangements.
26. The Trust explained during that time, it was not exploring the option to refer patients to alternative providers that were breaching the 18-week timeframe. It explained its priority (and the national priority) was focusing on accommodating patients waiting more than 78 weeks. The Trust explained it was only sending patients to different providers that had been waiting more than 70 weeks to reduce its ‘long waiters’. It said this was a national initiative to reduce these ‘long waiters’ across the region.
27. The Trust continued to explain that in December 2023 it had patients who had been waiting over 104 weeks for treatment. In January 2024, it was working on clearing patients waiting 78 weeks. In April, it was clearing patients waiting 65 weeks. The Trust explained the other providers in the area were also experiencing similar difficulties, so it had limited options for alternative providers.
28. We understand how frustrating it would have been for Mr A, especially considering he was still experiencing significant pain from his condition.
29. The Trust explained to us that it is aware of its long waiting lists and how this affects patients. Since the time of the events Mr A complains about, the Trust said it has made significant progress in terms of waiting times. In April 2024, the Trust said it had approximately 200-300 patients waiting over 65 weeks. As of January 2025, it only now has a handful of patients waiting the same time.
30. There is an indication of failing here in that the Trust did not act in line with the NHS Constitution. However, we accept this was outside of the Trust’s control, and so not a failing by the Trust. We understand there were long waits for the other providers in the region.
31. Our Principles of Administration say organisations should treat people fairly and consistently, so that those in similar circumstances are dealt with in a similar way.
32. As listed in paragraphs 26 to 27 the Trust was focusing on patients waiting even longer than 40 weeks, as per a national initiative. It was working through those waiting longer than 18 weeks in a fair and consistent manner.
33. We acknowledge the unavoidable delays on the Trust’s part, and how this affected Mr A. We do not wish to undermine the pain and impact this had on Mr A at the time. In its response to Mr A’s complaint, the Trust apologised for the delays and the dissatisfaction and upset this caused Mr A.
34. On the balance of probabilities, we think the explanations the Trust has provided here suggest it has acted in line with our Principles. Its explanations show how it has acted fairly to its patients, including Mr A, regarding its focus on ‘long waiters’.
Surgery
35. Mr A complains the Trust delayed in arranged surgery for him, instead providing ineffective pain management.
36. The Trust explained the treatment plan was for Mr A to carry on with painkillers and hip injections. It said if the hip injections did not provide Mr A with pain relief, the consultant would discuss with him further about proceeding with a hip replacement. The consultant advised it would not be appropriate to proceed with a hip replacement without attempting to alleviate the Mr A’s symptoms with injections.
37. Section 1.1.2 of the NICE guidance says clinician should support shared decision making by discussing treatment options with people offered primary hip replacement. These discussions should include alternatives to joint replacement, and the potential benefits and risks of the available procedures and type of implant for joint replacement. This includes discussing the possible need for more surgery in the future.
38. Following an arthroscopy in May 2023, as well as taking regular analgesia, Mr A’s pain was not resolving. The Trust reviewed Mr A in clinic in June. The record of this review says the consultant and Mr A agreed to continue with conservative management (non-invasive procedure) with exercises at that stage. The consultant’s plan was to review Mr A in six months’ time and, if required, to consider injections.
39. Mr A had a telephone consultation with the consultant in August regarding his ongoing pain. The record of this consultation shows the consultant explained to Mr A it was too early to intervene further with hip injections or any further management. It notes that Mr A and the consultant agreed that his pain needed to be management with analgesics at that stage. The plan was to review Mr A in six months to re-assess his symptoms. It says if Mr A’s symptoms were still bad after six months, it would consider hip injections.
40. Mr A attended a clinic appointment in October. The letter of this clinic says Mr A and the consultant discussed the different management options available, and it noted Mr A was keen to try bilateral injections.
41. Following a course of steroid injections, Mr A attended a review in September 2024. Mr A explained to the Trust that the injections did not provide him with any relief. The Trust explained to Mr A he is too young to have a total hip replacement, as he would need a few revisions in his lifetime. The Trust wanted to wait as long as it could for this and that it needed to try as many options as possible prior to any surgery. The records indicate Mr A understood this.
42. Mr A then underwent a course of PRP injections, and he attended a follow-up appointment in May 2025. The notes indicate that the injections were initially helpful for Mr A’s symptoms, however the pain returned later. It goes on to say that ‘at any cost [Mr A] would like to avoid a hip replacement as it is already arthritic on the right side’. The Trust planned further PRP injections.
43. Our adviser explains that for a young patient with early arthritis, it would be reasonable to try all non-operative measures to delay hip replacement surgery. They emphasise this needs to be shared decision with discussion of all options with the patient.
44. The records indicate that Mr A was involved in discussions regarding management of his condition, and the need to delay surgery for as long as possible. The Trust discussed alternative treatments, like the PRP injections, and the Trust provided this treatment.
45. The Trust’s actions here appear to be in line with the NICE guidance. Considering the evidence we have, we think there are no indications of failings in the Trust’s decision to delay surgery.
46. From our communication with Mr A, it is clear his symptoms are ongoing, and he is unfortunately still in pain and struggling with daily tasks. We can understand Mr A’s frustration that his pain is unresolved. We hope our decision here reassures Mr A that the Trust has followed the relevant guidance regarding his treatment, specifically regarding the surgery.