Evidence generation plan

Different leasing options for each technology may be negotiable based on procedural volume and contract duration.

The robotic technologies included in the assessment are 'closed' systems, which means they only work with implants made by the same manufacturer. Financial commitment to one robotic technology may limit the choice of implants available at that hospital. This should be considered when choosing to adopt specific systems.

Availability of operating theatre space may influence choice, if any, of robotic technology.

The published economic evaluations based on real-world evidence had to adjust for observed differences in patient characteristics between robot-assisted surgery (RAS) and conventional surgery arms (including age and body mass index). So, future analysis should account or adjust for all important differences in population characteristics between RAS and conventional surgery.

Issues with data quality may impact analysis. Clear reporting about data quality is important and approaches such as multiple imputation could be used to address them.

The ergonomic benefit to surgeons and their career longevity may be difficult to capture.

The impact of RAS on the development of the manual skills of trainees is unknown, but competency is reviewed through peer-review and reported in National Joint Registry audits.

Companies may improve their chances of a getting a recommendation in future assessments by also collecting data on other outcomes relevant to other national organisations, for example, data on returning to work and normal activities.

Robotic systems are more widely adopted in the private sector, which could drive health inequalities if they show promise in improving patient outcomes and are not adopted by the NHS.

Access to RAS may be restricted to people who live near larger specialist centres or high-volume centres that can afford the technology. Experts said that the geographical placement of additional robotic systems, and the availability of training, resources and staff to implement RAS services could worsen these disparities. These concerns were reiterated by patient organisations and patient expert feedback. The NHS England RAS steering group may be influential in moderating this with national strategy going forward. It is actively analysing and mapping current RAS provision in England. A key priority will be equitable provision of RAS based on need rather than current configuration. 

Having limited access to RAS in the NHS may drive health inequalities, worsening the post-code lottery, particularly for people living in deprived areas, or if the technology is more widely adopted in private healthcare systems.

RAS is not suitable for several subgroups, but people in these groups would still have access to conventional surgery. Manual skills will be maintained for these people and for conversion surgery.