1

March 2016

Draft v1.0

Draft in progress |

Paper Cii

2 Draft in progress |

Introduction and summary 3

Case for change 7

How we might improve elective orthopaedic Care 22

Outline model 28

3 Draft in progress |

4 Draft in progress |

Orthopaedic services in South East London are generally safe and high quality. Over the last ten years waiting times have come down

considerably and there has been substantial investment in the service. However, services are under considerable pressure which is

likely to intensify as demand increases and the NHS financial position comes increasingly difficult.

The challenge for us in south east London is how to improve the quality of care and meet waiting times targets in the face of a growing

population and constrained finances.

In order to meet this challenge the Our Healthier South East London programme has been working with clinicians, patients and

managers to explore the issues in the current service and consider alternative models of care.

Through a process of workshops and working groups with clinicians, managers and patient representatives, it has been agreed to test

the feasibility of consolidating inpatient elective orthopaedic services within South East London. The key features of the model are to

potentially centralise inpatient elective orthopaedic services on to fewer sites, while maintaining a reasonable geographic spread.

Orthopaedic trauma, day case and outpatient work would continue at existing sites.

The intention is to do this through a collaborative approach.

The purpose of this document is to establish the first step: why elective orthopaedic services need to change, and how the project group

arrived at a consolidated model as the direction to be explored against the status quo.

5

This document sets out the case for change for elective orthopaedic care (EOC)

in South East London (SEL). It builds on the work of the Our Healthier South East

London Strategy by testing a range of hypotheses developed by the planned care

clinical leadership group.

Our Healthier South East London

Our Healthier South East London is a five year commissioning strategy1 which

aims to improve health, reduce health inequalities and ensure all health services

in SEL meet safety and quality standards consistently whilst being sustainable in

the longer term. An integrated whole system model was developed through 6

clinical leadership groups throughout 2015 which were focused on different parts

of the system.

The planned care group brought together clinicians and stakeholders to develop a

vision for planned care in SEL. Through a series of workshops the group

developed a case for change and proposed that the case for elective orthopaedic

procedures being consolidated within SEL should be developed and evaluated.

Following the approval of the strategy in 2015 a working group of providers and

commissioners was established to develop a process and consider model and

options for consolidating EOC services in SEL for comparison against the status

quo.

Overarching health and care challenges facing SEL

The strategy was established to develop a response to the challenges facing the

health and care system in SEL. This provides the context of this work.

Analysis conducted in 2014 demonstrated that our health outcomes in south east

London are not as good as they should be.

• Too many people live with preventable ill health or die too early

• The outcomes from care in our health services vary significantly and high

quality care is not available all the time

• We don’t always treat people early enough to have the best results

• People’s experience of care is very variable and can be much better

• Patients tell us that their care is not joined up between different services

• The social care system is under increasing pressure

• The money to pay for the NHS is limited and need is continually increasing

• It is taxpayers’ money and we have a responsibility to spend it well

• South east London’s acute, community and mental health providers face a

similar and interrelated set of challenges and drivers

The longer we leave these problems, the worse they will get. There is a need to

change what we do and how we do it. The rest of this section describes the

above points in more detail and sets out our case for change in south east

London

Draft in progress | 1. The strategy and further information can be found on the Our Healthier South East London Website:

http://www.ourhealthiersel.nhs.uk/

This document sets out: This document doesn’t:

• Current challenges and problems

with our elective orthopaedic

services

• Provides evidence that other

ways of working my improve

quality, safety and efficiency.

• Suggests the evidence justifies

further work to develop potential

alternatives to the status quo.

• Provide a detailed description of

alternative clinical models

• Suggest any decisions have

been taken about models or

locations of services.

• Quantify financial or other

benefits

6

The evidence of problems with our current elective orthopaedic service is growing. This paper sets out the local and national evidence base to establish the case for

change. Where possible it also makes comparison with alternative models of consolidated services as a comparator with the status quo. Namely, the Royal National

Orthopaedic Hospital (RNOH) and the South West London Elective Orthopaedic Centre (SWLEOC). This will form the basis for ongoing development of alternative

models to contrast with current arrangements.

Draft in progress |

Case for change Comment

Meeting

future

demand

Additional capacity will be needed to deliver elective orthopaedic

care by 2021 based on demographic and non-demographic

growth.

Demand for elective orthopaedic services is increasing. Current capacity will not be able to cope, and demand management by itself will not be

sufficient to deal with the increasing number of patients.

Patient

experience

Trusts are struggling to manage with existing capacity which

impacts waiting times

The 18 week referral to treatment rule is regularly breached in orthopaedics, leading to delays in patients being seen, work being outsourced to

the private sector at additional costs and premium cost waiting list initiatives. Orthopaedics has the biggest 18 week backlog in the sector.

Cancellations of planned procedures are regularly occurring which

have an adverse impact on patient experience

Most orthopaedic beds are not "ring fenced" and so when there are emergency pressures patients are cancelled.

While length of stay has improved it remains below the London

average at most sites in SEL

There is strong evidence that we could have more effective patient pathways and use beds more efficiently if we systematically adopted best

practice.

Patient reported experience is variable across SEL Patient experience scores are variable and generally poorer than at consolidated orthopaedic centres.

Quality,

safety and

outcomes

Elective orthopaedics requires an environment in which the

infection and complication risk is minimised

Infections can be devastating in joints. The best infection control figures are seen at specialist and consolidated centres.

Evidence shows variability in hospital infection rates across South

East London and trends over time in hospital infection rates show

further improvements are possible

There is opportunity to further reduce the rate of hospital acquired infections

Readmission rates are in line with the national average but there

may be further opportunities to reduce further

While SEL trusts are performing in line with the National and London average for readmissions there are opportunities to improve. Improving

readmission rates will support both productivity and patient experience.

Litigation costs are rising in the NHS and orthopaedic surgery

account for about 14% of total claims

Orthopaedics is a major driver of litigation costs and systematically adopting best practice can improve outcomes and it make a financial

contribution to the health and care economy

Surgeons undertaking low volumes of specific activities that may

well result in less favourable outcomes as well as increased costs.

We know that some surgeons in SEL undertake low volumes of specific procedures. Evidence suggests that better outcomes come from

surgeons undertaking larger volumes of work.

Wider

benefits

There are opportunities to improve data collection and achieve

wider productivity benefits

There is evidence to suggest that networking services can enable the NHS to achieve improved productivity to reduce costs. As outlined above

readmissions and length of stay will help meet demand and present an opportunity to reduce costs. At the same time, collaboration can improve

help realise efficiencies in procurement

7 Draft in progress |

8 Draft in progress | 1. Getting it Right First Time

During 2015 the Planned Care Clinical Leadership Group

considered opportunities for improvement across a number of

pathways. During this time the group agreed that Elective

Orthopaedic Care offered the greatest opportunity for improvement

in South East London. This was based on a number of factors:

• Demand for EOC is increasing. The drivers for this are: the

expectancy of an active retirement in an aging, longer living

population; the overall increase in BMI; and the advances in

new technologies that underpin increasing surgical sub-

specialisation

• In South East London, approximately 6% of all elective spells

are related to trauma and orthopaedics yet T&O accounts for

about 25% of tariff spend – 10% more than the next specialty.

• Complications following orthopaedic surgery are costly to the

patient and the NHS.

• Waiting times for EOC are often longer than other specialties

and more people wait longer than 18 weeks for their treatment

• Feedback from the public, patients and clinicians that

experience and practice was variable across SEL

• Alignment with the national report “Getting it Right First Time”.

The CLG wanted to align itself with the ongoing work from the

GIRFT programme.

• Availability of evidence and good practice in developing

alternative models for orthopaedics such as the South West

London Elective Orthopaedic Centre, The Royal National

Orthopaedic Centre (and other specialist centres), and other

consolidated elective centres

Total number of

incomplete

pathways

Total within 18

weeks

% within 18

weeks

SEL - T&O 171,768 151,571 88.2%

SEL - all other specialties 1,299,297 1,216,693 93.6%

National 5,027,475 4,543,856 90.4%

London 490,422 437,587 89.2%

Waiting times for T&O and other specialties

Note: for a breakdown of ‘remaining specialities please see the additional information section Source: Health Evaluation Database (time period December 2014 - November 2015) Notes: data presented includes all national inpatient spells recorded on HED with an elective admissions method. Data is presented for the last 12 months available (December 2014 - November 2015). The SEL selection includes data for GST, KCH, DGT, EPSTH, and LGT.

9 Draft in progress |

In SEL elective orthopaedic care is delivered by each trust across 8 sites. The majority of procedures are delivered at either Guy’s Hospital (Guy’s and St Thomas’

Foundation Trust) or Orpington (Kings College Hospital Foundation Trust). The table also shows the mix of routine and complex procedures provided across sites in

SEL showing the variation in volume. Elective orthopaedic procedures can be grouped depending on the complexity and each category will require different

approaches and costs. The categories used in this document reflect the work of the GIRFT team

Complex procedures: Complex procedures are more challenging and have been defined by the GIRFT1 team and NHS England Clinical Reference Group2. They

include revision surgery, hip procedures with infections and ankle replacements amongst many others. The proposed NSHE service specification provides a

comprehensive list of orthopaedic procedures and/or relevant diagnoses.

Routine procedures: High volume procedures, such as primary hip replacements, that have been standardised. For the purposes of this work any procedure not

included in the complex category has been categorised as routine.

Hospital sites in South East London delivering Elective

Orthopaedic Procedures

Current EOC activity in South East London

1. NHSE draft specification for specialised orthopaedics

2. Getting it Right First Time

Orpington Hospital (as part of KCHT) is within 2-3 mile radius of PRUH

10

The pressures on EOC continues to grow. Nationally, Orthopaedic Consultant

episodes increased by 23% and hospital admissions by 14% from 1998 to 2004 and

continue to grow with annual increasing referral rates of 7-8% not unusual. Over the

last six years there has been a steady 4% increase in hip replacements and 10%

increase in other joint replacements. While this is a result of a number of factors an

ageing population is a key driver for the increased demand1. This is illustrated in the

graph on the following page.

While all health and care providers have a role in helping to reduce demand through

greater prevention and alternative pathways it is expected that demand for EOC will

continue to grow. Using the mid-case scenario below it is estimated that by 2021 an

additional 20 beds* will be needed in SEL to accommodate growth. Based on routine

cases additional theatre capacity will be required to provide up to 7 dedicated

theatres in SEL**.

Looking at SEL activity, current activity levels have been projected to 2020/21 across

three cases:

• Low case: Using GLA population growth forecasts by Borough (~1% p.a. for SEL

as a whole) and a 2% non-demographic growth assumption

• Mid case: Taking the mid-point between the Low and High cases assuming 4.6%

growth. It is expected that providers will use the mid-case assumptions for

planning purposes.

• High case: Using historic growth rates for orthopaedic activity at SEL providers

(11% p.a. from 2011/12 – 2014/15 for elective and non-elective activity)

Using the mid-case the table opposite suggests that by 2021 an additional 20 beds

will be needed across SEL.

Draft in progress |

1. Getting it Right First Time *Bed requirements assume 85% occupancy rate per annum **Based on 6 days per week operation, 50 weeks a year, and upper quartile theatre performance (4.9 patients per day)

A combination of creating additional capacity in the system and optimising the

current model of care will enable us to meet future demand. At the same time there

is a need to develop a standard pathway which will enable economies of scale

driving reduced complications, lower length of stay and wider productivity and

efficiency.

Case 2015/16

(Current) 2016/17 2017/18 2018/19 2019/20 2020/21

Low 6,805 7,015 7,232 7,454 7,681 7,913

Mid 6,805 7,125 7,461 7,811 8,175 8,554

High 6,805 7,507 8,283 9,137 10,076 11,110

Forecast demand requirements

*Source: Orthopaedic related activity data is provided by the SEL CSU for the period Jan-Dec 2015. This data is used as a proxy

for FY16 from which demographic and non-demographic growth is applied until FY21.

PLEASE NOTE: The activity shown above is for all orthopaedic activity conducted by SEL providers.

11

Referral to treatment times (RTT) are a key measure of patient experience and NHS performance. Patients in

England have the right to start their non-emergency NHS consultant-led treatment within a maximum of 18

weeks from referral, unless they choose to wait longer or it is clinically appropriate that they wait longer1. Ever

increasing demand and increased referrals have invariably led to regular underperformance in this area.

Importantly orthopaedic surgery continues to underperform comparted to other specialties2,3.

The charts below show the ‘backlog’ of patients having waited more than 18 weeks at the end of September

2015 is higher than the London average. Waiting times corroborate this information, with the 92nd percentile

waiting time being higher than 18 weeks.

Draft in progress |

Source: NHS England, based on “Incompletes” Unify2 Data, September 2015.. *KCHT are not submitting data to Unify2, backlog numbers were provided by the CSU, but please note that these DO NOT included “non-admitted” patients, i.e. those who had an outpatient appointment. Overall patients were not provided so a percentage could not be calculated. Please also note that KCHT data is more recent (October 2015). **SWL waiting times are based on a weighted average of median/92nd percentile waiting times, weighted by number of patients at each trust.

There is a need to support trusts to increase

capacity to reduce variation across SEL in

meeting the RTT standards. This is the result

of increase throughout and efficiency. It will be

supported by ring-fenced theatres and beds.

1. NHS Choices

2. NHS England, Referral to treatment (RTT) waiting times statistics for consultant-led elective care

annual report 2014

3. Getting it Right First Time

378 (12.3%) 415 (9.8%)

102 (4.0%)

556 (*%)

0

100

200

300

400

500

600

GSTT LGT DGT KCHT*

Num

ber

of patie

nts

Number of incomplete (admitted and non-admitted) patients waiting more than 18 weeks by the end of September 2015 in T&O

(Backlog)

SEL Trusts London average (11.6%)

0

5

10

15

20

25

GSTT LGT DGT KCHT*

Waitin

g tim

es (

we

eks)

Waiting times for T&O RTTs at the end of September 2015

92nd percentile waiting time (weeks)

Median waiting time (weeks)

Target

12

Number of last minute elective operations

cancelled for non clinical reasons

Number of patients not treated within 28 days of

last minute elective cancellation

Percentage of patients not treated within 28

days of last minute elective cancellation

RNOH 124 3 2%

GST 816 44 5%

LGT 284 14 5%

KCH 1,155 79 7%

DGT 270 36 13%

National 71,434 5,013 7%

Draft in progress |

Cancellations for all elective procedures: January - December 2015

Source: NHS England

Cancellations adversely impact patient experience, particularly those with more

complex needs. Patient feedback1 has told us

• With current services there are frequent delays. Pressures within hospitals to

deliver emergency care are responsible for the cancellation of planned

operations.

• There is high demand for planned orthopaedics among patients with learning

disabilities - cancelled operations are a major issue because these patients

come to hospital earlier to prepare, then have to stay in hospital while their

surgery is re-scheduled. It is very negative for them, carers and families.

• Cancelled operations have a significant impact on patients families and

carers, so it is not just about the patient. We need to consider this carefully.

• There are more cancellations where hospitals have a co-located A&E – it

would be good to resolve this issue so that A&E cannot take beds away from

planned services – ring-fenced beds would solve this dilemma.

The table below show the total number of last minute cancellations for elective

procedures in 2015. While providers in SEL have relatively low levels of

cancellations evidence suggests that there is room for improvement – particular

in terms of providing a revised procedure date within 28 days of the last minute

cancellation.

Ensuring ring-fenced elective theatres and beds can help reduce the

number of cancellations thus improving patient experience.

1. OHSEL – Planned Care Reference Group

13

Reducing hospital length of stay has the potential to be

an effective way of containing the growing demand for

beds and releasing capacity in the hospital system. It also

improves patient outcomes and had the potential to

reduce costs.

While performance in SEL has improved, overall length of

stay for elective T&O remains higher than the London

average across most of our sites. This also varies by

procedure and the length of stays for both elective hip

and knee procedures are higher than the London

average.

One way to reduce elective LOS is to routinely provide

rapid/enhanced recovery programmes. These ensure

patients follow standardised protocols and pathways

before, during and after surgery aiming to improve

outcomes whilst reducing hospital stay. Through

education and teamwork, the patient is well informed,

better prepared and motivated for the recovery process.

There is scope to apply these principles to a wider range

of orthopaedic procedures to benefit more patients1.

Overall, evidence suggests that dedicated units with

higher volumes of elective surgery and employing

evidence-based practice have been found to reduce

length of stay and costs2,3 .

Draft in progress |

Further separating elective and non-elective care across

SEL will improve LOS. In addition, incorporating

enhanced recovery programmes into the model will also

improve LOS. Overall, it is expected that a consolidated

model will reduce variation in LOS across SEL

Case study3: Emory Hospital (Atlanta, USA), is a purpose-built centre designed and equipped

specifically for joint and spine patients. They have developed many innovations and improvements to the

pathway to increase quality, value and patient centredness. These include; joint classes preadmission,

extensive screening pre-surgery to identify and resolve/manage potential risks, all day-of-surgery

admissions are staggered starts with, patients suitable for accelerated recovery scheduled earlier in the

day, optimised anaesthesia and theatre processes to support early mobilization and effective pain relief,

physiotherapy available 7 days a week and 12 hours a day, dedicated social worker to support

discharge. Emory hospital has an average LOS of 1.7 for hip replacements and 2.4 for knees.

1. Getting it Right First Time

2. Nuffield Trust, Improving length of stay: what can hospitals do?

3. Monitor, Improving productivity in elective care

4. Chart Data Source: HES, September 2014 – August 2015 (Latest 12 months of data available)

1.96 2.56

3.11 3.43

4.13 4.45 4.60

5.99

0

1

2

3

4

5

6

7

Orp. QMS GH DVH PRUH QEH UHL KCH

Avera

ge length

of

sta

y (d

ays

)

Average length of stay for Elective T&O

SEL Sites London Average

2.76 3.07 3.16

4.49

5.90 6.18 6.67

8.11

0

2

4

6

8

10

GH Orp. QMS* DVH UHL KCH PRUH* QEH*

Avera

ge length

of

sta

y (d

ays

)

Average length of stay for Elective Hips (Non Trauma)

Hips (Non Trauma) London average

2.30 3.00 3.04 3.15

3.70 3.94 4.77

7.25

0

2

4

6

8

Orp. PRUH* QMS GH QEH DVH UHL KCH

Avera

ge length

of

sta

y (d

ays

)

Average length of stay for Elective Knees (Non Trauma)

Knees (Non Trauma) London average

0.84 1.48 1.76 1.97

3.12 3.46

4.29 4.66

0

1

2

3

4

5

QMS* Orp. DVH QEH GH UHL PRUH* KCH

Ave

rage

len

gth

of

stay

(d

ays)

Average length of stay for Other Elective (Non Trauma)

Other (Non Trauma) London average

14

To support the development of the strategy we asked people about their current experience of services and

what matters most to them The table below summarises what we heard.

Draft in progress |

The planned care reference group

We have established a planned care reference

group to test emerging ideas and give

feedback on the model and process. At the

first meeting their were two main areas of

focus:

A high-level case for change was presented.

Overall, participants agreed that their

experiences, or the experiences of the people

that they support/work with, matched the

challenges highlighted during the presentation.

It was agreed that improvements need to be

made in order to reduce waiting times, the

number of cancelled operations and the

coordination of care.

Emerging ideas about how services could

be improved. Overall, there was support for

looking at alternative models such as the

SWLEOC centralised model – however, it was

noted that we need to be clear how the quality

of care will be improved. It was noted that if

there were more certainty about the care – in

terms of: procedures not being cancelled;

early discharge; higher quality services, more

confidence in treatment given; better

preparation and aftercare – then patients

would be prepared to travel

A second reference group meeting is

scheduled for 16 March 2016.

Source: OHSEL – Planned Care Reference Group)

Being prepared and

well-informed

Support to keep healthy and well “If I’d had support to lose the weight in the first place I wouldn’t have

needed surgery”

Clear information and choice “I want information such as hospital performance and transportation options so

I can make the best choice for my care”

Information on nutrition and exercise to prepare for surgery and recover faster “I’d like to know more about

what to do in advance to have an easy surgery and recovery such as advice on what to eat or what exercise to

do”

Resources and tools to aid recovery “I had to buy waterproof socks so I could clean myself. That small think

kept me independent but they didn’t give me advice”

Receiving great

quality care close to

home pre- and post-

surgery

Better access to specialist expertise and diagnostics for GPs “GPs aren’t getting enough expert support to

aid them in diagnosis, especially for mental health issues”

Emotional support “Good care should take into account the impact the surgery will have on my life and

emotions”

Easy transitions in

and out of hospital

Better coordination across services “I created an A4 sheet with all the information I usually have to repeat to

different professionals” “Shared record would enable better coordination”

Easy access to high quality services “Elective care centres will improve standards of care, but will make it

more difficult for patients to get there and back?”

Quick access to advice “I’d like a number to ring, or a person to get in touch with if I’m worried or if something

goes wrong”

Activating support

from my family,

friends, carers and

community to aid

recovery

Access to community support “My friends could have picked me up and helped me with cooking but this

wasn’t planned in” “People should be signposted to resources and support available in their community”

Involve family and carers in care plans “Family and carers should be involved in a patients recovery plan. If

they are isolated, they should get support from volunteers”.

Holistic support and guidance “Services should be integrated to ensure holistic and connected approaches

to support, recovery and planned care in general. This includes benefits, housing, social care, and the services

available from the community and voluntary sector”

15

Patient views on Operations and Procedures

Trust Overall Risk and

Benefits Operation Questions Expectations Information

Post-

Operation

Guy's and St Thomas' Trust 8.60 9.10 8.80 9.00 7.20 9.10 8.20

Dartford and Gravesham Trust 8.40 8.80 8.50 8.60 7.40 9.10 8.20

Lewisham and Greenwich NHS Trust 8.20 8.50 8.50 8.30 7.40 8.80 7.80

Kings College 7.80 8.40 7.90 8.20 6.70 8.50 7.20

Royal National Orthopaedic Centre 8.70 9.40 8.70 8.80 7.50 9.40 8.60

Draft in progress |

Level Total

Responses Total Eligible

Response

Rate

%

Recommended

% Not

Recommended

England (Including Independent Sector Providers) 2,331,319 8,489,565 27.5% 95.5% 1.5%

England (Excluding Independent Sector Providers) 2,164,033 8,077,002 26.8% 95.2% 1.6%

South West London Elective Orthopaedic Centre 2,130 4,666 45.6% 99.3% 0.2%

Royal National Orthopaedic Hospital NHS Trust 4,969 8,928 55.7% 96.1% 1.2%

Guy's And St Thomas' NHS Foundation Trust 29,565 92,154 32.1% 95.6% 1.6%

King's College Hospital NHS Foundation Trust 17,142 98,423 17.4% 94.5% 1.8%

Lewisham And Greenwich NHS Trust 14,302 37,943 37.7% 93.1% 2.3%

Dartford And Gravesham NHS Trust 6,629 36,950 17.9% 97.0% 0.7%

Overall patient experience of their interactions with the NHS is an important measure of success. To understand how trusts providing EOC perform in relation to each

other and current consolidated EOC centres two metrics have been considered – the friends and family test (FFT) and Care Quality Commission (CQC) inpatient survey.

The friends and family test gives providers an indication of how well they are looking after patients while they are in their care. While it shouldn’t be used to directly

compare providers it can be noted that response rates at the RNOH and SWLEOC are considerably higher and patient experience at SWLEOC is the highest. This

doesn’t however take into account variation in local populations and data collection.

CQC Inpatient survey results for operations and procedures (only answered by those patient who had the procedure)

Source: CQC Inpatient Survey 2014

Trust level summary of Friends and Family Test 2015 (calendar year)

Source: Friends and Family Test (January - December 2015)

The CQC inpatient survey is a

better comparator between

organisations. The CQC uses

surveys to find out about the

experience of patients when

receiving care and treatment from

healthcare organisations. Between

September 2014 and January 2015,

a questionnaire was sent to 850

recent inpatients at each trust. The

table opposite is a subset of

questions relating to the experience

people had when undergoing and

operation or procedure.

On the whole providers are ‘about the

same’ as other providers. However,

KCHT is worse on four indicators

while the RNOH is higher on two –

particularly post-operation.

Key About the same Below Better

There are opportunities to improve

patient experience. However, this data

should be treated with caution.

16

To improve quality and safety, professional guidance and the available evidence support the

separation of elective from emergency surgery - either geographically or through the

provision of dedicated facilities and staff. Furthermore. Elective surgical units should be

consultant-led1.

National evidence also shows that infection rates remain too high and, if reduced could lead

to improved outcomes and significant savings. The recent Carter report3 suggests that deep

wound infection rates for primary hip and knee replacements currently range from 0.5% to

4%. If all hospitals achieved 1% this would transform the lives of 6,000 patients and save

the NHS £300m per year. This view is also supported by GIRFT,3.

Similarly, if joint replacements fail early or complications arise such as infection there is then

a greater financial burden across the NHS and social service when these patients return to

hospital for more complex operations with longer inpatient stays, possible requirement for

antibiotics and expensive orthopaedic revision implants2.

GIRFT has shown that there is unacceptable variation in surgical site infection between

units which could amount to as much as a 20-fold difference. It also identified a number of

potential solutions for both professionals and provider units to improve this infection

problem. The BOA4 suggest that units performing EOC procedures should have dedicated

orthopaedic theatres with laminar flow and establish a ‘cold’ elective orthopaedic centre with

the appropriate adjacencies. International evidence also shows that consolidation and

dedicated facilities can result in lower infection rates5.

Evidence suggests that the post-surgical casts of admitted care in London was

approximately £1,042 per case. While this reflects the national average there is potential for

further impact2.

Draft in progress |

1. The Kings Fund, The Reconfiguration of Clinical Services

2. Getting it Right First Time

3. Carter, Operational productivity and performance in English NHS acute hospitals: Unwarranted variations

4. BOA, professional guidance to implement GIRFT in England

5. Monitor, Improving productivity in elective care

While local evidence suggests trusts in SEL perform relatively well in relation to

infections steps should be put in place to keep infection rates and complications to an

absolute minimum. Source: GIRFT Data Repository (Health Protection Agency data for 2011/12 (downloaded from website

July 2013); includes infections following: hip replacement, hip hemiarthroplasty, knee replacement,

reduction of long-bone fracture (incl. open reduction), and repair of neck of femur. Note: We recognise that

infections data is notoriously variable from year to year)

% of patients with infections - initial inpatient spell and readmission by

Local Area Team

17

Data presented in the table below for the period December 2014 – November

2015 (the last 12 months available) indicates significant variability across SEL

and when compared to consolidated specialist providers such as RNOH.

For clostridium difficile, rates across SEL range from 8.2 cases per 100,000 beds

(Dartford and Gravesham NHS Trust) to 14.7 cases. In comparison, the RNOH

rate is just 1.8 cases.

For MRSA, rates are generally low across the trust selection included, although

again the RNOH saw the lowest rate given that that no cases were recorded in

the time period. This was also the case for the RNOH around MSSA rates,

although greater variability exists in SEL here. MSSA rates per 100,000 bed days

ranged from 2.4 cases at Lewisham.

Lastly, Ecoli rates per 100,000 bed days also differ considerably across the peer

selection. Again, the RNOH had the lowest recorded rate of 7.18 cases. The

range in SEL goes from 58.26 (Guy’s and St Thomas’ NHS Foundation Trust) to

90.81 (Lewisham).

Infection numbers and rates per 100,000 beds from December 2014 – November 20151

Trust Bed Days Cdiff

count Cdiff rate

MRSA

count MRSA rate

MSSA

count MSSA rate

Ecoli

count Ecoli rate

RNOH 55,745 1 1.8 0 0 0 0 4 7.18

DGT 183,209 15 8.2 4 2.2 13 7.1 161 87.88

GST 369,042 49 13.3 4 1.1 29 7.9 215 58.26

KCH 551,263 81 14.7 3 0.5 33 6 399 72.38

LGT 375,498 41 10.9 3 0.8 9 2.4 341 90.81

National 37,141,022 4865 13.1 313 0.8 2549 6.9 33218 89.44

Draft in progress |

1. Data on this page was taken from Health Evaluation Database in February 2016. HED infection data

presents Lewisham Healthcare NHS Trust; it is unclear if this includes data for Queen Elizabeth

Hospital, Woolwich.

There is scope for greater standardisation of infection control procedures in

SEL.

Low rates for RNOH indicate that ring-fencing of orthopaedic beds and

separation of emergency departments can result in relatively fewer infection

rates across key infections such as c.diff, MRSA, MSSA, and Ecoli.

18 Draft in progress |

Readmissions data is an important measure of performance and patient experience. Reducing readmissions re also a

main source of efficiency. The chart below show readmission rates related to the number of elective readmission spells as

a percentage of total spells at the site. While there is some variation in performance trusts in SEL are, on the whole,

performing at or below the London and National average. Only Queen Elizabeth Hospital has a readmission rate greater

than the average rate across all NHS trust sites in London.

Monitor1 have identified potential productivity improvements related to readmissions and provide international case

studies demonstrating the potential to achieve readmission rates of 1%. It should be noted however that readmissions

may change depending on complexity of procedure and patient and this may explain some of the variation across sites

within SEL and, in particular in comparison with RNOH.

3.6%

2.8% 2.8%

2.4% 2.3% 2.3%

2.0% 2.0%

1.1%

0% 0.0%

1.0%

2.0%

3.0%

4.0%

QUEEN ELIZABETHHOSPITAL

Royal NationalOrthopaedic Centre

(RNOH)

ORPINGTONHOSPITAL

UNIVERSITYHOSPITALLEWISHAM

GUY'S AND STTHOMAS' NHS

TRUST

KING'S COLLEGEHOSPITAL

(DENMARK HILL)

DARTFORD ANDGRAVESHAM NHS

TRUST

ElectiveOrthopaedic Centre

PRINCESS ROYALUNIVERSITYHOSPITAL

KINGS @ QUEENMARY'S HOSPITAL

SIDCUP

Readm

issio

n r

ate

(%

)

30-day Elective Readmission Rate for Trauma and Orthopaedics, split by site

Source: Hospital Episode Statistics, Dec 2014 – Nov 2015

*We have assumed that the Elective Orthopaedic Centre is the same as the Epsom Hospital site within the Epsom and St Helier Trust

*

National Average – 2.4%

London Average – 3.0%

While SEL trusts are performing in

line with the National and London

average for readmissions there are

opportunities to improve.

Improving readmission rates will

support both productivity and patient

experience.

1. Monitor, Improving productivity in elective care

* Data not available

19

Civil claims against NHS bodies in England arising from the actions or inaction

of surgeons have risen by 66% in 5 years. Orthopaedics accounts for the

largest percentage of claims1. The NHS Litigation Authority state that in 2014/15

14% of claims related to orthopaedic surgery and resulted in 7% of the total

value of claims received2.

As GIRFT3 notes, “specialist orthopaedic services, when focused in a high

critical mass, have a very low litigation rate despite undertaking some of the

most complex orthopaedic procedures carrying the greatest risks.”

GIRFT notes that current variability in the way GPs inconsistently refer patients

to orthopaedic pathways leads to delayed referrals, contributing to an increased

numbers of claims. Specialist consolidation could enable more focused

channels of communication with GP practices, and greater standardisation of

orthopaedic pathways used by GPs.

In “Getting it Right First Time” Briggs notes Wrightington Hospital as an

example of a consolidated orthopaedic provider which has been able to lower

revision rates drastically, contributing to very low litigation rates despite the high

acuity of cases at the hospital.

Draft in progress |

Source: http://www.gettingitrightfirsttime.com/report/ * Values are for all claims reported in the 2011/12 NHSLA dataset ('claims during 2011/12'); or ** Values are for all claims

reported in the 2011/12 NHSLA dataset initiated during 2008, 2009 and 2010 ('3 year'). Estimated costs were added to open

claims using average price per claim, and total orthopaedic spells excludes spinal injection activity (see methods). Note: We

recognise that litigation data is notoriously variable from year to year. ***Note that the National figure and LAT figures have

altered from £54.48 as additional permissions for disclosure have been given by trusts, and the updated base for the

denominator (number of orthopaedic spells) now includes 2012 data.

NHSLA data by Local Area Team

1. Royal College of Surgeons, Trends in surgical litigation claims

2. NHS Litigation Authority, Report and accounts 2014/15

3. Getting it Right First Time

In SEL there is a need to take steps to improve quality of EOC in order to

reduce the number of successful litigation claims. Doing this will mean that

patients will have improved outcomes and it will make a financial contribution

to the health and care economy

20

There is an strong evidence base that suggests a positive link between

specialisation and outcomes of care1,5. These have shown that there is a strong

statistical relationship between the volume of cases carried out by a hospital or an

individual clinician and the chances of a successful outcome suggesting that:

• Hospitals and clinicians with higher volumes are likely to produce better than

average results

• Hospitals and individual clinicians treating very low numbers of patients (in any

category) are not likely to produce the best outcomes and therefore not

provide best value for financial resources

The GIRFT report suggests that more complex operations, such as revision

surgery, should be undertaken at suitably accredited specialised units with the

appropriate critical mass, by surgeons with a special interest in this field2. The

report also suggests that the increase in the number of orthopaedic consultants in

each unit over the last ten years has been considerable. Current figures suggest

one orthopaedic consultant for 25,000 of the population. The aim has always

been to reduce this ratio to one consultant to15,000 of the population.

While the BOA3 do not prescribe minimum figures for procedures their view is that

surgeons and units providing low volumes of specific procedures should examine

their practice with care, reflect on the potential patient safety consequences, and

actively consider whether continuing to perform the procedure is professionally

appropriate. At the same time the advice that it is not normally good practice for

there to be only one surgeon performing a given procedure in a unit. It is therefore

anticipated that, for low volume procedures, two surgeon operating will be

necessary to maintain good practice whilst improving the distribution of procedure

numbers.

Using the National Joint Registry dataset4 it is possible to show the variation in

SEL against the national averages for a range of EOC procedures.

The table below shows the total number of procedures delivered by surgeons

across sites over a 36 month period and uses RNOH and SWLEOC as a

comparison. The number of procedures also includes private activity delivered by

surgeons aligned to each of the trusts and is also based on voluntary returns. As

such the total volume presented may not correlate with actual activity. It suggests

that DGT and GST are in line with the national average but KCH and LGT

perform less.

.

The following pages show:

• How the number of procedures delivered at each site across the 12 sub-

specialties compares to the national average

• The distribution of the total volume of consultant procedures as a % of the

national average. Surgeons have also been aligned to trusts

Draft in progress |

1. NHSE draft specification for specialised orthopaedics

2. Getting it Right First Time

3. BOA professional guidance to implement GIRFT in England

4. The National Joint Registry

5. Public Health England, Surgical Site Infection (SSI) surveillance

There is an opportunity for trusts to work towards an improved distribution of

procedures between surgeons in SEL. This will reduce risk and improve

outcomes.

Procedures undertaken by surgeons as SEL sites from Apr 12 – Mar 15 against national

average for similar procedures

Trust Sum of procedures Sum of national

averages

% of national

average activity

SWLEOC 12650 7520 168%

RNOH 5426 4479 121%

DGT 3098 2736 113%

GST 4098 3964 103%

KCH 4945 7233 68%

LGT 1577 3598 44%

21

Trust GSTT KCHT

Site Guys St Thomas' GSTT total KCHT (DH) KCHT (Orp) KCH (PRU) KCH total

Operation type Average Total % of Nat Total % of Nat Total % of Nat Total % of Nat Total % of Nat Total % of Nat Total % of Nat

Hip Primary 613 1076 176% 84 14% 1160 189% 345 56% 475 77% 201 33% 1021 167%

Hip Revision 79 152 192% 9 11% 161 204% 55 70% 28 35% 57 72% 140 177%

Knee Primary (PFR) 11 16 145% 16 145% 6 55% 5 45% 2.5 23% 13.5 123%

Knee Primary (TKR) 619 1039 168% 1039 168% 498 80% 491 79% 119 19% 1108 179%

Knee Primary (UKR) 63 93 148% 93 148% 14 22% 47 75% 2.5 4% 63.5 101%

Knee Revision 48 137 285% 137 285% 49 102% 21 44% 24 50% 94 196%

Ankle Primary 8 15 188% 15 188% 2.5 31% 2.5 31%

Ankle Revision 3 2.5 83% 2.5 83% 2.5 83% 2.5 83%

Elbow Primary 6 8 133% 10 167% 18 300% 8 133% 8 133%

Elbow Revision 3 2.5 83% 2.5 83% 2.5 83% 2.5 83%

Shoulder Primary 37 62 168% 62 168% 20 54% 24 65% 10 27% 54 146%

Shoulder Revision 6 13 217% 13 217% 2.5 42% 2.5 42% 5 83%

Draft in progress |

Trust L&G DGT

Site UHL QEH L&G Total DVH QMH RNOH SWLEOC

Operation type Average Total % of Nat Total % of Nat Total % of Nat Total % of Nat Total % of Nat Total % of Nat Total % of Nat

Hip Primary 613 107 17% 107 17% 838 137% 650 106% 920 150% 3618 590%

Hip Revision 79 30 38% 30 38% 85 108% 8 10% 515 652% 368 466%

Knee Primary (PFR) 11 5 45% 8 73% 19 173% 94 855%

Knee Primary (TKR) 619 2.5 0% 91 15% 93.5 15% 1119 181% 924 149% 949 153% 4258 688%

Knee Primary (UKR) 63 22 35% 61 97% 39 62% 485 770%

Knee Revision 48 22 46% 22 46% 70 146% 38 79% 397 827% 182 379%

Ankle Primary 8 2.5 31% 35 438%

Ankle Revision 3 15 500%

Elbow Primary 6 2.5 42% 33 550%

Elbow Revision 3 46 1533%

Shoulder Primary 37 5 14% 5 14% 10 27% 10 27% 175 473% 12 32%

Shoulder Revision 6 2.5 42% 2.5 42% 182 3033%

The tables below show how the number of procedures delivered at each site across the 12 sub-specialties compares to the national average. Significant variation

from the national average is highlighted unless the national average is less than 5. It shows variation across site and, in some case trust even when procedures are

delivered over a number of sites.

Nb. Fewer than 5 procedures is counted as 2.5 to provide a % of national average. Where the average is 5 or less than 5 variances have not been highlighted Source Data is presented from the NJR site (http://njrsurgeonhospitalprofile.org.uk/).

22 Draft in progress |

23 Draft in progress |

Nationally there are a number of drivers that put this work into context:

• Five year forward view: Outlines the serious problems facing the NHS and focuses on how health care systems can work together with citizens to prevent ill

health and promote well-being

• Getting it Right First Time: Sets out the case for change for improving EOC in England and meeting future demand. The recommendations include the

development of provider networks and consolidation of EOC services to ensure a critical mass of procedures.

• Dalton review: A review of new options for healthcare provision. The review built on the service models outlined in the Five-year Forward View, to offer

mechanisms or ‘organisational forms’ for providers to deliver the new services

• Carter review: A review of productivity in the NHS, variations between providers and opportunities

In addition to the above there is a range of guidance from bodies such as NICE, the British Orthopedics Association and other advisory bodies recommending the

separation of elective and non-elective surgery and outlining the link between volume and outcomes. This evidence is referenced throughout the document.

24

The orthopaedic working group has been considering the case for consolidating

elective orthopaedic care as, drawing on the evidence presented, it may help

address some of the significant challenges in facing SEL.

Separating elective surgical admissions from emergency admissions is supported

by a number of bodies including the Royal College of Surgeons. They have

suggested that this can result in earlier investigation, definitive treatment and

better continuity of care, as well as reducing hospital-acquired infections and

length of stay1. Similarly, a recent study in the USA2 has shown that conducting

Total Knee Replacements in high-volume centres improves outcomes and lowers

costs.

At the same time providers need to ensure that both they, and their surgeons, are

delivering an appropriate volume of procedures. This is reflected in the GiRFT

report, the RCS and others. Consolidating services can support providers to

review procedures and ensure an appropriate distribution of procedures.

Potential for wider benefits in productivity

Reducing length of stay and complications with EOC can help reduce the costs of

delivering care as well as benefiting patients. Consolidation can enable providers

to develop standard protocols and ways of working that will deliver benefits in

these areas.

At the same time, further collaboration can lead to efficiencies in other areas.

Both GIRFT and Carter highlight the variation in prosthetic purchasing – evidence

base or relative cost. This is particularly true for their loan kit expenditure, rates of

cemented vs un-cemented hip fixation, and the amount spent on loan kit or

prosthesis selection the report states “The deep dives evidenced an average

spend of £200,000 per annum on loan kits and a reduction of 90% within the next

two years would generate a saving of £108m over the next five years. A potential

saving of £40m per year has been identified if trusts move to the best prices

available for prostheses. Moving all trusts to a position whereby approximately

75% of patients over 65 receive a cemented fixation would increase the number

of cemented fixations by 11,000 per annum leading to a saving of approximately

£16m per annum. Then the consequent savings from reduced revision rates and

also a reduction in the numbers of more complex revisions following fracture

would also begin to accrue over time”2.

Consolidating Elective Orthopaedic Care cannot happen in isolation

However, consolidating services in isolation is unlikely to deliver the full benefit.

Acute providers need to develop better links with primary care and support the

development of standardised pathways and protocols. Data and information

needs to support clinical decision making and Providers should also consider how

they work together to improve care delivered across SEL2,3.

Draft in progress |

“If orthopaedic services, within a certain geographical area and with an

appropriate critical mass were brought together, either onto one site or within

a network… and worked within agreed quality assurance standards, not only

would patient care improve but billions of pounds could be saved.

These hospitals or networks would receive recognition as “Specialist Units”,

and have agreed ring-fenced elective beds allowing efficient throughput of

patients treated to the highest standards. This would in itself allow different

models of working to be introduced with six or indeed seven day working and

allow for much more efficient guaranteed training for young orthopaedic

surgeons. More importantly, with this model, patients would feel confident

with the treatment being proposed and clinicians again feeling empowered to

deliver the best possible care for their patients”.

Getting it right first time: Improving the Quality of Orthopaedic Care within the National Health Service in England

1. The Kings Fund, The Reconfiguration of Clinical Services

2. American Academy of Orthopaedic Surgeons, The Cost-Effectiveness of Total Knee Arthroplasty at High Volume

Hospitals

3. Carter, Operational productivity and performance in English NHS acute hospitals: Unwarranted variations

4. Getting it Right First Time

25 Draft in progress |

The benefits map below summarises the benefits that can be achieved through consolidating orthopaedic care across SEL. These will be developed further through the

development of the clinical model and delivery options.

Improved Clinical standards and

outcomes Infection rates

Utilisation

Length of stay

Waiting times

Cancellations

Re-admissions

Income Volume

Costs Length of Stay

Theatres

Prosthetics

Estates

Consolidation of volumes drives better outcomes. This may attract increase activity and

repatriate some patients going out of area for care.

Care is optimised reducing LoS so costs fall due to a defined standard

Ring-fenced theatre lists will result in full theatre lists, improved throughput and potential to

reduce overall requirement

Potential to optimise estate footprint between providers in SEL and invest in improved

facilities for providing EOC

Improved utilisation of estates and workforce through increased volumes. These will be offset by improvements in

length of stay and readmissions

Creating the right environment – such as ring-fenced beds – can reduce infection rates. This will improve patient

outcomes and reduce cost.

Drivers for consolidation

Procedure

volumes

Demand and Capacity

Patient

Experience

Consolidating activity will enable a critical mass of procedures to be delivered by sites across SEL. This will

improve outcomes, reduce complications, and enable more effective training and research. Collaboration will also

result in reduced variation in protocols and prostheses.

Financial

Readmissions

Improving capacity and pathways will enable trusts improve waiting times for treatment. Ring-fenced capacity,

improved utilisation and improved length of stay will support flow throughout the system

Improved length of stay across SEL by implementing consistent pathways and enhanced recovery programmes

Ring-fenced elective beds will help to keep cancellations low

Increasing procedure volumes, improving recovery programmes and reducing infection rates will enable a reduction

in complications and associated readmissions.

Workforce Improved opportunities for workforce including training, education, recruitment and retention

Collaboration may result in shared procurement of prosthesis and other equipment resulting

in an overall cost saving to providers and more consistency for patients

Improved clinical standards, recovery and capability will result in fewer admissions and

lower costs through reduced ‘cost of failure’

26 Draft in progress |

The current phase of work is in the context of the longer-term development of an elective centre. The focus of this phase is to develop the strategic case and

clinical model enabling us to move towards consultation and/or implementation. The main output of this phase of work will be an Strategic Business Case and Pre-

Consultation Business Case that will set out the various options for consolidating EOC in SEL.

• Draft outline specification • Site option identification • Option appraisal • Outline commercial

(operating model) and management case (implementation route)

• Public engagement on the model and evaluation criteria

• Clinical and NHSE assurance • Determine requirement for

consultation

5: Full Business Case /Implement

2: Consultation (if required)

1: Strategic & Pre

Consultation Case

4: Outline business case

3: Confirm preferred

model

• Run consultation (if required)

• Revise business case to reflect outputs from consultation

• Agree preferred model

• Initiated preferred implementation route through agreed process

• Confirm plans for full business case (if required)

• Initiate any capital work

Current phase: Present – September 2016 September-November 2016 January 2017 – Summer 2017 December 2016 – January 2017

• Develop Outline Business case for each site (if required)

• Confirm detailed clinical model

• Confirm and agree detailed commercial model

• Alignment of business cases across sites

• Relevant clinical and regulatory assurance

From Summer 2017

27 Draft in progress |

Strategy, case for change and

design guide

Define (2015) Design and develop (November 2015 – May 2016) Appraise

(June 2016)

Define clinical model through provider and

commissioner working group

Development of detailed case for

change

Stage 1 option identification NHS providers currently delivering elective orthopaedic services in south east London to submit outline options for hosting consolidated activity

Development of evaluation criteria

Stage 2 – Option development: Providers to develop and submit detailed site options.

Appraisal of options by evaluation group against evaluation criteria

Development of business case

Assurance by clinical senate

Assure (July – August)

Assurance by NHSE

Confirm models for consultation (Committee in Common)

Launch consultation (if required)

Confirm (September)

Preparation for consultation

Consolidation of options and analysis

28 Draft in progress |

29

The section sets out an outline specification for a consolidated elective

orthopaedic centres (EOC) in South East London (SEL). This describes the

model of care desired to improve the quality, availability and value of elective

orthopaedic care in SEL and address the case for change. It will be used as a

vehicle for providers/ potential hosts to submit their proposals for the new model

of care, and as a comparison to the status quo.

The elective orthopaedic working group

Building on the work of the Clinical Leadership Groups a working group was

established to confirm the case for change and develop the proposal that elective

orthopaedic procedures should be consolidated within SEL for evaluation. During

a series of meetings, the working group agreed to devise a new model of service

delivery based on:

• Consolidation of elective inpatient services from the current nine sites to two

sites while retaining outpatient, day case and trauma services available locally

at base hospitals

• A higher quality and more efficient planned care pathway

• Exploring the case for consolidating specialist and complex cases

• Creating an orthopaedic network approach for procurement and service

design

• A business model which ensure the financial benefits of consolidation benefits

all providers rather than creating “winners and losers”

• This new model to be evaluated against the status quo/ do minimum option

Aims and objectives of service

Our aim is to develop world class orthopaedic services in SEL. These would

deliver excellent patient outcomes and reflect the highest levels of productivity.

The overall service is expected to deliver:

• Accurate and timely diagnosis utilising best practice in the assessment of

elective orthopaedic conditions to enable rapid access for new and existing

patients

• Delivery of evidence-based treatments plans (where incidence rates make this

possible) to enable improved treatment outcomes and the maximisation of

patients’ functional ability through best practice multi-disciplinary management

strategies

• Appropriate shared care arrangements between specialities for the

management of co-morbidities.

• Detailed audit of patient outcomes and experience, shared with colleagues in

other centres, enabling the dissemination of best practice and appropriate

• More complex operations, such as revision surgery, should be undertaken at

suitably accredited specialised units with the appropriate critical mass, by

surgeons with a special interest in this field

• Through the delivery of these services it is expected that providers will work

collaboratively to ensure that patients receive an optimum patient experience.

In addition, providers will also adopt a business model which ensures the

financial and other benefits of consolidation benefits all providers rather than

creating “winners and losers”.

• Ring fenced is defined as being solely available for elective orthopaedic care

and not available to trauma or other specialities.

• Following treatment patients would return to their usual setting of care and

receive follow-up appointments and rehabilitation at their local hospital or in

the community.

Draft in progress |

30 Draft in progress |

Model Option Description Comment

Multi-site

model (As-Is)

0 Multiple sites delivering complex

and routine procedures

A continuation of the current model of delivery with a range of complex and routine

procedures delivered across multiple sites.

This model will be considered alongside alternative

options in order to provide a base case

Single site 1 Routine Routine procedures consolidated onto a single dedicated site. Complex and

specialist procedures would take place at patients local hospital Based on the forecast demand and requirements it

is unlikely that a single site in SEL will be able to

meet the required capacity. This is on both space

and capital expenditure.

Discounted subject to sign-off /approval through

the OHSEL governance process: The working group

and Clinical Executive Group recommended to

discount a single site option

2 Routine & Complex/Specialist Both complex, specialist and routine procedures delivered on a single dedicated site.

Patients would continue to receive outpatient appointments locally.

3 Complex/Specialist Complex and specialist procedures consolidated onto a single site. Routine

procedures would take place at a patients local hospital (the complex site may also

be the local hospital for some patients and would therefore need to accommodate

this activity)

Two site

model

4 Site 1) Routine

Site2) Routine

Routine procedures are consolidated across two sites. Complex procedures continue

to be delivered locally.

The working group agreed that this would not be

appropriate clinically.

5 Site1) Routine, Complex/Specialist

Site 2) Routine, Complex/Specialist

Routine, complex and specialist procedures are consolidated across two sites. Only

day case procedures are delivered locally.

Agreed to progress these options to site

identification and selection stage 6 Site 1) Routine

Site 2) Routine, Complex/Specialist

Procedures are consolidated across two sites. Site 1 would offer routine procedures

and site 2 focuses on both complex, specialist and routine procedures. Complex and

specialist procedures will only be delivered from a single site in SEL.

7 Site 1) Complex/Specialist

Site 2) Complex/Specialist

Complex and specialist procedures from SEL are consolidated across 2 sites. Routine

procedures will continue to be delivered from local hospitals

Discounted subject to sign-off /approval through

the OHSEL governance process : Agreed that this

model does not meet the case for change regarding

consolidating routine activity

>Two site

model

Discounted subject to sign-off /approval through the OHSEL governance process : It was agreed that there will be enough demand for consolidating services across more than 2

sites (See demand and capacity section for detail). This model would be too similar to the as-is and may not fully address the case for change. And, additionally, feedback from the

EOC working group was that it would be impractical for clinicians to work across this number of sites.

31

Hosts would be expected to facilitate an optimised pathway so that elective

orthopaedic care in SEL as productive as possible. Monitor1 have set out 9 levers

for improving productivity in elective care. These are summarised below:

• Standardising pathways and protocols

• Implementing effective performance management conditions

• Making visible leaders accountable for continuous improvement

• Using adaptive staff contracts

• Making efforts to engage patients and families in their own care

The graphic below provides an example pathway on how the elective centre(s)

could work with base hospitals and how patients will move between base

hospitals and the elective centre for outpatients, treatment and rehabilitation. This

is illustrative rather than prescribed but potential hosts are asked to describe how

they will

Draft in progress |

1. Monitor (2015), Improving productivity in elective care

32 Draft in progress |

Summary

Elective orthopaedic care is delivered across two sites in South East London. ‘Local’ or

‘Base Hospitals’ will continue to provide outpatient services, day case procedures,

trauma and rehabilitation. This approach aims to improve efficiency to meet capacity and

reduce variation in care.

Services

The full range of EOC services will be in-scope and include both routine and complex

procedures. It is expected that providers will deliver these in a way that maximises

throughput and efficiency.

Both sites will only focus on inpatient procedures. Trauma, day cases, outpatients and

rehabilitation will be delivered at the ‘base hospital’. Some inpatient services may

continue to be delivered where clinically appropriate to do so.

Depending on the final site some ‘base hospital’ activities – such as outpatients – may

also be delivered from the centre where it is a patients local hospital.

Exclusions: Spinal surgery is currently out of scope and will be continued to be

delivered as is

Volume and capacity

It is expected that each centre would need to accommodate around 4,500 procedures

per year by 2021. This would require approximately 50 beds.

Workforce

• Networked staff: Staff will be drawn from across providers in SEL and will be

supported by the appropriate contracting arrangements set out in the commercial

model.

• Dedicated staff: The centre would directly employ some staff which may include an

orthopaedic team leader, nursing staff, anaesthetists, MSK radiologists,

administrative and clerical staff, pathway co-ordinators

Transport

Access is an important part of the model and is supported by the 2 site option. Further

work is required to identify an appropriate model .

Characteristics

Hosts should have all of the facilities and clinical adjacencies required to deliver the

procedures in scope. These include:

• ‘pre-hab’ assessment and support as well as a defined team to manage ongoing

patient care

• Access to MSK radiology including CT and MRI

• Outpatient consultation rooms

• Access to critical care or high dependency unit when required

• Theatre inventory of equipment and implant components

• ‘Ring-Fenced’ beds/wards and theatres

• Links to other specialities including; vascular, plastic surgery, pathologist,

radiotherapist and established MDT network

• Access to step-down facilities

• Effective links with social care

Commercial principles

It is expected that activity will be shared across hospitals with the EOC/s acting as a

‘host’ . It is therefore important, in order to mitigate the risk of ‘winners and losers’ that all

providers accessing the centre/s agree to a shared set of commercial principles.

Providers will be asked to submit their proposals on the commercial model based on the

principle that base hospitals will retain ownership of activity undertaken by the EOC. This

may take the form of a joint venture or profit share agreement or other model which

remains true to the principle.

Clinical dependencies and adjacencies

• Ring-fenced elective care beds and theatre services (cold site)

• Co-located with HDU and ICU

• Anaesthetics

• Routine diagnostic services (including radiology, pathology, pharmacy)

• Rehabilitation and occupational therapy services