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					   NHS GRAMPIAN
ORTHOPAEDIC SERVICE
      REVIEW



   FEBRUARY 2006
                            CONTENTS PAGE


                                            PAGE


EXECUTIVE SUMMARY                            1


INTRODUCTION                                 3


METHODOLOGY                                  4


BACKGROUND – What is the Problem?            5


DESCRIPTION OF THE SERVICE                   9


FINDINGS OF THE REVIEW                       14


RECOMMENDATIONS                              20


NEXT STEPS                                   22


CONCLUSION                                   23


APPENDIX 1 – BENEFITS REALISATION MATRIX     24
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t EXECUTIVE SUMMARY
 In 2005 Mr Richard Carey, then Chief Operating Officer and now Chief Executive
 Officer for NHS Grampian, commissioned the review of the NHS Grampian
 Orthopaedic Service (`the Service`).        The objective of the review was to make
 recommendations for the design and configuration of the Service that would:


       allow the Service to perform to agreed standards (clinical, financial and
        organisational) and
       ensure sustainability in terms of the workforce and work patterns


 A small team on behalf of the Service and NHS Grampian has conducted this review.
 The following activities were undertaken:

       a literature review to explore experience from elsewhere
       a survey of those working within the service
       a survey of those services with a close relationship to the service
       an in-depth assessment and assimilation of data, information, intelligence and
        knowledge already available.
       preparation of a draft report detailing the findings and recommendations from
        the above activities
       detailed consultation on the content of the draft report and incorporation of
        comments and suggestions into this final report.


 The principal findings are:


       There is much that is working well within the Service.     In particular there is a
        high level of commitment and enthusiasm within the service together with
        enormous respect from other services that work closely with the Service.
       Although a great deal of work has already gone into service redesign, the
        service is still under considerable pressure. This pressure is felt at various
        levels and points – by the medical, nursing and allied health professional staff
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t       working within the Service and by the principal support services associated with
        the Service.     Of concern, these pressures will continue to increase without
        significant investment, both financial and in further service redesign.
       Sustainable service planning and development requires that a whole system
        approach be taken. Redesign and investment must encompass primary care
        based services and hospital based services.
       New patterns of working are essential. Staff and skill shortages necessitate
        this approach and certain disciplines and professionals are very keen to adopt
        new ways of working and enhance their skills.


        A recommended and prioritised programme for redesign, development and
        investment is attached at appendix 1.          Examination of this programme will
        demonstrate that this prioritisation is based on likely outputs – effect on waiting
        lists, daycase rates, clinical governance issues and/or workforce development
        and retention.


        Recognising that nothing stands still, it is important to draw a line under this
        part of the review process and move to the next stage – implementation of the
        recommendations. A detailed implementation plan, including the waiting list
        plan, should be prepared by the Service Manager with the assistance of the
        review team. This work should incorporate an options appraisal.


        Implementation      will   require   support   and    it   is   therefore   a   further
        recommendation of this review that an implementation group should be set up
        under the chairmanship of a senior officer of NHS Grampian.


        The purpose of the implementation group is to take an overview of progress; to
        ensure delivery of the recommendations of this review; to demonstrate senior
        level support to the Service and finally to formalise the lines of accountability to
        OMT and the NHS Grampian Board


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t INTRODUCTION
 In recognition of the pressures that the Orthopaedic Service was experiencing, Mr
 Richard Carey, at that time Chief Operating Officer and now Chief Executive Officer
 for NHS Grampian commissioned a review of the Service.
 The objective of the review was to make recommendations for the design and
 configuration of the NHS Grampian Orthopaedic Service that will:


            allow the Service to perform to agreed standards (clinical, financial and
             organisational)
            ensure sustainability in terms of the workforce and work patterns


 The expected output was to be a recommended and prioritised programme for
 redesign, development and investment in the Service.


 The scope of the review was:


            to consider work practices and opportunities for redesign
            to encompass the entire Orthopaedic Service (including Dr Gray’s) but
             excluding, at this stage, services to children
            to involve partner services such as orthotics, OT, physiotherapy, podiatry,
             radiology, anaesthetics, CSSD, etc.
            to be multidisciplinary – to include the contribution made by doctors,
             nurses, GPs with a special interest, etc
            to examine physical accommodation and equipment


 A small core team was formed to perform this work. The team comprised:


            Mr Bill Ledingham, Head of Service, Orthopaedics
            Mrs Alison Melville, Service Manager, Orthopaedics
            Mrs Noelle Boddie, Clinical Nurse Manager, Orthopaedics

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t                  Mr David Anderson, Consultant Orthopaedic Surgeon, Dr Grays
                   Dr Pauline Strachan, GP and Associate Medical Director, NHS Grampian
                    (Team Leader)


    METHODOLOGY
    Considerable background information and intelligence was already available within the
    system. The review process simply gathered this information together.
    A literature review was conducted to identify if similar work had been conducted
    elsewhere in the UK and learn from the experience of others.               This revealed
    particularly useful work from Gwent in Wales. However, although NHS Grampian
    shares some similarities with Gwent, there are also significant differences. Indeed, in
    many respects NHS Grampian’s Orthopaedic Services is further on in their
    development than Gwent – for example the emergency/elective split and use of GPs
    with a special interest.
    Other literature of interest includes the CCI Orthopaedics Patient Pathway
    documentation. This helps in particular to describe the type and scope of services
    that should be provided in different settings.
    Significant effort went into designing, disseminating and analysing a questionnaire –
    for the Orthopaedic Service itself (all aspects and all disciplines) and also for services
    with a close working relationship to the Orthopaedic Service.
    43 separate responses were received – some from individuals and some representing
    collated responses from a whole department or discipline.
    Activities at Service level included a workshop session run by the clinical nurse
    manager for orthopaedics to identify issues and ideas for redesign and the Head of
    Service and his consultant colleagues actively discussed the review at several
    consultant meetings.
    Patient and public involvement was considered at an early stage of the review and
    discussions took place with a PFPI specialist in order to explore this important area.
    A draft report was prepared (“NHS Grampian Orthopaedic Service Review – June
    2005”).       Extensive consultation on this draft was then undertaken.    The Advisory
    Committees were formally consulted and numerous presentations were undertaken to
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t various groups and individuals.     Comments gained from this consultation process
  have been incorporated into this final report.


  BACKGROUND
  What is the problem?
  The elective Orthopaedic Service within the acute sector in Grampian does not have
  the capacity to meet demand. A national target of 26 weeks for in patients, day cases
  and outpatients currently exists and a target of 18 weeks must be achieved by
  December 2007. Recurring ring-fenced waiting times funding is available if this 18
  week target is achieved a year earlier for inpatients and day cases only – i.e. by
  December 2006.
  The 26 week out-patient target is now being achieved as a result of additional capacity
  in the form of consultant, GPwSI and ESP clinics and non-recurrently, referrals to the
  private sector.
  This is a significant achievement (in certain sub-specialties waiting times were in
  excess of 100 weeks). Capacity and demand however are not yet in balance in terms
  of the 26 week target, let alone the 18 week target. Referrals received between April
  and December 2005 exceeded capacity by on average 50 per month resulting in a
  continued reliance on the private sector.
  The Service is currently achieving the 26 week inpatient target with only a small
  number of referrals to the private sector and the Golden Jubilee National NHS
  Hospital. However, a further push on outpatient waiting will have a knock-on effect on
  inpatient and daycase waiting lists as will bringing in outpatient activity currently
  undertaken in the private sector. Achieving the new 18 week target will be particularly
  challenging.
  Whilst this is bad enough, demand is expected to rise further due to:


             an ageing population
             rising patient expectations
             technological advances - more can be done to improve functionality and
              mobility
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t              our current long waiting times suppresses referral activity
    Adjusting for the consultant physician service that ceased in April 2004, new
    outpatient attendances have risen by 18% since 2003/2004.           Return attendances
    have risen by 12% over the same period resulting in a net increase in attendances of
    14%.
    Similarly, at Woodend a total of 3,613 procedures were performed in 2001/2002, 73%
    of which were termed “non-complex” – i.e. were not major joint replacement surgery.
    In 2005/2006 (based on 10 months of data), the number of procedures performed is
    forecast at 4,356 with 68% being “non-complex”. So it can be seen that both numbers
    and complexity of case mix are increasing.
    This capacity/demand mismatch allegedly has a number of contributing factors:
          insufficient investment to meet demand
          complexity of case mix as described above
          mis-matched service investment and development.            There is widespread
           feeling that whilst there has been investment in the Service, this has not been
           matched across the whole system.
          contractual arrangements. For example the change in junior doctors’ hours of
           work, limitation of consultant’s hours of work, etc
          changing clinical practice, for example increasing sub-specialisation
          national targets
    It is therefore vitally important that robust plans are put in place to ensure the
    sustainability of the service.


    What has been done so far?
    The Orthopaedic Service has not stood still. Extensive efforts have already gone into
    redesigning the Service, managing waiting lists and clinical activities and piloting new
    ways of working.
    Recent work has included the CCI sponsored project, which is concentrating on triage
    and the contribution of GPs and physiotherapists with a special interest in
    orthopaedics. Early indications are that this has been very useful work, but not yet as
    productive in terms of the impact on waiting lists as first hoped primarily due to the
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t speed of implementation. GPwSI and ESPs now provide services in 8 locations with a
  capacity to see 276 new patients per month.
  Under the banner of the Diagnostic and Treatment Services Project a pathfinder
  project was established in North Aberdeen that utilises the skills of an expert
  physiotherapist to manage GP referrals for patients with acute back pain. This project
  is being evaluated, but appears to have successfully met its objectives.
  A 4th operating theatre was commissioned at Woodend during 2004/2005 and since
  November 2005 is fully operational.


  Use of Alternative Providers
  Achievement of targets has only been as a result of innovative use of the existing
  Service together with use of the private sector.
  Since April 2005, 807 outpatients have been referred to the Albyn Hospital on a “see
  and treat” basis. The out-patient cost will be incurred this year but any resulting in-
  patient or day case costs will be incurred partly this year and partly next year. So
  achieving this year’s out-patient target has a financial implication for next year.
  Patients on the in-patient waiting list have also been referred to the Golden Jubilee
  National NHS Hospital, Fernbrae Hospital in Dundee and Albyn Hospital.
  In the first 10 months of 2005/2006 this referral practice has resulted in incurring an
  expenditure of £1.6m, expended outwith the local NHS service. It is forecast that the
  full £2.2m waiting list budget will be spent.
  The impact on the NHS Grampian Service is described later in this report, but the use
  of alternative providers is one reason why the in-patient case mix has become more
  complex and there is a greater burden on supporting services such as physiotherapy.


  Scottish Regional Treatment Centre (Stracathro) Pilot Project
  At the time of writing this report, the ITN (invitation to negotiate) is virtually complete
  and it is hoped that it can be issued to bidders shortly, to enable them to submit their
  detailed proposals for the delivery of the project.
  The timescale for commencing clinical activity at Stracathro is provisionally June
  2006.
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t Much of the clinical concern has focussed on orthopaedics and the inclusion or
  otherwise of major joint surgery. Processes are in place to fully consider and deal
  with the concerns.
  Clearly, this pilot project will impact on the NHS Grampian Service and this impact will
  differ depending upon whether major joint replacements are included or not.




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t DESCRIPTION OF THE SERVICE
 The Orthopaedic Service is provided from Aberdeen Royal Infirmary, Woodend
 General Hospital, Dr Grays Hospital in Elgin and the new Royal Aberdeen Children’s
 Hospital.


 Aberdeen Royal Infirmary
 The emergency adult in-patient and day case orthopaedic service (Trauma) is
 delivered from the Trauma Unit in wards 46 and 47 at Aberdeen Royal Infirmary which
 has a bed complement of 68. There are also 4 in-patient Orthopaedic beds within the
 Accident & Emergency Department. Bed complement occupancy is averaging 92.7%
 this financial year.   Trauma admissions include fractured neck of femurs, spinal
 injuries and other multiple fractures/injuries and number approximately 2,600 with an
 average length of stay of 8.9 days. Orthopaedic consultant and junior medical staff
 deliver outpatient clinics (Fracture Clinics) from the Accident and Emergency
 Department, 5 days per week. Approximately 340 clinics take place annually with
 15,500 attendances.      In addition to admission via the Accident & Emergency
 Department, patients may be admitted to the Trauma Unit from the Fracture Clinic and
 may attend the Fracture Clinic for review following discharge.
 A combined Hand Clinic is undertaken fortnightly with the Plastic Surgeons.
 The trauma theatre is available 0830 to 1630 Monday to Friday and 0830 to 1300 on a
 Saturday.   Outwith these times trauma surgery is performed in the emergency
 receiving theatre.


 Woodend General Hospital
 The elective service is based in a purpose built unit at Woodend Hospital.          The
 Department deals with major surgery including joint replacements and spinal surgery
 as well as day case and minor surgery. There is an outpatient department on-site.


 The elective adult orthopaedic in-patient and day case service is delivered from wards
 7, 8, 9 and 10 which have 90 beds having recently opened ward 8 as a 5-day ward.
 Ward 5 south has been reopened for pre-assessment for patients undergoing major
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t joint replacement and spinal surgery (10 beds). Patients attend a few weeks before
  their surgery is planned to ensure that they are fit for surgery, to prepare them for their
  surgery and subsequent rehabilitation and to enable early discharge planning to
  begin. Bed complement occupancy is 70%. This year, approximately 4,400 patients
  are expected to be treated within the elective orthopaedic service, with an average
  length of stay of 6.2 days. Day cases make up approximately 32% (Woodend) and
  45% (Dr Gray’s) of overall activity. This compares with the Scottish average of 39.5%.
  There is a modern four-theatre operating suite, which includes anaesthetic facilities,
  an 8 bedded recovery area and an HSDU (sterilisation facility). The theatre suite
  operates on a 9 session per week basis and has a throughput of approximately 4,600
  per year, including 700 hip replacements (including revisions), 500 knee replacements
  (including revisions) and 90 major spinal procedures. An emergency service is also
  provided. Theatre utilisation is approximately 96%.
  The out-patient service is provided in a modern facility, which was opened in April
  1997. Clinics take place every day Monday to Friday and in 2004/2005 6,358 new
  patients and 9,021 return patients are seen in 806 clinic sessions per annum. The
  Consultant Physician Service ceased in April 2004 when the existing postholder
  retired.   One Consultant surgeon participates in a prosthetics clinic, which is
  undertaken fortnightly, the activity for which is recorded against Prosthetics.


  Peripheral Clinics
  There are three out-patient clinics held in peripheral locations on a monthly basis
  including Peterhead, Fraserburgh and Stonehaven that are staffed by Consultants and
  GPwSI and ESPs. Approximately 60 new out-patient attendances take place in these
  clinics per month. In addition, a Consultant-led service is provided over three days in
  Shetland and over two days in Orkney on a bi-monthly basis averaging 100
  attendances together.


  Royal Aberdeen Children’s Hospital
  Three of the Consultant Orthopaedic Surgeons provide an outpatient, elective and
  emergency service to the Royal Aberdeen Children’s Hospital. Approximately 458 in-
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t patients and day cases are treated per annum. There are three out-patient clinics per
  week at which 1,018 new and 2,251 return out-patients are seen per annum.             In
  addition a peripheral clinic is held at the Raeden Centre on a quarterly basis at which
  approximately 15 patients are seen each year. The emergency service is provided on
  a 24 hour 365 day a year basis by the three Consultants on a 1:3 rota.


  Dr Grays
  At Dr Gray’s hospital in Elgin, there are 4 orthopaedic consultants who carry out out-
  patient, elective and trauma work. There are 22 dedicated orthopaedic beds on a 28
  bed orthopaedic and surgical ward (ward 6). Bed occupancy is approximately 79%
  and the average length of stay 5.3 days. Ward 6 also has a pre-assessment clinic
  with input from physiotherapy and occupational therapy.         Responsibility for the
  emergency (trauma) out-patient and in-patient workload and theatre lists is shared
  across the four consultants on a 1:4 rota, each consultant concentrating entirely on
  trauma for 1 week of each month.
  Annually there are approximately 2,833 new out-patient attendances and 4,697 return
  out-patient attendances. Elective in-patient, including major joint replacement, and
  day cases number approximately 1,100 per annum (an increase of 24% over the
  previous year).


  Peripheral Clinics
  Peripheral clinics take place in Forres, Buckie, Banff, Huntly and Keith on a monthly
  basis with new and return patients numbering 1,000 per annum.

  Primary Care Services
  A large proportion of general orthopaedic support and care is provided by Primary
  Care in community settings.        These services include assessment and on-going
  management of patients with musculoskeletal problems; provision of peri- and intra-
  articular injections; community based therapies; community hospital services including
  inpatient and outpatient rehabilitation.



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t Staffing
  A number of different professional groups work together to ensure patients are cared
  for to the highest possible standards. This includes consultant and junior medical
  staff, anaesthetists, nursing staff, radiographers and radiologists, physiotherapists,
  occupational therapists, HSDU staff and clerical staff. Services are also supported by
  a number of other vital groups of staff including porters, domestic staff, catering staff
  and others.


  The On-Call Service
  The Consultant on-call service for Trauma at ARI is covered by ten consultants (8 wte)
  working on a 1:8 rota with prospective cover for colleague’s leave. The majority of
  hours attributable to on-call are fixed and relate to covering for trauma theatre lists,
  associated ward rounds and fracture clinics. Outwith these times, the consultants are
  on-call from home on a level 1 rota.


  Two orthopaedic surgeons also participate in the consultant on-call service for hands
  at ARI which is shared with colleagues in plastic surgery on a 1:4 rota, also level 1.


  In addition, consultant on-call cover is provided on an “as needed” basis for major
  pelvic and acetabular fractures and spinal trauma and major knee trauma including
  dislocations.


  Three consultants provide on-call cover for the RACH, in a level 1 rota.


  At Dr Grays, the consultant on-call service for Trauma is covered by four consultants
  working on a 1:4 rota with prospective cover for colleague’s leave, on a level 1 rota.
  This rota was a 1:3 until October 2003.


  FINANCE
  The 2005/2006 annual budget for the adult Orthopaedic Service in Grampian is £12.9
  million. The main items of expenditure are medical staff, nursing staff, and medical
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t supplies and drugs. The Department consistently struggles to live within the available
  resource especially for nursing staff and medical supplies.           This pressure is
  activity/case-mix related.
  In addition to the above budget, the Service expends £2.2million waiting list initiative
  funding on a non-recurring basis.           (£300k to the Golden Jubilee Hospital and
  £1.9million on private sector referrals).


  CLINICAL MANAGEMENT TEAM
  This is made up of:


  Head of Service                     Mr Bill Ledingham
  Service Manager                     Mrs Alison Melville
  Clinical Nurse Manager              Mrs Noelle Boddie
  Lead Consultant, Dr Grays           Mr David Anderson (succeeded by Mr Gerard Kilian
                                      in October 2005)


  Supported by the Orthopaedic Consultants Sub-Committee, which meets monthly.


  Apart from the service pressures already identified, the Clinical Management Team
  has experienced other pressures recently due to sickness.
  In addition, the redesign of the Acute Sector management arrangements (due to be
  finalised during April 2006) will result in further management changes that will take a
  little time to bed down. This change may impact on the current experience,
  knowledge and intelligence held within the Service.




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t FINDINGS OF THE REVIEW
 Good Points to be Preserved
 The review identified many aspects that were considered good practice and points
 that should not be lost in any future redesign work. These include:


    Emergency/elective split – highly effective at protecting elective activity. This is not
     the case at Dr Grays though, where there is tension on the availability of both beds
     and theatres
    Close working relationship with the Accident & Emergency Service
    Enthusiastic and committed teams – high levels of respect both within the Service
     and from outwith the Service
    Effective & respected management team – respect for the Service management
     team again extends within the Service itself and outwith the Service
    Successful teaching and training programmes – e.g. Orthopaedics is the most
     popular speciality amongst trainees on the BST course

 Areas to be Addressed
 A number of issues were identified during the review process. Whilst many are known
 to the Service, it is useful to summarise them here so that potential solutions can be
 considered collectively.


 Capacity Issues
 As previously mentioned, there is insufficient capacity to meet the demands placed on
 the Service.
 Specific capacity issues include:
    Length of stay. Current length of stay for the elective service at Dr Gray’s is 5.3
     days and at Woodend it is 6.2 days. Whilst it must be remembered that a large
     proportion of orthopaedic clients are elderly and may have co-morbidities, there is
     scope to reduce this length of stay both by fully utilising community hospital
     facilities and community based services such as therapists for rehabilitation (there


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t       is also the potential for early supported discharge arrangements to be put in
        place).
       Bed occupancy. Average bed occupancy within the trauma unit is high for an
        emergency receiving unit:
                                    Average        %        bed Peak occupancy
                                    complement occupancy
    2003/2004                       79.1                            90.1
    2004/2005                       81.2                            89.3
    2005/2006                       89.7                            102.2


        This very high level of occupancy demonstrates the pressures on the unit and is
        also poor practice with regard to infection control, etc.
       Decant numbers/delayed discharges.             Decant numbers are very variable.
        During 2005/2006 to date the highest number of decants was 17. However, when
        the hospital is on code red there may not be beds to decant into and patients are
        transferred to Woodend. In January 2006, 8 patients were transferred to Woodend
        and at mid February, 3 are still there as delayed discharges, blocking elective
        beds. Approximately 50% of fractured neck of femurs will require either interim
        care or slow stream rehabilitation and a shortage of both creates difficulties with
        delayed discharges.
       Day case rates. Current overall daycase rate is approximately 35% at Woodend
        and 45% at Dr Grays. Performance across the 4 procedures in the basket of
        cases has improved in 2004/2005.
                                    Target %                        Sept 04-Aug 05 Actual
    Dupuytren’s contracture         50                              40
    Carpal tunnel release           85                              90
    Arthroscopy                     75                              56
    Excision of ganglion            90                              81
        However, focussing on arthroscopy, where the national target is 75%, Grampian’s
        achievement is reported at 56%. When patients from the Islands are excluded,
        then the achievement level rises to 66%. This further increases to 84% when the
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t       very specialised arthroscopies (wrist and sub-acromial decompression) are
        excluded. There are other issues such as distance to travel that need to be taken
        account of when looking at day-case rates, but with targeted pre-assessment and
        discharge planning there remains scope to improve performance.
       Return to new ratios. The return to new ratio for orthopaedics in 2004/2005 was
        3.2 Whilst this is in line with many other health board areas, there is still scope to
        improve. There is considerable enthusiasm for nurse-led review clinics, which are
        common in other specialties and occur in other health board areas. An audit of
        review appointments at Woodend was undertaken during 2005 and established
        that there is indeed potential for this model of review.
       Consultant capacity. In order to comply with the requirement to limit job plans to
        48 hours, an additional 2-wte consultants is required. To meet the challenging
        new waiting time targets and be in a position to address the impact of Modernising
        Medical Careers then up to a further 2 wte consultants will be required. Any new
        consultants should have the necessary skills and expertise to complement the
        existing team and their role should include support for community based activities
        such as education and support for primary care based practitioners.
       Nurse capacity. Nursing teams at all locations are under considerable pressure.
        The increasing throughput and activity levels have not been matched with
        increasing nurse numbers. Many nurses are also keen to take on extended roles
        with greater responsibility. The out patient review audit mentioned above supports
        the need for such a role.       The clinical nurse manager for orthopaedics has
        indicated an estimated requirement for 22.15 wte over the whole hospital-based
        service and this will be tested using the Telford Method later this month.
       AHP capacity.       Increasingly complex procedures are being performed on
        increasingly frail patients resulting in an increased requirement for rehabilitation
        services both in the hospital sector and in the community.         Again, increased
        throughput has not been matched by the reciprocal increase in AHP support
        services. The new Regional Treatment Centre will also require to have community
        based AHP services in place. Discussions have also been had with the podiatry
        service over the possibility of developing a lower limb triage service. This service
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t       could work in two ways - alongside the current out-patient service and within the
        community setting. The benefits could be felt not only by patients and the existing
        out-patient service, but also by the orthotic service that shares some of the skills
        and techniques with the podiatrists. This model has been utilised elsewhere in
        Scotland to good effect.
       Theatres. The new 4th operating theatre at Woodend is now fully operational. Any
        further increase will require 3-session-days at further cost. There is also further
        capacity available at Dr Grays. The consultants there are keen to adjust their job
        plans to accommodate extra elective theatre activity.
       Administration/management capacity.          The present complement of senior
        management is overcommitted. This limits their ability to become fully involved in
        redesign efforts and creates unacceptable pressures.            Significant service
        efficiencies are possible with additional support. For example, a support manager
        for the Woodend inpatient activities could help with the scheduling of patients and
        lists in order to optimise the use of scarce resources such as the radiology image
        intensifier, beds and surgical equipment. The administrative support to the trauma
        teams is also woefully inadequate.       Much clinical time is spent on routine
        administrative duties.
       Out patient capacity. The clinical accommodation at Woodend is fully utilised. It
        will not be possible to increase capacity without identifying additional
        accommodation or moving to a three-session day.
       Equipment.      There is a view that there is a requirement for a second image
        intensifier for the hand service at Woodend. An increase in equipment turnaround
        is required to support additional activity. There is a need to equip ward 7 & 8 at
        Woodend to be able to safely take major joint replacements.          There should
        therefore be an audit of equipment needs to further describe the equipment
        requirements.




    Demand Issues
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t    Referral rates to the elective Service are generally not substantially different from
      other health board areas. However, there are considerable opportunities to modify
      referral patterns in line with NHS Grampian’s strategy to ensure that specialist
      services are used appropriately and only when essential. Conversion rates from
      out patient attendances to inpatient or daycase activity vary between 40-60%.
      Whilst it must be remembered that the orthopaedic service is much more than an
      operating service, there is scope to improve this conversion rate by filtering out
      more of the non-operative activity.     Any increase in conversion rates must be
      matched by increased theatre capacity.        The CCI funded project will have an
      impact, but work should also be directed towards ensuring that practitioners have
      access to services that might relieve some of the burden on the Service. For
      example, GPs do not at present have open access to the orthotics service.
     Community capacity.         The development of the GPwSI role will make a
      considerable contribution to the provision of intermediate care. However, there
      may be further scope to broaden this effort to include for example training
      practitioners in specific minor procedures such as carpal tunnel release. There is
      also a considered view that more could be done by GPs in general without a
      requirement to refer to specialist or intermediate services.       A comparison of
      general practice referral rates and rates of performing intra- and peri-articular
      injections show an inverse correlation. In general, those practices with the highest
      referral rates demonstrate the lowest rate of performing injections and vice versa.
      The performing of these injections could be considered as a proxy measure for a
      practice’s confidence and skill in dealing with musculoskeletal problems in-house.
      The Aberdeen North Back Pain Service, together with similar models elsewhere in
      the country, also clearly demonstrates that early appropriate intervention can help
      prevent the need for specialist care at a later stage.         Consideration should
      therefore be given to rolling out this model of care.


  Clinical Governance Issues
     HDU level 1 facility. There is widespread concern at the lack of an HDU level 1
      facility at Woodend for elective orthopaedic patients.       A case to convert a 6-
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t       bedded bay to a 5-bedded level 1 HDU is currently being developed. The drive for
        this is the increasing activity and the increasing complexity of patients. Many of
        the patients undergo major surgery such as hip joint revision, tumour resection and
        bilateral joint replacements. As previously mentioned most of the patients are also
        elderly and may have co-morbidity such as heart and lung disease.
       Sub-specialisation. There is a particular issue with regard to upper limb surgery.
        The current service is not sustainable. Achievement of 26 weeks targets is only
        possible with very significant private sector investment. There is also a need for
        redesign and investment in the hand service.
       Trauma Theatre, ARI.        More than 60% of emergency trauma activity is not
        conducted in the dedicated trauma theatre. This has consequences in terms of
        skilled staff availability, equipment, theatre layout, etc.
       Nurse staffing levels. As previously mentioned.
       Administrative support to the trauma teams.              Currently there are 2.4 wte
        secretaries covering 4 trauma teams (10 consultants, 6 registrars, 4 SHOs). Apart
        from the fact that it is inappropriate for consultants to perform routine
        administrative duties on a regular basis and that morale amongst the existing
        secretaries is very low, clinical governance issues are regularly arising –
        admission notes are not up to date, GP letters are not being sent out timeously,
        and relevant clinical information is not always available in the patient records.
       Standard of accommodation in the Trauma Unit.                 The general standard of
        accommodation and furnishings is poor. Apart from the aesthetic aspect, it is
        difficult to maintain good hygiene standards.




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t RECOMMENDATIONS
 Given the issues identified and listed above, it is necessary to consider some
 solutions. The suggested solutions have been compiled with consideration to the
 current environment – for example the political environment and direction of health
 care policy pushes us towards more community based services; finance and
 economics push us to maximise the return from investment; workforce and public
 expectations direct us to new ways of working and refined patient pathways; and
 technological advances are both enabling (for example telemedicine and PACS) and
 also drive us towards new treatment regimes (for example NICE guidelines).


 Some general principles can be formulated. These include:
    Adopting a whole system approach. In particular, matching activity (community
     based services, outpatient, inpatient and daycase activity and rehabilitation
     services) in order to improve the entire journey of care and performance of the
     Service.
    Respecting and promoting team and individual contributions. The Service is
     highly complex involving numerous disciplines and sites and interacts with many
     different services. The success of the Service is entirely dependent upon team
     commitment and performance.
    Maximising utilisation of assets. Where there are valuable assets (equipment,
     accommodation, people, skills) they should be utilised to their maximum potential
     and benefit to patients and the Service.


 Specific recommendations are to:
 1. Reduce the Demand on and Increase the Capacity of the Service
    Increase community based capacity
        Specific skills – improve primary care confidence and skills in dealing with
         musculoskeletal problems e.g. ensure all patients have access to intra and peri
         articular injections in the community. Training, support and feedback will be
         required.
        Enable direct access orthotics utilising clear referral guidelines
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t          Intermediate care – e.g. train community practitioners to perform minor
            procedures such as carpal tunnel release and ganglion surgery
           CCI projects –These projects must be allowed to continue and be fully
            evaluated
           Improve the access to community-based therapists (general and specialised)
            and explore the possibility of developing and extending specialist AHP services
            (e.g. the back pain service and podiatry triage service).
           Increase the utilisation of community hospitals (pre-admission assessment,
            rehabilitation & possibly review work).
       Increase consultant complement.         Four additional consultants are required to
        achieve hours of work and waiting times. These posts should be recruited to as
        soon as possible. There are several strong candidates currently available in what
        is normally a difficult recruitment market.       It should be recognised that an
        increased number of consultants will require matched increases in, for example,
        secretarial time, staffed theatre time, etc.
       Refine current patient pathways – for example for the basket of “daycase”
        procedures, the default should be to daycase rather than inpatient (recognising
        that if community practitioners take on the more minor end of procedures, then day
        case rates may actually increase).
       Consider deploying extended role practitioners to perform elements of the review
        workload in OPD and thereby free up consultant time. Consideration should also
        be given as to whether some of this review work could be performed in the
        community
       Undertake a review of the Service’s nursing complement using the tools identified
        for this purpose. The Telford Method of workload analysis will commence during
        February 2006
       Invest in AHP services, both within the hospital setting and in the community.
       Fully utilise theatre capacity – examine the potential to increase theatre capacity at
        Woodend and Dr Gray’s.
       Increase support services (radiology, CSSD, orthotics, podiatry)

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t    Invest in essential equipment
     Increase peripheral clinic efficiency by changing from single session to 2-session
      days – already been implemented to a large extent.
     Augment the management team.


  2. Address Clinical Governance Issues
     Commission a 5-bedded level 1 HDU facility at Woodend
     Reorganise trauma theatre scheduling to consistently accommodate emergency
      work in the dedicated trauma theatre
     Invest in nurse staffing levels (according to the Telford Method workload analysis)
     Improve standard of accommodation in Trauma Unit
     Increase administrative staff support to the Trauma Team


  Workforce matters (numbers, skills, development and support) are interwoven in the
  above recommendations.
  The availability of recurring waiting list funding presents NHS Grampian with an
  opportunity to implement some of these recommendations. However, progressing
  these recommendations will impact on the service in different ways and to different
  degrees and the availability of the funding is of course dependent upon achieving the
  waiting time target by December 2006. Inevitably there will be varying and potentially
  conflicting priorities regarding achievement of performance targets, etc. Consideration
  has therefore been given to the likely impact of implementing these recommendations
  on waiting times, daycase rates, the workforce issues and clinical governance issues.
  A summary of these impacts is attached as appendix 1.


  NEXT STEPS
  The preparation of this report is only the first stage of a much longer-term process.
  The draft report has been considered by the wider system and broad agreement
  gained for the principles contained therein. The next stage is the development of a
  detailed implementation plan, based on a service plan that includes the waiting list
  plan – i.e. activity levels and profiles that will allow NHS Grampian to achieve the
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t waiting time target as this is an absolute requirement for gaining the recurring funding.
  This work will inform the relative priority for implementing the above recommendations
  It is suggested that the development of this plan should be the responsibility of the
  Service Manager for Orthopaedics in the first instance with assistance from members
  of the review group.
  A formal reporting structure should also be agreed.             It is suggested that an
  Implementation Steering Group be formed, with representatives from across the
  system. This Group should be chaired by a senior officer of NHS Grampian who also
  sits on the Operational Management Team of NHS Grampian in order to achieve
  satisfactory lines of governance and accountability.
  .
  CONCLUSION
  This report summarises the findings of a review of NHS Grampian's Orthopaedic
  Service. The Service is highly complex, involving and impacting on many different
  disciplines, sites and partner services. The Service is currently under considerable
  pressure, requiring significant waiting list funding to be directed to the private sector in
  order to meet its performance targets. In addition the Service faces many challenges
  ahead. It is clear that major investment is required to support the development of a
  sustainable, holistic Service.
  The implementation of these recommendations will require to be carefully managed,
  both to ensure the required outcomes are achieved and also to support and
  encourage the development and implementation of new ways of working.
  Finally, there are enormous strengths in the current Service and it is important that
  these strengths are protected and enhanced.




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t Appendix 1
  Benefits Realisation Matrix
               Action              Impact on Waiting   Impact on Daycase     Impact on workforce   Clinical Governance/
                                        Times                Rates                                        Quality

  Development of specific skills          ++                  +                      ++                     +
  in Primary Care

  Direct access orthotics                 +                    -                      -                     +


  Intermediate Care (GP and               ++                  +                     +++                    ++
  AHP)

  Continuation of CCI Projects           +++                   -                    +++                    ++


  Fully utilise community                 ++                  +                      ++                    ++
  hospitals

  Increase consultant numbers            +++                  ++                    +++                    ++


  Increase nurse staffing levels          +                    -                    +++                    +++


  Implement revised patient               ++                 +++                     ++                    ++
  pathways

  Extended role practitioners to          ++                   -                    +++                     +
  perform review work

  Increase theatre capacity              +++                   -                      -                    ++


  Increase support services               +                    -                     ++                     +


  Invest in equipment                     +                    -                     +                     ++


  Improve peripheral clinic               +                    -                     +                      -
  efficiency

  Augment Management Team                 ++                  ++                     ++                    ++


  HDU level 1 facility                     -                   -                     ++                    +++


  Refurbish Trauma Unit                    -                   -                     ++                    +++


  Reorganise trauma theatre                -                   -                     ++                    +++
  scheduling

  Admin support for trauma team            -                   -                     ++                    +++




                                                                                                                 11 June, 2003

				
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