We are reviewing planned adult orthopaedic surgery in north central London and we’d like your views Barnet, Camden, Enfield, Haringey and Islington 1
About North London Partners in Health and Care • Our sustainability and transformation partnership (STP), brings together health and care commissioners and providers across five boroughs • We work together to provide joined-up health and care across the area • All partners are united behind a clear set of priorities, based on the needs of local people 2
Ambitions of the STP Ambition for the STP is built on Improve the Maximise care existing CCGs, Local Authorities and health of the out of hospital local population Providers values and strategy Reduce health inequalities A partnership of the NHS and local authorities, working together with the public and patients where it’s the most efficient and effective way to deliver improvements. 3
Context Within the planned care workstream of the STP there are four MSK projects of which this review is one Single point of First contact access practitioners Adult elective Pain orthopaedic management surgery 4
About the review • We think there may be opportunities to improve adult elective orthopaedic surgery in north central London by consolidating services onto fewer sites • We are undertaking a review of these services to see if these improvements can be achieved • The review has been established by North London Partners in Health and Care • A review group led by local clinicians is coordinating the development of how this kind of care could be delivered in the future • Clinical commissioners will make decisions on where and how this happens • The review covers services in Barnet, Camden, Enfield, Haringey and Islington 5
Stages of the review Stage 1 engagement • Patients & residents Engage to get feedback on the draft case for • Providers change • Clinicians Propose a service model describing how services might be delivered in future, informed by • Clinical Commissioners feedback Stage 2 Clinical commissioners consider the feedback from the engagement, agree a service model Produce a pre-consultation business case 6
What we want to achieve Make Improve quality Improve efficiencies as a and efficiency of outcomes and consequence of services by experience for these reducing patients improvements; unwarranted value for money variation 7
Less time The spent in benefits hospital for patients Much less Improved risk of clinical operations . being outcomes cancelled Shorter waiting times for an operation 8
Principles underpinning this review • Co-production (everyone working collaboratively) • Evidence based service model (using evidence from trusted sources) • Clinically led collaborative approach which enables meaningful engagement with all stakeholders, particularly front line clinical staff and the public (people involved in delivering and receiving care) • Independent experts to provide challenge and advice • Sharing what we learn • Clear separation of decision-making functions • Flexible timelines to ensure we are properly engaging with stakeholders and the public 9
Leadership and Review Group Chair: Professor Fares Haddad (UCLH) CEO Sponsor and Project SRO: Rob Hurd (RNOH) Review Group Members: Clinical representatives from each of the five largest providers of adult orthopaedic services Two clinical commissioning representatives from NCL CCGs NHS England Specialised Commissioning Two patient and public representatives (recruited by Healthwatch) NHS England Strategy and Reconfiguration In attendance: Trust management leads from each of the five largest providers of adult orthopaedic services Programme Director and Programme Manager Other workstream leads as required 10
Adult elective orthopaedic surgery • In 2016/17, north central London hospitals carried out over 23,000 adult elective orthopaedic operations across 10 sites • Adult elective orthopaedic surgery is planned (non- emergency) surgery of bones and joints, such as hip and knee replacements • There are already many areas of good practice in adult elective orthopaedic care in north central London – falls prevention schemes, how people access musculoskeletal care, people staying in hospital for a shorter time 11
Adult elective orthopaedic surgery currently takes place at ten different hospital sites in north central London Around 23,000 operations each year 12
Opportunities for improvement • Patients report different experiences and outcomes at different hospitals • Some hospitals carry out small numbers of some operations, leading to inconsistent approaches (ie - elective knee replacements in those who had an arthroscopy ) • Variation in ‘revision rates’ (ie – a follow-up procedure being needed if the first one didn’t work as expected) • Variations in the length of hospital stay, following an operation • Readmissions vary (but are low) (ie– a patient who has been discharged is admitted back to hospital) • Infection rates vary (but are low) • Waiting times vary and targets are being missed 13
Our current thinking Learning from the best, we believe that by consolidating adult elective orthopaedic surgery from multiple hospitals to a smaller number of larger units we could further improve care. Separate Co-located Expansion of Best possible Access to emergency and specialist high ‘joint school’ after-care innovations planned care dependency unit improve quality of for faster such as robotic Elective surgery split care through from non-elective recovery surgery greater patient emergency surgery for efficiency and quality engagement and enables all improvements education likely to deliver better cases to be better outcomes done on one outcomes Elective beds site separated from non- leading to faster elective beds to recovery and Links to prevent cancellations less time in improved patient and reduce the research and experience hospital incident of hospital clinical trials acquired infections 14
Aiming for excellence Performs more than 5,000 orthopaedic procedures each year The International Society of Is either a Conducts and dedicated exhibits a Orthopaedic orthopaedic commitment to specialty hospital basic and Centres considers or large clinical department research within a hospital a centre of orthopaedic excellence meets the following criteria: Has orthopaedic staff of more than Functions as an 20 surgeons who academic centre collectively publish (i.e. has residents more than five or fellows in articles in peer training) reviewed Source: www.isocweb.org publications 15
Rationale supporting change “ Separating elective care from emergency pressures through the use of dedicated beds, theatres and staff can… achieve a more predictable workflow, provide excellent training opportunities, increase senior supervision of complex / emergency cases, and therefore improve the quality of care delivered to patients ” The Royal College of Surgeons 16
Rationale supporting change “there is evidence that separation of the elective surgical workload can improve efficiency and avoid the cancellation of elective activity. However, the efficiency gains can be affected by patient case-mix and demand. Evaluation of the operation of the independent sector treatment centres has also suggested separating elective surgical care from emergency services could improve the quality of care” The King’s Fund and Nuffield Trust qualitative analysis of National Clinical Advisory Team reviews 17
Ideas from around the country…. In South London they created SWLEOC – South West London Elective Orthopaedic Centre: • surgeons from local hospitals use the centre for all their planned routine procedures • day cases take place at local hospitals • all preoperative, post operative and emergency care happens locally • opened in 2004 – 14 years in operation 18
SWLEOC The centre has revolutionised the management of joint surgery and has reduced the waiting time enormously South west London GP on their experience with the South West London Elective Orthopaedic Centre 19
Ideas from around the country…. Manchester is exploring a ‘layered’ approach with: • one ‘very specialist’ centre doing the most complex operations only • two ’specialist’ centres doing complex and routine care • local hospitals doing routine care only 20
Experience and evidence from…. • The Royal College of Surgeons (RCS) report Separating Emergency and Elective Surgical Care: Recommendations for practice (2007) • GIRFT literature review • National Orthopaedic Policy Unit • Economies of Scale and Scope in Hospitals, July 2017 • Separate and Concentrate: Accounting for Patient Complexity in General Hospital, July 2017 21
What do you think? Patients and residents 1. What are your views on our ideas? 2. What are the advantages and disadvantages of consolidating onto fewer sites? 3. What are the top three considerations to take into account when thinking about how these services are delivered in the future? 4. If you have used these services (or know someone who has) please tell us whether the challenges set out in this draft case for change reflect those experiences? 22
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