We are reviewing planned adult orthopaedic surgery in north central London and we’d like your viewsBarnet, Camden, Enfield, Haringey and Islington

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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

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Improve the health of the

local population

Reduce health inequalities

Maximise care out of hospital

Ambitions of the STP

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.

Ambition for the STP is built on existing CCGs, Local Authorities and

Providers values and strategy

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Context

Within the planned care workstream of the STP there are four MSK projects of which this review is one

Single point of access

First contact practitioners

Pain management

Adult elective orthopaedic

surgery4

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

Islington5

Stages of the review

Stage 1Engage to get feedback on the draft case for change Propose a service model describing how services might be delivered in future, informed by feedback

Stage 2Clinical commissioners consider the feedback from the engagement, agree a service modelProduce a pre-consultation business case

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• Patients & residents• Providers• Clinicians• Clinical Commissioners

engagement

What we want to achieve

Make efficiencies as a consequence of

these improvements; value for money

Improve quality and efficiency of

services by reducing

unwarranted variation

Improve outcomes and experience for

patients

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The benefits for patients

.

Less time spent in hospital

Much less risk of

operations being

cancelled

Shorter waiting

times for an operation

Improved clinical

outcomes

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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

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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 servicesTwo clinical commissioning representatives from NCL CCGsNHS England Specialised CommissioningTwo 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 servicesProgramme Director and Programme ManagerOther workstream leads as required

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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

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Adult elective orthopaedic surgery currently takes place at ten different hospital sites in north central London

Around 23,000 operations each year

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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

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Our current thinkingLearning 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 emergency and

planned care

Elective surgery split from non-elective

emergency surgery for efficiency and quality

improvements

Elective beds separated from non-

elective beds to prevent cancellations

and reduce the incident of hospital acquired infections

Expansion of ‘joint school’

improve quality of care through

greater patient engagement and

education

leading to faster recovery and

improved patient experience

Best possible after-care

for faster recovery

better outcomes

less time in hospital

Co-located specialist high

dependency unit

enables all cases to be

done on one site

Access to innovations

such as robotic surgery

likely to deliver better

outcomes

Links to research and clinical trials

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Aiming for excellence

The International Society of Orthopaedic Centres considers a centre of orthopaedic excellence meets the following criteria:

Source: www.isocweb.org

Performs more than 5,000

orthopaedic procedures each year

Conducts and exhibits a

commitment to basic and

clinical research

Functions as an academic centre (i.e. has residents

or fellows in training)

Has orthopaedic staff of more than 20 surgeons who

collectively publish more than five articles in peer

reviewed publications

Is either a dedicated

orthopaedic specialty hospital

or large department

within a hospital

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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 Surgeons16

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

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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

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South west London GP on their experience with the South West London Elective Orthopaedic Centre

SWLEOC

The centre has revolutionised the management of joint

surgery and has reduced the waiting time enormously

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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

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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

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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?

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Ways to feed back Please feed back by 19 October 2018*

•Read the full case for change on our website:www.northlondonpartners.org.uk

• Email us: nclstp.orthopaedics@nhs.net•Complete our online questionnaire •Write to us: North London Partners in Health and Care,

5th Floor, 5 Pancras Square, London N1C 4AG*Additional time will be allowed to hear more views if required

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Some definitions

• “adult elective orthopaedic surgery” • Planned (non-emergency) surgery of bones and joints, such as hip and knee

replacements

• “north central London”• Barnet, Camden, Enfield, Haringey and Islington

• “North London Partners in Health and Care - STP”• a partnership which represents clinical commissioning groups (CCGs), health

providers and local authorities in north central London

• “elective / emergency”• Elective care is planned in advance. Emergency care is not planned

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