REVIEW OF ORTHOPAEDIC SERVICES IN GWENT A REPORT TO THE WELSH ASSEMBLY GOVERNMENT

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1 REVIEW OF ORTHOPAEDIC SERVICES IN GWENT A REPORT TO THE WELSH ASSEMBLY GOVERNMENT PROFESSOR BRIAN EDWARDS JANUARY 2003

2 SUMMARY

3 1 FINDINGS 1. The current orthopaedic waiting lists in Gwent are far too long. The waiting time for an outpatient appointment of up to three years represents an unacceptable service.. 2. In Gwent patients are being added to lists quicker than they are being seen or treated. The problem overall is getting worse. A determined attempt to see more outpatients will quickly result in a longer waiting list for surgery. 3. The NHS in Wales and Gwent in particular does not have enough capacity in this speciality to handle current pressures and predicted future demand. In Gwent the gap between additions and removals is being partially bridged by special initiatives and referring patients to the independent sector for treatment with nonrecurrent funds. 4. Some of the existing bed capacity is being used regularly for medical emergencies and a significant number of other beds are occupied by patients whose discharge has been delayed. 5. The orthopaedic service has been badly affected by surges in emergency medical admissions which has resulted in significant numbers of patients having their elective admission cancelled at short notice. Work flows have also been disrupted by patients who do not turn up for their outpatient appointment or their surgery. 6. The Gwent health community needs to invest more in this specialty from the increased funding they are expecting to receive from the all-wales revenue equalisation process. 7. Joint replacement rates in Wales are significantly below those in England. 8. Whilst the Trust has worked hard to reduce its waiting times there is more that they can do to improve their own efficiency and waiting list management. 9. The number of joint replacement procedures could be significantly increased if the operating theatre working practices at the Royal Gwent Hospital were more flexible. 10. The demand on orthopaedic services could be managed better so as to ensure that the service is not swamped by cases that could be treated just as well by other means. 11. This problem cannot be solved by the Trust alone. It needs the whole health community engaged and committed to finding workable solutions.

4 2 RECOMMENDATIONS 1. Tighter management 1.1 Waiting list validation needs to be significantly improved. The status of all patients on the outpatient list needs to be checked at the six month point and then quarterly. The existing outpatients lists need to be vigorously reviewed with a view to re-referring suitable patients to alternative services. 1.2 A sample of patients who do not turn up for their appointment in the next three months should be reviewed with Local Health Boards to establish the reasons why and prompt a consideration of what action is required to improve matters. 1.3 The Trust should establish a closer relationship with patients on their inpatient waiting lists involving much more regular contact particularly in the days immediately prior to admission. This will materially help with validation, reduce DNAs and be much appreciated by patients. The existing inpatient lists should be validated much more intensively with special attention being paid to those waiting longer than one year. 1.4 The Trust should review with their consultants the operation of the suspended list. 1.5 The Trust should monitor very closely the progress of the policy of referring patients to the independent sector. 1.6 There should be a review of the use of day case facilities given the pressure on inpatient beds and main theatres. The waiting time target for day surgery should be reduced. 1.7 Clinicians and managers need to manage existing resources more tightly. A senior support team should work to the Clinical Head of Staff in creating an orthopaedics operations room which would provide a proper focus for this complex and expanding service. 1.8 The support team should include an experienced manager, nurse, physiotherapist and General Practitioner. It would also be very helpful if a member of the Assembly s staff could join the team so as to improve liaison and understanding. 1.9 Operating theatre working practices at the Royal Gwent Hospital should be reviewed quickly in order to make it possible for two joint replacements to be undertaken per session The number of short notice cancellations by the Trust must be reduced.

5 3 2 Capacity 2.1 Existing cold orthopaedic beds must have a higher degree of protection from encroachment by other specialties. 2.2 Once the first stage of the new investment in acute medicine is in place, with the recruitment of two new physicians at the Royal Gwent Hospital, 25 existing orthopaedic beds should be firmly ring-fenced and only accessed by other specialties in exceptional emergency situations. 2.3 The existing trauma work should be reviewed with primary care organisations to establish whether there are acceptable alternatives to hospital referral. 2.4 Local Health Boards should work with the Trust in seeking to manage the demand on orthopaedic services more tightly. 2.5 There should be immediate discussions about a protocol for outpatient referral that would lead to only the most urgent or clinically important cases being referred to a consultant, at least for the time being. 2.6 Alternatives to consultant referral should be explored with primary care organisations including more direct access to radiology, physiotherapy clinics, nurse specialists, chiropractors, GP specialists and orthopaedic equipment contractors. This will require targeted investment. 2.7 During the course of the next three years the overall investment in this specialty should be increased and additional capacity brought on stream at both Nevill Hall and the Royal Gwent Hospitals. Two capital schemes exist that would achieve this reasonably quickly. 2.8 The Assembly need to consider providing some level of additional capital funding and perhaps interim revenue support until such time as the Local Health Boards can provide for it in their forward spending plans. 2.9 The proposed Orthopaedic Centre for South-East Wales should proceed in Cardiff to serve its local community and not that of Gwent which, other than for the most complex spinal work, should be self sufficient As the longer term plans for hospital services for the whole of South-East Wales are developed future provision should include a clear separation of trauma and cold surgery.

6 4 3 Innovations 3.1 Once the waiting time position has improved, General Practitioners should be invited to test with the orthopaedic specialists new referral protocols based on predetermined slots which will allow them a far greater influence on patient priorities. 3.2 The proposed trauma review is likely to open up new ideas for managing accident cases. It should proceed quickly. 3.3 The better use of community hospital beds should be tested by the creation of a small specialist orthopaedic facility at the County Hospital. If it works more capacity of this kind should be developed. 3.4 The pioneering day case referral experiment at Caerphilly should be evaluated and tested in other centres in Gwent. 3.5 The Trust should explore with colleagues in Local Government whether the creation of a single social work focus within each of the large hospitals for managing delayed discharge patients would be helpful. 3.6 The public should be made more aware of the waiting times to see individual orthopaedic surgeons and the option of being referred by their general practitioner to the orthopaedic service rather than a named consultant. 3.7 The orthopaedic service should seriously explore becoming a managed clinical network within the Trust with its own budget and Service Level Agreements with other services.

7 MAIN REPORT

8 5 THE PROBLEM Outpatient Consultation At the end on November 2002 there were 13,109 people waiting for an orthopaedic outpatient consultation in Gwent. The time between referral and appointment could be as long as three years for non-urgent referrals. This is simply unacceptable in this day and age. Outpatients waiting-orthopaedics number of patients months 3-6 months 6-12 months months months 18+ months Inpatient treatment At the end of November 2002, 3,175 patients were waiting for treatment. 350 Num bers w aiting as at 30/11/ numbers waiting num bers waiting months waited

9 6 More than 140 patients will have been waiting for surgery longer than 18 months. This level of service is the worst in Wales and is far below the Assembly s own targeted standards, which I understand to be for 2001/2: Reduce significantly the number of people waiting over twelve months for orthopaedic treatment and eliminate waits over eighteen months Increase the number of joint replacements undertaken Sustainably reduce the number of people waiting over six months for an outpatient consultation. The Trust does however face the dilemma in that that if they invest heavily in seeing more outpatients this will inevitably work its way through to more patients being added to the inpatient and day case lists. For a few patients this means a wait of over four years from the point of referral to treatment. Despite this, the number of patients being referred for an outpatient appointment is expected to increase this year from 11,778 in 2001/2 to 12,511 in 2002/3. The agreed outpatient capacity through the LTA with commissioners is 7,066 in 2002/03. The number of patients with long waits for surgery has reduced in the last nine months (it was 552 in March 2002). The Trust also achieved the target set for it by the Welsh Assembly Government of ensuring that no patient had to wait longer than eighteen months by July 2002 but as they correctly predicted this could not be sustained. The waiting time is planned to reduce further, in the immediate future, to zero over eighteen month waiters by the end of February 2003 but again sustainability is in question. The Trust did deliver significantly more hip and knee replacements in 2001/2 than in the year before. The number of patients being added to lists (estimated for 2002/3 at 2,628) is currently higher than the number being treated or removed (estimated for 2002/3 at 2,169). The problem overall is still getting worse. The gap between additions and removals is being maintained purely through additional in house special initiatives and outsourcing of activity mainly from non-recurrent funds. In addition to the official live list there is a suspended list with 362 patients on it. These are patients who have been deferred for personal or clinical reasons and will be expected eventually come forward for treatment. When they are ready for treatment they will be returned to the active list although I doubt that many will do so. In accordance with Assembly guidelines they are not included in the waiting list count [1]. Over all level of Investment in Orthopaedic services The existing level of provision is acknowledged to be inadequate to meet existing demand and the inevitable growth in the future [4, 5, 6, 7]. The rate of joint replacement in Wales is substantially below that in England and Scotland [6]. The orthopaedic service is provided at present by fifteen Consultant Surgeons and one Orthopaedic Physician, through 54 elective beds and 154 elective operating theatre sessions per month at the Royal Gwent Hospital in Newport and Nevill Hall Hospital in Abergavenny. Orthopaedic surgeons also access up to ten beds and theatres at

10 7 Caerphilly Hospital for minor and intermediate cases. There are additional facilities for trauma (accident) patients, which represent two thirds of the surgical work and who have the highest degree of priority. 34% of non-emergency surgery in this specialty is undertaken on a day case basis and even here we see a few patients with surprisingly long waits. The principal problem at present is accessing the elective inpatient beds. Emergency demands regularly exceed available capacity resulting in elective beds being taken over for emergency medical cases. The elective beds have also been closed on occasion because of sickness or infection or occupied by patients awaiting discharge. As at the end of November 2002 there were 260 (up from 180 in the same month in 2001) patients in this latter category delayed transfers of care most of whom were waiting in community beds but 20 at least were occupying main acute beds and thus preventing new admissions for surgery. Local managers estimate that the impact of delayed transfers of care in community hospitals could be affecting another acute beds. The majority of these delayed transfers of care are due, I was advised, to Local Authority funding difficulties for placements in residential and nursing homes. The capacity pressures and the policy of prioritising emergency services has led to insufficient beds being firmly ring-fenced for elective cases and as a result the clinical process is difficult to organise resulting in far too many cancellations at short notice (57 patients were cancelled in November 2002). It makes it almost impossible to guarantee admission dates for patients in advance, which almost certainly works its way back to the high numbers of patients who fail to attend. Gwent has significantly less acute beds than other communities [8]. The Gwent health community are presently operating with a financial deficit and a consequential recovery plan that allows little short-term room for financial manoeuvre. They do however have the prospect of growth money in future years as the Assembly equalises health investment across Wales. Managing the lists The management of each consultant s list is handled separately although medical records staff often handle more than one list each. Most referrals in the south are to named consultants. There are more referrals to the orthopaedic service at Nevill Hall, which has the effect of adding these patients to the lists of those surgeons with the shorter lists. There is a substantial variation in the waiting lists of individual surgeons from 57 to 400 patients [See appendix A]. Those patients added to the list of the consultants with the longest lists must expect a significant delay before their treatment can be started. This information is available to General Practitioners but is not easily available to the general public. It should be. The length of a consultant s waiting list is not an infallible indicator of best practice. The longest list in Gwent is for treatment by a consultant who specialises in knees. It is important that patient choice is real which is why referral to a named consultant should be retained. Patients should however be made more aware of the option of referral to the orthopaedic service, which for

11 8 many patients will result in earlier treatment, as they will be added to the lists of those consultants with the shortest lists. If the lists were being managed optimally one would expect to see a high number of cases from the end of the list being selected each week. In practice this does not happen because consultants overlay the chronological list with their own judgement about clinical priority and treat the more urgent cases first. Problems arise immediately if services are curtailed, as happened in the summer of 2002, due to a community D&V outbreak which significantly impacted on local hospitals, emergency pressures within Gwent and the need to support orthopaedic services in Merthyr, resulting in Nevill Hall taking Merthyr s trauma for three weeks. The consequent loss of elective capacity resulted in an accumulation of urgent cases, which pushed the longer waiters even further back. In any case under current procedures each operating list needs a balance of major and minor cases to fully utilise a theatre session which makes strict chronological selection impracticable. I examined the case selection for the first two weeks of December The analysis below shows the section of the waiting list that patients were selected from. Patient selection Patients C en tiles Patients It is apparent that judgements about clinical priority significantly override the chronological list. This is entirely proper but unless patients waiting the longest are given some degree of special weighting they will never be treated. In practice some degree of weighting becomes essential if the Assembly target of nobody waiting longer than 18 months is to be achieved. A more detailed analysis is contained in appendix A. Waiting list validation The processes that govern the management and validation of waiting lists are properly set out in the Trust s procedure manuals [3]. Patients on outpatient lists are checked at six months on a rolling programme. If patients do not reply after three weeks confirming that they still wish to see a consultant they are removed from the list and their GP advised accordingly. Over one thousand such patients, who did not turn up for their appointment, were removed after checks in the last twelve months. There is something seriously wrong with the referral process here if these numbers of patients simply do not turn up for a consultation that could be very important to their health. This is not just an

12 9 orthopaedic problem as 20% of patients on all Gwent outpatient lists were removed either by patient election or for non-attendance in the 12 months to October Validation needs to be tightened up even further and undertaken at six months and thereafter on a quarterly basis. A review across all specialties undertaken in 2002 showed that the most common reason for patients removing themselves from lists was that their condition had cleared up and the second highest was that they had been seen privately. I suggest that a sample of patients who do not attend the orthopaedic service in the next three months be followed up and interviewed as to their reasons. A joint study with the Local Health Boards might prove very constructive The procedure for inpatients is slightly different and a distinction is made between those patients who could not attend and those who simply did not turn up. Inpatients and day cases are validated after ten months on a rolling programme. The patients are further validated at 16/17 months when treatment plans are finalised. I asked for an ad hoc telephone check to be made in December about a selection of patients waiting longer than one year. Of the 150 patients contacted seven wanted to be removed. A further 49 patients could not be contacted. Efforts to talk to them are continuing and it looks like a further 17 patients will be removed from the active list as a result of these conversations. Regular validation is vital when lists get as long as these. It should be routine and automatic and not based on one off occasional checks. The orthopaedic service should build a relationship with each patient on the inpatient list and keep them in touch with their status. This will help with validation, reduce DNA s and be much appreciated by patients. The names of those patients who do not attend for their surgery are referred to the appropriate surgeon with a view to removal from the waiting list. In the last year only 20% were authorised for removal, the majority (249) remain on the hospital s suspended list and in accordance with policy are not included on the active waiting list. I suspect that most of these patients will never present for treatment. There needs to be an early discussion with the surgeons about the application of the Trusts procedures for dealing with DNA s. The Assembly guidance does give consultants the discretion to override a cancellation but I am sure this was meant to be applied in exceptional circumstances. If there is an override it must be because treatment is likely and the patient should therefore remain on the main live list. Current practice confuses the picture and provides no practical benefit to patients. In the short term changing this practice will make the current picture marginally worse but at least it will be clear. Patients who cannot attend (CNA s) and who give the hospital notice are given a second opportunity, but if they cancel on a second occasion they are removed from the list unless the consultant overrides. In Gwent many of these patients appear to go onto the suspended list rather than being removed. All of these DNA and CNA cases need to be reviewed again, now, to establish clearly whether the patient intends to proceed with surgery or not. A personal call or visit is always more effective than a letter. There is little point in booking them in again if there is a significance chance of another non-attendance. When these patients are offered a second admission date I strongly recommend that close contact be established with them in the days immediately prior to admission. This will be

13 particularly important if they are amongst those selected for referral to another centre. 10

14 11 The sheer volume of patients on these waiting lists is generating problems of its own. Targets The current target within the Gwent health community for a first outpatient appointment is that no patient should wait longer than three years. This is no service at all. The Gwent health community should be required to reduce this to a maximum of six or at the worst twelve months within three years and build the required finance and capacity into their spending plans. New investment in the orthopaedic service is clearly essential either by a process of reallocating existing investment within Gwent or with growth money provided by the Assembly or a combination of the two. Gwent clearly can expect new investment over the next few years if the recommendations of the Townsend report are implemented [7]. For inpatients the current Assembly target is that the no over eighteen month waiting list target should have been achieved in July 2002 and then sustained month on month throughout the year. In Gwent the July target was not sustained and the current commitment is to achieve this by 28 February To do this the Trust will have to have treated (or removed from the lists) 381 patients currently waiting at the end of the current list at 30 November Based on the agreed Commissioner LTA and present performance it is not possible to achieve this within the local NHS so a significant number of patients (150 or more) will have to be referred to other centres for their treatment. This will start in the New Year with 120 cases being treated, with NHS funding, at the BUPA hospital in Cardiff. Further contracts at other centres, some in England, are being negotiated. Some patients will no doubt be reluctant to travel and the Trust needs to be clear what will happen with regard to their status on the waiting list if they do decline. In my experience most patients will travel if they have confidence in the centre to which they are being referred, transport is organised, and appropriate postoperative care arrangements are put in place. It needs superb clinical organisation, as many of these patients will require joint replacements. An all Wales review in February 2002 showed the case mix at the end of lists in Wales to be as follows: Shoulders 9% Feet and ankle 14% Backs 9% Hips 20% Knees 45% Other 3% Gwent will be pretty much the same. The Trust are confident that the first fifty patients who are to be treated in Cardiff in the coming weeks will present themselves but the position needs to be monitored very closely and action taken quickly if this should prove to be too optimistic. The identification of and booking for the next tranche of patients is underway but needs to be accelerated if the agreed target is to be guaranteed. Given the importance of this

15 action to the achievement of the target, day by day monitoring by the senior staff of the Trust would be appropriate. 12

16 13 The Trust is unable to guarantee that this target of no patient waiting longer than eighteen months can be held throughout 2003 without further funding. If it is achieved it is because of an investment of 1m by the Assembly, only half of which is recurrent, a one off special investment of 300,000 by the local health community and an additional commitment to outsourcing by the Trust of a further 300,000 which is currently not covered (if indeed it can be committed at this stage in the year). I am advised that further outsourcing capacity is available should funds become available and suitable patients can be identified. This would materially help with next year s targets. Efficiency Day case rates look to be at or around the Wales average as is the average length of stay (ALS) in hospital. However the ALS for both hip and knee replacement looks to be high [4]. Reported activity rates have been as follows but I am told there are reservations about the accuracy of the data for the earlier years and 1996 in particular. Provider Spells Day cases Elective Inpatient Emergencies TOTAL NOTE: Year to end September I could obtain no really satisfactory explanation for the drop in day case work other than perhaps a change in clinical demand and change in medical staff. A more detailed clinical audit would throw more light on this matter. There are 38 patients waiting longer than twelve months. This target could be reduced to twelve months or less. Some patients who could properly be dealt with as day cases are being operated on as part of major lists. This seems inappropriate given the pressure on inpatient beds and main theatres. Overall bed occupancy in the acute sector is 88% with the Royal Gwent operating at 91.5%. This is high. Occupancy in the community hospitals is currently 87.1%. Further work needs to be undertaken to establish how these assets, totalling over 600 beds, could be used to take some of the pressure off the acute wards. If some of these the community beds were appropriately staffed it ought to be possible to sharply reduce the time patients spend in the acute hospital, which is under such pressure. If surgeons are to transfer suitable patients four or five days after major surgery they would want to be sure first that the community beds would be protected for their transfers, sufficient rehabilitation services were available on site and the environment was suitably sterile so as to prevent infection which has such serious consequences for patients who have had a joint replacement. I was advised that a sixbed unit could be created quickly at County Hospital at a minimal cost. I did not myself review the trauma activity but given its size and importance a joint audit with primary care would be valuable to see whether any of this caseload could

17 14 be properly dealt with in ways that would avoid admission to hospital. Even a small change would have a significant impact on hospital resources. Operating sessions at the Royal Gwent Hospital are currently not flexible enough to permit two major joint replacement procedures per session although this is possible at Nevill Hall Hospital and in the private sector. Theatre policies need to be reviewed urgently with the surgeons and anaesthetists so that this is possible. The continued growth in the number of medical emergencies remains a major problem but a good plan has been agreed locally to deal with it. A Bed Bureau is now working for General Practitioners. A new Medical Admissions Unit with ten beds comes on stream at the Royal Gwent Hospital in September 2003 and two additional Physicians, with a particular responsibility for emergency care, start in the New Year. This should make a big difference. Other ways are, at last, being found of dealing with surges in medical admissions other than encroaching into surgical beds. Nevill Hall Hospital has also experienced increased medical emergency loads but has traditionally been under less pressure although I am told this is changing. Reducing the numbers of patients awaiting discharge from hospital would help enormously in the whole sector. I wonder if a single social work co-ordination point in each hospital would help matters. POSSIBLE SOLUTIONS In the short term the Trust can materially improve the present inpatient position by a stricter policy of ring-fencing cold orthopaedic beds, greater attention to the management of the waiting lists and changes in the manner in which the operating theatres are utilised. The Trust will also need to ensure that the policy of referring a significant number of patients to other centres actually works. Primary care organisations could help by much closer attention to demand management so as to ensure that specialist services are not swamped by minor cases whose needs could be met in other ways. In so far as ring fencing is concerned the Physicians to whom I spoke accepted the need to do this for orthopaedic services as did the Health Authority. I suggest 25 beds are firmly protected at the Royal Gwent Hospital as soon as the new Physicians are in post. If these beds are to be used intensively the orthopaedic services will need to be managed much more tightly. The outpatients problem is more difficult to resolve without a significant increase in the number of orthopaedic Surgeons or Physicians. In the short term I suggest that, after discussion with General Practitioners, a referral protocol is established that leads only to the most urgent or clinically important cases being referred for the time being. (There might be one or two exceptions to this including perhaps the innovative scheme at Caerphilly for rapid access to day surgery). General Practitioners might find an extended set of direct access Physiotherapist clinics helpful as a further alternative but the first priority for new clinics of this sort must be an attempt to divert suitable patients from existing outpatient lists in order to

18 15 reduce them to more acceptable levels. Current ideas, which seem sensible, centre on the development of muskulo-skeletal pathways, particularly for back pain, but they are not at present funded. Until recurrent funding can be found I suspect this will have to be achieved by reprioritising existing work within the physiotherapy discipline. In the short term the challenge will be to identify those orthopaedic patients with the greatest clinical need and see that they are treated. There may be other GP direct access options that could usefully be explored with the Local Health Boards including extended radiology, orthopaedic equipment contractors and if available General Practitioner specialists and chiropractors. The waiting lists need to be vigorously validated again for all patients who have been waiting longer than a year (and routine systems installed) and patients who do not attend referred back immediately to their General Practitioner. Once the list is reduced to more manageable proportions some General Practitioners might be persuaded to work within allocated outpatient slots, which gives them greater discretion over priority setting. In the longer-term more consultants is the only effective answer and this is provided for in the proposals that follow. For the medium term a decision needs to made about building additional capacity and employing more consultant Orthopaedic Surgeons or Physicians. One option is to build a new orthopaedic centre for South-East Wales but there is no clear consensus about where it should be located. This is an important issue because surgeons will have to travel from all over South East Wales from the bases at which they undertake their trauma work. They will spend a lot of time travelling. The surgeons in Gwent do not believe a centre planned to undertake the majority of the cold surgery for both their communitys and Cardiff s is practicable (particularly if this centre is built on the assumption that lengths of stay will be short because of enhanced rehabilitation and nursing support in both the home and in the community hospitals). I think they are right. For Gwent two intermediate solutions could be available quite quickly but the longterm answer will have to await the emergence of broader plans for the modernisation of hospital services across Gwent and the broader health economy in the whole of South-East Wales. Whatever long-term plan emerges it should include a separation between trauma and cold surgery in this speciality. This is inevitably some years away. Intermediate solutions are required. The first solution involves creating additional bed capacity at Nevill Hall Hospital to ensure the current operating theatres are used to maximum capacity. The capital cost of this would be 1m and the revenue 2. 2m for 600 additional treatments and 1,000 additional outpatients. This proposal could be implemented within eight months of a decision being made to support the plan. The second intermediate solution is to create a dedicated cold orthopaedic centre with its own operating theatres at St Woolos Hospital, which is situated immediately behind the Royal Gwent Hospital in Newport. Revenue considerations will dictate

19 16 whether this is a net increase in capacity or a replacement for some or all of the beds in the main hospital (where the trauma beds will stay). The capital costs of this scheme need to be worked out in some detail but million is the present estimate for two demountable operating theatres and ward adaptations. The revenue costs are estimated at 3-3.5m IF they are a full addition to capacity. But even if revenue is tight this scheme still looks to be a good investment as it provides a protected specialist facility for cold orthopaedics and releases beds in the main hospital for other specialties. It could be available within a year provided no problems are experienced with planning permissions. It would, it is thought enable an additional 840 patients a year to be treated and 2,000 extra outpatients. I have not myself checked any of these costs provided by the Trust and in any case LHB s will I am sure want the opportunity to review a more detailed business case. The revenue will need to be phased in over two or more years. These new developments would together provide for the appointment of five additional Orthopaedic Surgeons/Physicians, which should make a real impact on outpatient and inpatient waiting lists. At present the prospects of the capital to create this new capacity being available in Gwent are poor given their overall financial position. The Assembly will have to consider whether it can help with capital to get the change process working and this help may have to extend to transitional revenue funding until such time as recurrent funding is included in the forward spending plans of LHB s. My advice also is to proceed quickly with a major new centre based in Cardiff (presumably at Llandough) to serve its local patients and perhaps provide a tertiary service for particularly complex cases from elsewhere in Wales. I support those who will argue for an academic presence at such a unit and a partnership with those industries involved in this field. If this unit does develop into a major centre for teaching and research consultants from outside Cardiff should be encouraged to participate in the work, teaching and research at the centre even if their main base is elsewhere. I referred earlier to the need to manage orthopaedic services more tightly. It is already a large service and is growing. Clinicians and managers need to work very closely together to maximise the existing investment and plan for the future. Using ring-fenced resources to maximum effect will require great skill and considerable organisation. Orthopaedics needs to be run as a service with, at least in the short term, its own operations room under the direction of the clinical head of service where: Waiting lists are tightly managed Case selection is co-ordinated and patients that are referred to the orthopaedic service rather than an individual consultant are sensibly prioritised and allocated. Individual consultants must remain the final arbiter of the relative priority of patients referred to them directly but some sensible reallocation of cases by agreement and with the patients consent would help. Complex cases that require access to beds, theatres and high dependency care are pre-planned and the resources pre-committed

20 17 Connections between the beds in the main acute centres and the community hospitals are co-ordinated and used to maximum effect Performance against service agreements is monitored and made know to all clinical teams Beds and theatre sessions that become free when surgeons or anaesthetists are unavailable (annual leave, study leave or sickness) are reallocated quickly and appropriately Ensuring diagnostic and rehabilitation services are properly aligned with other services Ensuring available theatre time is fully utilised Ensuring the day case unit is used to maximum effect Case managing patients who are referred to other centres Acting as the principle day to day contact centre for primary care and monitoring agreed demand management policies Acting as the communication centre for patients on waiting lists Monitoring outpatient clinics and any new direct access physiotherapy clinics Ensuring annual leave and study leave for key staff is sensibly co-ordinated and anticipated in patient scheduling. In the short term I recommend that a senior support team be put in place to work to the Clinical Head of Staff for this service comprising a senior manager, experienced nurse and physiotherapist and if one can be found a General Practitioner. The Chief Executive of the Trust might wish to provide close support. It would also be very helpful if a member of the Assembly s staff could join the team so as improve liaison and understanding. The early priority is the management of the service based at the Royal Gwent Hospital but these services need to be closely co-ordinated with those at Nevill Hall. All of this might lead eventually to a fully functioning clinical network for orthopaedics with its own budget and service agreements and a working collaboration with the services in Cardiff in so far as the distribution of highly specialist work (e.g. complex spinal procedures) is concerned. The Local Health Groups need to think carefully about demand management for specialist services and work closely with the Trust in moving forward. The solutions to this problem needs the whole health community actively engaged.

21 18 REFERENCES 1. Waiting list policies. Letter from RC Williams to NHS Chief executives 11/03/ Innovations in Care outpatient report end October Service standards and Protocols. Dept of Medical Records. Gwent NHS Trust., Review of Orthopaedic Services, South-East Wales health economy July Gwent and Bro Taf Health Authorities. 5. Report of Orthopaedic services in South Wales. VFM Unit July Review of Trauma and Orthopaedic Services for Gwent, Bro Taf and Iechyd Morgannwg Health Authorities Townsend report. Targeting poor health, A Question of balance. A review of capacity in the Health Service in Wales 2002.

22 19 Appendix A Waiting List case selection Gwent December 2002 [two weeks] This table shows the chronological place of the patient on the active list when they were offered treatment in the first two weeks of December 2002.It also shows their clinical category. Consultant Total list Place of Category size Patient Urgent Routine 121 Soon 74 Soon 1 Routine 10 Routine 201 Soon Deferred Routine list Routine Routine Deferred Routine list 221 Urgent 6 Routine 152 Urgent 229 Urgent 153 Routine 210 Urgent 230 Routine Urgent Routine 19 Routine Deferred Routine list 55 Soon Soon 13 Routine 19 Routine Soon 115 Soon 161 Urgent Urgent Soon 258 Urgent Routine

23 20 79 Routine 80 Routine 74 Routine 76 Routine 55 Routine 46 Routine 178 Soon 11 2 Routine 62 Soon 180 Urgent Routine Urgent Soon 50 Urgent 121 Urgent Deferred Routine list Routine 116 Soon 97 Urgent 60 Urgent 122 Urgent Deferred Urgent list cases

24 21 Appendix B DNA analysis December 2001/November 2002 Patients who Did Not Attend; Consultant decision about removal or not from Waiting List. Not removed Removed Consultant IP DC OP IP DC OP Mr Grant Mr Jones Mr Hariharan Mr Tayton Mr Alderman Mr Roberts Mr Kulkarni Mr Savage Mr Mintowt Czyz Mr Hannaford Youngs Mr Nada Mr Davies Mr Mackie Mr Rice Mr Walker Mr Nathdwarawala Shared patients TOTALS

25 22 Appendix C Terms of Reference Background This year for the first time each health community agreed a SaFF with the Welsh Assembly Government. As part of this process there has been significant discussion with Gwent over their ability to meet certain waiting times targets. The Welsh Assembly Government are aware of the difficult issues surrounding the Trust at the moment and the impact these appear to have on achieving the agreed key elective targets. The work that the health community is doing to tackle these issues through its strategic and operational management approaches is acknowledged and appreciated. However, meeting these targets is essential if we are to provide the patient care that we are all striving for and the Minister is looking for this assurance. It is clear that there are issues (e.g. emergency medical admissions, outbreaks of D&V, Delayed Transfers of Care, impact from the Prince Charles Hospital) that the health community feel are having a serious effect on the delivery of key elective targets. Assembly Officials are already working with the health community on trying to resolve issues around emergency care and DToC. Aims 1. To provide the Minister with early assurance that the Gwent health community will, as soon as possible, achieve and sustain the position in Orthopaedics where: - no patient will wait over 18 months for inpatient or daycase treatment, and - work towards reducing the outpatient wait to 18 months. 2. To support the Gwent health community in identifying areas of development and good practice to achieve its targets as soon as possible this financial year. 3. To provide a report with conclusions and recommendations as to position in Gwent in relation to both short and longer term waiting times targets. 4. To inform the work of the all Wales Orthopaedic Project Group. Terms and Reference Taking account of issues affecting agreed elective targets: To assess and report on the capability of Gwent Healthcare Trust to deliver waiting times targets for orthopaedics. To assess the Trust s ability to maintain and improve such a position in the longer term. To assess opportunities in mitigating other issues and pressures to support the achievement of targets.

26 To assess the appropriateness and timeliness of waiting times information systems to support the delivering of targets. To confirm actual achievable targets for this financial year within existing resources. 23

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