Trauma & Orthopaedics Service Redesign July 2016 1
List of Contents 1 Introduction 2 Background 3 Case for Change 4 Stakeholder Engagement 5 Implementation 6 Capacity 7 Finance 8 Programme Risk 9 Conclusion List of Appendices A Comparison of Options B Risk Log C Quality Impact Assessment template D Work Stream Projects E Poole Predictor Tool F Letter from the Scottish Health Council G Letter from the Academy of Medical Royal Colleges and Faculties in Scotland 2
1. Introduction This paper will outline the proposed changes to the Orthopaedic Service commencing with the case for change and progressing to the commitment to deliver the preferred two site model of one site for Trauma and a separate hospital site as the single elective operative site for Orthopaedics within Lanarkshire through phased redesign of the service. It will provide detail on the imperative to implement immediate change to ensure safe and sustainable services for patients now and then develop the final phase of reconfiguration within the context of the wider NHS Lanarkshire Healthcare Strategy. It has been recognised by the clinicians and managers in Lanarkshire for some time that improvement should be made to the quality of the Orthopaedic Service; however, they have noted that effecting change involved a number of challenges which would inevitably impact upon other areas of service provision. The concerns about the quality of care were echoed and emphasised by the report from the Rapid Review of Safety and Quality of Care by Healthcare Improvement Scotland (HIS) in December 2013. In the period since the HIS report there have also been inspection visits by the General Medical Council (GMC) and the Postgraduate Dean for Medical Education on behalf of NHS Education Scotland (NES), reviewing the quality of training provided to doctors in training in the Orthopaedic service in Lanarkshire. As a consequence of the current three site configuration, senior medical staff are required to spend a disproportionate amount of their time staffing out-of-hours rotas and this limits their availability to supervise formal training.this has resulted in formal external assessments criticising aless than satisfactory level of training qualitybeing provided to junior doctors in Foundation and General Practice programmes attached to the service as well as Core Surgical and specialist Orthopaedic training programmes. NHS Lanarkshire has taken forward recommendations from the HIS report and the feedback from the training quality visits,and has carried out a full review of the Trauma and Orthopaedic Service configuration in order to develop more detailed options for the provision of a safe, effective, personcentred and sustainable service. These are discussed in more detail under the case for change in section 3 of this paper. The Orthopaedic Service review by NHS Lanarkshire has outlined options, risks and requirements for the redesign of Trauma and Orthopaedic services in NHS Lanarkshire. This work was subject to external, independent expert review by the Academy of Medical Royal Colleges and Faculties in Scotlandwho endorsed NHS Lanarkshire s approach to redesigning the service by moving to an interim model where Orthopaedic surgery is initially concentrated onto two sites both providing Trauma and Elective services. Orthopaedic outpatients will continue to be provided on three sites. 3
This interim move will allow NHS Lanarkshire to deliver the necessary improvements and ensure a safe and sustainable service for patients that: delivers improved and more consistent outcomes for patients reduces the time patients (particularly for trauma) spend in hospital after surgery improves waiting times performance and lessens dependence on capacity provided at the National Waiting Times Centre delivers improved support and training for junior doctors improves the sustainability of medical workforce at consultant and trainee levels. Our ultimate strategic aim is to move to a model that is in keeping with the proposals from the National Trauma Network which has subsequently been endorsed within the National Clinical Strategy andby the Academy of Royal Colleges and Faculties. This will necessitate a move to a twosite model with one single trauma unit on the Wishaw General site with one of the other district general hospitals (DGHs) providing elective operative services,which will be consulted on within the NHS Lanarkshire Healthcare Strategy. The Academy has also clearly stated that whilst the interim move will address some of the challenges presented in the HIS, Trauma and Orthopaedics GIRFT (Getting it Right First Time) and Deanery reports, it must be clear and explicit that this is part of a journey to a single site for trauma. It is this ultimate strategic aim that will be consulted on as part of the NHS Lanarkshire s Healthcare Strategy. However it is proposed that an interim model, where Trauma and Elective Orthopaedics are initially concentrated onto two sites both providing Trauma and Elective services, should be progressed as this will offer an immediate solution to the clinical risks within the service whilst being deliverable within the current constraints. It is further proposed that this initial phase can only be achieved by one of the developed options for reconfiguration, namely that the two sites be Wishaw and Hairmyres Hospitals; the rationalefor this is articulated below. 2. Background Orthopaedic services within NHS Lanarkshire are currently provided on an outpatient, day case surgery and inpatient basis from Lanarkshire s three district general hospitals Hairmyres Hospital, Monklands Hospital and Wishaw General Hospital. In addition, a proportion of elective inpatient services are provided at the Golden Jubilee National Hospital (GJNH). However this is in the context of a changing national picture and proposals on how both Trauma and Elective orthopaedic care will be provided in the future. There is recognition that the needs of the population are changing rapidly, and the volume of primary and revision joint replacement operations will continue to grow for the foreseeable future as a consequence of rapidly ageing population. As a result, NHS Lanarkshire s Trauma and Orthopaedics service expects a growth in activity by 12.9% by 2020 with further growth of 11.7% by 2025. 4
The National Clinical Strategy for Scotland 2016 document has commented on current national provision of orthopaedic services and highlights the need for quality improvement; there are known examples of where we accept a structure that is unlikely to produce the best possible outcomes. For example, evidence from the US suggests that a surgeon doing hip replacement operations should do at least 35 operations per year. At that level of activity the occurrence of complications falls to around the minimum level. It goes on to state; In Scotland we provided about 7,600 hip replacements and 7,170 knee replacements in 2013/14. There were also 950 hip arthroplasty revisions, and 460 knee arthroplasty revisions. Hip and knee arthroplasty revisions are recognised to be more complex and challenging procedures, and there is a greater risk of adverse outcome for the patient. The arthroplasty project report results show that 40% of hip revision operations were carried out by surgeons who do less than ten such operations per year, and just under one third of the knee revision operations were carried out by surgeons who do less than five procedures per year. Some of the revisions will have been non-elective, but a significant proportion were not. Whilst the surgeons may have produced acceptable results in the patients, it seems to be the case that such arrangements increase the risk of adverse outcomes a point acknowledged by the Arthroplasty Project Report It is set out in thegirft report produced by NHS Scotland in March 2016 that outcomes for patients were likely to be variable and measures to address this should be put in place as soon as possible: Hip replacements are conducted by 22 surgeons, of which 7 conduct less than 5 per annum. The average per orthopaedic surgeon per annum is 14.8 which is less than half the national average of 35.9. Knee replacements are conducted by 21 surgeons, of which 3 conduct less than 5 per annum. Hip revisions are conducted by 10 surgeons, of which 7 conduct less than 5 per annum. Knee revisions are conducted by 7 surgeons, of which 5 conduct less than 5 per annum. The surgeons at HM all carry out enough procedures as do the team at WG but the numbers from Monklands may seem lower as they have six surgeons operating from 4 days theatre access thus reducing the volume of cases possible and therefore do not hit the national average. The 5 year revision rate for both hips and knees at Monklands is the highest in the country. The GIRFT report also highlighted a number of recommendations which recognise the need to improve the NHS Lanarkshire service through delivery of a whole system approach. Recommendation 5 is highlighted below: 5
Evaluate the case for protected beds and develop strict protocols to maintain the efficient flow of planned orthopaedic surgical cases through them for the benefits of the patients and the service. The current service model, as evidenced in the report from the Academy of Medical Royal Colleges and Faculties in Scotland, has led to variations in practice across the 3 sites. The absence of an overarching team structure to the Trauma and Orthopaedic service has enabled sites to imbed individual practice over time. Consequently development of a board wide service with a whole system approach will ensure consistency of standards and support the delivery of proposed changes to the service. The move to a single site model for Trauma is the primary aim of the strategic objective within NHS Lanarkshire. Whilst this represents significant challenges to achieve, it forms the goal for service redesign as it is recognised as providing the greatest opportunity to meet the changing needs of the population, deliver a sustainable medical workforce and fit with national and regional service developments. It is clear from detailed modelling work that has been carried out that changes to the bed, theatre and outpatient clinic footprints and associated infrastructure will have a significant impact on the distribution of services within each of the three acute hospitals and NHS Lanarkshire will have to balance the need for optimal distribution of services and best use of resources across a range of services on each site. This will include the associated impacts on community based services. 3. Case for Change The case for change has been made through the need to achieve: improved patient outcomes, a sustainable medical workforce and establish pathways of care that meet the changing needs and demographics of the patient population highlighted through the NHS Lanarkshire review. The view of NHS Lanarkshire which has been confirmed by the Academy of Medical Royal Colleges and Faculties in Scotland is that maintaining the status quo is neither a sustainable option (care provided by consistent specialist teams), nor will it address the safety and quality issues raised in the 2013 HIS Rapid Review report. The Academy also noted that there was consensus on this opinion across Emergency Departments, Trauma & Orthopaedics and Care of the Elderly teams across NHS Lanarkshire. Whilst initial work within NHS Lanarkshire s orthopaedic review focussed on immediate changes necessary within the service and how they could be delivered, further consultation with clinicians led to wide acceptance that the strategic direction is to move to Trauma and Elective work on separate sites. These conclusions have been reinforced by the recent publication of the National Clinical Strategy for Scotland. 6
The NHS Lanarkshire review of Orthopaedic services focussed on 4 possible options for reconfiguration of services.these options are set out in the table 1 below. All options include Wishaw General due to its designation as a Trauma Unit within NHS Lanarkshire. Table 1 Maintain Trauma and Elective across 2 Sites 50/50 Split between 50/50 Split between Wishaw and Wishaw and Hairmyres Monklands Trauma and Elective on Separate Sites Wishaw Trauma Only Hairmyres Elective Only Wishaw Trauma Only Monklands Elective Only A full summary of the benefits and disadvantages of the two-site service models and the respective Hairmyres and Monklands sub-options is provided in (Appendix A). This offers a summary of the information, presented for comparative purposes along with the existing service provision (status quo). The scale of change that is required to achieve this within Lanarkshire is challenging and it is impossible that a single trauma unit can be achieved within the current bed complement and Emergency Department footprint at Wishaw without causing significant disruption to other services. The preferred approach is therefore to move towards this strategic objective in a phased manner by moving initially to two combined trauma and elective units. This will enable the development and implementation of a clinical model which improves services for patients, improves outcomes, delivers improvements to the length of stay in hospital (LOS) and improves the sustainability of the medical workforce model. Sustaining the medical workforce A key issue noted in the Healthcare Improvement Scotland (HIS) report was the need for a fundamental review of the distribution of orthopaedic services across NHS Lanarkshire to support the provision of safe, person-centred and effective care. The report noted significant and persistent issues, the solutions for which required models of care built around patients but which take account of the available workforce. Onerous and stretched out of hours and on-call rotas for consultants impacting on recruitment and retention was identified as a challenge of the current clinical model which has elective and trauma services provided across three sites. This pressure continues to exist and despite all efforts to improve the availability of staff with the appropriate knowledge and skills, a sustainable solution has not been found that meets the needs of the current service configuration. The service has an increasingly challenging vacancy rate in medical staffing. Consultant recruitment and retention has been stable with relatively short term vacancies filled with locums in order to minimise the impact on elective activity. However, middle grade vacancies are common with gaps totalling 14 months service in the past year (2015/16) and of this 8 months were filled with Agency locums. Junior doctor vacancies are high, especially in GP training posts allocated to the specialty with 49 months of service in gaps in the past year, of which 23 were filled by Agency staff. 7
It is felt there is a short window of opportunity to improve the training available in GP training posts in Lanarkshire where only 5 out of 18 training posts across NHSL are currently filled from the training programme, the remainder being filled with short term locum staff. Since March 2014, the service has been subject to enhanced monitoring by NHS Education for Scotland (NES) on behalf of the General Medical Council (GMC) to ensure that the necessary quality of training and environment of safe patient care in which training is provided can be assured. Without this continued assurance, which is currently at risk, training recognition will be removed and the service will not be sustainable within NHS Lanarkshire. At the most recent of the regular enhanced monitoring visits across NHSL, whilst it was acknowledged that a great deal of work was ongoing to support training quality, a number of outstanding concerns mean that the service will remain subject to enhanced monitoring in contrast to other areas which are progressing towards removal of this status. Concerns include; intensity of workload access to outpatients and theatres as educational opportunities non-educational ward based duties consume inappropriate amounts of training time inability to provide sufficient cover to ensure robust handovers lack of protected teaching time and opportunities to participate in learning from adverse events Trainees have commented on 'fragile rotas', cancelled lists impacting on training opportunities and gaps in rotas adding to intensity of work especially out of hours and at weekends. In preparation for reconfiguration, 10-person rotas have been designed for junior medical staff at each of two sites and 8-person rotas for middle grade medical staff that can ensure fully acceptable levels of staffing cover for all wards, theatre and emergency duties and provide training opportunities for all grades of doctors in training that would more than satisfy the requirement of the GMC and NES. The changing needs of the population Planning the future service provision will require account to be taken of a number of significant changes which will impact upon the demand for the service over the next twenty years. The largest factor is the increase in over 75s, recognising that patients are living longer and the added complexity of each individual s clinical presentation due to a number of age related factors. Orthopaedic activity is expected to increase by 12.9% by 2020 and a further 11.7% by 2025. Activity for 2015 is shown below as a baseline for future development as well as the predicted activity levels for 2020 and 2025. 8
Table 2 Patient Category 2015 2020 ( 12.9%) Day Cases 2075 2025 ( 11.7%) Elective In-Patients 1865 GJNH Patients 909 Elective Total 4849 Emergency /Trauma Patients 4682 Overall Total 9531 10,760 12,019 The proposed model for change cannot be a single step process. The complexity of change, staffing and resource implications, impact on other services, physical capacity and new models of care all point to the need to manage service redesign within a stepped programme of change. Engagement with other services will take place on completion of the move to a 2 site model in order to plan the next step of the programme and a move to split Trauma and elective sites. The agreed development of a case for a new hospital at Monklands presents opportunities and flexibility within the programme in order to ensure appropriate capacity is available to locate services whilst achieving the intended goal of a single site Trauma model. Lanarkshire will set out the case for the development of a trauma unit at Wishaw General Hospital, as part of a Lanarkshire emergency care service based on three EDs, and a West of Scotland major trauma network. The national case for the major trauma network identifies how this will save lives and reduce significant disabilities The move to the final configuration will see all trauma surgery at Wishaw, with all elective surgery on another site. The location of elective surgery will be shaped by: The final service model for the 5 National Elective Treatment Centres; The final service model for the West of Scotland major trauma network The capacity for surgery, diagnostics etc to be provided by the development of Monklands Hospital (earliest 7 years in the future) which would enable changes to beds, theatres and clinic capacity across Lanarkshire. This will also embed sufficient capacity to meet the future needs of the population for surgery The responses to public consultation as part of the NHSL Healthcare Strategy 9
Each NHS Lanarkshire acute Hospital is different and centres of excellence already exist. NHS Lanarkshire has committed to retain 3 emergency departments. The 3 Emergency Departments are supported by: Acute Medical and Surgical Services Diagnostics and Imaging Theatres Out-patients Other Clinical Support Services New service models will be underpinned by agreed patient pathways and workforce plans to optimise clinical expertise. As described in Table 3,Outpatient contacts account for greater than 85% of all Orthopaedic appointments and admissions. The service will remain local with the vast majority of patients accessing the service at their local hospital. The initial step in October 2016 will still see Orthopaedic outpatient care and care within emergency departments provided across all 3 sites.only inpatient and day case surgery currently provided at Monklands will be affected. Table 3 NHS Lanarkshire Trauma and Orthopaedics Patient Contacts 2015/2016 Outpatient Attendances Admissions New 26,266 Day Case 2075 Return 35,349 Inpatient 1865 Golden Jubilee 909 Trauma 4682 Total 61,615 Total 9531 Where specific inpatient care is required pathways will be developed to ensure patients are transferred directly to the nearest inpatient site and where the services of a Major Trauma centre is required for specialist care appropriate pathways will also be agreed with Queen Elizabeth University Hospital (QEUH)and the Scottish Ambulance Service(SAS). This provides a comprehensive package across all of 3 acute sites in NHS Lanarkshire ensuring patients can access the majority of their care as close to home as possible whilst concentrating specialist care to appropriate sites in order to improve outcomes. Even with the eventual consolidation of Trauma onto 1 site, Orthopaedics will retain a presence across all 3 sites. Alongside the need to restructure clinical delivery of the service the need to break down unnecessary variation in working practice and develop a cohesive, shared vision exists. A clinical lead will be appointed by summer 2016 alongside a newly appointed dedicated Trauma and Orthopaedic service manager role. This level of leadership and management across the 3 sites puts in place the 10
foundations required to build on and deliver the vision outlined. It is difficult to quantify the benefits of establishing a board wide Trauma and Orthopaedic unit but a team dedicated to managing and delivering care within such a complex and busy service will undoubtedly support the vision for redesign as well as delivery of the performance elements of the service. The Trauma and Orthopaedic management team will be responsible for ongoing performance management within the service, reporting directly via monthly service review meetings to the Director of Acute Services. Meetings will concentrate on service position and actions around - Length of Stay (LOS), Referral to Treatment Time (RTT) targets, Treatment Time Guarantee (TTG) performance, DNA rates as well as staffing position, progress against capacity plan and further planned changes and developments. The structure will provide management of the redesign programme via the steering group and operational performance and delivery through monthly service review. Detailed plans setting out the Clinical pathways and models of care which will be implemented to support the delivery of the reconfigured service are well advanced. They include details of bed allocations, theatre requirements and how the service will be supported by appropriate clinical workforce models and activity analysis. There are a number of key principles/issues which will be addressed in the planning process: Agreement of an Emergency Department pathway for patients with orthopaedic injury to be implemented at any site without inpatient orthopaedic activity. Agreement with the Scottish Ambulance Service (SAS) on the pathways for patients and pre hospital management of Trauma & Orthopaedic patients Recognition that there will be a requirement for orthopaedic resources to be reallocated across sites, with agreement, in accordance with the final service configuration. Workforce planning for all clinical, non-clinical and community based staff affected by changes to the current service models Develop a detailed protocol/pathway which sets out how the Care of the Elderly (COE) team will engage orthopaedic patients as part of their workload and to take over the care of appropriate patients at a much earlier point in the process. Produce a Joint Clinical Pathway Model for Orthopaedic, Care of the Elderly and locality services that is workable and achievable. This will require a whole system approach involving specialist and locality based services. Determine the impact on other priority services which will be impacted on by implementation of a service reconfiguration e.g. Theatres / Anaesthetics, Ward Staffing, Trauma and Out-Patient Clinics, Locality based services. Full staff engagement with affected staff and other stakeholders on the proposed service models 11
A significant level of engagement with Senor Clinical Staff at each site has been ongoing to ensure that the preferred configurations continue to be developed in conjunction with senior clinical decision makers to ensure the process is fully inclusive. Key to this is the bed model and theatre activity plan for the proposed inpatient configurations. Activity data, in particular length of inpatient stay (LOS), has been considered in context of regional and national benchmarking and it is clear that for NHS Lanarkshire the average length of stay for both elective and emergency orthopaedic inpatient admissions are consistently higher than the Scottish average. Improving LOS is key to implementing and achieving successful reconfiguration and revised bed allocations are reliant on completion of this modelling. It is also recognised that a key driver in this change process is the development and early implementation of a new clinical and social care pathway which delivers improved access to Care of the Elderly (COE) services and community based services. In particular services such as Hospital at Home and community based Care at Home will improve our ability to support patients within the community and will facilitate the Home First approach that will be applied. This will focus on patients being transferred home with appropriate support to manage their ongoing medical and rehabilitation needs and improve their outcomes. Implementation of this approach will ensure that the care of elderly patients is not disrupted and also that those patients that do require a longer stay in hospital are managed in the most appropriate location under the care of the most appropriate clinician. This improvement will deliver a significant benefit through improved patient outcomes as we move care from hospital to home. The reduced dependency on inpatient beds will facilitate the ability to accommodate orthopaedic beds within the existing bed allocation across the two sites.the exact distribution of these beds will be determined by the size of the specific components of the trauma and orthopaedic reconfiguration. 4. Stakeholder Engagement Throughout the review process NHS Lanarkshire has been committed to ensure that it informs, engages and consults with stakeholders and an orthopaedic planning group was established to take forward this review process. This group included clinical, managerial, patient and staff representation.as part of the NHS Lanarkshire Review process two key stakeholder events were held to consider and understand the challenges of the current configuration of orthopaedic services and to identify and appraise options for a revised service model which would address the review s key objectives. The events were held in December 2014 and in March 2015 with each attended by approximately 60 delegates including patients, patient representatives, carers, clinicians, managers, and staff representatives. Scottish Health Council representatives were also in attendance. The short list of service reconfiguration options from the December workshop was defined in detail prior to the next stage of formal option appraisal, which took place at the March 2015 workshop. The detailed process included identification and impact assessment of any changes required at 12
individual hospital level to facilitate implementation of any of the options. It also took account of working practices, capacity, demand, bed requirements, theatre availability and demographic changes. The analysis of final outcomes concluded that outpatient services should continue to be provided across three sites and that inpatient services should be located at Wishaw General Hospital and one other site. The Scottish Health Council have advised on the consultation process to move to a Single Trauma and Single Elective site within NHS Lanarkshire (Appendix G) and this will be delivered as part of a wider consultation process within NHS Lanarkshire s Healthcare Strategy. They have also acknowledged that there has been a recognised clinical need to move to an immediate interim position 5. Implementation With the recognition that NHS Lanarkshire s strategic direction of a single Trauma and Elective Orthopaedic site is not possible immediately and that the status quo is not an option, it is proposed that the first stage necessary in achieving this is an interim model where Trauma and Elective Orthopaedics are initially concentrated onto 2 sites, Wishaw General and Hairmyres Hospital, both providing Trauma and Elective services. As previously outlined this will offer an immediate solution to the clinical risks within the service whilst being deliverable within the current constraints. Table 4 Stage 1. Maintain Trauma and Elective across 2 Stage 2. Trauma and Elective on Separate Sites Sites 50/50 Split between Wishaw and Hairmyres Wishaw Trauma Only Elective Only Site It is proposed the revised inpatient service will be consolidated on two sites, Wishaw General and Hairmyres Hospital, with access to outpatient services being retained on all three sites. Both inpatient sites will provide a mix of elective and trauma services which are similar in size. This can be accommodated within the current orthopaedic bed and theatre footprint on each site with some adjustments to operational hours of theatres to ensure that the necessary capacity is available at each site. There has already been implementation of ring fenced beds and work is ongoing to develop theatre models for Orthopaedics. This will ensure that the capacity required for service delivery is available as well as the creation of an Orthopaedic multi professional team acrosslanarkshire. Delivering a single trauma site within the current bed complement and the ED footprint at Wishaw is simply not achievable without creating a need to restructure the inpatient configuration of other specialties. The consequential impact of additional unscheduled ED attendances at the single 13
trauma site would create concerns over the capacity of that site (Wishaw) to deliver safe front-door services. The move to a configuration of a single Trauma site at this time is therefore not tenable. Similarly the detailed review of required capacity and available infrastructure indicates that Monklands would be unable to accommodate sufficient theatre capacity to support the proposed interim model. Conversely the released theatre capacity at Monklands, from moving to Wishaw General and Hairmyres Hospital as inpatient Orthopaedic sites, would facilitate enhanced service provision in inpatient ENT and Urology services where Monklands is the existing centre of excellence. Through the considerable work carried out within the NHS Lanarkshire service review, the documented benefits and disadvantages of each option (Appendix A), as well as a shared vision for the service articulated by the Consultant group at the Orthopaedic Reconfiguration meeting held on the 9 th May 2016 the preferred option to proceed with is detailed below. The implementation programme for service redesign now relies on a decision on the proposed site options in order to move forward. In order to fully develop an implementation plan we ask that the board agree to supporting and proceeding with this model. Recommendation for Approval Begin implementation of strategy to achieve Single Trauma and Elective sites for Orthopaedics with the initial step of 2 sites at Wishaw and Hairmyres providing a 50/50 Trauma and Elective split. Stage 1. Maintain Trauma and Elective across 2 Stage 2. Trauma and Elective on Separate Sites Sites 50/50 Split between Wishaw and Hairmyres Wishaw Trauma Only Elective Site The implementation of the proposed model is reliant on improved patient pathways. The Healthcare Improvement Scotland (HIS) report noted significant and persistent issues, the solutions for which required models of care built around patients but which take account of the available workforce. Current Orthopaedic pathways are based on historical models of care and Length of Stay data shows increased length of stay in orthopaedic beds compared to other boards across Scotland. This is particularly the case for patients >65years of age where the average length of stay is more than 2 days longer than the Scottish average. Opportunity exists to remodel care for this group of patients; utilising greater input from Care of the Elderly physicians and associated clinicians to develop an integrated approach across acute and community services ensuring care is delivered in the most appropriate location. Further details of this are described in section 6. The key elements of this change are therefore to improve the efficiency of the service by concentrating inpatient provision on two centres of excellence and by focussing attention on the 14
orthopaedic elements of the service. Additional capacity for rehabilitation/shared care including a Home First approach, to ensure a patient s transfer home occurs sooner and is supported by appropriate staffing models and governance, will be developed and implemented in advance to enable this step change to be facilitated. Implementation of new pathways is underway; driving improvement in length of stay and developing closer working relationships with community teams in order to build on existing pathways and to ensure patients are cared for in the most appropriate location by the most appropriate provider and clinician. The Orthopaedic service redesign is being managed within a programme structure. This will is led through the Steering group which maintains overall responsibility for delivering the redesign programme in line with schedule. Reporting to the Steering Group are 6 work streams as outlined below. Figure 1 Orthopaedic Redesign Work Stream Governance Structure Steering Group Group established, Monthly meetings scheduled Review progress against plan for each working group Ensure programme delivered on time & mitigating actions in place Manage Risk and QIA across programme Theatres Wards Outpatients Unscheduled Care Groups established, meetings scheduled TOR completed Sub groups established in Ward group Project Plans in place Highlight risk and quality impact to steering group Workforce/ Job Planning Care of Elderly Hospital@Home & Community Services The steering group maintains and undertakes regular review of a detailed project plan, comprehensive risk and issue log for the programme of workwhilst overseeing the work streams and ensuring appropriate mitigating actions are in place. The Steering group also reviews Quality Impact Assessments of changes proposed (Appendix C). The steering group provides support to the work streams through the management of necessary resource and the interdependencies. 15
The work streams act as the engine room, developing and delivering key actions within the project plan to ensure implementation of the redesign by October 2016. Details of the work stream outputs are provided in Appendix D. 6. Capacity Length of Stay (LOS) LoS in Trauma and Orthopaedics is currently worse than comparator boards across Scotland. This represents an opportunity to redesign patient pathways such as greater integration with community services and the establishment of an early supported discharge model through the use Hospital@Home, to ensure patients rehabilitation is central to their orthopaedic management. The focus is to improve outcomes and safety for patients of which a reduction in Length of Stay can be regarded as a surrogate marker. Reduction in length of stay to a figure in line with other health Boards in Scotland has established a baseline for the bed requirements to facilitate the first phase of moves to a 2 site model with a shared Trauma and Elective split. The development of bed modelling has been taken forward recognising that material changes in process will be required to drive improvements in outcomes and to enable the development of a reconfigured service which is operationally deliverable. The starting point of the discussion identified a number of objectives which require to be achieved: Improved outcomes for patients Improved service integration Development of centres of excellence Definition of improved patient pathways Ability to develop service as demography alters Significant development of patient pathways and models of care recognising current good practice and consistent with current thinking has been undertaken in conjunction with key clinical decision makers. This has driven an agenda to deliver improvements and from a bed numbers and configuration perspective the key measurable is patient Length of Stay (LOS). The current LOS is relatively high and results from a combination of factors including the existing service configuration,access to clinical decision makers and current patient pathways. There are also variances across the three sites which have an impact. The initial assumptions for assessing bed requirements have been to determine an appropriate improvement in LOS by redesigning the clinical model/pathway and providing a service which best serves the needs of patients. The key elements of this are to improve the efficiency of the service by concentrating inpatient provision on two centres of excellence and by focussing attention on the orthopaedic elements of the service. Additional capacity for rehabilitation/shared care will require 16
to be created to enable this step change to be facilitated. The changes to LOS while challenging are achievable in the short term and will provide a platform for further continuous improvement. The inpatient activity profile has been subject to significant review and analysis and the emerging outcome is that there are two distinct patient groups with differing needs that should be considered separately. The groups are 0-65 and 65+ and the current LOS in emergency/trauma is 4.54 and 19.21 respectively with a combined LOS of 10.68. The key issue is the recognition that a large element of the care for the 65+ group, the largest patient group, need not be delivered in an orthopaedic setting, and may well be more effectively delivered in rehabilitation/shared care environment. The proposed model of care sets out two significant changes: Separation of the care for the 65+ group Improved patient pathway for elderly patients Subsequent reduction in length of inpatient stay The patient centred pathway outlined below shows that with early assessment and coordination of planned discharge and/or rehabilitation, significant improvements in quality of care and associated length of hospital stay can be achieved. Some aspects of the required supporting workforce are already in place and others will need further development to give a fully integrated team approach that will support the patient from the early stages of admission to an expedited transition to home with additional community input as appropriate. Delivering this change in service provision and driving a sustainable improvement in LOS not only has a significant impact on bed requirements but facilitates delivery of the proposed two site option within the existing orthopaedic bed complement. LOS within orthopaedic reduces to 4 and 7.5 for the 0-65 and 65+ groups respectively with a combined LOS of 5.28. While further work on the detail of bed configurations will continue, these changes facilitate the proposed bed model.separation of care for the 65+ group may require some temporary upward adjustment to beds allocated for rehabilitation as a transition to support this improvement in LOS. The location and detail of configuration of these transition beds is still the subject of discussion. It is recognised that these improvements in LOS will require to be achieved in a structured manner over a defined timescale that will be finalised on conclusion of the preferred option and delivered in conjunction with supporting staffing models. Care of the Elderly The Care of the Elderly work stream is a key element in delivering the improvements in LOS which will be achieved through the development of new models of care and the increased utilisation of Hospital@Home as part of an elderly supported discharge process (ESD) for appropriate emergency Orthopaedic patients. This model will provide a bridge between acute and community services on a 17
temporary basis to enable community based services to be developed. Work to implement a Test of Change model at Hairmyres has commenced. This will facilitate the early transfer of patients into Hospital@Home under the care of Geriatric Orthopaedic Rehabilitation Unit (GORU) physicians. It is recognised that this will require significant engagement with community based locality teams to ensure that services are in place to facilitate flow out of Hospital@Home back to community services. This must be managed by working together to utilise the available resources. This is a major shift in the management of Orthopaedic patients within NHS Lanarkshire and whilst it is recognised that the proposed initial management of the Hospital@Home service through the acute division rather than the community is at odds with the current strategy the requirement to develop confidence in the clinical leadership and governance structure necessitates a period of transition. Hospital@Home represents a key step in the journey from acute to community based care with the development of a fully integrated team pulling patients from acute care. The time frame for delivery and reorganisation does carry risk and it is proposed that, during the transition phase, that additional inpatient surge beds are made available in order to support flow and management of elective. This will provide support to ring fence elective beds which will again drive LOS reduction. This will ensure that the necessary pathways are developed which will build confidence in the models of care across the clinical teams and will mitigate against the risks of failing to achieve the necessary LOS gains. Figure 2 shows a breakdown of clinical complexity in patients with medical and rehabilitation needs. The present model indicates approximately 70% of patients fall into the Low Medical/ High Rehab quadrant where there will be a focus on transfer of care out of the acute hospital environment through an early supported discharge model utilising Hospital@Home in the first instance. Patients clinical requirements in terms of rehabilitation would remain however this will be delivered at home. 18
Medical Figure 2 HIGH High Medical/Low Rehab Patients with this acuity require Nursing input, junior medical staff at ward level, Minimal AHP input High Medical/ High Rehab Patients with this level of acuity require acute medical and nursing care and there is an opportunity for COE to provide support at ward level with in reach from specialist services eg: cardiology. Some of these patients will not be fit for surgery and will be managed conservatively. LOW Low Medical/ Low Rehab Patients with a low rehab and low medical acuity should be at home when safe with support as required. Home first approach as a result of early supported discharge planning. Home Rehab Low Medical/ High Rehab Current data estimates that 76% of trauma patients fall into this category and revised processes and clinical pathways could see this reduce to 44% with the shift of 32% moving to the LM/LR category HIGH A test of change will be run to implement the pathway changes and to evidence what the resource implications will be at each stage in the pathway. The detail of the resource requirements will be developed in conjunction with Joint Integrated Board partners. Early work to develop this model has already commenced with a commitment of 200k funding in an early supported discharge model of care through Hospital@Home. The Hospital@Home team will establish a ring fenced Orthopaedic team in conjunction with the proposed changes in theatre staffing and management structure in order to support the development of a NHS Lanarkshire wide Orthopaedic team. Further engagement is required with local homecare providers, particularly related to response times in order to facilitate smooth transition between services. Test of Change The rehabilitation pathway is integral to this work and there has been ongoing work related to mapping the Allied Health Professional (AHP - Occupational therapy and Physiotherapy) interventions, for both trauma, and elective conditions. A group comprised of inpatient AHPs, community AHPs, Director of AHPs, discharge facilitators, Acute Care of the Elderly (ACE) Nurse and pain nurse specialist, have been working on an agreed pathway, and planning a test of change. 19
The test of change is ongoing in 2 orthopaedic wards, (ward 5 Hairmyres Hospital, and ward 15 Wishaw General Hospital), where we will use an adapted version of the Poole Predictor tool (Discharge predictor tool - Appendix E). The ACE Nurse/ AHPs and discharge facilitator will work alongside the patient and family to indicate possible destination post surgery, indicative length of stay and support required for discharge. The aim is to commence this on day 0 or day 1. A Home first approach, will be tested when patients are orthopaedically and medically stable allowing transfer to hospital at home team with the therapists providing outreach therapy interventions. Early, enhanced home care/support will also support the therapy. There is evidence that on occasion, this can enable a reduced overall package of care and a potentially earlier discharge from community services overall. In recognising the growing number of community services available and the respective skill set therein, this test will be evaluated to inform the developing model of early recovery and rehabilitation for these patients within the community together with the respective staffing/resource implications in all aspects of the pathway. Hospital at Home Pathway 1. There is a shared vision of a future integrated model of rehabilitation based within the community. The model would ensure the community teams are involved in pre-operative planning to support patients home earlier and in a more coordinated fashion. This would include the use of the new Discharge Predictor Tool to risk score the predicted requirements on discharge. 2. The Hospital at Home model and its relationships with generic community/integrated Community Support Teams (ICST) would provide an ideal opportunity to demonstrate the scope to better enable preparedness of discharge from traditionally hospital based care to care in a community setting. 3. This model will be transitional to support rapid change, generate confidence in a home first support and allow time for community services to develop enhanced capacity and capability, and provide medical governance, in the initial phase. 4. Patients will be indentified pre/post op, by the ACE nurse/ Discharge facilitator and AHPs. The team will complete the adapted predictor tool to provide potential discharge destination, indicative Length of Stay/discharge date and support required within the community. This will be completed in collaboration with family and medical staff. This will direct most appropriate pathway for ongoing management. A clinical assessment, initiating Comprehensive Geriatric Assessment will commence linking with the ortho geriatricians. This will aid in identifying those who would benefit most from the hospital at home pathway. 20
5. If a patient is identified as requiring Hospital at Home (H@H) support on discharge they will be transferred in the normal manner. They will be reviewed on the hospital at home ward round daily until the geriatrician feels that consultant overview is no longer required. Rehabilitation goals will be identified by the orthopaedic and H@H AHP practitioners. The delivery of therapy will be supported by generic health care support workers using technology where able. Once a patient no longer requires consultant overview they will be monitored by the NMAHP Consultants for ongoing recovery and rehab with escalation and review from geriatrician if required. 6. Community supports will be provided via early enhanced reablement home care teams, with ongoing management supported via ICST/CARS, home care. There is evidence from reablement work, that an early enhanced approach of this model can show a reduction in homecare support of up to 30%. 7. Where there are existing community services in place, these would continue, maximising the joint health and social care resource. 8. As outlined in paragraph 3, the overall aim is to see provision of community based rehabilitation in each locality with appropriate resources to support this. As part of the Commissioning Plans of the respective Integrated Joint Boards, the evaluation of the transitional tests of change will be utilised to describe the future care model and how the impact on baseline data is demonstrated in shaping future service delivery and associated allocation of resources across the care pathway. This will also allow for clarity re the responsible medical officer role and at which stage this transfers to the patient s own GP. 21
Figure 3 Snap Shot Patient Census. 142 patients were profiled within Orthopaedic and Geriatric Orthopaedic Rehabilitation Unit (GORU) beds across the three sites. Multidisciplinary group was used to profile patients to ensure holistic evaluation of need and identification of appropriate place of future care. The aim was to inform proposed GORU models of care and identify support needs. This audit covered all age groups, (7 patients under 65). Figures are indicative, as based on current activity, and levels of occupancy. Results demonstrated N (Patients) = 142 Table 5 Place of Care % of patients Orthopaedic Speciality 31% Level 1 Home No Support 4% Level 2 Home with H@H rehab and 40% community supports Level 3 Intermediate Care 13% Level 4 GORU 12% Break down of Patients within the Level 2 Cohort n (Patients sub set of total patients) =50 22
Table 6 Rehab only 52% Rehab and POC 48% It is important to note that there is already overlap in these pathways with many patients being admitted to acute care from community settings with packages of care already in place. These pathways will support the management of patients back from acute care. 7. Finance The service redesign within orthopaedics will be revenue neutral. The table below highlights existing costs across the service and the costs following the proposed move to a 2 site model. Table 7 Orthopaedic service - current costs versus proposed costs 2016-17 Roll Forward Budget Proposed (Elective/Trauma) Variance Theatre nursing including Recovery 2,064,087 2,355,487 291,400 Orthopaedic Medical Staff 5,570,887 5,570,887 0 Ward staffing Staffing - Budget 5,322,966 3,879,774 (1,443,192) Supplies - Budget 830,541 830,541 0 Sub-total 13,788,480 12,636,688 (1,151,792) Additional Investment Required Additional Anaesthetic support (4 wte) 480,000 480,000 MINTS Nursing (5.5wte on 2 sites) 531,402 531,402 2.00 wte Anaesthetic Practitioners 95,840 95,840 Service Improvement Advisor 55,266 55,266 SAS Transportation 50,000 50,000 Additional Synergy costs for weekend cover 35,000 35,000 COE/rehab support (Hospital at Home) 278,003 278,003 Sub-total - 1,525,511 1,525,511 Assumed funding for: Contribution towards Healthcare @ Home 200,000 (200,000) 4 Orthopaedic beds at Hairmyres 132,000 - (132,000) 6 Orthopaedic beds at Wishaw 255,000 - (255,000) 587,000 - (587,000) Grand total 14,375,480 14,162,199 (213,281) The modelling indicates a preferable variance of 213,281 for 2016/17 with a 13k preferable variance going forward. 23
A number of assumptions have been made in developing the financial model. These have focussed on key areas such as theatres, ward budgets and staffing: The theatre nursing resource identified is purely associated with Orthopaedic and Trauma theatres. The extension of working days in theatres to increase elective throughput means additional Consultant Anaesthetists will be required. Additional Minor Injury Nurse Treatment Service (MINTS) staffing required to ensure 24/7 ward cover. At this stage, paper assumes other costs as being neutral, although there may be a requirement to move some resources between hospital sites and into the community.- Additional Scottish Ambulance Service (SAS) costs have been allocated within the model. It is likely that the staged approach to reducing length of stay and new models of care may require transitional funding however this will be offset against savings made within the programme over time. The programme will support the capacity plan and vision to pull high cost waiting list work back into core activity. Further work is required to clarify funding sources and baseline costs for 4 beds at Hairmyres and 6 beds at Wishaw which have been staffed on a non recurring basis. Greater understanding is also required for the costs to the acute service in delivering the early supported discharge model for GORU and any additional community investment. 8. Programme Risk Figure 4 Orthopaedic Redesign Work Stream Risk Initial Assessment Working Groups Apr 2016 Oct 2016 Theatres Wards Outpatients Unscheduled Care Workforce/ Job Planning Care of Elderly (Reduction LoS) Ensuring pace and delivery ahead of winter pressures is key to the programme. A formal risk log and quality impact assessment will be undertaken to support the steering group. By way of an initial assessment of delivery by October 2016 the 2 key areas of risk are staffing/ workforce and LOS 24
reductions required through a revised model in care of the elderly. These risks relate to timeframes for consultation with staff which can only start after a formal decision on the sites is taken and the shift in model of care with the use of Hospital@Home for far greater numbers of elderly orthopaedic patients and are formally recorded with mitigating actions in the Risk and Issues log (Appendix B). Outside of programme significant risk also exists around the decision to proceed, both at board and government level. 9. Conclusion Following a comprehensive review and ongoing engagement with clinicians NHS Lanarkshire has concluded that a strategic vision of split Trauma and Elective sites for the Orthopaedic service should be worked towards. Given the evidence and support for this strategy by the Academy of Medical Royal Colleges it is vital for NHS Lanarkshire to move forward with a decision on the future of the Trauma and Orthopaedic service. With this in mind permission is now sought to move to the next phase through agreement of the two sites at Wishaw and Hairmyres and the step to a 50/50 split Trauma and Elective model in order to facilitate an eventual move to a single site Trauma and Elective model in the future. As outlined within the case for change it will take a stepped approach to achieve this aim with consolidation of the service to two sites with a 50/50 Trauma and elective split by October 2016. A defined programme of work now exists across the work streams with resources in place to lead and implement the necessary changes within the service The programme will now rely on delivery at work stream level, continual review of progress against plan and most importantly close working with community teams to ensure pathways and resources meet the needs of patients. 25
Appendix A - Comparison of Options Sufficient Existing inpatient Bed Capacity for Orthopaedics on each site Sufficient Existing inpatient Bed Capacity for Care of the Elderly on each site Sufficient existing Day Unit capacity on each site Sufficient existing Theatre Capacity on each site Meet WoS Trauma Network proposals Orthopaedic medical staffing rotas would be improved Status Quo Under utilisation of designated bed capacity at Hairmyres and Monklands that results in boarding into Ortho and the reverse is true at Wishaw Foot print adequate but flows are inconsistently delivered. Day Surgery capacity Limited due to high volume general surgical workload and stand alone DSU at Monklands is poorly utilised. Conflict with general surgery and trauma. Not enough current theatre capacity at Monklands for each consultant to have and all day list Yes with Wishaw being designated trauma site although some reconfiguration of general surgery services may be required Current difficulties would continue. 20160707 Wishaw and Hairmyres 50-50 Split Trauma & Elective Wishaw and Monklands 50-50 Split Trauma & Elective Wishaw Trauma only Hairmyres Elective Only Yes both sites Yes - both sites Yes at Hairmyres however Wishaw would require to identify 24 additional beds for trauma patients. See below for COTE bed impact Detail still requires to be identified but will also include increased capacity from Hospital @ Home and supported earlier discharge to home Use of the day surgery facilities as an admissions area and for post op care of day case patients needs to be optimised at both sites Yes - both sites with extended day working and additional weekend Trauma sessions Yes with Wishaw being designated trauma site although some reconfiguration of general surgery services may be required Yes - rotas would become fully compliant although reinvestment of costs of Detail still requires to be identified but will also include increased capacity from Hospital @ Home and supported earlier discharge to home Use of the day surgery facilities as an admissions area and for post op care of day case patients needs to be optimised at Wishaw. Existing full utilisation of the stand alone Day Surgery Unit at Monklands will limit the ability to take a full elective component Yes at Wishaw with extended day working and additional weekend trauma but insufficient theatre capacity at Monklands without relocation of Urology or ENT to another site Yes with Wishaw being designated trauma site although some reconfiguration of general surgery services may be required Yes - rotas would become fully compliant although reinvestment of costs of additional sessions required to provide the supporting Additional beds will be required at Wishaw despite increased capacity from Hospital @ Home and supported earlier discharge to home Use of the day surgery facilities as an admissions area and for post op care of day case patients needs to be optimised at Hairmyres and may require structural change to accommodate Yes with extended day working and additional weekend Trauma sessions at Wishaw but insufficient theatre capacity at Hairmyres without relocation of Ophthalmology to another site Yes with Wishaw being designated trauma site although some reconfiguration of general surgery services may be required Yes - rotas would become fully compliant although reinvestment of costs of additional sessions Wishaw Trauma only Monklands Elective Only Yes at Monklands however Wishaw would require to identify 24 additional beds for trauma patients See below for COTE bed impact Additional beds will be required at Wishaw despite increased capacity from Hospital @ Home and supported earlier discharge to home Existing full utilisation of the stand alone Day Surgery Unit at Monklands will limit the ability to take a full elective component Yes at Wishaw with extended day working and additional weekend trauma but insufficient theatre capacity at Monklands without relocation of Urology or ENT to another site Yes with Wishaw being designated trauma site although some reconfiguration of general surgery services may be required Yes - rotas would become fully compliant although reinvestment of costs of additional sessions 26
Impact on other Hospital specialties No change additional sessions required to provide the supporting workforce Additional impact on Radiology and AHP services but can be managed across NHSL workforce Additional impact on Radiology and AHP services but can be managed across NHSL required to provide the supporting workforce Significant impact on Radiology and AHP services at Wishaw Significant impact on level 2 (HDU) beds at Wishaw required to provide the supporting workforce Significant impact on Radiology and AHP services at Wishaw Significant impact on level 2 (HDU) beds at Wishaw Requirement to transfer other surgical /medical specialties from current site Impact on Emergency Department Services No change No change No requirement to transfer existing specialties from either site Minimal additional impact on both sites Monklands would require to transfer an existing surgical specialty (ENT or Urology) plus transfer/move of OMFS Minimal additional impact on both sites Reduction in level 2 activity at both Hairmyres and Monklands. Wishaw would require to identify service/beds to be transferred to another site Significant additional impact at Wishaw. Hairmyres and Monklands ED workload reduced Reduction in level 2 activity in Monklands and Hairmyres. Wishaw would require to identify service/beds to be transferred to another site Monklands would require to transfer an existing surgical specialty (ENT or Urology) plus transfer/move of OMFS Significant additional impact at Wishaw. Hairmyres and Monklands ED workload reduced 20160707 27
Consequence Likelihood Risk Score Consequence Likelihood Risk Score Appendix B - Risk Log Orthopaedic Redesign Programme Risks and Issues Log Completed by: Stephen Peebles Date last updated: 01/07/16 Risk or Issue Workstream Project Date added Date Risk Applies Owner ID Risk / Issue Description (Cause & Consequence) Source Risk Rating Number Risk Level Issue Consequence (1- minimal impact 5- significant impact) Controls/Mitigating Actions Post Mitigation Risk Rating Target Date Escalation required? (Yes/No/date) Status (Open / Closed) Date Reviewed Risk Care of the Elderly Reducing LoS 19/04/2016 1 Ability for Joint Integrated boards to be able Heather to manage patient flow and support Knox hospital@home early supported discharge model and resultant reduction in LoS required for 2 site model Risk Care of the Elderly Reducing LoS 19/04/2016 2 Failure to achieve necessary GORU pathway changes to ensure patients managed at home and LoS reductions are achieved Stephen Peebles Risk Workforce 19/04/2016 3 Failure to complete workforce redesign via Stephen consultation and recruitment in time for Peebles October. Consultation will take 90 days after decission. Risk Other N/A 25/04/2016 Delays in board making a decision on the Colin proposed plan and impact on October 2016 Lauder implementation date Risk Other N/A 25/04/2016 Government view proposed change as a major service change that requires public consultation. Colin Lauder 4 4 16 High Work carried out through care of elderly work stream to link with Joint Boards and agree resource requirements (particularly the movement of resources rather than new resources) 4 4 16 High Care of the Elderly work stream developing pathways, tools and have outlined resource requirements to deliver. Day of Care audit undertaken to establish patients discharge location and resource shortfalls being established. 4 4 16 High Staff engagement sessions underway and review of staff groups affected underway 4 4 16 High Work streams are continuing to work to October implementation date. 5 3 15 Moderate Discussions on going regarding clinical imperrative for service change and phased approach 4 3 12 Yes Open 4 3 12 Yes Open 4 3 12 Yes Open 4 3 12 Yes Open 5 2 10 Yes Open 20160707 28
Likelihood (1-5) Impact (1-5) Total Likelihood (1-5) Impact (1-5) Total Appendix C Quality Impact Assessment Template NHS Lanarkshire Orthopaedic Redesign Programme Quality Impact Assessment Form Date: 19-Apr-16 Workstream:Theatres Orthopaedic Redesign Programme Completed by: Project Leads Frances Dodd Project purpose Quality indicator(s) Pre-mitigation scoring Post-mitigation scoring Quality Impact Area Details Positive/ Negative/ Mitigating / Supporting Action(s) Neutral Impact QI QA Escalatio n Impact on Patient Safety 0 0 Impact on Clinical Effectiveness 0 0 Impact on Patient Experience 0 0 Impact on Staff Experience 0 0 Impact on Timeliness of Care 0 0 Impact on Equitable Care 0 0 Impact on Privacy 0 0 Quality Assurance Methodology Overall QIA Score pre-mitigation (max quality impact score) Overall QIA Score post-mitigation (max quality impact score) 0 0 Director Acute Division Name Signature Date Medical Director Acute Division Associate Director Nursing Acute Division 20160707 29
Appendix D Work Streams The work streams NHS Lanarkshire Orthopaedic Redesign Group Lead : Director of Access Outpatient group. The outpatient group will look at a number of key areas including Pre assessment which is currently delivered over the three sites and the option of a single pre assessment clinic that includes joint school will be explored. This would serve as a one stop clinic for the patients scheduled for theatre. Orthopaedic outpatient clinics are currently governed from a nursing perspective by different directorates across the three sites and this group will review the sustainability of that as outpatient clinics will continue to function on three sites following the redesign process. In addition to this physical clinic space will be reviewed to ensure that we have sufficient space to accommodate growing consultant numbers. This will tie into work that is currently ongoing with evening clinics to meet demand and ensure that we deliver our TTG requirements. Within the current model there is one arthroplasty practitioner based at HM reviewing return patients and providing a post surgery liaison service. The outpatient group will review the need to create a business case for an additional practitioner to allow this service to run on the two inpatient sites. Fracture clinic redesign and the introduction of virtual clinics is in its infancy in NHSL and going forward this is a model that we need to implement and embed. The outpatient group will need to explore this model fully and create one that fits with what we require within NHSL. This will involve full engagement between ED and Orthopaedic teams. Primary care have expressed that they are keen to look at what can be done differently before that patients come to hospital and also reviewing links for post op patients to reduce the possibility for unnecessary readmission. 20160707 30
NHS Lanarkshire Orthopaedic Redesign Group Lead: Director of Nursing, Acute. Theatre group. The theatre group will begin by modelling extended day theatre sessions and staff resource implications around that. Start and stop times vary at present and there may be a requirement to review medical job plans to deliver a change in service model. There is variation across the three sites currently in terms of the theatre sessions offered for orthopaedic surgery and this will need to be standardised with variation smoothed. We will require to run6 orthopaedic theatres on 2 sites to deliver the demand both form planned care and unscheduled cases. Currently we do not have ring fenced orthopaedic trauma or elective theatres 7 days a week and in order to ensure that we not have delays to surgery we need to ring fence these theatres 7 days for trauma and 5 days as a minimum for planned care. This group will also look at sub specialities and how the services are structured. In addition to this we need to consider the centralising of specialist revision surgery to one site to improve outcomes. This will dramatically help with storage of specialist theatre equipment and also enable dual working for complex cases. Trauma Liaison exists on the three sites currently but the role is slightly different and this should be standardised to allow cross site communication to be facilitated to manage patient flow and fit within the Orthopaedic management structure. Other focus areas for this group include the option to explore a standalone orthopaedic team in theatre whilst allowing rotational staff training to continue. Core orthopaedic scrub staff will enable smooth turnaround and optimise theatre sessions to deliver maximum capacity. This would support consistency in theatre and aim to improve staff recruitment and retention. 20160707 31
NHS Lanarkshire Orthopaedic Redesign Group Lead : Chief of Nursing Services, Wishaw Ward group. The ward group have a number of key areas to explore including; Review the provision of inpatient trauma and planned care within either a one site or two site model both with a 50/50 split on each site Links with Care of the Elderly teams to support early rehab and discharge for all elderly patients, including links with ACE nurses Outline the staffing models needed to deliver the new service model Explore the proposal of ring fencing beds for elective surgery Agree the role for the development of a non medical workforce Establish the AHP model required to deliver the new service model Review the discharge planning processes and establish new patient pathways that include hospital at home Explore the need and model of enhanced level monitoring for orthopaedic patients Review the need for orthopaedic ambulatory care. Advise on any HR issues 20160707 32
NHS Lanarkshire Orthopaedic Redesign Group Lead : Chief of Medical Services, Monklands Unscheduled care group. The unscheduled care group will develop and agree clinical pathways with ED, Orthopaedics and Scottish Ambulance Service. This will involve creating pathways for patients that can be used by SAS to deal with trauma from the postcodes related to the non inpatient site. Protocols will be put in place to standardise the management of common injuries. There will be a role review of ESPs currently working in the ED`s and what they could offer to the sites that have inpatients and the non inpatient site. This group will look at junior and middle grade rotas on the 2 site model to cover ED referrals 24/7. This discussion will overlap with the workforce and job planning group that will look at consultant cover on the inpatient sites A further piece of work that will crossover with be the development of virtual fracture clinics. This work will link to the outpatient work on this topic. The trauma Liaison team will create a pathway to convert unscheduled presentations that require surgery to planned care with a scheduled admission where appropriate. This group will also detail any implication for radiology and resolve and issues arising from that. The trauma week rota and on call arrangement will be reviewed to ensure that both the 2 inpatient site and the non inpatient sites have appropriate grade medical cover 24/7. A pathway will define in patient falls on the non inpatient site in relation to orthopaedic review and treatment planning 20160707 33
NHS Lanarkshire Orthopaedic Redesign Group Lead : Associate Medical Director Acute Workforce and job planning group. A key area that this group will review is the medical staffing. This will involve a revising all the medical rotas. Currently the sites have different levels of cover over a 24 hour period and this will need to be standardised on the proposed two inpatient sites. Medical modelling has begun and the group will need to produce the detail around the resources available. There will be discussion around cross site working and in the context of centralisation of sub specialities this group will define which sites carry out certain cases and who the staff are that will be operating on specialty cases. In relation to the job planning there will require to be a change in the working day patterns if we are to achieve extended theatre sessions changing form 9-5 currently to 8-6 in the proposed model. This group will have ongoing support from HR and will run staff engagement sessions regularly to ensure that all staff are as informed as they can be. This group will define the non medical staffing (EPSs, MINTS Nurses PA`s,) and where they can contribute to the rotas. The group will take account of the fact that all staff who interact with the Trauma and Orthopaedic service (Radiology, Care of the Elderly, ED, Theatres) will be affected to some degree by the proposed changes however only a proportion of this group will require formal renegotiation of roles. The group will size and articulate the impact on staff. 20160707 34
NHS Lanarkshire Orthopaedic Redesign Group Lead: Clinical Director Older Persons. Older Persons Service/Geriatric Orthopaedic Rehabilitation Unit. (GORU) This group is comprised of members of the Older Persons directorate including Consultant Geriatricians, nurses, AHPs, and managers. This group will require to re-configure the GORU wards and Orthopaedic inreach in response to the Clinical Strategy. In doing this the groups are scoping pathways and mapping the future pathways and identifying the resources and skills to implement the changes required. In doing this the team will define the impact, outcomes, bed compliment, length of stay and community resources. A Sub group of this work stream will review the hospital @home service and how orthopaedic patients will access this as part of their pathway. 20160707 35
Appendix E Poole Tool (Discharge Predictor) REASON FOR FALL Mechanical fall 0 Medical reason i.e. cardiac 3 BLOODS ON ADMISSION Bloods all normal, FBC, U&E 0 Any bloods abnormal 3 ACCOMMODATION Nursing home 0 Residential Home 1 Lives with able bodied person 1 Lives at home with support 2 Lives alone, no support 3 IF NH RESIDENT STOP SCORING NOW MOBILITY Hoisted/immobile 0 Independent 0 Independent with aid 1 Requires supervision 2 Requires assistance 3 PRE-EXISTING MORBIDITY Normal healthy patient 0 Systemic disease; no compromise to activity 1 Severe incapacitating disease; limits activity 2 Incapacitating disease; threat to life 3 AGE 50 and under 0 51-65 1 66-80 2 81+ 3 COGNITION Fully orientated 0 Variable memory recall 1 Mild disorientation 2 Severe disorientation 3 FALLS First fall 0 2 falls in last 3 months 1 >2 falls in last 3 months 3 TOTAL SCORE 20160707 36
Appendix F Letter from the Scottish Health Council 20160707 37