Highland NHS Board 9 August 2011 Item 4.3 OPTIONS APPRAISAL PAPER FOR DEVELOPING A SUSTAINABLE AND EFFECTIVE ORTHOPAEDIC SERVICE IN NHS WESTERN ISLES Report by Sheila Cascarino, Divisional Manager, Surgical Specialties, Raigmore and Donna Smith, on behalf of Chris Lyons General Manager, Raigmore and Nigel Hobson, Western Isles The Board is asked to: Consider the recommendations for provision of a sustainable orthopaedic service in Western Isles. Support Option 2 and if not achievable move to Option 3 within 3 months. 1 Background and Summary The provision of orthopaedic services to NHS Western Isles has been the subject of discussions over a number of years. Orthopaedic care is currently provided by a single handed long term locum consultant based in Stornoway. Complex cases are transferred to NHS Highland and NHS Greater Glasgow. The current incumbent has indicated his notice to retire, and NHS Western Isles recognises it is no longer feasible for a single consultant to provide this service. NHS Highland has been asked by NHSWI to propose options for the provision of orthopaedic care to the Western Isles. In addition, through ongoing discussion with NHS Western Isles it is recognised that further consideration is needed to ensure the sustainability of other surgical services to Western Isles, namely general surgery and urology in the first instance, and the possibility of obstetrics and gynaecology in the medium term. The links between these specialties, particularly in respect of out of hours cover is well understood. 2 Sustaining an Orthopaedic Service for the population of the Western Isles Option 1 No Change. Option 2 Develop an Obligate Network between NHS Highland and NHS Western Isles. Option 3 Provide an outreach service in NHS Western Isles from NHS Highland. Option 4 NHS Western Isles provides an Orthopaedic Service with no / limited involvement from a Mainland Provider Unit. 3 Contribution to Board Objectives This paper recognises the current service provided on the island is no longer clinically viable. Partnership working between the health boards of NHS Highland and NHS Western Isles will allow long term stability and maintenance of high quality care for patients across the two health boards.
4 Governance Implications Staff Governance a joint approach to recruitment of clinicians and rotation of staff will ensure longer term stability and higher standards of care. Patient and Public Involvement options 2 and 3 maintain provision of care with minimal impact to patients. Clinical Governance the paper identifies the need to confirm clinical governance arrangements and is a pre-requisite to agreement. Financial Impact the option appraisal sets out the financial impact of the changes. 5 Risk Assessment The risks of the collapse of the current orthopaedic service on Western Isles without the provision of option 2 or 3 in place will necessarily result in an increase in demand on the Raigmore provision without capacity. 6 Impact Assessment The impact of these proposals has minimal impact on the Highland population. Sheila Cascarino Divisional Manager, Surgical Specialties, Raigmore Donna Smith Corporate SLA Performance and Partnership Manager 4 August 2011 2
NHS Highland and NHS Western Isles Options Appraisal Paper for Developing a sustainable and effective Orthopaedic Service in NHS Western Isles 28 July 2011 Executive Summary The provision of orthopaedic services to NHS Western Isles has been the subject of discussions over a number of years. Orthopaedic care is currently provided by a single handed long term locum consultant based in Stornoway. Complex cases are transferred to NHS Highland and NHS Greater Glasgow. Additional work to comply with the patient waiting time guarantee is undertaken at the Golden Jubilee Hospital. The current incumbent has indicated his notice to retire, and NHS Western Isles recognises it is no longer feasible for a single consultant to provide this service. NHS Highland has been asked by NHSWI to propose options for the provision of orthopaedic care to the Western Isles. In addition, through ongoing discussion with NHS Western Isles, it is recognised that further consideration is needed to ensure the sustainability of other surgical services to Western Isles, namely general surgery and urology in the first instance, and the possibility of obstetrics and gynaecology in the medium term. The links between these specialties, particularly in respect of out of hours cover is well understood. Four options are considered in the attached document. Whilst NHS Highland is supportive of Option 2 as the preferred option, i.e. three consultant orthopaedic surgeons employed by NHS Highland with 2 based on Western Isles with specialist support provided as an in reach service from NHS Highland it is recognised that recruitment is likely to be extremely difficult. History has shown that it has been difficult to attract suitably qualified and experienced surgeons to the island. If there is no success in recruitment, within 3 months of the decision to move ahead with this option, then it is proposed to move immediately to Option 3. WIOrthooption/vers 8. final 3
1.0 Introduction NHS Western Isles are exploring different options for delivering a safe and sustainable Orthopaedic Service to their population and have requested all possible options be explored including a proposal submitted by NHS Highland looking at the management of both trauma and elective activity. This paper cannot be considered in isolation, and needs to recognise the following: Remote and Rural Surgeons The training programme for the development of Remote and Rural Surgeons has not effectively delivered a consultant with the broad range of skills required to work across several specialties, particularly out of hours. In the absence of this type of surgeon, any patient requiring immediate operative intervention would need to be flown off island. General Surgical Service in NHS Western Isles The Consultant workforce in General Surgery is in a state of flux, and is currently provided by three locum consultants. The procedures that are undertaken on the are of moderate complexity. Consideration of a new model of working is underway. Any model would need to ensure clinical governance has been agreed. Urology Surgical Service in NHS Western Isles Consultant Urologists from NHS Highland currently support one of the locum General Surgery consultants, to provide a local urology service. Consideration is being given to the development of this service on island. Radiological Provision NHS Western Isles developed an Obligate Network for Radiology with NHS Borders, and this contract is due for review in 2011. If Orthopaedic services were to be provided by NHS Highland, it would be preferable for the Radiology provision to also be provided by NHS Highland. Dr Stewart (NHS WI) has approached Dr Shannon (NHS Highland) to commence discussions. 2.0 Background and Current Situation 2.1 Single Handed Consultant Service The Western Isles orthopaedic service is provided by a single handed long term locum consultant orthopaedic surgeon who is due to retire in 2011. Additionally patients are also treated in Inverness (4% of new outpatients and 19% of elective inpatients) and Glasgow (5% of new outpatients and 17% of elective inpatients). The supporting team in the hospital includes Emergency Nurse Practitioners (E.N.P.s) in the Accident and Emergency Department, and an Extended Scope Physiotherapist. WIOrthooption/vers 8. final 4
2.2 Demand based on 2009/10 activity for NHS Western Isles Residents NHS Western Isles Public Health Department has calculated the demand for Hip and Knee Replacements will increase by 33% and 31% respectively over the next 25 years. Table One: NHSWI Annual Total Demand (all providers 2009/10) Activity Demand New Patient Clinic 1319 Fracture Clinic 635 Return Patient Clinic 2643 Elective Theatre 423 Trauma Theatre 288 * 120 trauma cases were operated in NHS Western Isles in 2009/10 2.3 Capacity required for NHS Western Isles Residents Table Two Capacity Required for NHS Western Isles Population Activity per 4 hour session Total Consultant Demand (excl. ROTT / MSK) No of 4 hour sessions required per annum No of 4 hour sessions required per week New Patient Clinic 12 1038 86.5 1.7 Fracture Clinic 15 630 42 0.8 Return Patient Clinic 24 2643 110 2.1 Elective Theatre 2.5 423 169 3.3 Admin 2.0 Ward Round 3.5 On-call / Trauma Theatre 7 Sub-total 20.3 SPA 6.5 Total Sessions required 26.8 Assumptions included above: Clinics run 52 weeks of the year Ratio of Admin to direct clinical work is 25% 2 hours of ward round per day (7 days per week) 2.5 sessions of SPA time per 7.5 sessions of DCC On-call based on 4 hours every day 08:00hrs to 09:00hrs and 17:00hrs 20:00hrs (Monday to Friday) and 08:00 to 12:00hrs (Saturday and Sunday) The level of Consultant input required based on a 42 week working year is 33.2 sessions per annum which is the equivalent of 3 WTE Consultant Orthopaedic Surgeons, excluding any travel time commitment. WIOrthooption/vers 8. final 5
2.3 Bed Management Patients having joint replacement surgery patients are currently nursed in single rooms for at least 48 hours post operation. Should the volume of patients increase, there are other options to ensure the segregation of these patients from other surgical patients. This is considered essential for quality of care to ensure minimum infection rates and would be an absolute requirement. 2.4 Clinical Governance In considering any of the options it is important to ensure there is assurance from the general surgical team in the Western isles that they are willing to accept clinical responsibility for the trauma and elective orthopaedic patients managed locally. 3.0 Summary of Options This paper will consider 4 options: Option 1 No Change Option 2 - Develop an Obligate Network between NHS Highland and NHS Western Isles Option 3 - Provide an outreach service in NHS Western Isles from NHS Highland Option 4 NHS Western Isles provides an Orthopaedic Service with no / limited involvement from a Mainland Provider Unit. Options 2 &3 require assurance from the general surgical team in Western Isles that they will accept clinical responsibility out of hours for the trauma and elective orthopaedic patients managed locally. The conclusion of the paper is that the preferred option is Option 2. This option s principle risk is the failure to recruit the required number of suitably qualified consultants 3.1 Option 1 No Change This is not a viable or sustainable option as single handed consultant model is outdated and does not fulfil the clinical standards of care that are now expected. There are significant constraints in this model particularly around: Professional Isolation Lack of Peer Review Sustainability of service with a 1 in 1 on-call rota Capacity constraints This option is not considered further. WIOrthooption/vers 8. final 6
3.2 Option 2 Develop an Obligate Network between NHS Highland and NHS Western Isles NHS Highland and NHS Western Isles develop an Obligate Network with 3 additional Consultant Orthopaedic Surgeons employed by NHS Highland, based in NHS Western Isles to provide an effective and efficient orthopaedic service to the population. In addition a weekly visit from Highland by the specialist orthopaedic team would ensure sub-speciality expertise, for example hand or upper limb advice. Advantages of Proposed Employment arrangements include: Professional Development Network involvement in daily trauma meeting Improved cross cover Increased opportunities for tele-link activity Opportunities to access 6 weeks per year in a busy trauma and orthopaedic unit 3.2.1 Elective Service All non-complex elective orthopaedic surgery will be undertaken in Stornoway except where this is contra-indicated by the co-morbidity of the patient, or where access to services are required that are not available in Stornoway. The definitions of noncomplex and complex will be agreed in partnership with the orthopaedic team at Highland to ensure clinical governance including risk is appropriately managed. The Western Isles based consultants will be supported by a weekly visit, by a Highland based consultant, to maintain CPD provision, and allow sub-specialist advice to be provided to patients in the Outpatient setting. 3.2.2 Pre-operative Assessment (POA) The further development of NHSWI pre-operative assessment clinic, with Anaesthetic and Medical input in the Western Isles would be required to ensure that the patients attending Stornoway for their procedures were fit to progress with their surgery. Work has already commenced with the POA nursing team in NHS Western Isles, attending training and development sessions in NHS Highland, and using the same documentation. 3.2.3 Arthroplasty Nurse / AHP Consideration should be given to the development of an Arthroplasty Nurse / AHP, to undertake post-operative reviews, thereby reducing the new to: return ratio, and provide quality outcome data to allow the continued improvement of the service. It would be important to identify a nurse / AHP in the Western Isles who could provide the same service, this person can be supported and trained by the Arthroplasty Nurses in Raigmore. In addition this person would be able to work with the Audit Nurses to ensure that there is compliance with the 18 week RTT audit for the musculoskeletal pathway. WIOrthooption/vers 8. final 7
3.2.4 AHP Contribution The Enhanced Physiotherapy Service in NHS Western Isles would continue, and protocols developed that would work across the Obligate Network. It may be possible that this practitioner could develop the Arthroplasty Service referenced in 3.2.3. 3.2.5 Theatre Staff A development programme to rotate staff between the Theatres in Raigmore and in Stornoway would be developed to allow for CPD in both sites. 3.2.6 Trauma Service The two island based Consultants will provide a trauma service 08:00 to 20:00 hours Monday through Friday, and 08:00 to 12:30 Saturday and Sunday, retaining the clinical governance of the patients remaining on the. The ENP service within Accident and Emergency will triage the trauma outside of these hours, and will seek advice and support from Raigmore on the management of patients. The use of teleradiology (PACS) system, between Stornoway Hospital and the consultant on-call at Raigmore Hospital, perhaps with a Virtual Private Network, would allow for rapid management decision to be made on an individual patient basis, and a consultant assessment made as to whether the patient could be stabilised and managed conservatively on the until the based consultant was available. The governance of these patients will be with the Raigmore Consultant, until the handover to the based consultant team in the morning. Trauma would be managed through the emergency theatre facility out of core- working hours, in Stornoway Hospital, due to the limitations of theatre. 3.2.7 Beds Following current practice patients with significant trauma would be stabilised in Stornoway Hospital and flown to Raigmore Hospital. Patients in this category from the Southern Isles would continue to be transferred to NHS Greater Glasgow and Clyde. A dedicated 6 bedded area for Orthopaedics, with access to single rooms would be required in the Western Isles Hospital, to allow good infection control procedures essential for modern orthopaedic care to be attained. NHS Western Isles are currently exploring how this can be achieved. 3.2.8 Anaesthetic / HDU Provision Development of anaesthetic protocols to support orthopaedic surgery in the Western Isles Hospital would be developed jointly with NHS Highland, in line with the common Pre-operative Assessment documentation. The Western Isles Hospital has a 4 bedded HDU, to which the orthopaedic service would have access, as clinical need requires. Consideration would be required on the staffing of this facility, to meet the operating days identified by the orthopaedic surgeons. WIOrthooption/vers 8. final 8
3.2.9 Stock and Instrumentation NHS Western Isles currently carry an on consignment stock for their arthroplasties. Other stock such as plates and screws are owned. A review of this arrangement is required to identify any in year financial effects as a consequence of a new arrangement. NHS Western Isles Hospital is currently undertaking an option appraisal on both stock supply and instrumentation and have already been involving colleagues in NHS Highland. 3.3 Option 3 Provide an outreach service in NHS Western Isles from NHS Highland NHS Highland provides a visiting outpatient service only with all inpatient surgery and trauma management being provided in the mainland provider units. The consequence on service delivery, by varying the frequency and duration of visits is illustrated below: a) 1 day per week b) 2 days per week (with overnight stay) c) 3 days per week (with 2 overnight stays) Table 3 (A) Example of Programme Monday (Day 1) AM Fracture Clinic PM New / Return Clinic Tuesday (Day 2) New Clinic New /Return Clinic Wednesday (Day 3) Day Surgery Return Clinic Table 3 (B) Service Available On - Demand 1 day Visit 2 day visit 3 days per week New Patient Clinic 1.7 0.5 1.5 2.0 Fracture Clinic 0.8 1 1.0 1.0 Return Patient Clinic 2.1 0.5 1.5 2.0 Elective Theatre 3.3 1.0 Total 5.5 2 4 6.0 Travel 1 1 1 1 The above table demonstrates that a minimum of 3 days per week would be required from a visiting service to secure all Outpatient and Day Surgery activity on the. WIOrthooption/vers 8. final 9
This paper will only give further consideration to a visiting service of 2 or 3 days per week, based on a 52 week service. Some minor redesign would be required to reduce the New: Return Ratio and it would be proposed that all clinics ran as mixed clinics to allow for the maximum flexibility of use of capacity. The day case theatre component requires four patients per theatre list to meet demand, thus securing most day case orthopaedic surgery on the Western Isles. A visiting service would not allow for Inpatient activity to be undertaken on the, as there would not be sufficient governance arrangements in place for the safe management of patients following surgery. This would be a significant service model change from the current arrangements. RISKS The model of a 3 day visiting service, does not allow sufficient time in the normal working day for CPD of staff based in NHS Western Isles. There needs to be a recognition that this would have to be done in the evenings to maximize the time of the visiting surgeon when in Stornoway. Table 3 C Service to be provided on the Mainland with a visiting service Demand 3 days per week Difference On New Patient Clinic 1.7 2.0 +0.3 Fracture Clinic 0.8 1.0 +0.2 Return Patient Clinic 2.1 2.0-0.1 Day Surgery 0.6 1.0 +0.4 Sub - total 5.2 6.0 +0.8 Off Elective Surgery 2.8 Trauma Surgery 2.0 Admin 3.4 Ward Round 3.5 On-call 7.0 Travel 1.0 Sub-total 24.9 SPA 7.5 Total Sessions required 31.4 This option would require a significant proportion of NHS Western Isles residents leaving the island to receive an orthopaedic service. WIOrthooption/vers 8. final 10
3.4 Option 4 - NHS Western Isles provides an Orthopaedic Service with no / limited involvement from a Mainland Provider Unit. There are significant constraints in this model particularly around: professional isolation; lack of peer review; capacity constraints. This option is not considered further. Table Four Summary of Options Describing Service that will be available in each location Option 1 Option 2 Option 3 Option 4 Off Off Off Off OPD x x x x Fracture Clinic x x x x Day Surgery x x x x Primary Joints x x x Complex x x x x Joints Minor Trauma x x x x Major Trauma x x x Complex Trauma Out of Hours Ortho Consultant On Pool of Visiting Consultants x x x x Consultant cover 1 in 1 (not sustainable) MDT Approach ENP (supported by Consultant team off island) Consultant cover 1 in 4 would be required 1 2 1 4 (to cover on call workload) 3 (part of Obligate Network) 4 to 6 0 CPD x x Clinical x Governance Sustainability x x Acceptability - - - Affordability Implications Not Sustainable x Dedicated orthopaedic area increasing volume of activity in NHS WI Jobs reduced in Nursing, AHPs, Theatres & Anaesthetics WIOrthooption/vers 8. final 11
4.0 Financial Consequences The costs in NHS Western Isles for the theatre and ward staffing are estimated pending the outcome of the efficiency review in these areas. The implications of patient travel have been excluded from all options. Option I No Change not costed Option 2, 3 and 4 detailed below: Recurrent Cost of Options Option 2 Option 3 Option 4 Adjustments to Current NHSH SLA - 216,740-5,899-216,740 Adjustments to SLA s with other providers - Inpatients - 357,394 385,609-357,394 Adjustments to SLA s with other providers - Day Cases - 6,293 38,210-6,293 Changes in Western Isles based Medical Staffing Costs 232,178-120,338 215,373 Changes to Western Isles based Theatre Costs 200,734-122,243 200,734 Changes to Western Isles based Ward costs 100,865-351,173 100,865 Other changes in costs 33,536 22,005 33,536 Total - 13,114-153,829-29,919 High Risk adjustment for potentially unrealisable savings 193,946 646,414 193,946 Adjusted Total 180,832 492,585 164,027 WIOrthooption/vers 8. final 12
5.0 Option Appraisal Option Benefits Risks 1. Resident consultant available 24/7 but Professional Isolation No Change unsustainable Lack of Peer Review Sustainability of service Capacity constraints 2. Local delivery of care as part of a larger Financial affordability Develop an sustainable team Clinical Governance Obligate Increase % of patients treated on Framework needs to Network Sub-specialty availability be further developed Shared learning and professional development across both boards Recruitment Participation in audit Opportunities for role development of clinical teams in Stornoway Hospital Improved clinical governance capability including participation in multi-site audit Out of hours network to mainland specialist unit Retention of skills, expertise and activity within the Western Isles Hospital 3. Provide an Local delivery of Outpatient and day case care only Insufficient capacity created to deliver all of Outreach Sub-specialty availability the service locally. Service 3 Participation in audit Increased travel time for days per consultants and patients week Significant loss of inpatient capacity in the Western Isles Hospital Recruitment Incompatible with consultant s work life balance Theatre and bed capacity availability in Raigmore Hospital 4. NHS WI Local delivery of care with high % of patients treated on the Insufficient case-mix and volume to fulfil job Provided Service Retention of skills, expertise and activity within the Western Isles Hospital plans in a meaningful way Expensive Difficulty to recruit with an imbalance between elective and emergency commitment based on demand. WIOrthooption/vers 8. final 13