ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST Recruitment of Academic Consultant for the Shoulder & Elbow Service Clinical Lead: Clinical Director: Lead Director: Divisional General Manager: Mr Simon Lambert Mr Aresh Hashemi-Nejad Mrs Lynn Hill Dr Claire Euesden Funding Year: 2011/2012 1. Case for Change The main priority for this post will be to develop high quality research and clinical output programmes in orthopaedic surgery, specifically in the basic and translational sciences related to shoulder and elbow surgery within the research strategy of UCL Partners. This post will help in the establishment and development of a research and teaching programme based at the RNOH and therefore a substantial fixed sessional allowance for research and teaching has been included in the job plan. There has been a significant increase in the number and complexity of patients referred to the Shoulder unit. In order to provide a service to meet the national waiting time targets for both outpatients and inpatients the existing consultants have been working additional PAs. This arrangement is for a fixed period and is not sustainable in the long term. However, the demand for the service is such that further capacity is required to reduce the waiting times backlog and to manage this within national and local requirements. This business case is therefore also intended to provide capacity and support to the three existing consultants and to provide additional therapist and administrative support for their workload. Without this additional consultant the Unit cannot maintain the current level of activity or take further action to achieve national and local waiting time targets by distributing the current and anticipated work to the existing consultants so that each takes on more complex cases. 2. Rational, Introduction and Strategic Context University College London is one of the most successful of UK universities and has earned an outstanding reputation both for research and teaching, ranking within the top 20 of universities worldwide. The Royal National Orthopaedic Hospital NHS Trust (RNOH) enjoys a national and international reputation for innovative and complex tertiary referral orthopaedic surgery, and is the leading specialist orthopaedic hospital in the Orthopaedic Alliance. The Institute of Orthopaedic and Musculoskeletal Science (IOMS), a part of UCL, is hosted on the RNOH site. The director of the IOMS is currently Prof Allen Goodship. The Academic Clinical Orthopaedic department is currently chaired by Professor David Marsh, who is due to retire in March 2012. Active recruitment into the Chair is ongoing. The Shoulder Unit is a key element of the RNOH and provides upper arm and elbow orthopaedic surgery for complex cases. The RNOH aim is: 1
Advancing care for patients with neuro-musculoskeletal disease/disability through research, teaching and excellence in clinical practice and to be endorsed by others as a world class leader in this field. The RNOH business plan also accepts the 10 year NHS Plan (published 2000) as the main NHS strategic and performance driver. The following NHS Plan priorities are key to this business case and the need to recruit another Consultant Shoulder Surgeon: Provide fast and convenient care for patients reduced waiting, improved infrastructure Developing professions and the NHS workforce Improving performance implementing clinical governance and meeting financial targets There is a growing body of evidence that hospitals providing high volume of complex care have the best outcomes. A recent meta-analysis in the British Journal of Surgery has found that there is a positive relationship between volumes of specialist surgery and three key outcome indicators (mortality rates, reduced lengths of stay and complication rates). Healthcare for London - A Framework for Action Professor Sir Ara Darzi 2007 The report also sets out the need for Academic Health Science Centres: internationally- recognised centres of excellence where research and clinical practice is considered to lead within the UK. The RNOH is well placed to take up this accolade; however, investment is required across the Trust. The creation of a part academic and part clinic consultant post will give the unit an opportunity to develop its academic function There is a very active teaching programme, at all levels. There is a strong local programme of basic surgical training, in which the RNOH plays a full part. Specialist trainees rotate around the London North-east Programme for specialty training in Trauma and Orthopaedic Surgery. Professor TRW Briggs and Mr B Ferris are the Training Programme Co- Directors. The RNOH hosts the weekly Post-graduate training programme in the Postgraduate Centre at RNOH. The RNOH runs nationally advertised ATLS, arthroscopy, arthroplasty, external fixation, fragility fracture, radiology, and paediatric orthopaedic courses in addition to therapy courses for AHPs. In collaboration with the UCL, the RNOH organises major events to share best practice, including a Masters in Trauma & Orthopaedic Surgery, cadaveric surgery courses and expert seminars. There is an active audit programme assisted by the Clinical Audit department and this is being developed further in line with clinical governance and setting standards for clinical practice. All medical staff are required to participate in audit. Both medical (Mr Lambert) and therapy (Miss Anju Jaggi) members of the service have prominent positions in national and international shoulder and elbow education, training committees, course faculties, and research programmes. Mr Lambert chairs courses for the AO/ASIF, leads Masters level teaching programmes for the AO, and is PI for a multicentre shoulder replacement trial. Nevertheless, the unit, amongst others, can be criticised for its lack of research output and publication productivity notwithstanding the number of podium presentations, publications, and book chapters by Mr Lambert over the recent years. As the RNOH strives to become a more researchorientated institution, the opportunity has arisen to promote this ambition through the appointment of a suitable individual to an academic clinical post, the intention of which is to facilitate research and 2
publication including the generation of high level grant-funded activity. This will enhance the shoulder service s standing at national level, but most importantly contributes to the Trust s overall goal of academic excellence, evidence for which is currently lacking. 3. Current Service Profile There has been an exponential growth in the understanding of disorders of the shoulder and elbow and an increase in the number, type and complexity of surgical procedures available to improve mobility, reduce pain, repair and reconstruct joints, muscles and nerves. In addition, a range of nonsurgical procedures are now being used both for detailed assessment of shoulder/elbow problems and for conservative treatment, particularly to deal with shoulder instability and the manifestation of shoulder problems within joint hyper-mobility syndrome, again aimed at increasing functionality. The application of the principles of rehabilitation is a key factor for the complete recovery and retraining of the shoulder/elbow both post-operatively and in patients treated non-operatively. The surgical and rehabilitation (therapy) elements of the service are fully integrated with joint ward rounds and clinics, and provide a model for service provision in similar units at the RNOH. The shoulder service is recognised as an exemplar service in the multidisciplinary management of a complex group of patients requiring a variety of therapeutic inputs within the context of an holistic approach to individual patients. The Shoulder surgeons collaborate closely with the Director of Rehabilitation, Dr J Cowan, who provides electro-physiological assessments and leadership of the Pain Management Programme, and who also collaborates in the electrophysiological research portfolio; Dr J. Berman (chronic pain service); the Bio-Medical Engineering Department (under Professor Blunn); the Centre for Tissue Engineering and the Centre for Academic Orthopaedics (Professor Marsh). There is collaboration with the Nuffield Orthopaedic Centre, University of Oxford and with the University of Liverpool Shoulder & Elbow service Joint clinics are held with Dr R. Wolman (Consultant in Sports Medicine and Rheumatology), and Professor F. Muntoni (Dubovitz Neuromuscular Centre, Hammersmith Hospital), and ad hoc clinics with the Rheumatology department, and the Spinal Injuries Unit. The shoulder and elbow service sees approximately 700 new patients and 1800 follow-up patients annually from 222 beds, several ITU and HDU beds, with access to 9 operating theatres. Between 15 and 20 operations are undertaken weekly, but this is anticipated to increase as a result of this appointment. The Service runs weekly outpatient clinics at Stanmore and Bolsover Street and theatre lists at Stanmore. The clinical service is based at the RNOH. It provides secondary care for a resident population of almost 1,000,000 and tertiary care for at least another 12,000,000 from London and the Home Counties. The shoulder and elbow service provides a tertiary level service and a service for the local commissioners: the hospital aims for an 80:20 split in referral pattern overall. This is reflected in the overall capacity of the Shoulder and Elbow Service: Mr Lambert has an almost exclusively tertiary referral case/mix. Mr Falworth and Miss Higgs have proportionately fewer tertiary referrals and provide a local primary shoulder and elbow service. The service has access to laboratories for cellular and molecular biology at the IOMS and within the centre for Biomechanical Engineering on the RNOH campus. The new appointee would be expected to provide a primary shoulder and elbow clinical service, the cases from which would be recruited into the various research programmes to be developed, eg the minimally-invasive management of young adult shoulder arthritis, and the early (arthroscopic) management of rotator cuff disease. The appointee will be expected to work closely with the physiotherapy service to provide an arthroscopic assessment and management service for selected shoulder instability patients. Most cases will therefore be conducted on a short-stay or day-case basis, and outpatient activity will reflect this. 3
Current Shoulder Unit Consultants: There are 3 Full-time Clinical Consultants and an Honorary Consultant, Mr J Ian Bayley, who does ad hoc theatre sessions. Mr Simon Lambert Clinical Lead Complex reconstruction of the shoulder and elbow, including post-traumatic reconstruction. Mr Mark Falworth Primary and revision shoulder and elbow surgery, including arthroscopic surgery. Miss Deborah Higgs Primary and revision shoulder and elbow surgery, including arthroscopic surgery. In addition there are the following 1 post-cct Fellow 2 ST3-ST8 Specialist Registrars on the Stanmore Programme. 1 ST1-ST2 Specialist Trainee 2 Clinical Specialist Physiotherapists 2 Senior Physiotherapists 4 Senior Occupational therapists Each consultant has a secretary and the department is further supported by a full time administrator and inpatient and outpatient scheduling staff. Current Academic Structure RNOH works closely with the Institute of Orthopaedics and Musculoskeletal Sciences (IOMS) on supporting joint academic strategy to develop the site as research centre of excellence. Specific themes have evolved over the last few years, which aim to support translational research, which has the potential to improve the lives of our patients and to lead in the field. The demanding clinical service makes it at times difficult to facilitate research and as such academic clinical lecturer posts provide the essential component to ensure that adequate time can be dedicated to research. The Institute is directed by Professor Allen Goodship and comprises a number of centres, currently: Clinical Orthopaedics, directed by Professor David Marsh. Biomedical Engineering, directed by Professor Gordon Blunn. Centre for Disability Research and Innovation directed by (currently vacant). Tissue Engineering, directed by Professor Robert Brown. In addition there are the following: 1 Senior Clinical Lecturer (Andrew Goldberg, Foot and Ankle Surgery). 3 Academic Clinical Fellows. 1 Research Manager. 1 lead research nurse, 1 research assistant and 0.2 WTE of research coordinator. 1 Statistician (visiting). PhD/MD students and MSc students. The activities of the Institute are mainly research based, and are aligned with the interests of the RNOH research and development centres. Research themes that cross the disciplines of the centres, such as osteoporosis, bone tumour biology, joint replacement, tissue engineering, performance/rehabilitation, peripheral nerve and spinal injury are being encouraged. The post holder would have a link with the Academic Chair but would be expected to collaborate with Professor Blunn. 4
The Unit s research capacity has been evolving and the appointment of a clinical lecture would allow further expansion and support in developing world class research proposals. 4. Service Demand and Market Analysis The RNOH provides tertiary specialist shoulder and elbow surgical and non-surgical care for neurodegenerative, skeletally degenerative, post-traumatic and developmental conditions, and specific pain syndromes around the upper limb. There are very few Consultant Shoulder Surgeons and Physiotherapists with the expert knowledge, skills and experience of the shoulder service clinicians currently at the RNOH. The referral rate is steadily increasing and these complex patients cannot be seen at a local DGH as expertise is not available, or the providers are unwilling to treat them. In addition, the conversion rate is increasing as the range of surgical and rehabilitation options available for treating patients increases. The Upper Limb Service is currently unable to meet the national waiting times targets for outpatients and inpatients. This is due to an increase in referrals to the service which in turn has led to an increase in additions to the inpatient waiting list. The conversion rate of outpatients to inpatients is high at 48% for 2010/11 when compared to 36% for the Trust as a whole over the same period. Variance in Weekly Capacity and Demand, across the substantive surgeons in post at present. 1st OPA Follow-Up Inpatient Activity Demand 24 37 43 Capacity 20 28 19 Variance -4-9 -24 The table below shows that the number of referrals rose by 14% in 2009/10 and that this was sustained in 2010/11. In line with this the number of first outpatient attendances increased by 19%. The rise in referrals has been sustained in 2010/11 and although the number of first outpatient attendances fell in 2010/11, demand has risen from 2008/9 by 8%. Elective admission activity has seen a similar increase with activity rising in 2009/10 by 18% and by 19% in 2010/11. 2008 / 2009 2009 / 2010 2010 / 2011 Referrals received 686 865 915 1 st Outpatient appointment 792 1005 1020 Added to waiting list 919 1266 2097 Elective Admissions 801 950 1137 The Consultants operate on circa 30 patients each per month. However, during 2010/11 an average of 103 patients were added to the elective waiting list each month. Mr Bayley has continued to provide support through additional ad hoc operating sessions but despite this the 18 week wait is not being achieved. The consultants are working additional sessions (3 PAs each) in an attempt to address the demand but these measures have not been effective in reducing the backlog on either the outpatient or inpatient waiting lists. 5. Proposed service profile The new Consultant will initially work closely with the current Consultants in the following outline weekly pattern. A new Consultant would work at a slower pace while gaining experience, and competence and clinical throughput will increase with ongoing experience and time. 5
The detailed job plan will be agreed according to the sub-specialty interest of the applicant in consultation with the Trust and the University. The following is an outline job plan. Monday Tuesday Wednesday Thursday Friday 0800-1200 Research / Theatre Stanmore Clinic Stanmore / Bolsover St Research / Admin / SPA 1300-1700 Research / Theatre Stanmore Clinic Stanmore / Bolsover St/ Admin/SPA Research / Research / Academic sessions are shown in bold On-call for the hospital equivalent to 0.5 PA Research Research will follow four linked strands: Primary clinical effectiveness and epidemiological studies. We design, lead and perform studies to provide primary evidence of the effectiveness and cost effectiveness of treatments. We intend to be at the centre of national networks to perform multicentre, publicly funded observational studies and trials to measure and compare the clinical effectiveness of operations and other interventions. We seek to establish international collaborations to achieve greater breadth and generalisability. Cost effectiveness and best design of health care systems are included in many studies. Basic Science. We perform cell- and tissue- based laboratory studies on the effects of strain on cell development, differentiation, and growth. This work is integrated with that of Professor Blunn. A specific aim is to create tissue-implant interfaces with biomechanical properties consistent with longevity and applicability throughout the musculoskeletal system. This post will be expected to link with Dr Vivek Mudera (IOMS), and Professor Blunn and the scientists of the Royal Veterinary College allied to the IOMS in this work. Innovation and translational science We are seeking an innovative surgeon-scientist who is willing to develop the instruments and tools with which to deploy the tissue-based research into clinical practice. There are programmes of instrumented implant research which will require clinical support, which they will be required to support and promote. Database development. We develop methods to audit, summarise evidence of, and produce guidance for the most effective treatments for use in clinical decision-making. The expectation is that this post will enable the Unit to: 1. Establish a sound research base in order to pursue individual and collaborative research of international quality in line with the objectives of IOMS/UCL. 6
2. Secure, in collaboration with colleagues as appropriate, external funding through research grants or contracts to support a research agenda. 3. Maximise accruals to CLRN portfolio studies in Trauma and Orthopaedics. Initially this will be principally in London but as research develops this will include accruals from large multi-centre portfolio studies 4. Secure contract work (where appropriate and expedient) to the benefit of research activity and to provide resources (clinical activity: outpatient clinics and operating theatre capacity) to underpin this activity. 5. Publish research outcomes in appropriate journals of international standing and to publish and disseminate the results of research and scholarship in other outlets. 6. Identify and explore with UCL any entrepreneurial opportunities which may arise and to ensure that intellectual property rights are protected for the benefit of the University, the researcher and the RNOH. 7. Attend and present research findings and papers at academic and professional conferences and to contribute to the external visibility of the RNOH, IOMS/UCL. 8. Contribute fully to the research plans developed by IOMS/UCL, including providing such information as may be required to monitor the progress of each member of staff s research programme and to support UCL fully in the preparation of material required for the RAE / REF or similar activities. 9. In relation to the above we would expect achievement of the following within the first three years of the post, subject to the resources to support and assist in these aims: 3 publications (submitted or published) in peer-reviewed journals in field of study 3 podium presentations at learned societies in field of study; The post holder should be Principle Investigator on 2 grants; The post holder should be Co-Applicant on at least 2 other grants; The post holder will be expected to have shown grant-related programme or project funding of at least 500,000 over the course of the three years. It is recognised that these achievements are dependant to some extent on the facilities and resources available in IOMS/RNOH: the appraisal process at three years will take this into account. Responsibilities will include 1. Delivery of lectures, seminars, tutorials and other classes in support of the required teaching obligations of the RNOH, as discussed with the Heads of Programme (Mr Barry Ferris and Professor TWR Briggs). 2. Co-operation with colleagues in the design and development of specific areas of teaching and learning as discussed with the Professor of Academic Clinical Orthopaedics. 3. Contribution as appropriate to the UCL BSc and MSc Programmes. 4. Supervision of MD, DPhil, MPhil, DocOrth, and PhD students on a regular basis, under the guidance of the Professor of Academic Clinical Orthopaedics. 7
5. Undertaking of academic duties (i.e., setting examination questions, marking, invigilation and pastoral support of students) required to sustain the delivery of high quality teaching. 6. Support and compliance with the University and departmental teaching quality assurance standards and procedures including the provision of such information as may be required by UCL. Administration and Other Activities 1. Undertake such specific administrative roles and management functions as may be reasonably required by the Chair of Academic Orthopaedics. 2. Attend Divisional meetings at UCL and to participate in other committees and working groups as may be reasonably required by the Chair of Academic Orthopaedics. 3. Engage in continuous professional development. 4. Undertake external commitments which reflect and enhance the reputation of the RNOH and IOMS/UCL. 5. Ensure compliance with health and safety in all aspects of work. The duties and responsibilities outlined are not intended to be an exhaustive list but provide guidance on the main aspects of the job. The post holder will be required to be flexible in his/her duties. 6. Resource & other implications Financial implications Support for this post has been received from the IOMS by Professor Marsh and Professor Blunn. If funding for these academic PAs is not made available it would be necessary to convert this aspect of the role to clinical and these sessions would then need to be funded. A new Consultant would work at a slower pace in order to ensure accuracy and competence will increase with ongoing experience. This will also be demonstrated though the income generated, with an increase as the workload and case mix complexity increases. The table below shows a positive contribution from surgical activity which will be realised when the full level of activity and throughput currently associated with the Unit s performance is attained. At times of annual and/or study leave the Unit currently offers some ad hoc theatre sessions to Mr Bayley. This post would give the consultants an opportunity to provide greater cross cover as the competence of the new consultant develops and a number of inpatient sessions currently handed back to other services would be retained by the Unit and in addition, the need to utilise the services of Mr Bayley would decrease. It is anticipated that a business case for a fifth full-time consultant to support the demand-lead expansion of the clinical workload will be submitted to the Board but this will require extra theatre and outpatient clinic resources not currently available. 8
Table Revenue & Capital Impact Revenue Type/ Department WTE Recurrent Costs k Non- Recurrent Costs k Pay SDU Consultant 10PAs including on-call 1.00 117,700 Consultant Cover (Currently provided by Mr Bayley) 0.20 21,800 Secretary B4 1.00 29,500 Theatres (2x4hour sessions) 2 x Scrub Nurses B5 0.42 14,600 1 x Scrub Nurses B3 0.21 5,500 1 x ODP B5 0.21 7,300 2 x Recovery Nurses B5 (5 hour sessions) 0.53 18,500 Anaesthetist with on-call 0.30 35,000 Therapies Occupational Therapist B7 1.00 49,500 Physiotherpist B7 1.00 49,500 Centralised Booking Inpatient Scheduler B4 0.27 8,000 Outpatient Scheduler B4 0.50 14,800 Total 6.14 371,700 0 Non-Pay Prosthesis 210 78,800 Drugs 210 14,700 Consumables 210 10,500 Total Non-Pay Costs 104,000 0 Income Outpatient New 310 54,000 Outpatient Follow-Up 175 17,200 Day Case 105 120,750 Elective 105 493,500 Total NHS Patient Income 685,450 0 Contribution (beneficial)/adverse (209,750) 0 9
10 PAs would need to be funded but it is anticipated that through the 5 PAs given to the academic service, the income generated will exceed the cost of these sessions ( 54,500) and on that basis the contribution of this post would then be in excess of 264,250. Key assumptions for the revenue table : 2010/11 prices and tariffs this provides a relatively accurate assessment of the impact in 2011/12 NHS patient income is based on actual income generated by the consultants currently in-post with a case-mix that is similar to the expected case-mix of the new consultant 7. Service benefits and risks Benefit to the Trust / purchasers / patients: Enhanced reputation for the Trust as a world class leader in treating patients with complex shoulder conditions, carrying out research and teaching; Continuing to be at the forefront of innovation in the delivery of research (evidence)-based treatments for shoulder and elbow conditions, particularly in the field of minimally-invasive (largely arthroscopic) surgery; Continuing provision of a high-volume specialist care not readily available elsewhere in the UK, and rarely in the EU. Enhanced recruitment & retention opportunities Ability to meet the NHS Plan waiting time targets Improved patient satisfaction and access to service The opportunity for the new Consultant to develop excellent clinical skills under the guidance of the existing consultants. Risks of not undertaking change: The opportunity to enhance / establish the Trust s profile nationally as a research active institution will be adversely affected: clinical, translational and basic science research as applied to relevant clinical need will not be promoted while other institutions (eg Oxford, Warwick) are currently actively seeking to do exactly this: if the Trust does not engage in this process then it will send a negative message to UCL, UCLP, and to national orthopaedic services; It is not viable for the existing consultants to continue working an additional 3 PAs. However, the existing consultants would have to continue working as they are, to provide the current level of complex cases which are the most lucrative part of our core business The existing consultants would not be able to devote as much time to the increase in the number of complex cases (having to provide a primary service as well as the complex service), thus limiting the generation of new income The Trust would have to turn away this work which is very lucrative (the shoulder service performs more joint replacements than any other unit in the UK The profile of the RNOH would be adversely affected if this work had to go elsewhere in high numbers The Trust will not have access to specialist consultant staff to maintain the service to meet patient demand 10
8. Timetable and deliverability Executive Committee approval October 2011 Trust Board approval October 2011 Advertisement October 2011 Interviews & recruitment November 2011 Start date March 2012 9. Recommendation The urgent nature of the capacity and waiting list issues requires that this post is approved and recruitment processes commenced without delay. Signed Director of Operations and Transformation Date: 11