Achieving the 18 Weeks Referral to Treatment Standard in Orthopaedic Services. Task & Finish Group Interim Output Report.

Achieving the 18 Weeks Referral to Treatment Standard in Orthopaedic Services Task & Finish Group Interim Output Report October 2010 F3130196 Page 1 of 63 October 2010

Contents Page No. Foreword 3 Chair s Reflections 4 1 Introduction... 6 1.1 The 18 Weeks Referral to Treatment Standard and Programme Structure... 6 1.2 Task & Finish Groups... 6 1.3 Orthopaedic Services Facts and Figures... 7 2 Orthopaedic Services Task & Finish Group... 17 2.1 18 Week RTT Risks to Delivery... 18 2.2 Priority Task & Finish Group Improvement Actions... 18 3 Task & Finish Group Outputs... 19 3.1 Measurement and Definitions... 21 3.2 Demand/Capacity/Activity/Queue (DCAQ) Analysis... 22 3.3 Primary Care Solutions... 27 3.4 Performance Management... 30 3.5 Service Redesign and Transformation... 31 3.6 Cultural / Change... 42 3.7 Making the Most of Your Workforce... 42 3.8 Communication... 44 4 Catalysts for Change... 45 Appendices - Appendix A Task & Finish Group Membership 47 Appendix B MSK Audit Monthly Demand & Activity Data 48 Appendix C Orthopaedic Case Studies 49 F3130196 Page 2 of 63 October 2010

Foreword by Robert Calderwood, Chair of the 18 Weeks Operational Delivery Team The work of the Orthopaedic Services Task and Finish Group was sponsored by the Operational Delivery Team within the Scottish Government s 18 Week Referral to Treatment programme. The group includes NHS clinicians, managers and GPs. The contents of this Interim Output Report is commended to you by the Operational Delivery Team to support detailed assessment of your service and intensive action where required. It is essential that all opportunities for streamlined service management and ongoing improvement and transformation are optimised, with the patient s interest s right at the centre. Delivery and improvement will require whole systems ownership and strong organisational leadership (both clinical and managerial) in order to embed and operationalise change on a sustainable basis. The core elements commended to Health Communities and NHS Boards for action are: 1. Use the Check List for Boards box in each section of this report to identify the priority areas for change that apply to your service, and work with stakeholders and change champions to drive their implementation, making full use of the extensive range of tools and techniques available through the Improvement and Support Team. (See http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/pages/about.aspx). 2. Use available information, local knowledge and analysis of what if? scenarios to identify key areas for urgent change and drill into the processes which will unlock bottlenecks and remove non-value adding steps (See section 3.2). 3. Evaluate the findings from the audits of Arthroscopy, Carpal Tunnel Syndrome and Hip and Knee Arthroplasty pathways to identify improvement opportunities, remove variation and to enhance your action plans (See section 3.5 for commended actions and http://www.18weeks.scot.nhs.uk/how-to-achieve-and-maintain-18-weeks/task-and-finish-groups/orthopaedics/ for the audit reports). 4. Ensure that your Board has fully engaged with the Enhanced Recovery Programme (see Section 3.5.3). 5. Undertake comprehensive Demand, Capacity, Activity, Queue analysis [DCAQ] at sub-specialty level to understand your service and proactively manage your demand/capacity balance. Ensure that Waiting List Initiatives [WLI s] and the private sector are only used for one-off backlog removal and that reliance on ongoing WLI s and the private sector are removed. 6. If resource gaps in capacity are identified, consider options for using your workforce differently and maximising the use of skills across clinicians, specialist nurses, AHPs, GPwSI and admin and clerical staff. If additional resource is definitely required, back-up the case with robust DCAQ analysis. F3130196 Page 3 of 63 October 2010

7. Ensure your Board s submission to the monthly MSK Audit Demand and Activity sheet is accurate and that the information is used to identify improvement opportunities for your Board. 8. Ensure learning is shared across Scotland. Use the appendix of case studies to identify improvement opportunities and projects in other Boards to learn from. Use the attached blank case study template to enhance this resource by adding additional case studies for your Board. 9. Reinforce continuous focus on all dimensions of quality in line with the NHS Scotland Quality Strategy. It is expected that Boards will continue to develop their local Orthopaedic Services Action Plan. The Task and Finish Group and Improvement Support Team will continue to provide implementation support to ensure Boards achieve the 18 Weeks RTT Standard. Should 18 Weeks RTT performance in this specialty prove unsatisfactory, the escalation process could include further action planning with the Access Support Team, more detailed tailored support, intervention as needed and submission of detailed recovery plans. Boards progress on implementation will be reviewed at the Chief Executives meeting and individual mid-year reviews. Chair s Reflections by Prof. Jimmy Hutchison Chair of the Orthopaedic Services Task and Finish Group I was delighted to be invited to chair the Task and Finish Group for Orthopaedic Services as the 18 Weeks Referral to Treatment [RTT] standard is fundamentally all about good medicine. A risk analysis identified Orthopaedic Services as one of the specialties most likely to need additional support to achieve 18 Weeks RTT, largely due to the shear volume of referrals. We are the elephant in the room (in the nicest possible sense) and to some extent, a Cinderella. Orthopaedic disease is often not life-threatening, but it is quality-of-life threatening and our treatments can transform patients lives. F3130196 Page 4 of 63 October 2010

The Orthopaedic Task and Finish Group was established in January 2009 and harnesses expertise from across NHSScotland to consider the existing evidence base for delivery of timely treatment for Orthopaedic patients. The purpose is to encourage best practice across NHSScotland and support Boards in the use of tools and techniques to make service improvements. A comprehensive engagement strategy was adopted that included Service Manager Workshops, an Enhanced Recovery event in March 2010 and two national events in November 2009 and June 2010. A significant amount of our work has involved identifying and validating the critical data that describe a service and inform planning decisions. This Interim Output Report recognises that one size does not fit all and the Checklist for Boards box in each section offers a range of improvement actions that encompass enhancing primary and secondary care relationships, getting patients on the right pathways, standardising and improving pathways, improving access, managing waiting lists, balancing Demand, Capacity and Activity, maximising the value of information, ensuring timely diagnostics, making the most of your workforce and equality of access, quality and safety. Through engagement with patients throughout the redesign process, these improvement actions will place the patient at the centre of the planning and design of services. Providing improved access to high quality care by designing out unnecessary waits and delays that add no value to the patient will improve the patient experience. In essence, striving to ensure the patient is seen by the right person, at the right time and in the right place, i.e. simply good medicine. The improvement resources should enable Clinicians, Service Managers, members of Multi-Disciplinary Teams and 18 Weeks Teams to drive their local improvement strategy to deliver the 18 Weeks RTT Standard for December 2011, provide a platform to support the improvements necessary to deliver the NHS Quality Strategy and ultimately to improve services for patients. I believe that the Task and Finish Group has created a momentum for change within Orthopaedic Services. Achieving a full referral To Treatment Standard of 18 Weeks by December 2011, however, will be a considerable challenge for Orthopaedic Services, and there is a real concern amongst clinicians that it may be impossible within current resource. They will require repeated reassurance that attempts to achieve this will not prejudice priorities of clinical care. Evidence from work around the country suggests that it is achievable, and information within this Interim Output Report can help in that goal. I wish you every success as you move forward in developing your service, and the Task and Finish Group will continue work to support you in this. F3130196 Page 5 of 63 October 2010

1 Introduction 1.1 The 18 Weeks Referral to Treatment Standard and Programme Structure The 18 Weeks Referral to Treatment [RTT] Standard builds on the considerable improvements Boards have made in recent years to patient waiting times for first outpatient appointment, access to eight key diagnostic tests and inpatient/daycase treatment. From December 2011, 18 weeks will become the maximum wait from referral to treatment for non-urgent patients. The 18 Weeks RTT Standard shifts concentration on managing waiting times for each stage of treatment to whole pathways of care. The 18 Weeks RTT Programme is designed to support NHS Boards in transforming the whole patient journey including early diagnosis, treatment and patient experience. The Programme Board has four Delivery teams reporting to it; the Operational Delivery Team, the Information Delivery Team, the Diagnostic Steering Group and the Emergency Access Delivery Team. These teams all have members from NHS Boards and the Scottish Government. Within the Scottish Government s Delivery Directorate the Improvement and Support Team [IST] and the Access Support Team [AST] are also focussing on 18 Weeks RTT. To ensure absolute focus on achieving the 18 Weeks RTT and managing associated risks to delivery, these teams link closely with each Board s 18 Week team to ensure progress on all work-strands. 1.2 Task & Finish Groups At the start of the programme, the Operational Delivery Team undertook analysis to identify the specialties most likely to need additional support to achieve the 18 Weeks RTT Standard. Orthopaedic Services was identified as one of six such specialties. This decision was on the basis of the high level of demand for Orthopaedic services, the need to embed sustainable change, to support a move away from reliance on waiting list initiatives and to develop whole system working with quality and safety as a central tenet (See NHS Scotland Quality Strategy http://www.scotland.gov.uk/topics/health/nhs-scotland/nhsquality ). In addition to the specialty based Task and Finish Groups, two crosscutting groups have been formed to address Diagnostics and Capacity Demand Management. F3130196 Page 6 of 63 October 2010

1.3 Orthopaedic Services Facts and Figures Significant improvements in orthopaedic services have been achieved in the last decade, at the same time as balancing changes in workforce brought about by the European Working Time Directive, Junior Doctors Working Hours and Hospitals at Night policies. Boards have made significant progress in improving waits for Orthopaedic Services. The March 2010 Stage of Treatment target of no more than a 12 week wait for the first Outpatient appointment and 12 weeks for Inpatients/Day Case (All Boards opted to work to a target of 9 weeks for Inpatient/Day Case) were achieved. There has been an increase in complex cases, such as hip and knee replacement (approximately doubled in the last 10 years) and shoulder surgery (a 27% increase in the last 10 years). There has been a reduction in length of stay (7 days down to 6 days in the last 10 years) and in same day surgery (50% increase in last ten years). The percentage of hip fractures operated on within 24 safe operating hours increased from 80% in April 06 to 98% in Dec. 08. There has also been an increase in the provision of community-based services to reduce unnecessary hospital appointments. Max. waiting 18 months Overall guarantee 1991 Max. waiting 9 months Inpatient/daycase 31 December 2003 Max waiting 18 weeks Outpatient & Inpatient/day case 9 weeks Diagnostics 31 December 2007 Max. waiting 12 weeks OP/IP (all source) 31 March 2010 18 week RTT This diagram represents targets that have been consistently met over the last 20 years. 1 April 1997 Max. waiting 12 months Inpatient/daycase 31 December 2005 Max. waiting 6 months Inpatient/daycase 31 March 2009 Max. waiting 15 weeks OP/IP 6 weeks Diag. The 20 Year Journey F3130196 Page 7 of 63 October 2010

The following charts can be used at national level and Board level to understand Demand for Orthopaedic Services. Number of Referrals Actual Trends - New Outpatients - NHS Scotland - Trauma & Orthopaedic Surgery 12 000 10 000 8 000 6 000 4 000 2 000 0 Jan-05 Jan-06 Jan-07 Jan-08 Jan-09 Jan-10 This graph shows demand coming from GPs, A&E, Consultant to Consultant and Other. It demonstrates the significant degree of seasonal variation in demand. (N.B. only those referrals where the patient was given an appointment are included. The date is the date the referral was received.) At Board level the percentage of demand from different sources varies significantly e.g. one Board has as big a percentage from A & E as it does from GPs. Boards need to understand the patterns for their own Board for pro-active demand management. Source: SMR00 Month ending SMR00 - GP/GDP SMR00 - Consultant SMR00 - A&E SMR00 - Other 12 000 IP/DC Activity - NHS Scotland - Orthopaedics - Principle Procedures 10 000 Arthroscopy Hip Replacement Carpal Tunnel Release Foot Procedures Knee Replacement 8 000 Admissions 6 000 4 000 Source: SMR01 2 000 0 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 Financial Year This graph shows the increase in principal procedures between 2003 and 2009. (N.B. Some additional Carpal Tunnel Releases are undertaken in other specialties e.g. plastic surgery and neurosurgery). F3130196 Page 8 of 63 October 2010

Percentage Increase in Referrals from Previous Year 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% Acceleration & Deceleration in Increase in Referrals Orthopaedics - NHS Scotland Patients given New OP appointments (consultant-led service) dated from date of referral This graph shows the acceleration and deceleration in the increase in referrals to Orthopaedics since 2006. The percentage shown at each quarter end compares the year back from that quarter end with the year prior to that. This method removes the effect of seasonality from the calculation of the overall increase in referrals. During 2008 the increase accelerated and remained high in early 2009. By the second quarter of 2009, however, the increase was decelerating and has continued to do so for the next three quarters. 0.0% Dec-06 Mar-07 Jun-07 Sep-07 Dec-07 Mar-08 Year Ending Note - SMR00 data. Each data point compares the four quarters prior to the 'year ending date' with the four quarters prior to that. E.g. first data point is a comparison of Jan '06 to Dec '06 with Jan '05 to Dec '05 Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 F3130196 Page 9 of 63 October 2010

Percentage Increase / Decrease from Previous Quarter 20.0% 15.0% 10.0% 5.0% 0.0% -5.0% -10.0% Mar-06 Jun-06 Sep-06 Quarterly Change in Referrals patients given new OP appointments Orthopaedics - NHS Scotland Dec-06 Mar-07 Jun-07 Sep-07 Dec-07 Mar-08 Jun-08 Sep-08 Dec-08 Mar-09 Jun-09 Sep-09 Dec-09 Mar-10 This graph shows the effect of seasonality in Orthopaedics. Between 13% and 16% more referrals were received in April June in each of the last four years than in the period January to March. The effect of seasonality on referral rates is predictable. Capacity planning must be flexed to account for the variation. -15.0% Quarter ending Note that the above figures are from SMR00 (using data from Jan05 to Mar10) and are based on Consultant-led New Outpatient appointments, dated from the date referral was received. F3130196 Page 10 of 63 October 2010

Number of Referrals - New OP and IP/DC 20 000 18 000 16 000 14 000 12 000 10 000 8 000 6 000 4 000 2 000 Conversion Rate - NHS Scotland - Trauma & Orthopaedic Surgery Conversion Rate - NHS Scotland - Trauma & Oth di S 0.60 0.50 0.40 0.30 0.20 0.10 Conversion rate 0 Jan-05 Jan-06 Jan-07 Jan-08 Jan-09 Jan-10 0.00 Mont h ending Source: SMR00, SMR01 and New Ways Data Wareho se New OP seen (SMR00) IP/DC added to WL (SMR01) Conversion Rate This graph shows the conversion rate (black line) from New Outpatients Seen (red line) to Additions to List (blue line). Ideally, conversion rates should not be affected by a seasonal rise and fall in demand. Boards should review this graph for their own Board to assess the degree of seasonal variation in conversion rates. If there is a variation, Boards should consider whether the rate is influenced by a seasonal increase in referrals where an Orthopaedic consultant is not necessarily the most appropriate professional to see these patients as a lower percentage convert to surgery or if there is a lowering or raising of the criteria for surgery at certain times of year. In terms of the overall trend in conversion rates over several years, Boards should consider whether community and primary care projects are having a positive effect on conversion rates. F3130196 Page 11 of 63 October 2010

The following graphs can be used at national and Board level to understand how waiting lists are being managed. 1. Total num ber of patients on the w aiting list at m onth end (census) Inpatients - NHS Scotland - Traum a & Orthopaedic 1. Total num ber of patients on the w aiting list at m onth end (census) New Outpatients - NHS Scotland - Traum a & Orthopaedic 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 Jan Feb Mar A pr May Jun Jul A ug Sep Oct Nov Dec Source: New W ays data, as at 30 Jun 2010 2008 2009 2010 35000 30000 25000 20000 15000 10000 5000 0 Jan Feb Mar A pr May Jun Jul A ug Sep Oct Nov Dec Source: New Ways data, as at 30 Jun 2010 2008 2009 2010 6600 6400 6200 6000 5800 5600 5400 5200 1. Total num ber of patients on the w aiting list at m onth end (census) Day Cases - NHS Scotland - Trauma & Orthopaedic 5000 Jan Feb Mar A pr May Jun Jul A ug Sep Oct Nov Dec Source: New Ways data, as at 30 Jun 2010 2008 2009 2010 These graphs show the size of the Inpatient, Outpatient and Day Case waiting lists in 08/ 09/ 10. They show a seasonal variation in waiting list sizes. The Inpatient graph shows a steady reduction in numbers waiting over the two and a half year timescale. For Outpatients the reduction in 2009 was significant but unfortunately the 2010 pattern shows a steep increase in the late spring to levels almost as high as those in 2008. The Day Case graph shows a big increase between 08 and 09, possibly due to a shift in practice from Inpatients to Day Case but without the availability of sufficient Day Case capacity. The start of 10 shows a promising reduction but since April, levels have risen higher than in either of the previous two years for the early summer months. F3130196 Page 12 of 63 October 2010

Patients waiting in one week bands as % of total waiting list Inatients waiting in one week time bands as % of total waiting lists - Trauma Orthopaedic - New ways data, March 2010 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 0 <01 weeks 01 <02 weeks 02 <03 weeks 03 <04 weeks Source: New Ways data, as at 31 Mar 2010 04 <05 weeks 05 <06 weeks 06 <07 weeks 07 <08 weeks 08 <09 weeks 09 <10 weeks Week Bands 10 <11 weeks 11 <12 weeks 12 <13 weeks 13 <14 weeks Scotland Board B Board A 14 <15 weeks This graph shows that in March 10 the Stage of Treatment Target of no more than 9 weeks wait for Inpatients treatment was being achieved. It also shows the variation in shape of waiting lists between different Boards. The shape of Board B s waiting list is not sustainable as the service is extremely vulnerable to the impact of any increase in demand or decrease in available capacity. 3. Waiting List Activity - Additions to list & removals from list within month Inpatients - NHS Scotland - Trauma & Orthopaedic 4000 3500 3000 2500 2000 1500 1000 500 0-500 -1000 Jan 2008 Feb 2008 Mar 2008 Apr 2008 May 2008 Jun 2008 Jul 2008 Aug 2008 Sep 2008 Source: New Ways data, as at 31 Mar 2010 Oct 2008 Nov 2008 Dec 2008 Jan 2009 Feb 2009 Mar 2009 Apr 2009 May 2009 Jun 2009 Jul 2009 Aug 2009 Sep 2009 Oct 2009 Nov 2009 Dec 2009 Jan 2010 Feb 2010 Mar 2010 Gap betw een additions/removals Additions to list Removals to list This graph shows seasonal variation in additions and removals from the waiting list. It highlights months where removals did not balance additions and waiting lists grew. It is essential for Boards to understand their own variation and to plan sustainable capacity accordingly. F3130196 Page 13 of 63 October 2010

Outpatient appointments Operations 30% 25% 20% 15% 10% 5% 0% 30% 25% 20% 15% 10% 5% 0% Lanarkshire GG&C D&G Tayside Grampian Fife Lothian Highland A&A FVAH Borders All Boards Lanarkshire GG&C D&G Tayside Grampian Fife Lothian Highland A&A FVAH Borders All Boards WLI Private GJNH SRTC WLI Private GJNH SRTC The graphs show Additional Activity as a percentage of all activity (scheduled and unscheduled), April 09 to March 2010. F3130196 Page 14 of 63 October 2010

Risk Assessment- Outpatients (All Sources of Referrals) Trauma & Orthopaedic, New Ways Jun-10 15 Bubble Area proprtional to number waitng > 9 weeks (all source of referrals) Risk Assessment- Inpatients Trauma & Orthopaedic, New Ways Jun-10 15 Bubble Area proprtional to number waitng > 6 weeks no of weeks required to clear the list (allowing periods of unavailability) Grampian 10 Highland Lanarks Lothian GG & C D & G Fife A & A FV Tayside 5 WI 41 166 373 664 1037 no of weeks required to clear the list (allowing periods of unavailability) Borders Lothian Grampian 10 A & A Lanarks D & G Tayside FV Fife Highland GG & C 5 19 77 173 308 481 0-10% -6% -2% 2% 6% 10% % change in monthly queue size (averaged over the year ending Jun-10) 0-10% -6% -2% 2% 6% 10% % change in monthly queue size (averaged over the year ending Jun-10) no of weeks required to clear the list (allowing periods of unavailability) Lanarks Risk Assessment- Day Cases Trauma & Orthopaedic, New Ways Jun-10 15 A & A Tayside 10 Lothian 5 FV Highland D & G Grampian GG & C Fife Borders 0-10% -5% 0% 5% 10% % change in monthly queue size (averaged over the year ending Jun-10) Bubble Area proportional to number waiting > 6 weeks 17 69 156 278 434 These graphs show the balance of three risk factors: The size of the bubble is in relation to the number of patients on the waiting list. The vertical height of the bubble is in relation to the estimated number of weeks required to clear the waiting list based on recent activity. The horizontal position of the bubble is in relation to the monthly increase/decrease in waiting list size Activity figures include waiting list initiatives as well as core activity. If the number of weeks required to clear is relatively low this does not guarantee there is no risk for example, activity could be being increased by unsustainable waiting list initiatives. It is important for Boards to understand the level of activity required for business as usual, i.e. to meet appropriate demand as opposed to the oneoff activity required for back-log clearance. F3130196 Page 15 of 63 October 2010

All the graphs on the previous pages have been for stages of treatment and they can be used to measure performance and identify and monitor improvement opportunities. In order to be sure that Boards are meeting milestones towards achieving the 18 Weeks RTT standard by December 2011 it is essential that full RTT patient journeys are being accurately measured. Boards have been asked to submit their journey measurement completeness figures on a monthly basis. % Complete 100 90 80 70 60 50 40 30 Trauma & Orthopaedic Admitted Completeness Boards have been anonomised on these graphs. The graphs show that most Boards need a significant improvement in journey measurement before 18 Weeks performance can be assessed. Admitted completeness is relatively high at some Boards but there is little sign of significant measurement improvements over time. 20 10 0 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 100 Trauma & Orthopaedic Non Admitted Completeness Non Admitted completeness is very low in a number of Boards and being erratically reported in other Boards. 90 80 70 % Complete 60 50 40 30 20 10 0 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 F3130196 Page 16 of 63 October 2010

2 Orthopaedic Services Task & Finish Group The Orthopaedic Services Task and Finish Group was set up in January 09 and includes Service Managers, Orthopaedic Consultants, Anaesthetists, Extended Scope Physios, GPs and Scottish Government members (see Appendix A for full membership). The group have focussed their actions so far in the following work-streams; Measurement and Definitions; Demand / Capacity / Activity / Queue (DCAQ); Primary Care Solutions; Performance Management; Service Redesign and Transformation; Cultural; Workforce and Communication. From the outset the Orthopaedics Task and Finish Group aimed to support clinically appropriate and evidence based sustainable improvements and to support a reduction in reliance on Waiting List Initiatives [WLI s] and the private sector. The following chart shows a Glenday Sieve analysis of the volume of activity by procedure. Just nine Orthopaedic procedures (4%) account for 50% of activity. This has provided a clear focus for national work to support improvements in pathway management that will have the highest impact across NHSScotland. The Task and Finish Group is running projects to support improvements for the following pathways: Enhanced Recovery Total Hip and Total Knee Replacement Suspected Carpal Tunnel Arthroscopy In addition, a Spinal Pathway project and a Community MSK Pathway project are in progress. Glenday sieve analaysis of St Elsewhere Trauma and Orthopaedic Inpatient/Day-case activity 2007/8 120.00% 100.00% % of activity 80.00% 60.00% 40.00% 20.00% 0.00% 1 7 13 19 25 31 37 43 49 55 61 67 73 79 85 91 97 1. Primary Total Hip Replacement 2. Primary Total Knee Replacement 3. Carpal Tunnel Decompression Nine procedure accounted for 50% of Trauma and Orthopaedic activity, these procedure are: 1. Total prosthetic replacement of hip joint using cement 2. 5. Total prosthetic Fracture replacement of Fixation knee joint using cement 3. Release of entrapment of peripheral nerve at wrist 4. 6. Theraputic Arthroscopy endoscopic operations on semilunar (diagnostic) cartliage 5. Other internal fixation of bone 6. 7. Diagnostic Arthroscopy endoscopic examination of (other) knee joint 7. Other theraputic endoscopic operations other joint structures 8. 8. Excision Dupuytren s of other facia Contracture 9. Puncture of joint 4. Arthroscopy (menisectomy) 9. Joint Injection procedure number 103 109 115 121 127 133 139 145 151 157 163 169 175 181 187 193 199 205 211 F3130196 Page 17 of 63 October 2010

2.1 18 Week RTT Risks to Delivery Scottish Government Health Directorates Through consultation with Boards, the following risks to delivery in Orthopaedic Services were identified from the outset: Significant variation by Board and sub-specialty in terms of the time it takes from referral to treatment. For example, the gaps between the value-adding steps of the pathway and the number of non-value-adding steps included. Difficulties in measuring performance and improvement due to non-integrated and disparate IT systems. Significant variation in patient experience of access to services and the pathways they follow. Significant variation in the service provided for patients living in Boards with a regional centre and those without. Pathways with hand-offs to other departments, particularly diagnostic tests, prosthetics, orthotics and consultant to consultant referrals in other specialties or Boards. Difficulties in measuring Demand and Capacity to identify whether a service is in balance. Unsustainable reliance on WLI s and the private sector. 2.2 Priority Task & Finish Group Improvement Actions The following priority actions for the group to support NHS Boards mitigate delivery risks and develop sustainable solutions were identified: To augment available data by creating a data set to support service planning and improvements. To ensure boards are using available data and tools to understand areas for improvement and manage demand and capacity. To gain an understanding of the Demand and Capacity balance and Queue Size and Shape through collection and analysis of comparable information for Orthopaedic Services across Scotland. To drill down into available information to identify local, regional and national planning and training requirements, risk areas, high impact changes, improvement opportunities, benchmarking and the identification of best practice. To undertake individual projects for high volume pathways Arthroscopy, Suspected Carpal Tunnel Syndrome, Enhanced Recovery for Total Hip and Knee Replacement Surgery and the Spinal problems Pathway. To identify ways to reduce the number of outpatient appointments required with consultants in secondary care by ensuring patients access care at the most appropriate place e.g. community MSK assessment services. To share good practice for adoption and spread through national events managed by the Improvement and Support Team. F3130196 Page 18 of 63 October 2010

3 Task & Finish Group Outputs The following is a summary of the Orthopaedic Services Task and Finish Group outputs achieved so far. Items are then described more fully in the following sections. Workstream Completed In Progress 1 Measurement & Definitions Input to national Principles & Definitions. Encouragement of Clinical Outcoming in Orthopaedic clinics. Encouragement of improvements in 18 Weeks Completeness and Performance reporting (particularly for Non-Admitted pathway). Analysis of clinical outcome data to highlight further opportunities for service redesign including return appointments and onward referrals to other specialities. 2 Demand/Capacity/ Activity/Queue 3 Primary Care Solutions Monthly Demand and Activity MSK Audit data being used for identification of improvement opportunities (now on HEAT website see Section 3.2.1). Audit of Referral to Diagnosis Pathways & Additional Capacity Used 08/09. Information for Improvement Letter sent to Exec Leads encouraging use of IST tools & all available data. Community based MSK Pathway project (pilot in Lanarkshire). Assessment and triaging of back pain patients. Pilot DCAQ project with NHS Lothian to proactively plan capacity. Health Intelligence Group analysing all available data sources (e.g. MSK Audit data, New Ways/QueSSTCap data) to identify risks and inform performance and improve action planning. Clarification of referral criteria e.g. spinal pathways, carpal tunnel. Link with Demand Management Group focusing on Orthopaedics. Identification of best practice clinical guidance intranets and collaboration between primary and secondary care. F3130196 Page 19 of 63 October 2010

4 Performance Management 5 Service Redesign and Transformation New Ways / QueSSTCap data used to identify trends and risk areas. Support of good Waiting List management principles and reduction of reliance on WLIs. Focus on improvement opportunities for high volume pathways through re-design of: o Suspected Carpal Tunnel Syndrome pathway (including role and provision of Nerve Conduction Studies) o Arthroscopy/Knee Pain Pathway o Total Hip & Total Knee Replacement through participation in Enhanced Recovery Programme. Work with Boards on specific areas identified by the data. Safe Space Risk Assessment with specific Boards. Spinal Pathways collaboration between Neurosurgery and Orthopaedics. Agreement of protocols for which patients should be seen by which professionals locally and regionally. 6 Cultural Encouragement of full completion of Monthly MSK Audit Demand and Activity data as gaps from individual hospitals or Boards reduce the value of the rest of the data for comparison purposes and national analysis. Presentations at Scottish Orthopaedic Club 09 & 10. Consideration of an Orthopaedic Supportive Visits Programme (with Scottish Committee for Orthopaedics & Trauma). Implementation of Enhanced Recovery Programme to further develop multi-disciplinary team working in Orthopaedics. 7 Workforce Input to Workforce Solutions Event. Identification of best practice and pilots with Update of SWISS Workforce database (via SCOT). opportunities for changing clinical roles (e.g. extended role practitioners). 8 Communication National Orthopaedic Events (Nov 09 & June 10) to Identification and roll out of best practice. demonstrate best practice and take re-design projects forward. Orthopaedic Managers & Lead Clinicians events held (May & July 09). Presentations to Scottish Committee for Orthopaedics & Trauma. F3130196 Page 20 of 63 October 2010

3.1 Measurement and Definitions 3.1.1 Definitions The application of common definitions is fundamental to the accurate measurement of waiting times. The generic clock start / clock stop definitions apply as set out in 18 Weeks: The Referral to Treatment Standard Principles & Definitions (issue 2.0, January 2009. See http://www.18weeks.scot.nhs.uk/how-to-measure-and-monitor-performance/principles-and-definitions/ N.B. The Information Delivery Team advise that the document is currently being revised. For further information please contact kate.james@scotland.gsi.gov.uk. Check List for Boards: o Ensure that all staff involved in recording clock starts / clock stops, understand and apply the definitions uniformly. This includes the understanding and application of New Ways Rules to support the recording of periods of patient unavailability. 3.1.2 Measurement Stage of Treatment measurement has been undertaken for many years. Boards are now required to undertake 18 Weeks measurement. Check List for Boards: o Ensure robust and fit for purpose management information. Embed use of the data into operational management to support delivery of 18 Weeks and highlight opportunities for improvement. Use data to drill into problem areas and to inform next steps, including opportunities for the development of models of care in community settings. o Ensure 18 Weeks reporting of Completeness and Performance and work towards improving these on a monthly basis (particularly Non- Admitted Completeness). Are your systems 18 Weeks and New Ways compliant in terms of recording and correctly taking account of periods of patient unavailability for reporting purposes. Do all relevant staff understand the rules and how to apply them? o Review the recording of the Unique Care Pathway Number [UCPN] at each stage of each patient s 18 Week Journey, including for Onward Referrals. Automate wherever possible. o Review recording of Clinical Outcomes at all new and return appointments and remove paper recording where possible. Make sure all clinical staff and administrators understand which codes should be used in which circumstances. If a clock stopping code is being used, has the 18 Week journey been correctly stopped so that the patient will not be counted in any reports as having an ongoing wait? F3130196 Page 21 of 63 October 2010

o Evaluate where treatment is occurring, for example with AHPs, and ensure all staff understand the importance of stopping the clock. o Ensure that reports and systems designed to link elements of patient pathways are used to identify bottlenecks, unnecessary waits and improvement opportunities as well as individual patients about to breach. (See Patient Journey Analyser http://www.improvingnhsscotland.scot.nhs.uk/tools/pages/search.aspx ) 3.2 Demand/Capacity/Activity/Queue (DCAQ) Analysis Maintaining a balance between demand, capacity and activity, to ensure an efficient service where queues do not develop, requires robust information. It also requires a detailed understanding of the parameters and the impact that a change in any of the parameters has on the others. For example, demand can vary weekly or seasonally and can increase or decrease gradually over-time. Actions can be taken to influence a decrease in demand for secondary care appointments. Efficiencies can be gained through management and redesign that optimise capacity utilisation or some demand can be redirected to other professionals. Accurate data input and capture from systems is integral to undertaking robust DCAQ analysis to underpin the management of variation, to support service planning and inform service redesign and transformation. 3.2.1 Information for Improvement Maximising the Value of Information The following information, tools and support are available to Boards: MSK Audit The MSK Audit team are funded by the Access Support Team and harness the expertise from the Hip Fracture Audit, a highly successful vehicle to develop clinically credible data to improve timeliness of patient care. The MSK Audit is run by ISD and provides resource for each NHS Board to employ an MSK Audit Coordinator. The Audit has two elements: Monthly management information on Demand and Activity by site. Aggregated to national level and real time feedback to managers and clinicians (See Appendix B). A series of sprint audits to support pathway redesign (see section 3.5 Service Redesign and Transformation). The MSK management information has been collected since March 2009. There has been considerable investment to improve the coverage and quality of the data, and support offered for NHS Managers to use this as part of a suite of information (see Tools and Support section below), to enable them to more effectively manage capacity, demand and backlog clearance. F3130196 Page 22 of 63 October 2010

The development of the MSK data pre-dated the comprehensive availability of QueSSTCap data derived from the National New Ways Data Warehouse. The intent is to rationalise the MSK management information data set and data sources. This includes work to understand the differences between NHS Boards in the way they collect and use this information, which often results as a consequence of different service models. Importantly, the MSK Audit data adds the following value: All referrals are counted, not just those referrals added to list, enabling full quantification of referrals and those not added to list. Level of Additional Activity e.g. waiting list initiatives, GJNH and private sector is quantified. This enables core capacity vs. capacity to manage current backlog clearance to be assessed. It counts elective procedures actually undertaken (rather than admissions). Non Consultant-led AHP activity is quantified. New Ways Data and QueSSTCap Analysis Boards submit data to the national New Ways data warehouse which is then analysed by ISD. A set of charts have been developed to enable easy analysis for performance management and improvement purposes. This is referred to as QueSSTCap analysis (Queue Size, Shape and Trend and Capacity analysis). Some of these graphs have been include in Section 1.3 Orthopaedic Facts and Figures. Boards can access the information at Board level on the HEAT website (Call 0131 275 7777 or email nss.csd@nhs.net if you do not currently have access). The aim is to ensure that this information is fully utilised as a key tool for operational management, with data systematically derived and used at local level. Additional Data, Tools and Support Better Quality Better Value Indicators (such as Length of Stay, DNA rates, etc.) are useful to benchmark your hospitals against other hospitals. (Link http://www.bqbvindicators.scot.nhs.uk/ ). DCAQ training sessions are provided by the Improvement and Support Team [IST] and incorporate the principles of capacity planning, good waiting list management and demonstrate how the principles of LEAN methodologies might be applied in practical settings. Practical tools to support prospective DCAQ and waiting list management are available at http://www.improvingnhsscotland.scot.nhs.uk/tools/pages/search.aspx. Bespoke support is also available to Boards as needed, to ensure detailed understanding of demand and capacity (email istmailbox@scotland.gsi.gov.uk ). F3130196 Page 23 of 63 October 2010

What If Scenario Analysis Boards are commended to undertake What If scenario analysis to explore what impact an improvement in one or more parameters could have on the demand, capacity and activity balance. A number of parameters are detailed below but Boards are encouraged to consider others. Analysis at sub-specialty level (e.g. shoulders, knees, foot and ankle, etc.) is important to identify variation and improvement opportunities. See Appendix C for case studies of work already undertaken at Boards. What if GP referral patterns could be influenced so that all referrals meet clearly defined and jointly agreed pathway criteria and unexplained variation is reduced? This analysis could lead to a GP/Consultant engagement and education action plan. Boards can use the Locally Enhanced Services process to improve working between primary and secondary care. What if New Outpatient Appointments could be reduced by X% and the conversion rate to surgery therefore increased to Y% This analysis could lead to a Community MSK project see Section 3.3 Primary Care Solutions. What if Procedure X or Diagnostic Test Y was undertaken at the median rate per 100,000 of population? This analysis could lead to a review of referral criteria and a reduction in variation. What if the New to Return appointment ratios were optimised? New attendances could potentially increase if return appointment slots were freed-up. Could AHPs (e.g. physios or OTs) in primary or secondary care see some return patients? Allow for differences in new to return ratios between sub-specialties. What if all scheduled clinics went ahead and all slots at scheduled clinics were utilised? Analysis may show a significant number of gaps in clinics that actually occur. Clinics may be cancelled for valid reasons but not reinstated if the reason changes. Analysis may also show a significant variation in the number of patients seen each week at each clinic. This offers the opportunity to improve capacity utilisation. Templates and staffing may also need to be clarified. Consider reducing infrequent sub-specialty clinics and/or ensure empty slots are filled with general patients at an agreed timescale prior to the clinic. What if all new appointments were allocated X minutes & follow-ups were Y minutes and all clinics ran for at least 4 hours? This analysis may identify potential for additional clinic slots. The amount of time allocated will need to vary by sub-specialty and for more complex cases. There may be significant variation in the length of scheduled clinic times. There may be historic reasons for this. Where possible these clinic profiles should be re-negotiated as it is likely that a minimum of 4 hours is more efficient use of the time for all the staff involved. F3130196 Page 24 of 63 October 2010

What if some clinics ran for more than 42 weeks a year? This scenario is only relevant where space is a rate limiting factor rather than consultant availability. This may be relevant at some Boards where other consultants can use the space for clinics in the weeks where the normal clinic is not running. What if. Pre-op length of stay could be reduced to achieve upper quartile in Better Quality Better Value Indicators? Analysis may identify opportunities to reduce pro-operative stay potentially releasing beds days and increasing productivity. What if. Average length of stay could be reduced to achieve upper quartile in Better Quality Better Value Indicators? Analysis may identify opportunities to reduced average length of stay potentially releasing bed days and increasing productivity. Implementation of Enhanced Recovery should be considered to support the reduction in average length of stay (See Section 3.5.3). What if Same Day Surgery Rates were optimised? Analysis of BADS directory of procedures or Better Quality Better Value Indicators may highlight opportunities to increase day surgery rates and improve efficiency of pathways. (See http://www.bads.co.uk or http://www.bqbvindicators.scot.nhs.uk/ ). What if Administration delays were eliminated from pathways? Analysis of MSK Carpal Tunnel and Arthroscopy Audits, as well as 18 weeks Readiness Assessment (See http://www.improvingnhsscotland.scot.nhs.uk/programmes/18weeks/pages/resources.aspx) may highlight opportunities for improvement of pathways through reduction in administration delays (See Section 3.5). What if Theatre utilisation was optimised? Analysis of data collected through the National Theatres Benchmarking Project may identify opportunities to improve theatre efficiencies. (See http://www.isdscotland.org/isd/6321.html ). What if Capacity matched Demand! Demand and its seasonal variation can be predicted through statistical modelling. Analysis of demand data (SMR00) over the last four years has shown an average of a 13% increase in demand in April-June of each year compared with Jan-March. Proactive capacity planning needs to be in place to increase capacity to meet this demand. Capacity needs to be flexed seasonally to meet demand and prevent queues building up (this will probably require changes to annual leave policy and job plans.) What if the backlog was removed once? Would queues build up again or would capacity and demand be in balance? F3130196 Page 25 of 63 October 2010

Check List for Boards: o Ensure you regularly access the MSK Audit and QueSSTCap information available on the HEAT system, make full use of IST support and tools and the Better Quality Better Value Indicators (see links given earlier in this section). o Undertake robust Demand, Capacity, Activity, Queue analysis to understand whether your service is in balance. Understand source of demand, case mix, conversion rates from outpatient appointments to listing for surgery, queue sizes and shapes. o Develop and manage your Capacity Plan, including scheduling, managing variation, improving and optimising use of available capacity, and where appropriate, one-off backlog removal to ensure a sustainable service. o Understand Seasonality. Ensure leave is managed to match demand peaks and troughs. Once a service s DCAQ information is routinely shared with consultants they understand the need for a leave policy to be enforced, swift vetting, focus on capacity utilisation, and improvements in clinical administration. o Following identification and implementation of improvement opportunities, identify if a gap exists between capacity and predicted demand. If there is a gap, produce a business case for additional staff that demonstrates full understanding of DCAQ to ensure a sustainable service without an ongoing requirement for WLIs or the private sector. o Assess the DCAQ balance between sites. Is there inequity in terms of patients experiencing longer waits in some locations? o Proactively plan your Board s use of the GJNH. A quantity of work negotiated with the GJNH over several years will be significantly cheaper than resorting to the private sector at short notice. o Consider options for regional working for some sub-specialties. o Undertake What If scenario analysis at sub-specialty and consultant level to identify variation and improvement opportunities. Ensure you develop an Action Plan of improvements. See Appendix C for case studies of work already undertaken at Boards. o Consider best practice capacity planning guidelines of ensuring that available capacity can cope with at least 80% of the variation in demand to ensure that queues do not build up. o If you are concerned by your Board s ability to balance capacity and demand for Orthopaedic services and meet the 18 Weeks RTT without reliance on WLIs and the private sector then contact AST for Safe Space discussion. (Contact Mike.Lyon@scotland.gsi.gov.uk). F3130196 Page 26 of 63 October 2010

3.3 Primary Care Solutions The Task and Finish Group consider that there is significant scope for elements of Orthopaedic care currently undertaken in secondary care to move to primary care. There is also scope for streamlining pathways into secondary care to ensure patients get onto the right pathway, first time. 3.3.1 Community-based MSK Pathway Project This project is being led by the AHP and Healthcare Sciences Branch of the Scottish Government. Pilot projects are currently being run in Lothian and Lanarkshire health board areas. For the pilots, back pain MSK services have been redesigned to test the national model as follows: Standardise self-referral through NHS24. Incorporate work status within assessments and outcomes. Shift ESP (advanced practitioner) capability into the community, allowing earlier assessment and triage. Standardise criteria for when MRI should be used. Standardise criteria for referrals to Orthopaedics, thus reducing outpatient appointments and increasing conversion rates for surgery. Develop protocols for all exit routes to appropriate professionals. The following measures of success are in place: Increase % of patients accessing physio via self referral. The National AHP dataset includes patient outcomes through their journey which will enable economic evaluation. Reduce volume of MRI investigations. Increase conversion rate to surgery in Orthopaedics. The following patient benefits and staff / organisational benefits have been identified: Rapid access to community services for patients. Equitable access to services. Fewer hand-offs between different professionals and services throughout the patient s journey. Cost savings. Increased ability to meet the 18 Week RTT standard as consultant s time is freed-up from outpatient appointments. F3130196 Page 27 of 63 October 2010