Trauma & Orthopaedics Service Redesign July 2016€¦ · 1 Trauma and Orthopaedics Service Redesign...

1 Trauma and Orthopaedics Service Redesign 20160708

Trauma & Orthopaedics

Service Redesign

July 2016


List of Contents

1 Introduction

2 Background

3 Case for Change

4 Stakeholder Engagement

5 Implementation

6 Capacity

7 Finance

8 Programme Risk

9 Conclusion

List of Appendices

A – Comparison of Options

B – Risk Log

C – Quality Impact Assessment template

D – Work Stream Projects

E – Poole Predictor Tool

F – Letter from the Scottish Health Council

G – Letter from the Academy of Medical Royal Colleges and Faculties in Scotland


1. Introduction

This paper will outline the proposed changes to the Orthopaedic Service commencing with the case

for change and progressing to the commitment to deliver the preferred two site model of one site

for Trauma and a separate hospital site as the single elective operative site for Orthopaedics within

Lanarkshire through phased redesign of the service. It will provide detail on the imperative to

implement immediate change to ensure safe and sustainable services for patients now and then

develop the final phase of reconfiguration within the context of the wider NHS Lanarkshire

Healthcare Strategy.

It has been recognised by the clinicians and managers in Lanarkshire for some time that

improvement should be made to the quality of the Orthopaedic Service; however, they have noted

that effecting change involved a number of challenges which would inevitably impact upon other

areas of service provision. The concerns about the quality of care were echoed and emphasised by

the report from the Rapid Review of Safety and Quality of Care by Healthcare Improvement Scotland

(HIS) in December 2013.

In the period since the HIS report there have also been inspection visits by the General Medical

Council (GMC) and the Postgraduate Dean for Medical Education on behalf of NHS Education

Scotland (NES), reviewing the quality of training provided to doctors in training in the Orthopaedic

service in Lanarkshire. As a consequence of the current three site configuration, senior medical staff

are required to spend a disproportionate amount of their time staffing out-of-hours rotas and this

limits their availability to supervise formal training.This has resulted in formal external assessments

criticising aless than satisfactory level of training qualitybeing provided to junior doctors in

Foundation and General Practice programmes attached to the service as well as Core Surgical and

specialist Orthopaedic training programmes.

NHS Lanarkshire has taken forward recommendations from the HIS report and the feedback from

the training quality visits,and has carried out a full review of the Trauma and Orthopaedic Service

configuration in order to develop more detailed options for the provision of a safe, effective, person-

centred and sustainable service. These are discussed in more detail under the case for change in

section 3 of this paper.

The Orthopaedic Service review by NHS Lanarkshire has outlined options, risks and requirements for

the redesign of Trauma and Orthopaedic services in NHS Lanarkshire. This work was subject to

external, independent expert review by the Academy of Medical Royal Colleges and Faculties in

Scotlandwho endorsed NHS Lanarkshire’s approach to redesigning the service by moving to an

interim model where Orthopaedic surgery is initially concentrated onto two sites both providing

Trauma and Elective services. Orthopaedic outpatients will continue to be provided on three sites.


This interim move will allow NHS Lanarkshire to deliver the necessary improvements and ensure a

safe and sustainable service for patients that:

• delivers improved and more consistent outcomes for patients • reduces the time patients (particularly for trauma) spend in hospital after surgery • improves waiting times performance and lessens dependence on capacity provided at

the National Waiting Times Centre • delivers improved support and training for junior doctors • improves the sustainability of medical workforce at consultant and trainee levels.

Our ultimate strategic aim is to move to a model that is in keeping with the proposals from the

National Trauma Network which has subsequently been endorsed within the National Clinical

Strategy andby the Academy of Royal Colleges and Faculties. This will necessitate a move to a two-

site model with one single trauma unit on the Wishaw General site with one of the other district

general hospitals (DGHs) providing elective operative services,which will be consulted on within the

NHS Lanarkshire Healthcare Strategy. The Academy has also clearly stated that whilst the interim

move will address some of the challenges presented in the HIS, Trauma and Orthopaedics GIRFT

(Getting it Right First Time) and Deanery reports, it must be ‘’clear and explicit that this is part of a

journey to a single site for trauma.”

It is this ultimate strategic aim that will be consulted on as part of the NHS Lanarkshire’s Healthcare

Strategy. However it is proposed that an interim model, where Trauma and Elective Orthopaedics

are initially concentrated onto two sites both providing Trauma and Elective services, should be

progressed as this will offer an immediate solution to the clinical risks within the service whilst being

deliverable within the current constraints. It is further proposed that this initial phase can only be

achieved by one of the developed options for reconfiguration, namely that the two sites be Wishaw

and Hairmyres Hospitals; the rationalefor this is articulated below.

2. Background

Orthopaedic services within NHS Lanarkshire are currently provided on an outpatient, day case

surgery and inpatient basis from Lanarkshire’s three district general hospitals – Hairmyres Hospital,

Monklands Hospital and Wishaw General Hospital. In addition, a proportion of elective inpatient

services are provided at the Golden Jubilee National Hospital (GJNH). However this is in the context

of a changing national picture and proposals on how both Trauma and Elective orthopaedic care will

be provided in the future.

There is recognition that the needs of the population are changing rapidly, and the volume of

primary and revision joint replacement operations will continue to grow for the foreseeable future

as a consequence of rapidly ageing population. As a result, NHS Lanarkshire’s Trauma and

Orthopaedics service expects a growth in activity by 12.9% by 2020 with further growth of 11.7% by

2025.


The National Clinical Strategy for Scotland 2016 document has commented on current national

provision of orthopaedic services and highlights the need for quality improvement;

“there are known examples of where we accept a structure that is unlikely to produce the best

possible outcomes. For example, evidence from the US suggests that a surgeon doing hip

replacement operations should do at least 35 operations per year. At that level of activity the

occurrence of complications falls to around the minimum level.”

It goes on to state;

“In Scotland we provided about 7,600 hip replacements and 7,170 knee replacements in 2013/14.

There were also 950 hip arthroplasty revisions, and 460 knee arthroplasty revisions. Hip and knee

arthroplasty revisions are recognised to be more complex and challenging procedures, and there is a

greater risk of adverse outcome for the patient. The arthroplasty project report results show that

40% of hip revision operations were carried out by surgeons who do less than ten such operations per

year, and just under one third of the knee revision operations were carried out by surgeons who do

less than five procedures per year. Some of the revisions will have been non-elective, but a significant

proportion were not. Whilst the surgeons may have produced acceptable results in the patients, it

seems to be the case that such arrangements increase the risk of adverse outcomes – a point

acknowledged by the Arthroplasty Project Report”

It is set out in theGIRFT report produced by NHS Scotland in March 2016 that outcomes for patients

were likely to be variable and measures to address this should be put in place as soon as possible:

Hip replacements are conducted by 22 surgeons, of which 7 conduct less than 5 per annum.

The average per orthopaedic surgeon per annum is 14.8 which is less than half the national

average of 35.9.

Knee replacements are conducted by 21 surgeons, of which 3 conduct less than 5 per

annum.

Hip revisions are conducted by 10 surgeons, of which 7 conduct less than 5 per annum.

Knee revisions are conducted by 7 surgeons, of which 5 conduct less than 5 per annum.

The surgeons at HM all carry out enough procedures as do the team at WG but the numbers

from Monklands may seem lower as they have six surgeons operating from 4 days theatre

access thus reducing the volume of cases possible and therefore do not hit the national

average.

The 5 year revision rate for both hips and knees at Monklands is the highest in the country.

The GIRFT report also highlighted a number of recommendations which recognise the need to

improve the NHS Lanarkshire service through delivery of a whole system approach.

Recommendation 5 is highlighted below:


Evaluate the case for protected beds and develop strict protocols to maintain the efficient flow of planned orthopaedic surgical cases through them for the benefits of the patients and the service.

The current service model, as evidenced in the report from the Academy of Medical Royal Colleges

and Faculties in Scotland, has led to variations in practice across the 3 sites. The absence of an

overarching team structure to the Trauma and Orthopaedic service has enabled sites to imbed

individual practice over time. Consequently development of a board wide service with a whole

system approach will ensure consistency of standards and support the delivery of proposed changes

to the service.

The move to a single site model for Trauma is the primary aim of the strategic objective within NHS

Lanarkshire. Whilst this represents significant challenges to achieve, it forms the goal for service

redesign as it is recognised as providing the greatest opportunity to meet the changing needs of the

population, deliver a sustainable medical workforce and fit with national and regional service

developments.

It is clear from detailed modelling work that has been carried out that changes to the bed, theatre

and outpatient clinic footprints and associated infrastructure will have a significant impact on the

distribution of services within each of the three acute hospitals and NHS Lanarkshire will have to

balance the need for optimal distribution of services and best use of resources across a range of

services on each site. This will include the associated impacts on community based services.

3. Case for Change

The case for change has been made through the need to achieve:

improved patient outcomes,

a sustainable medical workforce and

establish pathways of care that meet the changing needs and demographics of the patient

population highlighted through the NHS Lanarkshire review.

The view of NHS Lanarkshire which has been confirmed by the Academy of Medical Royal Colleges

and Faculties in Scotland is that maintaining the status quo is neither a sustainable option (care

provided by consistent specialist teams), nor will it address the safety and quality issues raised in the

2013 HIS Rapid Review report. The Academy also noted that there was consensus on this opinion

across Emergency Departments, Trauma & Orthopaedics and Care of the Elderly teams across NHS

Lanarkshire.

Whilst initial work within NHS Lanarkshire’s orthopaedic review focussed on immediate changes

necessary within the service and how they could be delivered, further consultation with clinicians led

to wide acceptance that the strategic direction is to move to Trauma and Elective work on separate

sites. These conclusions have been reinforced by the recent publication of the National Clinical

Strategy for Scotland.


The NHS Lanarkshire review of Orthopaedic services focussed on 4 possible options for

reconfiguration of services.These options are set out in the table 1 below. All options include

Wishaw General due to its designation as a Trauma Unit within NHS Lanarkshire.

Table 1

Maintain Trauma and Elective across 2 Sites Trauma and Elective on Separate Sites

50/50 Split between Wishaw and Hairmyres

50/50 Split between Wishaw and Monklands

Wishaw Trauma Only Hairmyres Elective Only

Wishaw Trauma Only Monklands Elective Only

A full summary of the benefits and disadvantages of the two-site service models and the

respective Hairmyres and Monklands sub-options is provided in (Appendix A). This offers a

summary of the information, presented for comparative purposes along with the existing service

provision (status quo).

The scale of change that is required to achieve this within Lanarkshire is challenging and it is

impossible that a single trauma unit can be achieved within the current bed complement and

Emergency Department footprint at Wishaw without causing significant disruption to other services.

The preferred approach is therefore to move towards this strategic objective in a phased manner by

moving initially to two combined trauma and elective units. This will enable the development and

implementation of a clinical model which improves services for patients, improves outcomes,

delivers improvements to the length of stay in hospital (LOS) and improves the sustainability of the

medical workforce model.

Sustaining the medical workforce

A key issue noted in the Healthcare Improvement Scotland (HIS) report was the need for a

fundamental review of the distribution of orthopaedic services across NHS Lanarkshire to support

the provision of safe, person-centred and effective care. The report noted significant and persistent

issues, the solutions for which required models of care built around patients but which take account

of the available workforce. Onerous and stretched out of hours and on-call rotas for consultants

impacting on recruitment and retention was identified as a challenge of the current clinical model

which has elective and trauma services provided across three sites. This pressure continues to exist

and despite all efforts to improve the availability of staff with the appropriate knowledge and skills, a

sustainable solution has not been found that meets the needs of the current service configuration.

The service has an increasingly challenging vacancy rate in medical staffing. Consultant recruitment

and retention has been stable with relatively short term vacancies filled with locums in order to

minimise the impact on elective activity. However, middle grade vacancies are common with gaps

totalling 14 months service in the past year (2015/16) and of this 8 months were filled with Agency

locums. Junior doctor vacancies are high, especially in GP training posts allocated to the specialty

with 49 months of service in gaps in the past year, of which 23 were filled by Agency staff.


It is felt there is a short window of opportunity to improve the training available in GP training posts

in Lanarkshire where only 5 out of 18 training posts across NHSL are currently filled from the training

programme, the remainder being filled with short term locum staff.

Since March 2014, the service has been subject to enhanced monitoring by NHS Education for

Scotland (NES) on behalf of the General Medical Council (GMC) to ensure that the necessary quality

of training and environment of safe patient care in which training is provided can be assured.

Without this continued assurance, which is currently at risk, training recognition will be removed

and the service will not be sustainable within NHS Lanarkshire.

At the most recent of the regular enhanced monitoring visits across NHSL, whilst it was

acknowledged that a great deal of work was ongoing to support training quality, a number of

outstanding concerns mean that the service will remain subject to enhanced monitoring in contrast

to other areas which are progressing towards removal of this status.

Concerns include;

intensity of workload

access to outpatients and theatres as educational opportunities

non-educational ward based duties consume inappropriate amounts of training time

inability to provide sufficient cover to ensure robust handovers

lack of protected teaching time and opportunities to participate in learning from adverse

events

Trainees have commented on 'fragile rotas', cancelled lists impacting on training opportunities and

gaps in rotas adding to intensity of work especially out of hours and at weekends.

In preparation for reconfiguration, 10-person rotas have been designed for junior medical staff at

each of two sites and 8-person rotas for middle grade medical staff that can ensure fully acceptable

levels of staffing cover for all wards, theatre and emergency duties and provide training

opportunities for all grades of doctors in training that would more than satisfy the requirement of

the GMC and NES.

The changing needs of the population

Planning the future service provision will require account to be taken of a number of significant

changes which will impact upon the demand for the service over the next twenty years. The largest

factor is the increase in over 75s, recognising that patients are living longer and the added

complexity of each individual’s clinical presentation due to a number of age related factors.

Orthopaedic activity is expected to increase by 12.9% by 2020 and a further 11.7% by 2025. Activity

for 2015 is shown below as a baseline for future development as well as the predicted activity levels

for 2020 and 2025.


Table 2

Patient Category 2015 2020 (↑12.9%)

2025 (↑11.7%)

Day Cases 2075

Elective In-Patients 1865

GJNH Patients 909

Elective Total 4849

Emergency /Trauma Patients 4682

Overall Total 9531 10,760 12,019

The proposed model for change cannot be a single step process. The complexity of change, staffing

and resource implications, impact on other services, physical capacity and new models of care all

point to the need to manage service redesign within a stepped programme of change.

Engagement with other services will take place on completion of the move to a 2 site model in order

to plan the next step of the programme and a move to split Trauma and elective sites.

The agreed development of a case for a new hospital at Monklands presents opportunities and

flexibility within the programme in order to ensure appropriate capacity is available to locate

services whilst achieving the intended goal of a single site Trauma model. Lanarkshire will set out the

case for the development of a trauma unit at Wishaw General Hospital, as part of a Lanarkshire

emergency care service based on three EDs, and a West of Scotland major trauma network. The

national case for the major trauma network identifies how this will save lives and reduce significant

disabilities

The move to the final configuration will see all trauma surgery at Wishaw, with all elective surgery

on another site. The location of elective surgery will be shaped by:

The final service model for the 5 National Elective Treatment Centres;

The final service model for the West of Scotland major trauma network

The capacity for surgery, diagnostics etc to be provided by the development of Monklands

Hospital (earliest 7 years in the future) which would enable changes to beds, theatres and

clinic capacity across Lanarkshire. This will also embed sufficient capacity to meet the future

needs of the population for surgery

The responses to public consultation as part of the NHSL Healthcare Strategy


Each NHS Lanarkshire acute Hospital is different and centres of excellence already exist. NHS

Lanarkshire has committed to retain 3 emergency departments. The 3 Emergency Departments are

supported by:

Acute Medical and Surgical Services

Diagnostics and Imaging

Theatres

Out-patients

Other Clinical Support Services

New service models will be underpinned by agreed patient pathways and workforce plans to

optimise clinical expertise.

As described in Table 3,Outpatient contacts account for greater than 85% of all Orthopaedic

appointments and admissions. The service will remain local with the vast majority of patients

accessing the service at their local hospital. The initial step in October 2016 will still see Orthopaedic

outpatient care and care within emergency departments provided across all 3 sites.Only inpatient

and day case surgery currently provided at Monklands will be affected.

Table 3

NHS Lanarkshire Trauma and Orthopaedics Patient Contacts 2015/2016

Outpatient Attendances Admissions

New 26,266 Day Case 2075

Return 35,349 Inpatient 1865

Golden Jubilee 909 Trauma 4682

Total 61,615 Total 9531

Where specific inpatient care is required pathways will be developed to ensure patients are

transferred directly to the nearest inpatient site and where the services of a Major Trauma centre is

required for specialist care appropriate pathways will also be agreed with Queen Elizabeth University

Hospital (QEUH)and the Scottish Ambulance Service(SAS).

This provides a comprehensive package across all of 3 acute sites in NHS Lanarkshire ensuring

patients can access the majority of their care as close to home as possible whilst concentrating

specialist care to appropriate sites in order to improve outcomes. Even with the eventual

consolidation of Trauma onto 1 site, Orthopaedics will retain a presence across all 3 sites.

Alongside the need to restructure clinical delivery of the service the need to break down

unnecessary variation in working practice and develop a cohesive, shared vision exists. A clinical lead

will be appointed by summer 2016 alongside a newly appointed dedicated Trauma and Orthopaedic

service manager role. This level of leadership and management across the 3 sites puts in place the


foundations required to build on and deliver the vision outlined. It is difficult to quantify the benefits

of establishing a board wide Trauma and Orthopaedic unit but a team dedicated to managing and

delivering care within such a complex and busy service will undoubtedly support the vision for

redesign as well as delivery of the performance elements of the service.

The Trauma and Orthopaedic management team will be responsible for ongoing performance

management within the service, reporting directly via monthly service review meetings to the

Director of Acute Services. Meetings will concentrate on service position and actions around - Length

of Stay (LOS), Referral to Treatment Time (RTT) targets, Treatment Time Guarantee (TTG)

performance, DNA rates as well as staffing position, progress against capacity plan and further

planned changes and developments. The structure will provide management of the redesign

programme via the steering group and operational performance and delivery through monthly

service review.

Detailed plans setting out the Clinical pathways and models of care which will be implemented to

support the delivery of the reconfigured service are well advanced. They include details of bed

allocations, theatre requirements and how the service will be supported by appropriate clinical

workforce models and activity analysis.

There are a number of key principles/issues which will be addressed in the planning process:

Agreement of an Emergency Department pathway for patients with orthopaedic injury to be

implemented at any site without inpatient orthopaedic activity.

Agreement with the Scottish Ambulance Service (SAS) on the pathways for patients and pre

hospital management of Trauma & Orthopaedic patients

Recognition that there will be a requirement for orthopaedic resources to be reallocated

across sites, with agreement, in accordance with the final service configuration.

Workforce planning for all clinical, non-clinical and community based staff affected by

changes to the current service models

Develop a detailed protocol/pathway which sets out how the Care of the Elderly (COE) team

will engage orthopaedic patients as part of their workload and to take over the care of

appropriate patients at a much earlier point in the process.

Produce a Joint Clinical Pathway Model for Orthopaedic, Care of the Elderly and locality

services that is workable and achievable. This will require a whole system approach involving

specialist and locality based services.

Determine the impact on other priority services which will be impacted on by

implementation of a service reconfiguration e.g. Theatres / Anaesthetics, Ward Staffing,

Trauma and Out-Patient Clinics, Locality based services.

Full staff engagement with affected staff and other stakeholders on the proposed service

models


A significant level of engagement with Senor Clinical Staff at each site has been ongoing to ensure

that the preferred configurations continue to be developed in conjunction with senior clinical

decision makers to ensure the process is fully inclusive.

Key to this is the bed model and theatre activity plan for the proposed inpatient configurations.

Activity data, in particular length of inpatient stay (LOS), has been considered in context of regional

and national benchmarking and it is clear that for NHS Lanarkshire the average length of stay for

both elective and emergency orthopaedic inpatient admissions are consistently higher than the

Scottish average. Improving LOS is key to implementing and achieving successful reconfiguration and

revised bed allocations are reliant on completion of this modelling.

It is also recognised that a key driver in this change process is the development and early

implementation of a new clinical and social care pathway which delivers improved access to Care of

the Elderly (COE) services and community based services. In particular services such as Hospital at

Home and community based Care at Home will improve our ability to support patients within the

community and will facilitate the ‘Home First’ approach that will be applied. This will focus on

patients being transferred home with appropriate support to manage their ongoing medical and

rehabilitation needs and improve their outcomes. Implementation of this approach will ensure that

the care of elderly patients is not disrupted and also that those patients that do require a longer stay

in hospital are managed in the most appropriate location under the care of the most appropriate

clinician.

This improvement will deliver a significant benefit through improved patient outcomes as we move

care from hospital to home. The reduced dependency on inpatient beds will facilitate the ability to

accommodate orthopaedic beds within the existing bed allocation across the two sites.The exact

distribution of these beds will be determined by the size of the specific components of the trauma

and orthopaedic reconfiguration.

4. Stakeholder Engagement

Throughout the review process NHS Lanarkshire has been committed to ensure that it informs,

engages and consults with stakeholders and an orthopaedic planning group was established to take

forward this review process. This group included clinical, managerial, patient and staff

representation.As part of the NHS Lanarkshire Review process two key stakeholder events were held

to consider and understand the challenges of the current configuration of orthopaedic services and

to identify and appraise options for a revised service model which would address the review’s key

objectives. The events were held in December 2014 and in March 2015 with each attended by

approximately 60 delegates including patients, patient representatives, carers, clinicians, managers,

and staff representatives. Scottish Health Council representatives were also in attendance.

The short list of service reconfiguration options from the December workshop was defined in detail

prior to the next stage of formal option appraisal, which took place at the March 2015 workshop.

The detailed process included identification and impact assessment of any changes required at


individual hospital level to facilitate implementation of any of the options. It also took account of

working practices, capacity, demand, bed requirements, theatre availability and demographic

changes.

The analysis of final outcomes concluded that outpatient services should continue to be provided

across three sites and that inpatient services should be located at Wishaw General Hospital and one

other site.

The Scottish Health Council have advised on the consultation process to move to a Single Trauma

and Single Elective site within NHS Lanarkshire (Appendix G) and this will be delivered as part of a

wider consultation process within NHS Lanarkshire’s Healthcare Strategy. They have also

acknowledged that there has been a “recognised clinical need to move to an immediate interim

position”

5. Implementation

With the recognition that NHS Lanarkshire’s strategic direction of a single Trauma and Elective

Orthopaedic site is not possible immediately and that the status quo is not an option, it is proposed

that the first stage necessary in achieving this is an interim model where Trauma and Elective

Orthopaedics are initially concentrated onto 2 sites, Wishaw General and Hairmyres Hospital, both

providing Trauma and Elective services. As previously outlined this will offer an immediate solution

to the clinical risks within the service whilst being deliverable within the current constraints.

Table 4

Stage 1. Maintain Trauma and Elective across 2 Sites

Stage 2. Trauma and Elective on Separate Sites

50/50 Split between Wishaw and Hairmyres Wishaw Trauma Only Elective Only Site

It is proposed the revised inpatient service will be consolidated on two sites, Wishaw General and

Hairmyres Hospital, with access to outpatient services being retained on all three sites. Both

inpatient sites will provide a mix of elective and trauma services which are similar in size. This can be

accommodated within the current orthopaedic bed and theatre footprint on each site with some

adjustments to operational hours of theatres to ensure that the necessary capacity is available at

each site. There has already been implementation of ‘ring fenced’ beds and work is ongoing to

develop theatre models for Orthopaedics. This will ensure that the capacity required for service

delivery is available as well as the creation of an Orthopaedic multi professional team

acrossLanarkshire.

Delivering a single trauma site within the current bed complement and the ED footprint at Wishaw is

simply not achievable without creating a need to restructure the inpatient configuration of other

specialties. The consequential impact of additional unscheduled ED attendances at the single


trauma site would create concerns over the capacity of that site (Wishaw) to deliver safe front-door

services. The move to a configuration of a single Trauma site at this time is therefore not tenable.

Similarly the detailed review of required capacity and available infrastructure indicates that

Monklands would be unable to accommodate sufficient theatre capacity to support the proposed

interim model. Conversely the released theatre capacity at Monklands, from moving to Wishaw

General and Hairmyres Hospital as inpatient Orthopaedic sites, would facilitate enhanced service

provision in inpatient ENT and Urology services where Monklands is the existing centre of

excellence.

Through the considerable work carried out within the NHS Lanarkshire service review, the

documented benefits and disadvantages of each option (Appendix A), as well as a shared vision for

the service articulated by the Consultant group at the Orthopaedic Reconfiguration meeting held on

the 9th May 2016 the preferred option to proceed with is detailed below.

The implementation programme for service redesign now relies on a decision on the proposed site

options in order to move forward. In order to fully develop an implementation plan we ask that the

board agree to supporting and proceeding with this model.

Recommendation for Approval

Begin implementation of strategy to achieve Single Trauma and Elective sites for Orthopaedics

with the initial step of 2 sites at Wishaw and Hairmyres providing a 50/50 Trauma and Elective

split.

Stage 1. Maintain Trauma and Elective across 2 Sites

Stage 2. Trauma and Elective on Separate Sites

50/50 Split between Wishaw and Hairmyres Wishaw Trauma Only Elective Site

The implementation of the proposed model is reliant on improved patient pathways. The

Healthcare Improvement Scotland (HIS) report noted significant and persistent issues, the

solutions for which required models of care built around patients but which take account of the

available workforce. Current Orthopaedic pathways are based on historical models of care and

Length of Stay data shows increased length of stay in orthopaedic beds compared to other boards

across Scotland. This is particularly the case for patients >65years of age where the average

length of stay is more than 2 days longer than the Scottish average. Opportunity exists to

remodel care for this group of patients; utilising greater input from Care of the Elderly physicians

and associated clinicians to develop an integrated approach across acute and community services

ensuring care is delivered in the most appropriate location. Further details of this are described in

section 6.

The key elements of this change are therefore to improve the efficiency of the service by

concentrating inpatient provision on two centres of excellence and by focussing attention on the


orthopaedic elements of the service. Additional capacity for rehabilitation/shared care including

a ‘Home First’ approach, to ensure a patient’s transfer home occurs sooner and is supported by

appropriate staffing models and governance, will be developed and implemented in advance to

enable this step change to be facilitated.

Implementation of new pathways is underway; driving improvement in length of stay and

developing closer working relationships with community teams in order to build on existing

pathways and to ensure patients are cared for in the most appropriate location by the most

appropriate provider and clinician.

The Orthopaedic service redesign is being managed within a programme structure. This will is led

through the Steering group which maintains overall responsibility for delivering the redesign

programme in line with schedule.

Reporting to the Steering Group are 6 work streams as outlined below.

Figure 1

The steering group maintains and undertakes regular review of a detailed project plan,

comprehensive risk and issue log for the programme of workwhilst overseeing the work streams and

ensuring appropriate mitigating actions are in place. The Steering group also reviews Quality Impact

Assessments of changes proposed (Appendix C). The steering group provides support to the work

streams through the management of necessary resource and the interdependencies.

Orthopaedic Redesign Work Stream – Governance Structure

Steering Group

Theatres

Wards

Outpatients

Unscheduled Care

Workforce/ Job Planning

Care of Elderly

•Group established, Monthly meetings scheduled•Review progress against plan for each working group•Ensure programme delivered on time & mitigating actions in place•Manage Risk and QIA across programme

•Groups established, meetings scheduled•TOR completed•Sub groups established in Ward group•Project Plans in place•Highlight risk and quality impact to steering group

Hospital@Home &Community Services


The work streams act as the engine room, developing and delivering key actions within the project

plan to ensure implementation of the redesign by October 2016. Details of the work stream outputs

are provided in Appendix D.

6. Capacity

Length of Stay (LOS)

LoS in Trauma and Orthopaedics is currently worse than comparator boards across Scotland. This

represents an opportunity to redesign patient pathways such as greater integration with community

services and the establishment of an early supported discharge model through the use

Hospital@Home, to ensure patients’ rehabilitation is central to their orthopaedic management. The

focus is to improve outcomes and safety for patients of which a reduction in Length of Stay can be

regarded as a surrogate marker.

Reduction in length of stay to a figure in line with other health Boards in Scotland has established a

baseline for the bed requirements to facilitate the first phase of moves to a 2 site model with a

shared Trauma and Elective split.

The development of bed modelling has been taken forward recognising that material changes in

process will be required to drive improvements in outcomes and to enable the development of a

reconfigured service which is operationally deliverable.

The starting point of the discussion identified a number of objectives which require to be achieved:

Improved outcomes for patients

Improved service integration

Development of centres of excellence

Definition of improved patient pathways

Ability to develop service as demography alters

Significant development of patient pathways and models of care recognising current good practice

and consistent with current thinking has been undertaken in conjunction with key clinical decision

makers. This has driven an agenda to deliver improvements and from a bed numbers and

configuration perspective the key measurable is patient Length of Stay (LOS). The current LOS is

relatively high and results from a combination of factors including the existing service

configuration,access to clinical decision makers and current patient pathways. There are also

variances across the three sites which have an impact.

The initial assumptions for assessing bed requirements have been to determine an appropriate

improvement in LOS by redesigning the clinical model/pathway and providing a service which best

serves the needs of patients. The key elements of this are to improve the efficiency of the service by

concentrating inpatient provision on two centres of excellence and by focussing attention on the

orthopaedic elements of the service. Additional capacity for rehabilitation/shared care will require


to be created to enable this step change to be facilitated. The changes to LOS while challenging are

achievable in the short term and will provide a platform for further continuous improvement.

The inpatient activity profile has been subject to significant review and analysis and the emerging

outcome is that there are two distinct patient groups with differing needs that should be considered

separately. The groups are 0-65 and 65+ and the current LOS in emergency/trauma is 4.54 and 19.21

respectively with a combined LOS of 10.68.

The key issue is the recognition that a large element of the care for the 65+ group, the largest

patient group, need not be delivered in an orthopaedic setting, and may well be more effectively

delivered in rehabilitation/shared care environment. The proposed model of care sets out two

significant changes:

Separation of the care for the 65+ group

Improved patient pathway for elderly patients

Subsequent reduction in length of inpatient stay

The patient centred pathway outlined below shows that with early assessment and coordination of

planned discharge and/or rehabilitation, significant improvements in quality of care and associated

length of hospital stay can be achieved. Some aspects of the required supporting workforce are

already in place and others will need further development to give a fully integrated team approach

that will support the patient from the early stages of admission to an expedited transition to home

with additional community input as appropriate.

Delivering this change in service provision and driving a sustainable improvement in LOS not only has

a significant impact on bed requirements but facilitates delivery of the proposed two site option

within the existing orthopaedic bed complement. LOS within orthopaedic reduces to 4 and 7.5 for

the 0-65 and 65+ groups respectively with a combined LOS of 5.28.

While further work on the detail of bed configurations will continue, these changes facilitate the

proposed bed model.Separation of care for the 65+ group may require some temporary upward

adjustment to beds allocated for rehabilitation as a transition to support this improvement in LOS.

The location and detail of configuration of these transition beds is still the subject of discussion.

It is recognised that these improvements in LOS will require to be achieved in a structured manner

over a defined timescale that will be finalised on conclusion of the preferred option and delivered in

conjunction with supporting staffing models.

Care of the Elderly

The Care of the Elderly work stream is a key element in delivering the improvements in LOS which

will be achieved through the development of new models of care and the increased utilisation of

Hospital@Home as part of an elderly supported discharge process (ESD) for appropriate emergency

Orthopaedic patients. This model will provide a bridge between acute and community services on a


temporary basis to enable community based services to be developed. Work to implement a Test of

Change model at Hairmyres has commenced. This will facilitate the early transfer of patients into

Hospital@Home under the care of Geriatric Orthopaedic Rehabilitation Unit (GORU) physicians.

It is recognised that this will require significant engagement with community based locality teams to

ensure that services are in place to facilitate flow out of Hospital@Home back to community

services. This must be managed by working together to utilise the available resources.

This is a major shift in the management of Orthopaedic patients within NHS Lanarkshire and whilst it

is recognised that the proposed initial management of the Hospital@Home service through the

acute division rather than the community is at odds with the current strategy the requirement to

develop confidence in the clinical leadership and governance structure necessitates a period of

transition. Hospital@Home represents a key step in the journey from acute to community based

care with the development of a fully integrated team pulling patients from acute care.

The time frame for delivery and reorganisation does carry risk and it is proposed that, during the

transition phase, that additional inpatient surge beds are made available in order to support flow

and management of elective. This will provide support to ring fence elective beds which will again

drive LOS reduction. This will ensure that the necessary pathways are developed which will build

confidence in the models of care across the clinical teams and will mitigate against the risks of failing

to achieve the necessary LOS gains.

Figure 2 shows a breakdown of clinical complexity in patients with medical and rehabilitation needs.

The present model indicates approximately 70% of patients fall into the Low Medical/ High Rehab

quadrant where there will be a focus on transfer of care out of the acute hospital environment

through an early supported discharge model utilising Hospital@Home in the first instance. Patients

clinical requirements in terms of rehabilitation would remain however this will be delivered at home.


Figure 2

A test of change will be run to implement the pathway changes and to evidence what the resource

implications will be at each stage in the pathway. The detail of the resource requirements will be

developed in conjunction with Joint Integrated Board partners.

Early work to develop this model has already commenced with a commitment of £200k funding in an

early supported discharge model of care through Hospital@Home.

The Hospital@Home team will establish a ring fenced Orthopaedic team in conjunction with the

proposed changes in theatre staffing and management structure in order to support the

development of a NHS Lanarkshire wide Orthopaedic team.

Further engagement is required with local homecare providers, particularly related to response

times in order to facilitate smooth transition between services.

Test of Change

The rehabilitation pathway is integral to this work and there has been ongoing work related to

mapping the Allied Health Professional (AHP - Occupational therapy and Physiotherapy)

interventions, for both trauma, and elective conditions. A group comprised of inpatient AHPs,

community AHPs, Director of AHPs, discharge facilitators, Acute Care of the Elderly (ACE) Nurse and

pain nurse specialist, have been working on an agreed pathway, and planning a test of change.

Me

dic

al

RehabLOW

HIGH

HIGH

High Medical/ High Rehab

Low Medical/ High Rehab

High Medical/Low Rehab

Low Medical/ Low Rehab

Patients with this acuity require ↑Nursing input, ↑junior medical staff at ward level, Minimal AHP input

Patients with this level of acuity require acute medical and nursing care and there is an opportunity for COE to provide ↑ support at ward level with in reach from specialist services eg: cardiology.

Some of these patients will not be fit for surgery and will be managed conservatively.

Patients with a low rehab and low medical acuity should be at home when safe with support as required.

Home first approach as a result of early supported discharge planning.

Current data estimates that 76% of trauma patients fall into this category and revised processes and clinical pathways could see this reduce to 44% with the shift of 32% moving to the LM/LR category

Home


The test of change is ongoing in 2 orthopaedic wards, (ward 5 Hairmyres Hospital, and ward 15

Wishaw General Hospital), where we will use an adapted version of the Poole Predictor tool

(Discharge predictor tool - Appendix E). The ACE Nurse/ AHPs and discharge facilitator will work

alongside the patient and family to indicate possible destination post surgery, indicative length of

stay and support required for discharge. The aim is to commence this on day 0 or day 1. A ‘Home

first’ approach, will be tested when patients are orthopaedically and medically stable allowing

transfer to hospital at home team with the therapists providing outreach therapy interventions.

Early, enhanced home care/support will also support the therapy. There is evidence that on

occasion, this can enable a reduced overall package of care and a potentially earlier discharge from

community services overall.

In recognising the growing number of community services available and the respective skill set

therein, this test will be evaluated to inform the developing model of early recovery and

rehabilitation for these patients within the community together with the respective

staffing/resource implications in all aspects of the pathway.

Hospital at Home Pathway

1. There is a shared vision of a future integrated model of rehabilitation based within the

community. The model would ensure the community teams are involved in pre-operative

planning to support patients home earlier and in a more coordinated fashion. This would

include the use of the new Discharge Predictor Tool to risk score the predicted requirements

on discharge.

2. The Hospital at Home model and its relationships with generic community/Integrated

Community Support Teams (ICST) would provide an ideal opportunity to demonstrate the

scope to better enable preparedness of discharge from traditionally hospital based care to

care in a community setting.

3. This model will be transitional to support rapid change, generate confidence in a home first

support and allow time for community services to develop enhanced capacity and capability,

and provide medical governance, in the initial phase.

4. Patients will be indentified pre/post op, by the ACE nurse/ Discharge facilitator and AHPs. The

team will complete the adapted predictor tool to provide potential discharge destination,

indicative Length of Stay/discharge date and support required within the community. This

will be completed in collaboration with family and medical staff. This will direct most

appropriate pathway for ongoing management. A clinical assessment, initiating

Comprehensive Geriatric Assessment will commence linking with the ortho geriatricians. This

will aid in identifying those who would benefit most from the hospital at home pathway.


5. If a patient is identified as requiring Hospital at Home (H@H) support on discharge they will

be transferred in the normal manner. They will be reviewed on the hospital at home ward

round daily until the geriatrician feels that consultant overview is no longer required.

Rehabilitation goals will be identified by the orthopaedic and H@H AHP practitioners. The

delivery of therapy will be supported by generic health care support workers using

technology where able. Once a patient no longer requires consultant overview they will be

monitored by the NMAHP Consultants for ongoing recovery and rehab with escalation and

review from geriatrician if required.

6. Community supports will be provided via early enhanced reablement home care teams, with

ongoing management supported via ICST/CARS, home care. There is evidence from

reablement work, that an early enhanced approach of this model can show a reduction in

homecare support of up to 30%.

7. Where there are existing community services in place, these would continue, maximising the

joint health and social care resource.

8. As outlined in paragraph 3, the overall aim is to see provision of community based

rehabilitation in each locality with appropriate resources to support this. As part of the

Commissioning Plans of the respective Integrated Joint Boards, the evaluation of the

transitional ‘tests of change’ will be utilised to describe the future care model and how the

impact on baseline data is demonstrated in shaping future service delivery and associated

allocation of resources across the care pathway. This will also allow for clarity re the

‘responsible medical officer’ role and at which stage this transfers to the patient’s own GP.


Figure 3

Snap Shot Patient Census.

142 patients were profiled within Orthopaedic and Geriatric Orthopaedic Rehabilitation Unit (GORU)

beds across the three sites. Multidisciplinary group was used to profile patients to ensure holistic

evaluation of need and identification of appropriate place of future care. The aim was to inform

proposed GORU models of care and identify support needs. This audit covered all age groups, (7

patients under 65). Figures are indicative, as based on current activity, and levels of occupancy.

Results demonstrated N (Patients) = 142

Table 5

Place of Care % of patients

Orthopaedic Speciality 31%

Level 1 Home No Support 4%

Level 2 Home with H@H rehab and community supports

40%

Level 3 Intermediate Care 13%

Level 4 GORU 12%

Break down of Patients within the Level 2 Cohort n (Patients – sub set of total patients) =50


Table 6

Rehab only 52%

Rehab and POC 48%

It is important to note that there is already overlap in these pathways with many patients being

admitted to acute care from community settings with packages of care already in place. These

pathways will support the management of patients back from acute care.

7. Finance

The service redesign within orthopaedics will be revenue neutral. The table below highlights existing

costs across the service and the costs following the proposed move to a 2 site model.

Table 7

The modelling indicates a preferable variance of £213,281 for 2016/17 with a £13k preferable

variance going forward.

Theatre nursing including Recovery 2,064,087 2,355,487 291,400

Orthopaedic Medical Staff 5,570,887 5,570,887 0

Ward staffing

Staffing - Budget 5,322,966 3,879,774 (1,443,192)

Supplies - Budget 830,541 830,541 0

Sub-total 13,788,480 12,636,688 (1,151,792)

Additional Investment Required

Additional Anaesthetic support (4 wte) 480,000 480,000

MINTS Nursing (5.5wte on 2 sites) 531,402 531,402

2.00 wte Anaesthetic Practitioners 95,840 95,840

Service Improvement Advisor 55,266 55,266

SAS Transportation 50,000 50,000

Additional Synergy costs for weekend cover 35,000 35,000

COE/rehab support (Hospital at Home) 278,003 278,003

Sub-total - 1,525,511 1,525,511

Assumed funding for:

Contribution towards Healthcare @ Home 200,000 (200,000)

4 Orthopaedic beds at Hairmyres 132,000 - (132,000)

6 Orthopaedic beds at Wishaw 255,000 - (255,000)

587,000 - (587,000)

Grand total 14,375,480 14,162,199 (213,281)

Orthopaedic service - current costs versus

proposed costs

Variance

£Proposed

(Elective/Trauma)

2016-17 Roll

Forward

Budget


A number of assumptions have been made in developing the financial model. These have focussed

on key areas such as theatres, ward budgets and staffing:

The theatre nursing resource identified is purely associated with Orthopaedic and Trauma theatres.

The extension of working days in theatres to increase elective throughput means additional

Consultant Anaesthetists will be required. Additional Minor Injury Nurse Treatment Service (MINTS)

staffing required to ensure 24/7 ward cover.

At this stage, paper assumes other costs as being neutral, although there may be a requirement to

move some resources between hospital sites and into the community.-

Additional Scottish Ambulance Service (SAS) costs have been allocated within the model.

It is likely that the staged approach to reducing length of stay and new models of care may require

transitional funding however this will be offset against savings made within the programme over

time. The programme will support the capacity plan and vision to pull high cost waiting list work

back into core activity.

Further work is required to clarify funding sources and baseline costs for 4 beds at Hairmyres and 6

beds at Wishaw which have been staffed on a non recurring basis. Greater understanding is also

required for the costs to the acute service in delivering the early supported discharge model for

GORU and any additional community investment.

8. Programme Risk Figure 4

Ensuring pace and delivery ahead of winter pressures is key to the programme. A formal risk log and

quality impact assessment will be undertaken to support the steering group. By way of an initial

assessment of delivery by October 2016 the 2 key areas of risk are staffing/ workforce and LOS

Orthopaedic Redesign Work Stream Risk – Initial Assessment

Working Groups

Theatres

Wards

Outpatients

Unscheduled Care

Workforce/ Job Planning

Care of Elderly (Reduction LoS)

Oct 2016

Apr 2016


reductions required through a revised model in care of the elderly. These risks relate to timeframes

for consultation with staff which can only start after a formal decision on the sites is taken and the

shift in model of care with the use of Hospital@Home for far greater numbers of elderly orthopaedic

patients and are formally recorded with mitigating actions in the Risk and Issues log (Appendix B).

Outside of programme significant risk also exists around the decision to proceed, both at board and

government level.

9. Conclusion

Following a comprehensive review and ongoing engagement with clinicians NHS Lanarkshire has

concluded that a strategic vision of split Trauma and Elective sites for the Orthopaedic service should

be worked towards.

Given the evidence and support for this strategy by the Academy of Medical Royal Colleges it is vital

for NHS Lanarkshire to move forward with a decision on the future of the Trauma and Orthopaedic

service. With this in mind permission is now sought to move to the next phase through agreement of

the two sites at Wishaw and Hairmyres and the step to a 50/50 split Trauma and Elective model in

order to facilitate an eventual move to a single site Trauma and Elective model in the future.

As outlined within the case for change it will take a stepped approach to achieve this aim with

consolidation of the service to two sites with a 50/50 Trauma and elective split by October 2016. A

defined programme of work now exists across the work streams with resources in place to lead and

implement the necessary changes within the service

The programme will now rely on delivery at work stream level, continual review of progress against

plan and most importantly close working with community teams to ensure pathways and resources

meet the needs of patients.


Appendix A - Comparison of Options

Status Quo

Wishaw and Hairmyres 50- 50 Split Trauma & Elective

Wishaw and Monklands 50-50 Split Trauma & Elective

Wishaw Trauma only Hairmyres Elective Only

Wishaw Trauma only Monklands Elective Only

Sufficient Existing in-patient Bed Capacity for Orthopaedics on each site

Under utilisation of designated bed capacity at Hairmyres and Monklands that results in boarding into Ortho and the reverse is true at Wishaw

Yes – both sites Yes - both sites Yes at Hairmyres however Wishaw would require to identify 24 additional beds for trauma patients. See below for COTE bed impact

Yes at Monklands however Wishaw would require to identify 24 additional beds for trauma patients See below for COTE bed impact

Sufficient Existing in-patient Bed Capacity for Care of the Elderly on each site

Foot print adequate but flows are inconsistently delivered.

Detail still requires to be identified but will also include increased capacity from Hospital @ Home and supported earlier discharge to home

Detail still requires to be identified but will also include increased capacity from Hospital @ Home and supported earlier discharge to home

Additional beds will be required at Wishaw despite increased capacity from Hospital @ Home and supported earlier discharge to home

Additional beds will be required at Wishaw despite increased capacity from Hospital @ Home and supported earlier discharge to home

Sufficient existing Day Unit capacity on each site

Day Surgery capacity Limited due to high volume general surgical workload and stand alone DSU at Monklands is poorly utilised.

Use of the day surgery facilities as an admissions area and for post op care of day case patients needs to be optimised at both sites

Use of the day surgery facilities as an admissions area and for post op care of day case patients needs to be optimised at Wishaw. Existing full utilisation of the stand alone Day Surgery Unit at Monklands will limit the ability to take a full elective component

Use of the day surgery facilities as an admissions area and for post op care of day case patients needs to be optimised at Hairmyres and may require structural change to accommodate

Existing full utilisation of the stand alone Day Surgery Unit at Monklands will limit the ability to take a full elective component

Sufficient existing Theatre Capacity on each site

Conflict with general surgery and trauma. Not enough current theatre capacity at Monklands for each consultant to have and all day list

Yes - both sites with extended day working and additional weekend Trauma sessions

Yes at Wishaw with extended day working and additional weekend trauma but insufficient theatre capacity at Monklands without relocation of Urology or ENT to another site

Yes with extended day working and additional weekend Trauma sessions at Wishaw but insufficient theatre capacity at Hairmyres without relocation of Ophthalmology to another site

Yes at Wishaw with extended day working and additional weekend trauma but insufficient theatre capacity at Monklands without relocation of Urology or ENT to another site

Meet WoS Trauma Network proposals

Yes with Wishaw being designated trauma site although some reconfiguration of general surgery services may be required





Orthopaedic medical staffing rotas would be improved

Current difficulties would continue.

Yes - rotas would become fully compliant although reinvestment of costs of

Yes - rotas would become fully compliant although reinvestment of costs of additional sessions required to provide the supporting

Yes - rotas would become fully compliant although reinvestment of costs of additional sessions

Yes - rotas would become fully compliant although reinvestment of costs of additional sessions


additional sessions required to provide the supporting workforce

workforce required to provide the supporting workforce

required to provide the supporting workforce

Impact on other Hospital specialties

No change Additional impact on Radiology and AHP services but can be managed across NHSL

Additional impact on Radiology and AHP services but can be managed across NHSL

Significant impact on Radiology and AHP services at Wishaw

Significant impact on Radiology and AHP services at Wishaw

Significant impact on level 2 (HDU) beds at Wishaw

Significant impact on level 2 (HDU) beds at Wishaw

Reduction in level 2 activity at both Hairmyres and Monklands.

Reduction in level 2 activity in Monklands and Hairmyres.

Requirement to transfer other surgical /medical specialties from current site

No change No requirement to transfer existing specialties from either site

Monklands would require to transfer an existing surgical specialty (ENT or Urology) plus transfer/move of OMFS

Wishaw would require to identify service/beds to be transferred to another site

Wishaw would require to identify service/beds to be transferred to another site

Monklands would require to transfer an existing surgical specialty (ENT or Urology) plus transfer/move of OMFS

Impact on Emergency Department Services

No change Minimal additional impact on both sites

Minimal additional impact on both sites Significant additional impact at Wishaw. Hairmyres and Monklands ED workload reduced

Significant additional impact at Wishaw. Hairmyres and Monklands ED workload reduced


Appendix B - Risk Log

Orthopaedic Redesign Programme

Completed by: Stephen Peebles

Risk or

Issue

Workstream Project Date

added

Date Risk

Applies

Owner ID Risk / Issue Description (Cause &

Consequence)

Source Risk Level Issue

Consequence (1-

minimal impact 5-

significant impact)

Controls/Mitigating Actions Target Date Escalation

required? (Yes/No/date)

Status (Open

/ Closed)

Date

Reviewed

Co

nse

qu

en

ce

Lik

eli

ho

od

Ris

k S

co

re

Co

nse

qu

en

ce

Lik

eli

ho

od

Ris

k S

co

re

Risk Care of the Elderly Reducing LoS 19/04/2016 1 Ability for Joint Integrated boards to be able

to manage patient flow and support

hospital@home early supported discharge

model and resultant reduction in LoS

required for 2 site model

Heather

Knox

4 4 16 High Work carried out through care of

elderly work stream to link with Joint

Boards and agree resource

requirements (particularly the

movement of resources rather than

new resources)

4 3 12 Yes Open

Risk Care of the Elderly Reducing LoS 19/04/2016 2 Failure to achieve necessary GORU pathway

changes to ensure patients managed at

home and LoS reductions are achieved

Stephen

Peebles

4 4 16 High Care of the Elderly work stream

developing pathways, tools and have

outlined resource requirements to

deliver. Day of Care audit undertaken

to establish patients discharge location

and resource shortfalls being

established.

4 3 12 Yes Open

Risk Workforce 19/04/2016 3 Failure to complete workforce redesign via

consultation and recruitment in time for

October. Consultation will take 90 days after

decission.

Stephen

Peebles

4 4 16 High Staff engagement sessions underway

and review of staff groups affected

underway

4 3 12 Yes Open

Risk Other N/A 25/04/2016 Delays in board making a decision on the

proposed plan and impact on October 2016

implementation date

Colin

Lauder

4 4 16 High Work streams are continuing to work to

October implementation date.

4 3 12 Yes Open

Risk Other N/A 25/04/2016 Government view proposed change as a

major service change that requires public

consultation.

Colin

Lauder

5 3 15 Moderate Discussions on going regarding clinical

imperrative for service change and

phased approach

5 2 10 Yes Open

Risk Rating Number Post Mitigation Risk Rating

Risks and Issues Log

Date last updated: 01/07/16


Appendix C–Quality Impact Assessment Template

Date: 19-Apr-16 Workstream:Theatres

Completed by:

Project Leads

Project purpose

Quality indicator(s)

Like

lih

oo

d (

1-5

)

Imp

act

(1-5

)

Tota

l

Like

lih

oo

d (

1-5

)

Imp

act

(1-5

)

Tota

l

Impact on Patient Safety 0 0

Impact on Clinical

Effectiveness0 0

Impact on Patient

Experience0 0

Impact on Staff Experience 0 0

Impact on Timeliness of

Care0 0

Impact on Equitable Care 0 0

Impact on Privacy 0 0

Quality Assurance

Methodology

0

0

Name

Director Acute Division

Medical Director Acute

Division

Associate Director Nursing

Acute Division

Overall QIA Score pre-mitigation (max quality impact score)

Overall QIA Score post-mitigation (max quality impact score)

Signature Date

Post-mitigation scoring

Escalatio

nQA

NHS Lanarkshire Orthopaedic Redesign Programme

Pre-mitigation scoring

Frances Dodd

Quality Impact Assessment Form

Orthopaedic Redesign Programme

Quality Impact Area Details

Positive/

Negative/

Neutral Impact

Mitigating / Supporting Action(s) QI


Appendix D – Work Streams

The work streams

NHS Lanarkshire Orthopaedic Redesign

Outpatient group.

Group Lead : Director of Access

The outpatient group will look at a number of key areas including Pre assessment which is currently delivered over the three sites and the option of a single pre assessment clinic that includes joint school will be explored. This would serve as a “one stop” clinic for the patients scheduled for theatre. Orthopaedic outpatient clinics are currently governed from a nursing perspective by different directorates across the three sites and this group will review the sustainability of that as outpatient clinics will continue to function on three sites following the redesign process. In addition to this physical clinic space will be reviewed to ensure that we have sufficient space to accommodate growing consultant numbers. This will tie into work that is currently ongoing with evening clinics to meet demand and ensure that we deliver our TTG requirements. Within the current model there is one arthroplasty practitioner based at HM reviewing return patients and providing a post surgery liaison service. The outpatient group will review the need to create a business case for an additional practitioner to allow this service to run on the two inpatient sites. Fracture clinic redesign and the introduction of virtual clinics is in its infancy in NHSL and going forward this is a model that we need to implement and embed. The outpatient group will need to explore this model fully and create one that fits with what we require within NHSL. This will involve full engagement between ED and Orthopaedic teams. Primary care have expressed that they are keen to look at what can be done differently before that patients come to hospital and also reviewing links for post op patients to reduce the possibility for unnecessary readmission.



Theatre group.

Group Lead: Director of Nursing, Acute.

The theatre group will begin by modelling extended day theatre sessions and staff resource implications around that. Start and stop times vary at present and there may be a requirement to review medical job plans to deliver a change in service model. There is variation across the three sites currently in terms of the theatre sessions offered for orthopaedic surgery and this will need to be standardised with variation smoothed. We will require to run6 orthopaedic theatres on 2 sites to deliver the demand both form planned care and unscheduled cases. Currently we do not have ring fenced orthopaedic trauma or elective theatres 7 days a week and in order to ensure that we not have delays to surgery we need to ring fence these theatres 7 days for trauma and 5 days as a minimum for planned care. This group will also look at sub specialities and how the services are structured. In addition to this we need to consider the centralising of specialist revision surgery to one site to improve outcomes. This will dramatically help with storage of specialist theatre equipment and also enable dual working for complex cases. Trauma Liaison exists on the three sites currently but the role is slightly different and this should be standardised to allow cross site communication to be facilitated to manage patient flow and fit within the Orthopaedic management structure. Other focus areas for this group include the option to explore a standalone orthopaedic team in theatre whilst allowing rotational staff training to continue. Core orthopaedic scrub staff will enable smooth turnaround and optimise theatre sessions to deliver maximum capacity. This would support consistency in theatre and aim to improve staff recruitment and retention.



Ward group.

Group Lead : Chief of Nursing Services, Wishaw

The ward group have a number of key areas to explore including; Review the provision of inpatient trauma and planned care within either a one site or two site model both with a 50/50 split on each site Links with Care of the Elderly teams to support early rehab and discharge for all elderly patients, including links with ACE nurses Outline the staffing models needed to deliver the new service model Explore the proposal of ring fencing beds for elective surgery Agree the role for the development of a non medical workforce Establish the AHP model required to deliver the new service model Review the discharge planning processes and establish new patient pathways that include hospital at home Explore the need and model of enhanced level monitoring for orthopaedic patients Review the need for orthopaedic ambulatory care. Advise on any HR issues



Unscheduled care group.

Group Lead : Chief of Medical Services, Monklands

The unscheduled care group will develop and agree clinical pathways with ED, Orthopaedics and Scottish Ambulance Service. This will involve creating pathways for patients that can be used by SAS to deal with trauma from the postcodes related to the non inpatient site. Protocols will be put in place to standardise the management of common injuries. There will be a role review of ESPs currently working in the ED`s and what they could offer to the sites that have inpatients and the non inpatient site. This group will look at junior and middle grade rotas on the 2 site model to cover ED referrals 24/7. This discussion will overlap with the workforce and job planning group that will look at consultant cover on the inpatient sites A further piece of work that will crossover with be the development of virtual fracture clinics. This work will link to the outpatient work on this topic. The trauma Liaison team will create a pathway to convert unscheduled presentations that require surgery to planned care with a scheduled admission where appropriate. This group will also detail any implication for radiology and resolve and issues arising from that. The trauma week rota and on call arrangement will be reviewed to ensure that both the 2 inpatient site and the non inpatient sites have appropriate grade medical cover 24/7. A pathway will define in patient falls on the non inpatient site in relation to orthopaedic review and treatment planning



Workforce and job planning group.

Group Lead : Associate Medical Director Acute

A key area that this group will review is the medical staffing. This will involve a revising all the medical rotas. Currently the sites have different levels of cover over a 24 hour period and this will need to be standardised on the proposed two inpatient sites. Medical modelling has begun and the group will need to produce the detail around the resources available. There will be discussion around cross site working and in the context of centralisation of sub specialities this group will define which sites carry out certain cases and who the staff are that will be operating on specialty cases. In relation to the job planning there will require to be a change in the working day patterns if we are to achieve extended theatre sessions changing form 9-5 currently to 8-6 in the proposed model. This group will have ongoing support from HR and will run staff engagement sessions regularly to ensure that all staff are as informed as they can be. This group will define the non medical staffing (EPSs, MINTS Nurses PA`s,) and where they can contribute to the rotas. The group will take account of the fact that all staff who interact with the Trauma and Orthopaedic service (Radiology, Care of the Elderly, ED, Theatres) will be affected to some degree by the proposed changes however only a proportion of this group will require formal renegotiation of roles. The group will size and articulate the impact on staff.



Older Persons Service/Geriatric Orthopaedic Rehabilitation Unit. (GORU)

Group Lead: Clinical Director Older Persons.

This group is comprised of members of the Older Persons directorate including Consultant Geriatricians, nurses, AHPs, and managers. This group will require to re-configure the GORU wards and Orthopaedic inreach in response to the Clinical Strategy. In doing this the groups are scoping pathways and mapping the future pathways and identifying the resources and skills to implement the changes required. In doing this the team will define the impact, outcomes, bed compliment, length of stay and community resources. A Sub group of this work stream will review the hospital @home service and how orthopaedic patients will access this as part of their pathway.


Appendix E – Poole Tool (Discharge Predictor)

REASON FOR FALL

Mechanical fall 0

Medical reason i.e. cardiac 3

BLOODS ON ADMISSION

Bloods all normal, FBC, U&E 0

Any bloods abnormal 3

ACCOMMODATION

Nursing home 0

Residential Home 1

Lives with able bodied person 1

Lives at home with support 2

Lives alone, no support 3

IF NH RESIDENT STOP SCORING NOW

MOBILITY

Hoisted/immobile 0

Independent 0

Independent with aid 1

Requires supervision 2

Requires assistance 3

PRE-EXISTING MORBIDITY

Normal healthy patient 0

Systemic disease; no compromise to activity 1

Severe incapacitating disease; limits activity 2

Incapacitating disease; threat to life 3

AGE

50 and under 0

51-65 1

66-80 2

81+ 3

COGNITION

Fully orientated 0

Variable memory recall 1

Mild disorientation 2

Severe disorientation 3

FALLS

First fall 0

2 falls in last 3 months 1

>2 falls in last 3 months 3

TOTAL SCORE


Appendix F – Letter from the Scottish Health Council


Appendix G – Letter from the Academy of Medical Royal Colleges and Faculties in Scotland

Trauma & Orthopaedics Service Redesign July 2016€¦ · 1 Trauma and Orthopaedics Service Redesign...

Documents

Transcript of Trauma & Orthopaedics Service Redesign July 2016€¦ · 1 Trauma and Orthopaedics Service Redesign...