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Adult Elective Orthopaedic Services:
Pre-Consultation Business Case
Partnership for orthopaedic excellence: North London
FINAL DRAFT Version 1.0
30 December 2019
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Foreword ............................................................................................................................. 5
1. Executive summary ............................................................................................... 7
1.1 Introduction ............................................................................................................. 7
1.2. Case for change ...................................................................................................... 7
1.3. Elective orthopaedic care model, services and expected benefits ........................... 9
1.4. Governance ........................................................................................................... 11
1.5. Stakeholder engagement ...................................................................................... 12
1.6. Options appraisal .................................................................................................. 13
1.7. Preferred model of care ......................................................................................... 15
1.8 Financial impact .................................................................................................... 18
1.9 Assurance ............................................................................................................. 20
1.10 Decision-making and next steps ............................................................................ 21
2. Introduction ......................................................................................................... 22
2.1. Pre-Consultation Business Case overview ............................................................ 22
3. Context ................................................................................................................. 23
3.1. What is planned orthopaedic surgery? .................................................................. 24
3.2 National context..................................................................................................... 24
3.3 Regional context (orthopaedic care in north central London) ................................. 24
3.4 North London Partners in Health and Care: working together for better health and
care (NCL STP) ..................................................................................................... 25
3.5 Current delivery of planned (elective) orthopaedic services ................................... 26
3.6 Proposal development ........................................................................................... 27
4 Case for change .................................................................................................. 28
4.1. National and international impetus for change ....................................................... 28
4.2. The north central London context: Why we need to change .................................. 31
4.3. Providing sustainable services that are fit for the future ......................................... 32
4.4. Delivering adult elective orthopaedic services that meet the diverse needs of the
NCL population...................................................................................................... 38
4.5. Transport and travel impact assessment ............................................................... 45
4.6. Improving patient outcomes and experience ......................................................... 45
4.7. Fragmented commissioning landscape ................................................................. 51
5. Elective orthopaedic care model, services and expected benefits .................. 51
5.1. Aims and objectives of the service ........................................................................ 52
5.2. Partnership for Orthopaedic Excellence: North London ......................................... 52
5.3. Levels/tiers of service ............................................................................................ 54
Contents
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5.4. Number of proposed elective centres .................................................................... 55
5.5. The patient pathway .............................................................................................. 55
5.6. Summary of service model specification ................................................................ 58
5.7. Standards and performance of the elective orthopaedic service ............................ 69
6. Programme leadership and governance ............................................................ 70
6.1. North central London Joint Commissioning Committee (NCL JCC) ....................... 71
6.2. Programme board – adult elective orthopaedic services review ............................ 71
6.3. Other workstreams ................................................................................................ 72
7 Stakeholder engagement .................................................................................... 74
7.1 Overview 74
7.2 Legal principles ..................................................................................................... 74
7.3. Pre-consultation engagement on the draft case for change ................................... 75
7.4. Process for developing the criteria ........................................................................ 82
7.5. Governance and assurance for involvement and consultation ............................... 82
7.6 Public sector equality duty ..................................................................................... 83
7.7 Local authority scrutiny .......................................................................................... 83
8. Options appraisal process.................................................................................. 84
8.1. The process for selecting a preferred option .......................................................... 87
8.2. Proposals submission ........................................................................................... 88
8.3. Creating the shortlist ............................................................................................. 88
8.4. Assessment of non-financial criteria ...................................................................... 89
8.5. Options appraisal day ............................................................................................ 90
8.6. Non-financial criteria .............................................................................................. 91
8.7 Scoring against the non-financial criteria ............................................................... 95
8.8 Financial assessment .......................................................................................... 100
8.9 System-wide sense check ................................................................................... 101
8.10. Sensitivity analysis of options scoring .................................................................. 101
9. Preferred model of care .................................................................................... 101
10. Financial impact ................................................................................................ 108
10.1. Background ......................................................................................................... 108
10.2. General 109
10.3. Northern partnership: Royal Free and North Middlesex ....................................... 110
10.4. Southern partnership: UCLH and Whittington Health ........................................... 111
10.5. Royal National Orthopaedic Hospital ................................................................... 113
10.6. Cross-trust agreements and financial arrangements going forward ..................... 113
11. NHS England assurance – Four tests .............................................................. 114
11.1 Test 1: Strong public and patient engagement .................................................... 114
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11.2 Test 2: Consistency with current and prospective need for patient choice ........... 116
11.3 Test 3: A clear clinical evidence base .................................................................. 116
11.4 Test 4: Support for proposals from clinical commissioners .................................. 120
11.5 NHS England’s bed test ...................................................................................... 121
11.6 Mayor of London’s six tests ................................................................................. 121
12 Decision-making and next steps ...................................................................... 125
12.1 Consultation plan ................................................................................................. 126
Glossary .......................................................................................................................... 131
APPENDICES................................................................................................................... 134
Appendix A – Engagement evaluation report ............................................................... 134
Appendix B – Options appraisal .................................................................................. 154
Appendix C – Assumptions underpinning financial modelling ...................................... 156
Appendix D – North London Partners in Health and Care adult elective orthopaedic
services review – Memorandum of Understanding .............................................. 158
Appendix E – Initial equalities analysis – Desk research ............................................. 162
Appendix F – Project implementation plan ................................................................... 186
Appendix G – Progress against London Clinical Senate recommendations ................. 189
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North London Partners in Health and Care is a partnership of health and care organisations
which exists to help residents in Barnet, Camden, Enfield, Haringey and Islington live the
fullest lives possible, stay well, and recover from ill-health more quickly.
Our review of elective (planned) orthopaedic services
(for problems of hips, knees and other joints and bones)
is a good example of how we are working together to
improve the health and wellbeing of our residents.
Hip and knee replacement, and other bone and joint
orthopaedic surgery, can be life-changing for those in
pain or who find it difficult to get around. Demand for
these operations is growing all the time and it is
increasingly challenging to ensure residents can access
care in a timely way.
The issues tend to be worse when winter sets in and
planned operations frequently have to be cancelled at
the last minute because of emergency admissions. This
is distressing for patients and frustrating for clinical
teams.
This document sets out our proposals to improve the experience of patients who require
planned orthopaedic care. Hospitals across north central London, by planning together and
with patients and stakeholders, and sharing expertise and facilities, have agreed a new way
of organising orthopaedic surgery to ensure a consistently high quality of care and patient
experience. This approach highlights the benefits of NHS organisations working
collaboratively to solve local issues.
We’ve drawn on national and international research into what works and have also taken
advice from similar services around the country, so that we know our suggestions would
improve the quality of care we provide.
At the heart of our proposals are the patients and residents of north central London. We are
proud of the deep engagement and partnership working with patients, residents, third sector
and local authority partners that have created proposals to deliver consistently excellent
orthopaedic services. Patients have been central to the development of our plans, with
representation on every board, workshop and committee in our review.
We want this review of elective orthopaedic services to be an example of how we plan to
work in future so that health and care professionals, working alongside patients and
residents, use their collective knowledge and expertise to tackle some of the big challenges
we face.
Helen Pettersen
Accountable Officer: Barnet, Camden, Enfield, Haringey and Islington Clinical
Commissioning Groups
Convenor of the North London Partners in Health and Care (the NCL Sustainability
and Transformation Partnership).
Foreword
Our vision is that by
working together as a
partnership, north central
London will be a place
where people experience
the best possible health
and wellbeing, and
experience fewer health
inequalities and less
unwarranted variation in
health and care. Making
north central London is a
place where no-one is
left behind.
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North central London (NCL) residents should have timely access to consistently high-quality
orthopaedic surgery regardless of where they live.
At present, there is unwarranted variation1 in outcomes and quality of care for patients in
NCL, access to services is not equitable and there are challenges attracting and retaining
staff. Additionally, we do not maximise opportunities for training or research. People are
waiting too long for their operations and experiencing too many cancellations, especially
during winter.
As our population changes, demand for orthopaedic services will grow. We want to ensure
every resident in north central London can access the best possible orthopaedic care at the
time that they need it. We need to ensure that not only are our current services fit for
purpose but that we are prepared for the future.
Residents, staff, NHS organisations and councils across north central London have been
working together to co-design future services. We believe that services delivered in a single
network across north central London with two dedicated, state-of-the-art planned
orthopaedic centres, and local, convenient outpatient and day surgery facilities, would
deliver the best care for people who require orthopaedic surgery.
The proposed elective centres would operate under the guidance of the Partnership for
Orthopaedic Excellence: North London, an orthopaedic clinical network that will join together
orthopaedic services under one quality improvement umbrella. The network would deliver a
model where patients would have part of their care at their local hospital of choice, including
outpatient and follow-up appointments and day surgery; with surgery which requires an
overnight stay taking place at two NHS hospitals with dedicated operating theatres and
beds, for patients who need to stay overnight after their operation.
Networked and partnership working would improve staff morale, support recruitment and
retention, enhance training opportunities for newly qualified staff and support ongoing
workforce development. It would create a culture of research and innovation, giving patients
access to research trials and advanced orthopaedic intervention and surgical techniques,
contributing to improved quality of care and outcomes.
Caroline Clarke Group Chief Executive The Royal Free London NHS Foundation Trust
Rob Hurd Chief Executive Royal National Orthopaedic Hospital NHS Trust
Maria Kane Chief Executive North Middlesex University NHS Trust
Siobhan Harrington Chief Executive Whittington Health NHS Trust
Marcel Levi Chief Executive University College London Hospitals NHS Foundation Trust
1 Unwarranted variation is where patient outcomes may vary, clinical practice can be different across different areas, or where
providers’ costs for similar items also range widely.
A joined-up approach to adult elective orthopaedic
services in North Central London
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This section summarises the key points in this pre-consultation business case
(PCBC).
1.1 Introduction
This pre-consultation business case:
Makes the case for change for the proposed
future of planned adult orthopaedic services in
north central London (NCL)
Describes the proposed clinical model of care
which would allow for more efficient and effective
services
Details the process undertaken with
stakeholders2 to inform, develop, and evaluate
viable options for the service changes needed,
driven by the needs of patients, staff and
location, and considering the benefits and impact
of these options on patients
Describes the process undertaken to engage
residents, patients, staff and other stakeholders
in the pre-consultation phase and demonstrate
how their feedback is shaping the development and selection of the preferred option
Describes the process that would engage residents, patients, staff and other
stakeholders in the consultation process and demonstrate how their feedback would
shape development of the new service model
Demonstrates how development of the preferred option is compliant with the Secretary
of State for Health and Social Care’s four tests of service reconfiguration, NHS England’s
bed closure test and the Mayor of London’s six tests
Makes the case to commissioners to undertake a public consultation on the preferred
option.
1.2. Case for change
More than 1.5 million people live in north central London and this is expected to rise.
Increasing numbers of people have one or more long-term conditions, and lifestyle risk
factors are growing as are patient expectations resulting in increasing demand for
healthcare.
Demand for planned orthopaedics is predicted to increase due to increasing incidence of
age-related conditions affecting joints and bones (particularly hips and knees), the impact of
lifestyle factors including obesity, and more people having falls.
Improving planned adult orthopaedic services is a complex task. Local challenges, together
with national and international evidence and national policy, provide a unique opportunity to
2 Stakeholders include staff, public, patients, health and wellbeing boards, overview and scrutiny committees and voluntary
sector organisations, among others.
1. Executive summary
Elective (or planned)
orthopaedic services are for
patients who suffer from a
medical condition related to
bones or muscles (like a hip
or knee, tendons, ligaments or
joints) where an operation to
correct the condition, like a hip
replacement, is recommended
as the best choice of
treatment by a specialist. It
does not cover emergency or
trauma service.
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create innovative, sustainable services that deliver the best possible elective orthopaedic
experience and outcomes for patients.3
We currently deliver planned adult orthopaedic services for NHS patients from 10 separate
NHS and private sector sites in north central London. While many of these services are of
good quality, we know there is unwarranted variation in the quality of care we are able to
offer.
We know that:
Waiting lists are too long
Cancellations are common and emergency care is prioritised over planned care
More patients would need orthopaedic care in the future.
We also know from our review of evidence that consolidating services onto fewer sites
improves quality outcomes.
Evidence shows us that:
Care is improved when emergency and planned care are separated
More operations in one place results in better outcomes for patients
Separating planned and emergency care leads to lower infection rates.
While there are many areas of good practice in elective orthopaedic care in NCL, the current
system does not fully realise opportunities to deliver the best possible care for patients.
We are proposing a new way to organise planned orthopaedic surgery for patients in
north central London.
Two partnerships have been formed by local NHS hospital trusts – with University College
London Hospitals (UCLH) and Whittington Health working together, and The Royal Free
London (Royal Free, Barnet Hospital, Chase Farm Hospital) working with North Middlesex
University Hospital (North Mid). If the proposal is agreed, these partnerships would deliver
real improvements in how we provide planned orthopaedic surgery.
The partnerships would offer two hospitals with dedicated operating theatres and beds for
patients who need to stay overnight after their operation. They would also offer patients the
choice of which hospital they go to for day surgery, outpatient appointments and education
classes for patients prior to their operation. Appointments would be with a named surgeon;
the surgeon and their surgical team would stay with patients throughout their care.
Both partnerships would be overseen by a network of health professionals who would
ensure that, regardless of where patients receive care, it is of a consistently high standard.
Evidence from the UK and around the world shows that doing surgery in operating theatres
which only do orthopaedics, means better quality of care for patients. We believe that by
organising services in this way, we would be able to improve care and help more patients
before, during and after their operation.
The proposed change could affect anyone living in our five boroughs (and a small number in
neighbouring areas) who needs orthopaedic surgery in the future. To inform our decision-
making, we’d like feedback from anyone with an interest in these services.
3 A National Review of Adult Elective Orthopaedic Services in England (2015) http://gettingitrightfirsttime.co.uk/surgical-specialty/orthopaedic-surgery/
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Summary of the preferred model of care
Two NHS hospitals with dedicated operating theatres and beds, for patients who
need to stay overnight after their operation
A choice of NHS hospitals for those needing day surgery
Within each partnership, a choice of NHS hospitals for outpatient appointments
Improved education classes for patients so they understand their operation and what
to do to before surgery to support their recovery afterwards
Appointments would be with a named surgeon, who, with their surgical team, would
stay with patients throughout their care, regardless of where it takes place
Rehabilitation support for patients after their surgery
Access to high dependency or intensive care units for patients who need additional
care after their surgery
Care coordinators to support patients with conditions such as dementia or a learning
disability to understand their care and where it might take place
More complex surgery would continue at the Royal National Orthopaedic Hospital, a
super-specialist centre
Patients with other complex medical conditions, such as haemophilia, would have
their surgery at the hospital which specialises in their condition
Emergency orthopaedic care would continue at all local hospitals with an accident
and emergency department.
1.3. Elective orthopaedic care model, services and expected benefits
Our proposal is to develop a networked model of care that has an international reputation for
high-quality patient outcomes and experience, education and research.
We would aim to achieve this through:
Timely diagnostics and outpatient care, both before and after surgery, at local base
hospital sites, working seamlessly within local musculoskeletal services4 (MSK)
pathways, including prevention and self-management
Two elective centres that would provide at-scale delivery of consolidated, elective
orthopaedic surgery in dedicated beds, with excellent care
Focusing on consistently excellent patient education and rehabilitation before and
after surgery
Flows to a super specialist centre for the most complex patients who cannot be
appropriately cared for in either the local, base hospitals or elective centres
Improving local trauma services by separating planned and emergency orthopaedic
services, while maintaining a surgical workforce trained to provide both to best-
practice standards.
Driving this model is the creation of a single elective orthopaedic network, Partnership for
Orthopaedic Excellence: North London. This clinical network would enable high quality
elective orthopaedic care, improved outcomes and consistency of care across north central
London, as well as providing an overarching framework for system-wide quality
improvement.
4 Musculoskeletal conditions’ is a broad term, encompassing around 200 different conditions affecting the muscles, joints and
skeleton. Around 10 million adults, and around 12,000 children, have a musculoskeletal condition in England today.
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We want to move to a three-tiered model of hospital provision for adult elective (planned)
orthopaedic services. In this document we refer to these as ‘base’ hospitals, elective
orthopaedic centres and the super specialist hospital.
Table 1: Proposed three-tiered model of hospital provision
Base hospitals Planned orthopaedic
centres Super specialist centre
These are the existing local
hospital sites.
They would act as the entry
point to elective orthopaedic
care for patients, support
the operation of the elective
orthopaedic centres as part
of a clinical network,
manage outpatients and
post-operative follow-up,
some day-cases and all
trauma care alongside an
accident and emergency
department.
These would provide
surgical care for patients
who would require an
overnight stay. They would
be able to undertake a
mixture of some complex
and all routine elective
activity.
Able to treat medically
complex, as well as some
orthopaedically complex,
patients, with appropriate
back up medical services
and step-up care.
This activity is (mostly)
commissioned by local
clinical commissioning
groups, although some
would sit with NHS England
(NHSE) specialised
commissioning.
Tertiary and complex
orthopaedic care is
undertaken here that cannot
appropriately take place at
either the base hospitals or
the elective centres.
This activity is (mostly)
commissioned by NHS
England with a national
catchment area and would
be fulfilled by the Royal
National Orthopaedic
Hospital NHS Trust (RNOH)
in Stanmore.
This super specialist work
does not form part of this
review.
The overarching principle of this proposed model of care is that orthopaedic surgeons would
remain employed by their existing base hospital and move with their elective surgical
inpatient commitments to the elective centre with a job-plan of programmed activities
covering both elective and emergency care.
Base hospitals would continue to work with their local MSK services to take referrals through
established primary and community care routes (GP practices, other single points of access,
first contact practitioners and referral management centres).
Patients would be treated at the proposed elective centres by the consultant overseeing their
care. This would be expected to be within the 18-week referral to treatment window using
the agreed NHS protocols and arrangements for transfer.
Expected benefits
We believe that services overseen by a single network for orthopaedic care, delivered from
two dedicated state-of-the-art planned orthopaedic surgical centres, would deliver the
best care for orthopaedic patients:
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Providing the right number of dedicated (ring-fenced) beds for elective (planned)
orthopaedics to meet the need for NHS-funded care would ensure that cancellations for
non-medical reasons would be virtually eliminated, and capacity could be well-
managed, so that maximum use could be made of available resources, resulting in
shorter waiting times
Our new centres would improve patient outcomes and ensure that all patients who
attend these centres would receive high-quality care and support. The centres
would focus on meeting the needs of patients with vulnerabilities and people who
sometimes find services hard to navigate
The proposals would foster a culture of openness and transparency between all
participating organisations, facilitating multidisciplinary team working focusing on
continuous quality improvement
The additional capacity would also enable us to future-proof our services as our
population ages and demand for orthopaedic services increases
The Partnership for Orthopaedic Excellence: North London would support a model where
patients have part of their care at their local (base) hospital, including outpatient and
follow-up appointments and day surgery, with surgery which requires an overnight stay
taking place at dedicated elective orthopaedic inpatient facilities
Freeing-up beds and theatres would also improve the experience for emergency
patients and the proposed separation of emergency and planned care supports the
North London Partners in Health and Care urgent and emergency care strategy
Efficiencies as a natural consequence of these improvements would offer better value
for money. The Getting It Right First Time (GIRFT)5 programme reports that 75% of
trusts from its 2015 review have renegotiated the costs of implants and rationalised their
use, and there remain opportunities for further rationalisation as a result of the proposed
new model of care
For staff, working in a state-of-the-art facility would improve morale and support
recruitment and retention. Networked and partnership working would improve training
opportunities for newly-qualified staff across all disciplines and their development
The centres would also support research and innovation, so that patients would have
access to research trials which would contribute to improved quality of care and
outcomes.
1.4. Governance
The NCL adult elective orthopaedic services review has a clear governance structure in
which the north central London Joint Commissioning Committee (NCL JCC) is the decision-
making body for the pre-consultation business case and will decide whether to proceed to
consultation.
The commissioning-led governance framework which underpins these adult elective
orthopaedic care proposals was established following agreement from the NCL JCC in
January 2019. The NCL JCC is a joint committee of the CCGs under s.14Z of the NHS Act
5 Getting It Right First Time (GIRFT) is an NHS improvement programme designed to improve the quality of care within the
NHS by reducing unwarranted variations.
12
2006. All five of the CCGs’ governing bodies approved the proposals to establish the NCL
JCC and agreed its terms of reference.
Should the programme proceed to consultation and, following the outcome of that
consultation, the next stage of decision-making will be to discuss the Decision-Making
Business Case (DMBC). This will be taken by the North Central London CCG (a merged
organisation of the five NCL CCGs which is expected to come into being on 1 April 2020)6. It
will take forward and support any required implementation plans as part of its support to a
north central London integrated care system.
Before January 2019, a review group of NCL provider representatives, patients and clinical
commissioners, oversaw wider engagement around a draft case for change and creation of
key design principles, developing a culture of common purpose, collaboration and quality
improvement.
The NCL JCC is advised by a programme board for the adult elective orthopaedic services
review which oversees programme delivery to:
Make collective recommendations to the NCL JCC
Connect local organisation-based accountability structures with the review
Consider and champion the interests of the public, patients, carers and staff
Provide feedback on elements of the plan
Provide a forum where political and public engagement could be considered and
reviewed.
1.5. Stakeholder7 engagement
A robust approach to engagement has been at the core of the adult elective orthopaedic
review from the outset with local residents, patients and staff fully involved in shaping the
outcome of the review. Engagement work undertaken is laid out in section 7.
Public and patient engagement has informed the planning process from its earliest stages
and this would continue through 2020 and into future planning phases, a potential public
consultation, transition and the next stage of service delivery.
1.5.1. Overall aim for involvement and consultation
The overall aim of our stakeholder engagement has been to implement best practice
involvement to influence and support our plans during 2019 and onwards, and to embed
sustainable involvement for future engagement of staff, residents, patients and carers in
developing the proposal.
To define the scope of the proposed consultation, the programme board signed-off a
consultation mandate on 16 September 2019. It stated that:
The five CCGs in NCL (Barnet, Camden, Enfield, Haringey and Islington) in
partnership with NHS providers, intend to consult on the future configuration of adult
elective orthopaedic care. Our proposals are to create a single network, overseeing
two partnerships of NHS providers, which will result in some changes to where
patients have surgery.
6 Further information on the approval to merge can be found here. 7 Stakeholders refers to staff, public, patients, health and wellbeing boards, overview and scrutiny committees and voluntary
sector organisations, among others.
13
Working through North London Partners in health and care, we would like to
understand the views of past, current and prospective patients and carers of adult
elective orthopaedic services, staff and stakeholders.
Our aim is that, by April 2020, when the consultation has closed and feedback has
been evaluated, we will understand the impact of the proposals and be able to
review, improve or amend them, to achieve better access and outcomes for patients
of adult elective orthopaedic care in NCL.
The aim of our consultation exercise is to understand the views of stakeholders (including
the public, current and future service-users and staff) to our proposals for the future model of
Adult Elective Orthopaedic Services in north central London.
We would be consulting people on:
How they view the proposal and the way in which it might affect them
Their views on the service model we are proposing, and the ways in which it might
affect them
What matters most to patients and how this might affect implementation
The wider implications of the proposed change – and any unintended consequences.
Following the consultation period, we would provide an evaluation of the responses,
produced by an independent organisation (Participate Ltd). Future decision-making and
plans would be informed by feedback on the issues laid out above and influence the next
steps of the programme and how our plans would be implemented.
Our consultation documents would lay out our proposals clearly, explaining the thinking
behind them, how we arrived at them in light of the engagement already undertaken and
how people could feedback on them. The document would contain a questionnaire for
structured feedback, alongside quantitative responses. It would also give information about
other ways to feedback and engage in the process. A full consultation plan is being
developed collaboratively; a summary of which is provided in section 7.
1.5.2. Local authority scrutiny
CCGs are under a duty to consult with the local authority about any proposals for a
substantial development or variation of service. Therefore, in line with scrutiny regulations,
the North Central London Joint Health Overview and Scrutiny Committee (JHOSC) is leading
a joint scrutiny process for these proposals.
The lead member for health and social care (or committee lead) and the directors of adult
social services in Barnet, Camden, Enfield, Haringey and Islington have been regularly
briefed about the proposals during their development and their input sought.
1.6. Options appraisal
The process of assessing and selecting a preferred option is an important step before a
public consultation and we have involved our stakeholders, clinicians, patients and residents
fully.
The proposals were developed in an innovative, collaborative way between the providers of
health services in north central London. A number of steps have happened along the way
which have narrowed the number of options that could be considered and led to the
proposed service model which is planned to be being put forward for consultation.
14
Drawing on feedback from commissioners, clinicians, providers, patients and residents and
other stakeholders, and a series of clinical design workshops, a number of clinical design
principles were developed for the new service and agreed by the NCL JCC in December
2018.
As a direct consequence of the clinical design principles, in January 2019 the NCL JCC
agreed that because of the interdependencies with other services – particularly emergency
care and the need to provide high dependency support – that planned orthopaedic services
should remain within the NHS by way of variations to existing annual contracts.
In May 2019, the NCL JCC then agreed a clinical delivery model for the new service based
on the clinical design principles which had already been agreed. This set out a number of
tests which had to be met, these were:
The provider must already be a provider of planned orthopaedic surgery
The dedicated operating theatres and supporting facilities for orthopaedic care must
be located on a site operated by members of North London Partners in Health and
Care
The option must demonstrate a favourable income and expenditure impact for the
system after two years of operation
Each of the five eligible NHS organisations in north central London was invited to put forward
options that would meet these requirements. In putting forward proposals, providers
themselves discounted some remaining options.
Providers were able to submit proposals to become a base hospital, an elective centre, or
both. The invitation set out the ambition for a system-wide partnership approach to
delivering services rather than establishing a competitive process in which providers
compete with each other to deliver services.
The deadline for proposals was noon on 5 July 2019, and two joint proposals were received
from:
North Middlesex University Hospital NHS Trust and The Royal Free London NHS
Foundation Trust
University College London Hospitals NHS Foundation Trust and Whittington Health
NHS Trust.
The Royal National Orthopaedic Hospital chose not to submit a proposal to be a local
elective centre. It would continue in its role as a super specialist centre providing local and
national tertiary care and would be a key partner in developing local services.
Through a rigorous options appraisal process, a panel of patients and residents, healthcare
professionals and commissioners judged the two partnerships put forward to deliver care as
meeting the criteria and to be better than what is currently available.
The scoring of the non-financial criteria was carried out by a panel consisting of patients,
residents and clinical commissioners. Following the options appraisal process, a
collaborative system-wide sense check took place with provider trusts, patients, residents
and commissioners to ensure that there were no unintended consequences arising from the
preferred option.
The outcome of the options appraisal and system-wide sense check were informally
reported to the NCL JCC and key stakeholders prior to presentation to the London Clinical
Senate for review.
15
1.7. Preferred model of care
The preferred model of care would create a single adult elective orthopaedic service for
patients and staff across the whole of NCL, overseen by a clinical network.
Figure 1: The locations for orthopaedic care in north central London under our proposals
Table 2: Detail of the preferred model of care
North Middlesex University Hospital NHS Trust/The Royal Free London NHS Foundation Trust partnership
University College London Hospitals NHS Foundation Trust/Whittington Health NHS Trust partnership
Partnership for Orthopaedic Excellence: North London
Creates a quality improvement framework delivering a standardised approach to pre-assessment, post-operative procedures and protocols, joint school and patient education.
Providers in the partnership
A partnership between the North Middlesex University Hospital NHS Trust and The Royal Free London NHS Foundation Trust – the ‘northern partnership’
A partnership between University College London Hospitals NHS Foundation Trust and Whittington Health NHS Trust – the ‘southern partnership’
Inpatient elective orthopaedic surgery
A change: all inpatient orthopaedic
care would take place at an elective
orthopaedic centre on the Chase
Farm site.
Approximate annual number of
patients impacted by the changes:
A change: all inpatient
orthopaedic care would take
place in an elective orthopaedic
centre specialising in inpatient
care at UCLH’s new building on
Tottenham Court Road (known
at the moment as phase 4).
16
North Middlesex University Hospital NHS Trust/The Royal Free London NHS Foundation Trust partnership
University College London Hospitals NHS Foundation Trust/Whittington Health NHS Trust partnership
400 inpatients who currently use
the North Middlesex would in the
future have their surgery at
Chase Farm Hospital
225 patients referred to the
RNOH for non-specialist care
could be suitable for treatment in
the elective centres
Up to 560 patients a year currently treated in the private sector would over time have their treatment in the NHS.
Approximate annual number
of patients impacted by the
changes:
360 inpatients a year who
use the Whittington would in
future have their surgery at
UCLH
75 patients referred to the
RNOH for non-specialist care
could be suitable for
treatment in the elective
centres
Up to 40 patients a year
currently treated in the
private sector would over
time have their treatment in
the NHS.
Day-case
elective
orthopaedic
surgery
A change: In local NHS
organisations day surgery would
continue to take place at both at
North Middlesex and Chase Farm
hospitals.
Approximate annual number of
patients impacted by the changes:
Up to 1,020 patients a year
currently treated in the private
sector would over time have their
treatment in the NHS as part of
the new model of care.
A change: as part of the
partnership approach, the
Whittington would become a
centre specialising in day-case
orthopaedic surgery, with some
day-case surgery moving from
UCLH to Whittington Health.
Approximate annual number
of patients impacted by the
changes:
Approximately 360 day-
cases would move from
UCLH and have their surgery
at Whittington Health
Day-surgery would also
continue to be carried out at
UCLH
80 patients currently treated
in the private sector would
over time have their
treatment in the NHS as part
of the new model of care.
Pre-operative and post-operative
No change: patients would continue to be seen at the three Royal Free hospital sites and North Middlesex
No change: patients would be seen at UCLH and Whittington Health both pre- and post-operatively.
17
North Middlesex University Hospital NHS Trust/The Royal Free London NHS Foundation Trust partnership
University College London Hospitals NHS Foundation Trust/Whittington Health NHS Trust partnership
outpatient care.
hospital both pre- and post-operatively.
Pre-operative and post-operative outpatient care
No change: patients would continue to be seen at the three Royal Free hospital sites and North Middlesex hospital both pre- and post-operatively.
No change: patients would be seen at UCLH and Whittington Health both pre- and post-operatively.
Trauma – emergency orthopaedic care
No change: would continue to take place as now at both the North Middlesex, Royal Free and Barnet hospital sites.
No change: would continue to take place as now at both UCLH and Whittington Health hospitals.
Table 3: Benefits of the preferred model
Improved clinical outcomes including reduced cancellations, decreased waiting
times, reduced infection rates, decreased revisions and readmissions.
At-scale orthopaedic surgery at dedicated facilities would deliver consistently excellent
clinical intervention across end-to-end pathways. There would also be a focus on patients
with vulnerabilities. Patients would have access to high dependency or intensive care
units for those who need additional care after their surgery, plus rehabilitation support for
patients after their surgery.
Increased research activity
Bringing the collective research elements together and supporting the development of all
clinical staff would strengthen research capabilities in the wider NCL orthopaedic network
for the continued improvement of orthopaedic care.
Increased staff satisfaction
The development of innovation into the workforce through the introduction of new roles
and effective ways of working would provide excellent opportunities for learning and
development via rotational programmes.
Increased patient satisfaction
Patient satisfaction would be increased by providing diagnostics and outpatient care in
local hospitals that are familiar to our patients. The inclusion of care co-ordinators in the
model would ensure a seamless transition along the pathway, a benefit especially to
those patients who have vulnerabilities.
Reduced patient time wasted
18
The physical separation of elective and non-elective care would eliminate the pressures of
high emergency demand on theatres and wards, which means patients would have their
surgery on the day that it is planned and reduce waiting times.
Improved clinical education
The preferred model would provide an opportunity for students from across many different
professions to experience a collaborative delivery model within orthopaedics, achieve
competencies and develop knowledge, through a combination of class-based sessions,
online education, simulation training as well as clinically based sessions.
Long-term commissioning strategy for orthopaedics
Create a strategy and the long-term capacity, delivering all NHS-commissioned care as
part of a single model as set out in this pre-consultation business case. The proposed
new service model would be delivered solely by NHS providers and, following the
proposed public consultation, there may need to be consequential contractual changes
with private sector providers to reflect the changed commissioning strategy for
orthopaedics.
Major trauma services are out of the scope of this model and would continue to be
delivered via existing designated sites (St Mary’s Hospital in Paddington and at The Royal
London Hospital in Whitechapel).
Spinal surgery is also not included within the planned scope of an elective orthopaedic
centre, although a base hospital which is also an elective centre could manage their own
spinal activity through the elective centre.
Additionally, the Royal National Orthopaedic Hospital care for only those tertiary and
complex patients that cannot be appropriately cared for in local or elective hospitals. This
super specialist work does not form part of this review.
1.8 Financial impact
The Clinical Delivery Model approved at the 2 May 2019 Joint Commissioning Committee
(JCC) defined high-level financial principles to support reconfiguration of adult elective
orthopaedic services in north central London.
An initial financial assessment was made alongside the options appraisal process in July
2019, which demonstrated that the two options that had been submitted should have, at
least, a net neutral financial impact on the health economy, and the short-term costs of
introducing the proposed changes would be managed internally within the sector without
affecting the viability of the trusts involved.
A group that has included finance directors of all the trusts involved, together with
commissioners, has been considering the financial impact of the proposals on the whole
health economy and on the individual trusts. The group looked at the financial impact at both
the point when the proposals are fully implemented and during the implementation period.
Each of the trusts has considered the future cost of the service based on a set of common
assumptions and prudent assumptions regarding efficiency gains and interim costs. This has
been compared to the current level of expenditure and a counterfactual (a projection of how
finances would appear if the proposals were not to go ahead).
19
The analysis undertaken to date currently shows that in the medium term there would be
savings from the economies of scale and better use of available capacity, but that in the
short term there would be some stranded and transition costs8. The savings would be
sufficient to offset the additional costs by the second year of operation. Once fully
implemented in 2023-24, the proposal would show a financial gain to the health economy of
£1.18m per annum when compared to the counterfactual. The financial analysis would be
refined as work progresses in support of the proposed service changes.
The gains would be greatest in the North Middlesex University Hospital NHS Trust/The
Royal Free London NHS Foundation Trust partnership where an elective centre is already in
operation at Chase Farm Hospital, thereby reducing the likely transition costs and operating
costs. Also, in this partnership, the elective centre would allow for a more efficient use of
capacity which would be used to treat patients currently treated in the private sector. Once
fully implemented the proposal would, by 2023-24, contribute a positive contribution of £677k
a year.
In the University College London Hospitals NHS Foundation Trust/Whittington Health NHS
Trust partnership, inpatient elective care would transfer into a new facility, part of UCLH,
currently under construction (referred to as the Phase 4 development). The elective centre
would be a new service in a new building and therefore likely to attract higher operating
costs and transitional costs in the interim. In addition, it is anticipated that there would be
stranded costs at Whittington Health that would take time to fully absorb. As a consequence,
there would be a net cost of the proposal in the interim years before the service is fully
implemented. However, once this period is over, the service in this partnership would, by
2023-24, make a positive contribution to the health economy of £502k a year.
Table 4: Summaries of financial impact of proposals by partnership and year in comparison
to the counterfactual
£000 2019-20 2020-21 2021-22 2022-23 2023-24 Total
Northern partnership 0 (79) 228 540 677 1,366
Southern partnership 0 (696) (170) 423 502 59
Total 0 (775) 58 963 1,179 1,425
There would be a further financial benefit to the health economy (but neutral to the NHS as a
whole) resulting from the contribution of the Royal National Orthopaedic Hospital (RNOH).
The trust currently turns away some referrals that in future could be treated by the trust if it
made use of capacity in the elective centres.
This financial analysis has been done at a sufficient level of detail to demonstrate a proof of
concept. Subject to consultation, this analysis would need to be repeated in more depth,
post-consultation and prior to making a final decision to proceed. At that time one or more
formal agreements would need to be put in place between the trusts to ensure that losses
and gains across the health economy are smoothed out, ensuring that no trust’s financial
viability would be impacted by these proposals.
8 Stranded costs arise when costs incurred in providing capacity cannot be fully recovered out of future income because the
capacity is under-utilised.
20
Progress has been made in the STP to agree principles that cover economy-wide initiatives
and, by agreeing a memorandum of understanding, commit each trust to enter into formal
agreements in the future. A copy of this MOU is included at Appendix D.
1.9 Assurance
1.9.1. The Secretary of State’s four tests
The 2014/15 mandate from the Secretary of State to NHS England outlined that any
proposed service changes by NHS organisations should be able to demonstrate evidence to
meet four tests before they could proceed. The adult elective orthopaedic services review
has met these four tests in the following ways to date:
Strong public and patient engagement: robust stakeholder engagement has been at the
heart of the adult elective orthopaedic review from the outset. Patients, residents, clinical
staff, commissioners, GPs, local authority and third sector partners have worked in
partnership to design a model of care that works for everyone. The options appraisal scoring
panel had equal representation from local residents, engagement on the draft case for
change received hundreds of individual pieces of feedback and resident representatives
have been part of our programme board. Patients, residents and other stakeholders have
continued working in many of the programme’s workstreams, including patient input into a
further workshop on transport and access, resident involvement in consultation planning and
the delivery of a full public consultation in the future.
Patient choice: the proposed model of care is consistent with the NHS approach to patient
choice. In north central London we currently deliver planned adult orthopaedic services for
NHS patients from 10 separate NHS and private sector sites. Under our proposals, patients
would continue to have a choice of care providers both inside and outside north central
London. The clinical delivery model ensures that referrals would continue to be made to
base hospitals, with pre- and post-operative care managed locally. Surgeons from the base
hospital would carry out inpatient surgery at the proposed elective centres. Commissioners
and providers would continue to work together at a system-level to ensure that networks and
pathways are developed to improve how patients access elective orthopaedic care services;
how clinicians and staff would deliver those services; and how, by integrating research with
service delivery, this would create a huge benefit for clinical outcomes.
Clinical evidence base: The case for change sets out the evidence on which the proposals
are based. Drawing on local and global examples of best practice and building on the
evidence, such as GIRFT’s national review of adult elective orthopaedic services in
England9, we have considered how pathways could be redesigned, to address local needs
and maximise opportunities. As described in section 11.3, the London Clinical Senate
reviewed our proposals and confirmed that the proposal has a clear case for change, is
based on national best practice and has considered local issues. Additional clinical
advice and guidance has been provided to support the development of proposed
consultation documentation.
Support from clinical commissioners: NCL commissioners have supported the
development of our proposals in principle and subject to consultation. The NCL JCC has
been fully informed and significantly involved in the development of these proposals:
At its meeting on 1 February 2018, commissioners signed off the mandate for the
adult elective orthopaedic services review
9 A national review of adult elective orthopaedic services in England, Getting It Right First Time
21
At its meeting on 6 December 2018, commissioners approved the design principles
for a new proposed model of care and received the feedback from the engagement
on the draft case for change
At its meeting on 3 January 2019, commissioners approved the overarching timeline,
revised governance and accepted the recommendation around final contract form
At its meeting on 2 May 2019, the NCL JCC agreed the clinical delivery model and
options appraisal process.
1.9.2. NHS England’s bed closures test
From 1 April 2017, NHS England introduced a new test to evaluate the impact of any
proposal that includes a significant number of bed closures. There is no intention for a
significant change to the occupancy of beds associated with this programme. We anticipate
an increase in the number of beds available to planned adult orthopaedic services
associated with additional activity attracted by RNOH and a general growth in demand. The
trusts estimate that:
Across North Middlesex and Chase Farm Hospitals, approximately 47 beds are
currently used for elective orthopaedic surgery. By 2023-24 this would increase to 52
beds at Chase Farm Hospital
Across UCLH and Whittington Health hospitals approximately 21 beds are currently
used. By 2023 this would increase to 27 at UCLH.
1.9.3. The Mayor of London’s six tests
The King’s Fund and Nuffield Trust published a report10 in September 2017 recommending
greater city-wide leadership to successfully support the implementation of the five NHS
Sustainability and Transformation Plans (STPs) for London. In response, the Mayor of
London developed a six-test framework for major hospital reconfiguration. To enable the
Mayor to give support for individual reconfigurations, each proposal is required to specify
how it meets the requirements of each test. As part of our assurance process we have met
with the Mayor’s health policy team for initial discussions and guidance. We are confident
that our proposal and processes meet the criteria set out in the tests, which will be tested by
the Mayor’s health team during the proposed public consultation (tests 1 to 4); and following
its conclusion (tests 5 and 6).
1.10 Decision-making and next steps
In order to proceed to public consultation, the process requires approval from the NCL JCC
who will review this pre-consultation business case and the response from the London
Clinical Senate.
However, to give an indicative timeline, the programme expects the following milestones for
this process. These may be subject to change.
9 January 2020 – Joint Commissioning Committee of the five NCL CCGs to be
asked to (i) approve the pre-consultation business case and (ii) consider the decision
to move to a public consultation
13 January 2020 Public consultation starts (12 weeks)
6 April 2020 Consultation finishes (subject to the volume and content of
responses)
10 Sustainability and transformation plans in London, an independent analysis of the October 2016 STPs
(completed in March 2017)
22
April/May 2020 Following consultation, all responses from members of the public
and local organisations would be independently evaluated and a draft report
produced.
Timescales for post-consultation decision-making, subject to the volume and content of
responses received:
May 2020 Stakeholders would have the opportunity to comment on the draft report
of the consultation evaluation together with the review of the equalities impact
assessment
June 2020 The evaluation of responses, feedback from stakeholders and impact
assessments would be shared with the Joint Health Overview and Scrutiny
Committee (JHOSC)
June 2020 A decision-making business case (DMBC) would be developed
outlining the recommended decision as a result of the consultation evaluation, impact
assessments and feedback from the JHOSC
June/July 2020 The final DMBC presented to NCL CCG for decision (TBC).
July to November 2020 - Assurance of implementation plans and trust internal
governance processes.
2. Introduction
NHS organisations and residents across north central London have been working in
partnership to co-design the future of planned adult orthopaedic services. This process has
put patients and clinicians at the heart of our planning, developing a model for future adult
elective orthopaedic services that works for patients, their families, staff and clinicians.
At the moment, elective (planned) orthopaedic surgery can be hard to access, waiting times
are too long and vary between providers. Services and patients’ experiences are
inconsistent across NCL, planned operations can be cancelled, especially during the winter
months, and outcomes could be better.
Our vision is to develop a single network across north central London with two dedicated,
state-of-the-art orthopaedic elective surgical centres and local, convenient outpatient and
day surgery facilities. The specialist centres would be separated from existing emergency
departments and co-located with high-dependency units (HDU), with the size and scale to
enable a full elective orthopaedic service staffed by doctors, nurses and specialists who are
in the right place at the right time.
Emergency and trauma orthopaedic care would be maintained at local hospital trusts,
freeing-up beds and theatres for planned operations, resulting in efficiencies as a natural
consequence of these improvements and offering better value for money.
2.1. Pre-Consultation Business Case overview
North London Partners in Health and Care is representing clinical commissioning groups in
Barnet, Camden, Enfield, Haringey and Islington and working together with NHS England
specialised commissioning, hospital and community trusts, to develop a new and improved
planned adult orthopaedic service which:
Has dedicated beds for inpatient orthopaedic surgery
Has improved and consistently high standards of pre- and post-operative care (with
pre-operative assessment, patient education and post-operative care)
Provides day surgery at high-quality centres
23
Gives patients access to excellent care from clinicians who would receive the best
education and training.
This PCBC sets out the proposal to reorganise orthopaedic surgery (surgery of hips, knees
and other joints and bones) that currently takes place at 10 NHS and private sector sites in
north central London:
It does not cover:
Major trauma services which would continue to be delivered at existing designated
sites (St Mary’s Hospital in Paddington and at The Royal London Hospital in
Whitechapel)
Spinal surgery
Paediatric orthopaedic surgery
Services provided by the Royal National Orthopaedic Hospital which undertakes
surgery only for those tertiary and complex procedures on patients that cannot be
appropriately cared for in local or elective hospitals.
The PCBC informs a public consultation on the preferred option, scheduled take place
between December 2019 and March 2020 in advance of the development of a decision-
making business case.
Parties involved in PCBC development
Robust stakeholder engagement has been at the heart of the adult elective orthopaedic
review from the outset. Patients, residents, clinical staff, commissioners, GPs, local authority
and third sector partners have worked in partnership to develop the PCBC, including:
The local CCGs (and lead commissioning CCGs):
o Barnet CCG
o Camden CCG
o Enfield CCG
o Haringey CCG
o Islington CCG
NHS hospital providers:
o North Middlesex University NHS Foundation Trust Hospital
o The Royal Free London NHS Foundation Trust
o The Royal National Orthopaedic Hospital NHS Trust
o University College Hospital London NHS Foundation Trust
o Whittington Health NHS Trust
NHS England specialised commissioning London
Local authorities, including through the NCL Joint Health Oversight and Scrutiny
Committee (JHOSC), as set out in section 7 – Stakeholder engagement
We have also involved key stakeholders such as NHS East and North Hertfordshire
CCG, Herts Valley CCG, East London Health and Care partnership and North West
London Collaboration of CCGs and are keeping them informed.
3. Context
This section sets the background of the current healthcare challenges faced both
nationally and in north central London in elective orthopaedic care; how services are
currently commissioned and provided in the area, and how North London Partners in
Health and Care propose to meet these challenges.
24
3.1. What is planned orthopaedic surgery?
Orthopaedic surgery treats damage to bones, joints, ligaments, tendons, muscles and
nerves (the musculoskeletal system). Patients may be referred to an orthopaedic surgeon for
a long-term condition that has developed over many years, such as osteoarthritis or other
non-emergency damage.
Surgery, such as hip and knee replacements, is the most common orthopaedic surgery
offered in the NHS. However, other surgery of hips, knees, shoulders, elbows, feet, ankles
and hands also falls under this heading.
Planned surgery is when patients have an appointment booked in advance. It is planned
treatment, following a referral to hospital by a GP and an assessment by specialists. It is
sometimes called ‘elective’ or ‘non-emergency’ care.
3.2 National context
Now is a time of change for the NHS as the system adapts to the opportunities and
challenges of the NHS Long Term Plan (LTP). The issues faced by the NHS are well
documented: funding, staffing, increasing inequalities and pressures from a growing and
ageing population have all been highlighted as key areas of concern. National evidence has
played a significant role in informing our plans for the future of orthopaedic services,
especially the NHS Getting It Right First Time (GIRFT) programme – which aims to help to
improve quality of care within the NHS by reducing unwarranted variations, bringing
efficiencies and improving patient outcomes.
Evidence set out in both the Long Term Plan and evaluation of national orthopaedic practice
by GIRFT, has identified innovation and best practice strategies that have the potential to
reduce unwarranted variation and improve patient outcomes for elective secondary care
orthopaedic services. These initiatives are set out in section 4.1. National and international
impetus for change.
3.3 Regional context (orthopaedic care in north central London)
There are five CCGs in north central London – Barnet, Camden, Enfield, Haringey and
Islington – each coterminous with their local London borough and in total serving a total
population of approximately 1.5 million.
Over the next 10 years, the population of London is expected to increase by 9%. By 2028,
the 65 years and over age group is expected to increase by 18% to 200,000 people, of
whom 37,000 would be 85 years and over.
While older people are the fastest growing segment of the population, in total numbers this
age group would remain the second smallest in 2020, after children aged up to four years
old.11
Table 5: Population growth over 10 years (2018-2028)
Age group Increase within age group 2018-28
Number %age increase
CYP 300,000 11%
>65 200,000 18%
11 Source: Population Projections Unit, Office for National Statistics, 2012
25
>85 37,000 25%
ALL 800,000 9%
Demographic pressures
An ageing population has an impact on health services as people are more likely to access
services when they are older. This is particularly so for elective orthopaedics due to the
prevalence of age-related conditions, affecting people’s hips and knees and a higher
prevalence of falls. To understand the impact of demographic growth on health services
fully, it is important to understand the age profile of patients accessing a particular service.
By examining this, it is possible to gain an understanding of the demographic pressure on
the service – as opposed to just the demographic growth of the population.
3.4 North London Partners in Health and Care: working together for
better health and care (NCL STP)
North London Partners in Health and Care is a partnership of health and care organisations
from the five London boroughs of Barnet, Camden, Enfield, Haringey and Islington, working
together to improve the health of local people through the sustainability and transformation
partnership (STP).
The partnership includes:
Barnet, Camden, Enfield, Haringey and Islington CCGs
Barnet, Camden, Enfield, Haringey and Islington councils
Barnet, Enfield and Haringey Mental Health NHS Trust
Barnet Federated GPs CIC
Camden and Islington NHS Foundation Trust
Camden Health Evolution, known as CHE GP Federation
Central and North West London NHS Foundation Trust
Central London Community Healthcare NHS Trust
Enfield GP Federation
Federated4Health (The Pan Haringey GP Federation)
Great Ormond Street Hospital NHS Foundation Trust
Haverstock Healthcare, Federation of Camden GP practices
Islington GP Federation
Moorfields Eye Hospital NHS Foundation Trust
North Middlesex University Hospital NHS Foundation Trust
The Royal Free London NHS Foundation Trust
The Royal National Orthopaedic Hospital NHS Trust
The Tavistock and Portman NHS Foundation Trust
University College London Hospitals NHS Foundation Trust
Whittington Health NHS Trust.
Planned care is a core component of the NCL STP plan, published in 2017. The planned
care workstream focuses on reducing variation, improving patient outcomes and experience
through the development of consistent safe and effective patient pathways. The adult
elective orthopaedic programme sits within the planned care workstream, on improving
planned surgical orthopaedic care.
26
Across north central London, work has been progressing with partners to develop new ways
of working with the aim of having the greatest positive impact for the health and lives of north
central London residents.
To simplify the system, have greater impact and deliver better services, collective plans are
in development to introduce an integrated care system (ICS). This would move to health and
social care planning services together to meet the needs local populations and individuals
rather than acting as individual organisations. A north central London ICS would be
supported by one north central London CCG in place of the existing five CCGs, which would
work together to reduce health inequalities through borough-based integration of services,
increasing the focus on residents, communities and prevention.
This ambition is closely aligned with the NHS Long Term Plan. In developing a response to
the LTP, the NCL system is refreshing its own plans in areas which need strengthening or
additional focus. The adult elective orthopaedic programme remains a priority as part of the
NCL response to the LTP, and many of the other ambitions and clinical priorities set out in its
response are already being progressed or are a logical next step for its current partnership
programmes of work, for example:
Integrated networks based around 30,000 to 50,000 population through the NCL
Health and Care Closer to Home programme.
Simplification of urgent and emergency care system across NCL
Proposed radical transformation of planned care and outpatients
A strong focus on workforce and digital as drivers for, and enablers of, change.
Specifically, initial scoping has begun to identify how the adult elective orthopaedic review
could align to other existing programmes that are already working to improve digital
capability across the system. This includes working in collaboration with the NCL digital
strategy, the Once for London project and the NCL diagnostics programme. Through the
NCL Orthopaedic Clinical Network, additional work would take place to define data sets and
agree clinical information sharing protocols. Some aspect of digital enhancement would be
taken forward by the individual trusts, based on existing local systems and digital
capabilities.
The NCL health system has an underlying deficit of £200m a year and work is underway to
develop a medium-term financial plan. This would outline the work needed to support the
financial sustainability of the health service and include a plan across several years to
reduce and remove costs through a set of collective actions across all partners.
3.5 Current delivery of planned (elective) orthopaedic services
NHS-funded adult elective orthopaedic surgery in north central London is delivered at 10
NHS and private sector sites:
North Middlesex University Hospital NHS Trust
Royal Free London NHS Foundation Trust London (Royal Free Hospital)
Royal Free London NHS Foundation Trust London (Chase Farm Hospital)
Royal National Orthopaedic Hospital NHS Trust (Stanmore site)
University College London Hospitals NHS Foundation Trust (University College
London Hospital)
University College London Hospitals NHS Foundation Trust (National Hospital for
Neurology and Neurosurgery)
Whittington Health NHS Trust
27
The Cavell Hospital (BMI Healthcare)
Highgate Private Hospital (Aspen)
The Kings Oak Hospital (BMI Healthcare).
Figure 2: Location of current NHS-funded elective orthopaedic surgery sites in NCL
3.6 Proposal development
There has been continued development of the proposed changes since the programme was
formally initiated in February 2018. This has included work on pre-consultation activities,
stakeholder engagement and options development, as well as scoping work before the
formal initiation of the programme. Further detail of the options development is set out in
section 8 – Options appraisal process.
The NCL adult elective orthopaedic services review was established in 2018 to look at the
opportunities and potential options. This review process was split into seven phases:
1. Set up and planning for the review (February to July 2018)
2. Early public and stakeholder engagement (summer and autumn 2018)
3. Engagement and co-design with orthopaedic service providers on the clinical model
(summer and autumn 2018)
4. Reflection on inputs from the engagement phase and finalising proposed service
model (October 2018 to May 2019)
5. Call for submissions of options and options appraisal process (May to July 2019)
6. Development of a pre-consultation business case (April to November 2019)
7. NHS Assurance process (September to November 2019).
Throughout these phases, patients, residents, staff, clinicians and local stakeholders have
been involved and engaged on the proposals, helping to shape them.
This document sets out in detail the development of this proposal and how a preferred option
has been developed.
28
This section sets out our refreshed case for change. The original NCL draft case for
change,12 published in August 2018, set out the rationale and evidence for changing the way
planned adult orthopaedic services could be delivered in the future in the best interests of
patients.
The refreshed clinical case for change builds on national, regional and local evidence
supporting the need for change, and validates the proposition that by separating elective
orthopaedic and trauma services and by providing elective intervention from a smaller
number of specialist centres, major benefits could be delivered for NCL residents.
Improving adult elective orthopaedic services is a complex and challenging task. Local
challenges, together with national and international evidence, provide a unique opportunity to
create innovative, sustainable services that deliver the best possible elective orthopaedic
care, experience and outcomes for patients.13 The refreshed clinical case for change
focuses on two key themes:
The national impetus for change
The north central London context.
4.1. National and international impetus for change
A number of national and international best practice policy and evaluation documents have
been published that provide supporting evidence that care quality and efficiency benefits are
optimised by consolidating and ring-fencing high volume surgical and orthopaedic elective
care and co-locating them with appropriate clinical support services and infrastructure.14
Table 6: Policy and documentary evidence supporting change
Policy/best practice
document
Evidence supporting change
A national review of adult elective orthopaedic services in England Getting It Right First Time
(GIRFT 2015).
Higher volumes of surgical activity lead to better patient
outcomes.
Clinical advantages of dedicated beds are well
documented and include reduced infection rates, shorter
length of stay and fewer cancellations.
GIRFT is piloting separating
trauma and planned surgery
and ring-fencing
orthopaedic services in
eight national sites.
United Lincolnshire Hospitals NHS Trust (April 2018 to December 2018)
Reduced length of stay from 3.6 to 2.5 days
Reduced cancellation rates (decrease from 32% to 3%)
Reduced infection rates
Reduced waiting times
12 North London Partners in Health and Care Case for Change: Adult elective orthopaedic services - draft for feedback.
http://www.northlondonpartners.org.uk/ourplan/Areas-of-work/Ortho-service-review/ 13 A National Review of Adult Elective Orthopaedic Services in England (2015) http://gettingitrightfirsttime.co.uk/surgical-specialty/orthopaedic-surgery/ 14 Briggs Tim, Hurd Rob (2017) Review of Elective Orthopaedics in North Central London – opportunities for improving quality,
productivity and efficiencies.
4 Case for change
29
Policy/best practice
document
Evidence supporting change
Increased capacity of emergency beds making A&E more efficient.
Gloucester Hospitals NHS Trust
(six-month trial to May 2018)
Increase in the volume of elective activity (14%)
Reduction in the number of patients cancelled in the week prior and on the day (50%)
Trauma cancellations down from an average of eight per week to three per week
Length of stay reductions for all hip replacement (5.2 to 4.49 days) and all knee replacements (4.7 to 4.4 days)
Number of A&E breaches attributable to trauma and orthopaedics down from average of eight per week to one per week.
East Kent Hospitals University NHS Foundation
Trust.
(Comparison November to March 2017/18 and
November to March 2018/19)
Increase in productivity (30%)
Royal Cornwall Hospitals NHS Trust (April 2018 to April 2019)
Increase in activity (37%)
Reduction in backlog (19%)
Reduction in 52 week waits to zero
Separating emergency and surgical care: recommendations for practice
Royal College of Surgeons (2007)
Separating elective care from emergency pressures through the use of dedicated beds, theatres and staff can, if well planned, resourced and managed, reduce cancellations, achieve more predictable workflow, provide excellent training opportunities, increase senior supervision of complex/emergency cases, and therefore improve the quality of care delivered to patients.
Hospital-acquired infections could be reduced by providing protected elective wards and avoiding admissions from the emergency department and transfers from within/outside the hospital.
Reconfiguration of clinical services: what is the evidence?
The King’s Fund (2014)
Separating elective surgical workload could improve efficiency and avoid cancellations However, the efficiency gains could be affected by patient case-mix and demand.
30
Policy/best practice
document
Evidence supporting change
Separation may improve the quality of care due to the more predictable workflow and increased senior supervision of complex cases.
Patients could be willing to choose a more distant provider to receive higher-quality or faster care.
International Society of
Orthopaedic Centers
The International Society of Orthopaedic Centers (ISOC) facilitates the exchange of ideas and best practices among the premier specialty orthopaedic institutions in the world and collaborates on patient care, education, and research-based programs to advance improvements in orthopaedic care on a global scale.
The organisation defines a centre of orthopaedic excellence as:
A dedicated orthopaedic specialty hospital or a
large department within a hospital
Performs more than 5,000 orthopaedic procedures
each year
Has an orthopaedic staff of more than 20 surgeons
who collectively publish more than five annual
articles in peer-reviewed publications
Conducts and exhibit a commitment to basic and
clinical research, and
Functions as or within an academic centre (i.e.
there must be orthopaedic residents or fellows in
training).
Examining new options and opportunities for providers of NHS care.
The Dalton Review (2014)
Alternative organisational models help drive improvements in the quality of NHS services the report highlights the importance of execution in turning potential gains into real benefit.
There are several joint ventures in place in the NHS with this type of reconfiguration primarily implemented where critical mass enables the effective delivery of clinical standards or performance targets, such as in elective orthopaedics.
South West London Elective Orthopaedic Centre is highlighted as a model of good practice. Some of the outstanding features of the elective orthopaedic centre have been enabled by its status as a joint venture, which, crucially, has separated the activity of the centre from that of its member trusts, allowing them to plan care strategically and without disruption from other services. Major benefits of this separation have been the ability to standardise patient care pathways, pool clinical excellence and make sizeable savings on procurement.
31
Policy/best practice
document
Evidence supporting change
NHS Long Term Plan NHS England (2019)
Separating urgent care from planned services could make it easier for hospital trusts to run efficient surgical services. Ring fenced capacity from cold (elective) sites reduce the risk of operations being postponed. Complex urgent care delivered from hot (emergency) sites improve trauma assessment, access to specialist care and ensure patients get the right expertise at the right time.
4.2. The north central London context: Why we need to change
More than 1.5 million people live in north central London and this is expected to rise.
Increasing numbers of people have one or more long-term conditions, and lifestyle risk
factors are growing as are patient expectations resulting in increasing demand for
healthcare.
Demand for planned orthopaedics is predicted to increase due to increasing incidence of
age-related conditions affecting joints and bones (particularly hips and knees), the impact of
lifestyle factors including obesity, and more people having falls.
Improving planned adult orthopaedic services is a complex task. Local challenges, together
with national and international evidence and national policy, provide a unique opportunity to
create innovative, sustainable services that deliver the best possible elective orthopaedic
experience and outcomes for patients.15
We currently deliver planned adult orthopaedic services for NHS patients from 10 separate
NHS and private sector sites in north central London. While many of these services are of
good quality, we know there is unwarranted variation in the quality of care we are able to
offer.
We know that:
Waiting lists are too long
Cancellations are common and emergency care is prioritised over planned care
More patients would need orthopaedic care in the future.
We also know from our review of evidence that consolidating services onto fewer sites
improves quality outcomes.
Evidence shows us that:
Care is improved when emergency and planned care are separated
More operations in one place results in better outcomes for patients
Separating planned and emergency care leads to lower infection rates.
While there are many areas of good practice in elective orthopaedic care in NCL, the current
system does not fully realise opportunities to deliver the best possible care for patients.
15 A National Review of Adult Elective Orthopaedic Services in England (2015) http://gettingitrightfirsttime.co.uk/surgical-specialty/orthopaedic-surgery/
32
Evidence from the UK and around the world shows that doing surgery in operating theatres
which only do orthopaedics, means better quality of care for patients. We believe that by
organising services in this way, we would be able to improve care and help more patients
before, during and after their operation.
The proposed changes could affect anyone living in the five NCL five boroughs (and a small
number in neighbouring areas) who needs orthopaedic surgery in the future.
4.3. Providing sustainable services that are fit for the future
4.3.1. Addressing rising demand for services
Nationally, demand for orthopaedic services is rapidly rising with referrals increasing above
the rate expected from demographic change alone.16 An ageing population, the impact of
obesity on joint and bone health, and the positive impact on quality of life provided by
surgery, have all been identified as key drivers in demand.17
Despite redesign of MSK pathways in primary care (see section 4.3.2) to support self-
management and alternative evidence-based interventions, demand for planned adult
orthopaedic services is predicted to grow in the next 10 years, with underlying demand
forecast to increase by an average of 1.5% per year in north central London. This equates to
an additional 2,149 procedures between 2017 and 2029, a rise of 17.5%.18
Changes being introduced to the MSK pathway are expected to reduce demand by around
1,000 procedures over the next five years.
The net increase in activity is therefore forecast to be 1,148 procedures (9.5%). Figure 3
demonstrates the scale and pace of demand for elective orthopaedic procedures across
NCL.
Figure 3: Predicted demand for NCL planned adult orthopaedic services 2017 to 202619
16 GIRFT (2015) - A national review of adult elective orthopaedic services in England 17 American Academy of Orthopaedic Surgeons (2015) Position Statement: Impact of Obesity on Bone and Joint Health 18 Modelling carried out by the NCL Orthopaedic Review April 2019 19 These are estimated figures used purely to demonstrate the possible trajectory of change.
33
4.3.2. NCL musculoskeletal improvement plans
The proposals in this PCBC are focused on changes in configuration of planned adult
orthopaedic services in NCL. It is recognised that these sit within the context of other work to
improve MSK pathways in the area, and that the proposed changes in planned adult
orthopaedic care would complement other improvement plans described in this section.
Pathways in and out of orthopaedic surgical services are often fragmented and difficult for
patients to navigate. The traditional route into elective orthopaedic care is through
musculoskeletal (MSK) services20. Historically across NCL there has been a piecemeal
approach to the commissioning and design of MSK services with each CCG having variable
access and service provision.
To address this, and in line with the recommendations from NHS England’s elective care
transformation programme,21 many of the CCGs and providers in north central London have
developed MSK improvement plans to achieve more consistent access and better quality
care. The plans consist of a number of strategic and locally-led programmes that aim to:
Support development of end-to-end pathways that ensure patients receive timely
access to the right treatment at the right time
Develop services in the best interests of patients that improve patient experience and
outcomes
Work towards the implementation of system-wide models of care that reduce
unwarranted variation.
Key to these improvement plans would be the opportunity to learn and scale-up pockets of
innovative practice from north central London. The London Clinical Senate review panel
recognise that further development of the pathway is needed, which “includes clarity
regarding triage; admission; High Dependency Unit beds; and rehabilitation as well as
consideration to the role of care navigators/ co-ordinators throughout the system”. These are
being addressed through the MSK improvement plans across NCL.
MSK improvement plans are delivered across three system levels (as set out in in figure 4):
System-wide across NCL
Multi-borough across multiple locations
Locally initiatives that are borough-based.
20 Musculoskeletal conditions’ is a broad term, encompassing around 200 different conditions affecting the muscles, joints and
skeleton. Around 10 million adults, and around 12,000 children, have a musculoskeletal condition in England today. 21 NHS England Transforming Musculoskeletal and Elective Orthopaedic Services: A handbook for local health and care
systems
34
Figure 4: NCL MSK improvement structure
System-wide across NCL
Orthopaedic clinical network
The development of the NCL adult elective orthopaedic services review has created a
culture of collaboration to link different aspects of the orthopaedic quality improvement
programme together under a single clinical orthopaedic network, the Partnership for
Orthopaedic Excellence: North London. The network aims to facilitate integration and drive
consistent, high quality care across NCL. The scope and remit of the network is set out in
section 5.2.
Transformation of outpatient services
In line with the ambition set out in the NHS LTP, NCL is responding to the challenge of
reducing face-to-face outpatient appointments by 30%.
The overarching aim of the NCL outpatient transformation programme is to ensure patients
have a better experience of care, access to more flexible and convenient advice and
treatment and more opportunity to take greater control of their health.
To support the programme, provider services were tasked to develop innovative solutions to
trial in 2019/20 and onwards. Initial proposals included strategies to reduce inappropriate
first and follow-up appointments for orthopaedic services. The programme is at a very early
stage, and further work would be undertaken to develop the plans further.
NCL specialist pain network
The specialist pain network is a multidisciplinary collaborative network established in 2014
by the pain management departments at the Royal National Orthopaedic Hospital NHS Trust
and the Royal Free London NHS Foundation Trust.
Over time, the network has evolved and expanded and now also includes University College
London Hospital NHS Foundation Trust, Whittington Health NHS Trust and North Middlesex
35
University NHS Foundation Trust. All trusts have signed up to overarching principles that aim
to improve patient experience and care quality.
The network aims to:
Standardise patient pathways across NCL
Develop sector-wide clinical recommendations and standards
Create a multidisciplinary forum for sharing collective knowledge, experience and
best practice
Provide an opportunity for professional education and development
Collaborate on workforce planning, workforce projections
Identify and review of opportunities for service development and service expansion.
The network meets every six months biannually with mechanisms in place to share
information and support the development of common working practices between meetings.
The network has successfully:
Streamlined triage processes to ensure patients receive the right treatment at the
right time
Introduced mechanisms to ensure patients could access the right clinical expertise as
rapidly as possible
Created an NCL-wide quality improvement structure for pain management.
Multi-borough across multiple locations
Single point of access for MSK services
Camden MSK Service
Established in 2017, the Camden MSK service integrates a full range of MSK services,
including assessment, diagnosis, treatment, advice, education and care planning. The
service is led by University College London Hospital NHS Foundation Trust, in
partnership with the Royal Free London NHS Foundation Trust, Connect Health,
Camden’s GP federations (Haverstock Healthcare and CHE) and Central and North
West London NHS Foundation Trust and InHealth Diagnostics.
The service provides access to community and acute MSK services and diagnostics. All
referrals are triaged by advanced practitioner physiotherapists (APP) who are
specialist MSK clinicians via a single point of access (SPA). Services accessed through
the SPA and triage system include MSK physiotherapy, MSK podiatry, the specialist
Clinical Assessment and Treatment Service (CATS), community diagnostics, as well as
acute care, rheumatology, orthopaedics, pain and diagnostics.
The 2018/19 service report highlights between April 2018 and July 2019:
o Camden MSK processed almost 32,000 referrals via the SPA
o Almost 13,000 referrals received a specialist clinical triage
o Waiting times for CATS appointments reduced by nine weeks, decreasing
from 11 to two weeks
o Waiting times for the Camden pain service decreased by seven weeks falling
from 12 to five weeks
o Waiting times for specialist consultant pain management review fell by five
weeks, down from 23 to 18 weeks
o Did not attend (DNA) rates for Camden pain team decreased by 6% to 13%
o DNA rates in CATS decreased by 5%, from 11% to 7%.
36
Haringey and Islington single point of access
In January 2018, a pilot MSK SPA started in Haringey and Islington. The programme
was led by Whittington Health MSK services and was developed in partnership with
Haringey and Islington CCGs.
Referrals are triaged by advanced practice physiotherapists and patients are directed
into MSK physiotherapy, MSK podiatry services or the specialist MSK CATS (delivered
by MSK APPs). The referrals are also triaged directly into hospital-based pain clinics,
trauma and orthopaedics (not including fracture clinic) or rheumatology clinics at the
hospital of patient’s choice as appropriate.
The project aims to reduce inappropriate referrals to secondary care for trauma and
orthopaedic, rheumatology and pain management services and ensure patients are seen
in the right place first time. Initial audit data suggested this redirection might equate to
20% of patients. Evaluation of the 11-month pilot demonstrated a third of referrals (34%)
were diverted to more appropriate community, primary care support services or self-
management with fewer than 9% of those patients requiring onward referral to hospital-
based services at the one-year follow-up point. The programme was fully implemented
across both boroughs in July 2019 and evaluation is ongoing.
Borough-based local initiatives
First Contact Practitioner programme
Work has begun to improve early access to MSK services through the implementation of
the national early intervention MSK First Contact Practitioner (FCP) programme.
The programme aims to improve early access to MSK intervention and advice. This is
achieved by enabling patients to self-refer to local physiotherapy services based in GP
practices.
National data suggests FCPs22 can:
Improve access to MSK care
Provide longer more in-depth appointments
Reduce waiting times
Reduce referrals to other NHS departments
Provide higher quality care
Reduce inappropriate prescribing
Upskill GPs in MSK conditions
Result in cost-savings.
In 2018/19, through the NCL STP planned care workstream, two six-month pilots were
set up through national NHSE funding streams in Barnet and Enfield GP practices.
Provisional data showed:
67% of patients were seen only once by MSK services
There was a 1.6% reduction on referrals to secondary care compared to the
previous year
There was a 6% decrease in investigations
Telephone review at six months indicated continued behavioural change and a
reduction in the need for medication
22 NHS England/Improvement, Elective Care High Impact Interventions: First Contact Practitioner for MSK services
37
Patients had a positive experience with 96% likely to recommend the service to
friends and family.
Following the pilots, four FCP posts have been substantively funded in Enfield. These posts
would form the building blocks to the longer-term aim of establishing FCPs in all localities,
developing a single point of access and creating a self-referral online/telephone triage
service for physiotherapy. NCL would develop learnings and best practice models from
these pilots, with a view to ensuring the learning is applied consistently throughout NCL.
The FCP programme is due to be expanded across NCL from April 2020 through the
evolving national Primary Care Networks (PCNs) programme. PCNs would facilitate the
provision of proactive, personalised, co-ordinated and integrated health and social care
through better access to a wider range of health professionals, including FCPs, in primary
care. Additional funding would support implementation with 70% of the cost of FCP posts
provided by NHSE in 2020/21.
Pain management
Following recognition that patients with persistent pain frequently experienced difficulty
accessing services, frequently waiting up to four months for assessment, Enfield CCG, in
partnership with Barnet, Enfield and Haringey NHS Mental Health Trust, has commissioned
a new community chronic pain service.
Begun in May 2019, the services build on the existing community physiotherapy service,
utilising the already established single point of access. A range of patients would be able to
access the services, a high proportion of which would be MSK patients. A multidisciplinary
approach to management includes medical consultants trained in chronic or acute pain
medicine, nurses, physiotherapists and psychologists.
Patients are offered options including one-to-one treatment, consultant review, joint
physiotherapy and psychology sessions, supported self-management intervention including
signposting patients to self-help resources and support groups.
Initial data from August 2019 indicates more than double the number of anticipated referrals
were received. Only 2% of referrals accepted were referred on to secondary care with 98%
of patients managed within the pain management service.
Discharge to Assess programme
The national Discharge to Assess (D2A) programme is a collaboration between health and
social care which seeks to ensure patients who are medically fit for discharge could access
timely and appropriate needs-based social support and community care.
It has four distinct pathways, with implementation locally-led and with flexibility to focus on
different clinical areas. In September 2019, a 12-month pilot was launched to include non-
weight bearing orthopaedic patients in Barnet’s D2A pathways. The learning from this
initiative would be shared across NCL and would enable the D2A team during
implementation to build a seamless pathway for elective orthopaedic patients.
38
4.4. Delivering adult elective orthopaedic services that meet the diverse
needs of the NCL population.
To ensure North London Partners in Health and Care has fully considered the potential
impacts on the nine characteristics protected under the Equality Act 201023, a three-stage
assessment process to develop an integrated health inequalities and equality impact
assessment (HIEIA) to support decision making is under way. This process would ensure
that any decisions made would advance equality and ensure fairness by removing barriers,
engaging patients and community – and deliver high quality care.
Stage 1 (complete) – A rapid scoping report which identified potentially impacted
groups and informed pre-engagement activities in summer/autumn 2018. The
findings from this assessment have been made publicly available24
Stage 2 (to be delivered before consultation begins) – Looking explicitly at the
impact of the proposed model of care and proposed sites, this integrated health
inequalities and equality impact assessment uses the stage 1 report as a building
block, rather than repeating the existing analysis
Stage 3 (to be delivered post-consultation) – A revised and final integrated HIEIA,
updated to reflect the results of the public consultation.
The objectives of the stage 1 assessment were to:
Identify which (if any) of the protected characteristics groups could be affected by the
proposals due to their propensity to require different types of health services
Set out how the core constituent public sector health organisations are fulfilling their
Public Sector Equality Duty (PSED)
Provide recommendations on ways in which positive impacts could be maximised
and ways in which to mitigate or minimise any adverse effects.
In developing the stage 1 assessment, data from other programmes looking at elective
orthopaedic services in other parts of the country were evaluated as part of the assessment.
Data reviewed included:
Strategic Health Asset Planning and Evaluation (SHAPE)
Local joint strategic needs assessments
London Observatory data
Local insight work
London Data
EDS2 documents across each CCG (where available)
Equality impact assessments from Our Healthier South East London which draw on
relevant national research from NHS England and the British Orthopaedic
Association.
The stage 1 assessment enabled the programme to:
Identify positive and negative impacts for the population to underpin service
reconfiguration
Identify which protected characteristic groups could be affected by the proposals due
to their propensity to require different types of health services
Develop strategies to maximise the positive impact and mitigate or minimise any
adverse effects.
23Equality Act (2010) http://www.legislation.gov.uk/ukpga/2010/15/pdfs/ukpga_20100015_en.pdf 24 Verve Communications: Initial equalities assessment: desk top analysis (2018)
39
A number of groups were identified as being at increased risk of needing planned
orthopaedic services, and therefore would be included in any potential future engagement or
consultation. The characteristics most affected include:
Age: those who are over 65 years-old
Disability: people with learning disabilities
Gender: women
Gender reassignment: people who have undergone gender reassignment
Ethnicity and race: those from the Caucasian population and black and minority ethnic
backgrounds
Socio-economic status: deprivation.
The report:
Examined the demand for elective orthopaedics services by each protected
characteristic group and identify groups for engagement throughout the review
process
Identified existing health inequalities, access barriers and equality issues to be
considered
Identified groups who share one or more protected characteristics and might have a
higher need for orthopaedic services and may be impacted more by a change in the
delivery of service
Provided recommendations about key groups that may be targeted if there is a need
for consultation
Provided advice on equalities questions for inclusion for any potential public
consultation.
The assessment recommended the following areas of focus that might highlight variation in
access, quality and outcomes relevant to equalities during a consultation process:
Location of rehabilitation services
Liaison between community care services and planned care centres
How planned care centres could meet the requirements of people with specific
complex needs
The location and access of services
The design of services monitoring and feedback.
The social demographic analysis demonstrates the difference in population groups across
the five boroughs represented by the NLP. For example, Barnet and Enfield have a higher
population density of older people and carers, while Camden and Islington have a higher
population density of people with long-term disability or who suffer deprivation.
The assessment also recommended focusing consultation activities on certain groups in
specific areas according to the trends identified in the report. The full report can be found in
appendix C.
In developing the clinical delivery model, features were introduced or enhanced to take into
consideration the needs of particular groups which had been identified through the
assessment and pre-consultation activities.
40
4.4.1. Age
A major driver of demand for elective orthopaedic services is advancing age. Across NCL,
the number of people aged 65 and over is projected to increase by 34.5% by 2030, three
times greater than other age groups25. This would significantly impact on the need for
planned adult orthopaedic services in the future.
11 per cent (179,435) of the NCL population is over 65 years of age, an increase of
32% since 2010.
Barnet has the highest proportion of residents aged over 75; almost three times as
many as Islington which had the lowest proportion of older people.26
Those aged 85 and over equate to 1.5% (23,940) of the total NCL population and
has grown by 28% since 2010.27 This is significantly less than the English average of
15% and 2% of the population respectively.
4.4.2. Disability
People with learning disabilities have an increased prevalence of osteoporosis and lower
bone density than the general population. Contributory factors include lack of weight-bearing
exercise, delayed puberty, entering menopause at an earlier-than-average age for women,
malnutrition, obesity and use of anti-epilepsy medication28. The prevalence of people with
learning disabilities in NCL is 0.36%, slightly lower than the English average of 0.48%.
The proposed delivery model includes a number of mechanisms to support patients with
vulnerabilities, including early care planning, the ability of carers and relatives to stay
throughout the admission, care co-ordinators to help people with learning difficulties navigate
the system, and organising joined-up care that meets individual needs.
4.4.3. Gender
Nearly half the NCL population is female (49%). Women are at higher risk of requiring
orthopaedic services due to living longer and the subsequent risk of osteoporosis, hormonal
changes related to menopause, incidence of specific conditions such as Lupus, and
exposure to specific medications such as those prescribed to treat breast cancer29.
Older women are likely to be a key user of planned orthopaedic services and a high
proportion could be impacted by any proposed changes to services. Significant engagement
with this patient population has identified challenges, including increased travel times and
coordination of care. These are being addressed in the evolving delivery model and options
appraisal.
4.4.4. Gender reassignment
Information on the number of people undergoing gender reassignment is limited. There is
evidence that people who have undergone gender reassignment treatment have a
disproportionate need for orthopaedic services due to hormone treatment which can affect
bone density.30 As any proposed new services emerge, there would be local links to
25 Verve Communications: Initial equalities assessment: desk top analysis (2018) 26 Verve Communications: Initial equalities assessment: desk top analysis (2018) 27 Public Health Profiles 28 Emerson, E. et al. (2012): Health inequalities & people with learning disabilities in the UK 29 What Breast Cancer Survivors Need To Know About Osteoporosis National Institutes of Health Osteoporosis and Related
Bone Diseases National Resource Center (2018) 30 Verve Communications: Initial equalities assessment: desk top analysis (2018)
41
specialist organisations to help raise awareness and facilitate access to early support and
self-help.
4.4.5. Ethnicity and race
NCL has a diverse population with a black and minority ethnic (BAME) population of 36%
and a Caucasian population of 64%. This is significantly different from the average of 13%
and 87% respectively in England.
The number of BAME people across NCL is expected to increase slightly from 37% in 2012
to 38% in 2020, with the biggest increases forecast for Barnet and Enfield. Additionally, the
fastest growing ethnic communities across NCL are the Chinese and Other group followed
by Black Other and Asian groups. Overall, around a quarter of people in NCL do not speak
English as their main language.
Levels of ethnic diversity vary across NCL boroughs, ranging from 32% of people in Islington
from a BAME group to 42% in Enfield. The largest such communities in NCL are Turkish,
Irish, Polish and Asian (Indian and Bangladeshi). There are also high numbers of people
from Black Caribbean and African communities, especially in Enfield and Haringey. The
number of people from BAME communities is much greater in younger age groups.
Health needs across different communities are variable, for example those of Caucasian
origin are at higher risk of osteoporosis due to bone density,31 while there is a greater risk of
diabetes, stroke or renal disease for some BAME people compared to White English people.
Additionally, people from some communities, including Black Caribbean, African and Irish,
use more hospital services, and people of BAME backgrounds are more likely to undergo
surgery when disease is more advanced, indicating potential issues over access to services.
However, it should also be noted the proportion of the Black and African population
undergoing orthopaedic surgery is less than anticipated. Although this is partially explained
by risk, further examination is required to identify any specific factors that would improve
access to services.
All of which presents challenges, both in addressing potentially new and complex health
needs and delivering accessible healthcare services. Designing services that ensure all
patients could access the right treatment at the right time is paramount to improving access,
outcome and experience of the entire NCL population.
4.4.6. Socio-economic status
Deprivation is associated with greater need of elective orthopaedic surgery.32 People from
lower socio-economic backgrounds tend to have more severe disease, have suffered with
arthritis for longer by the time they undergo surgery, and are more likely to stay in hospital
for longer.33 The prevalence, among people who suffer from deprivation, of malnutrition,
obesity and pre-existing health conditions such as diabetes, have all been cited as risk
factors.34
The prevalence of deprivation across NCL is varied35. With the exception of Barnet, all
boroughs have index of multiple deprivation scores significantly above the average for
England. Developing mechanisms to address the complex and multiple needs of this
31 Verve Communications: Initial equalities assessment: desk top analysis (2018) 32 Hollowell et al 2010: Major elective joint replacement surgery: socioeconomic variations in surgical risk, postoperative morbidity and length of stay, Journal of Evaluation in Clinical Practice. 33 Arthritis Research UK 2012: Socio-demographic factors influence timing of joint replacement surgery 34 Public Health England (2014): Adult obesity and type 2 diabetes 35 Source: IMD 2015 by LSOA, ONS release
42
vulnerable group is key to improving access to services and delivering joined-up care.
Including care co-ordinators in the delivery model would help patients with vulnerabilities to
access the most appropriate health and social care intervention, improving experience and
outcomes.
Table 7: Deprivation index scores36 37
England Barnet Camden Enfield Haringey Islington
Deprivation Score
21.8 17.8 25 27 31 32.5
Using the indices of multiple deprivation, the following map highlights areas of high levels of
multiple deprivation with Islington and Haringey experiencing the most. Deprivation impacts
life expectancy, for example, in areas of higher deprivation in Enfield, men live 8.7 years
less, and women live 8.6 years less than in more affluent areas.
Figure 5: Areas of deprivation in NCL
36 Deprivation indices are a measure of the level of deprivation in an area 37 Public Health Profiles
43
4.4.7. Addressing associated risk factors
Parity of esteem for mental health conditions
Poor mental health and other psychiatric disorders are associated with poorer outcomes
following elective orthopaedic surgery, as well as negative effects on mortality, morbidity and
patient satisfaction.38
The prevalence of poor mental health is varied across NCL. The incidence of severe mental
health conditions, and the number of people with anxiety and depression accessing social
care, is significantly higher across all five NCL boroughs that the England average. The rate
of long-term mental health conditions and anxiety and depression is higher in Camden and
Islington that national prevalence rates.
Care co-ordinator posts are part of the proposed delivery model and would play a pivotal role
in ensuring individuals with complex mental health needs have access to appropriate health
and social care support. The proposed elective centres would have protocols for inpatients
and would provide additional specialist mental health support for patients undergoing
surgery.
Table 8: Incidence of mental health39
England Barnet Camden Enfield Haringey Islington
Incidence of severe mental health
0.94 1.05 1.46 1.1 1.34 1.53
Rates of depression and anxiety
13.7 11.9 15.2 11 13.4 18.8
Incidence of individuals with anxiety and depression using social care
54.4 57.2 59.1 56.6 55.3 58.3
Prevalence of long-term mental health conditions
5.7 4.4 6 4.2 5.5 7.1
Incidence of dementia in individuals over 65
4.33
4.99 5.37 5.22 4.02 4.82
Weight management
Being overweight or obese is increasingly prevalent amongst patients with orthopaedic
conditions. Obesity has been shown to contribute to soft tissue damage, with its impact
especially related to osteoarthritis of the hip and knee joints.40 Individuals with obesity are 20
times more likely to need a knee replacement than those who are not overweight. Obesity
also has an adverse impact on surgical outcome results and complication rates including
higher rates of infection and prosthesis.
38 Mental health is a consideration in patients undergoing planned orthopaedic surgery 2019 Orthopaedics Today 39 Public Health Profiles 40 American Academy of Orthopaedic Surgeons (2015) Position Statement: Impact of Obesity on Bone and Joint Health
44
In NCL 52% of the population are overweight or obese. Rates vary across NCL but were
predominately lower than the national average with the exception of Barnet. World Health
Organisation modelling based on current trends, predicts UK rates would increase to 69% of
the population by 2030 putting additional strain on health care resources.41
The national drive to embed first contact practitioners in primary health care networks would
facilitate early advice and self-management including signposting to appropriate support
services such as weight management services and dietetics.
Table 9: Prevalence – overweight and obesity in NCL42
England Barnet Camden Enfield Haringey Islington
Percentage of population who are overweight and obese
61% 61% 53% 61% 50% 53%
Smoking and orthopaedic conditions
Smoking has been associated with decreased bone mass at the hip, lumbar spine,
calcaneus and forearm and a 43% increased risk of developing osteoporosis.43 44 Smoking is
also associated with poorer outcomes after surgery including poor wound healing, infection
and less satisfactory final outcomes.45 The percentage of the NCL population who smoke is
higher or in line with the national average.
Increasing the utilisation of first contact practitioners in primary health care networks to
deliver pre-surgery education programmes would support signpost to smoking cessation
services.
Table 10: Smoking rates across NCL46
England Barnet Camden Enfield Haringey Islington
Percentage of population who smoke
14.9% 17.3% 16.4% 14.9% 15.6% 20.1%
Prevalence of musculoskeletal (MSK) conditions
The most common reason for joint replacement is osteoarthritis or rheumatoid arthritis.
Occurrence of MSK disorders as a whole in NCL is 25% less than the national average
(17%) equating to just under 13%. Incidence of osteoarthritis and rheumatoid arthritis are in
line with national prevalence data.
41 Breda J, et al. WHO projections in adults to 2030. Presented at: European Congress on Obesity; May 6-9, 2015; Prague. 42 Public Health Profiles. https://fingertips.phe.org.uk 43 Ward KD, Klesges RC. A meta-analysis of the effects of cigarette smoking on bone mineral density. Calcified Tissue International 2001; 68(5):259-270. 44 Costenbader KH, Feskanich D, Mandl LA, Karlson EW. Smoking intensity, duration, and cessation, and the risk of rheumatoid arthritis in women. American Journal of Medicine 2006; 119(6):503-509 45 Surgery and Smoking America Academy of Orthopaedic Surgeons 46 Public Health Profiles
45
The rollout of first contact practitioners in across primary health care networks would ensure
patients with MSK conditions could access early advice to support self-management and
reduce unnecessary surgical intervention.
Table 11: Prevalence of MSK disorders in NCL47
England Barnet Camden Enfield Haringey Islington
Prevalence of all MSK disorders
17% 13.2% 11.3% 14.5% 12.9% 11.3%
Prevalence of hip osteoarthritis
10.9% 10.3% 10.4% 10.6% 10.6% 10.1%
Incidence of knee osteoarthritis
17% 16.3% 16.3% 17.6% 17.1% 16.2%
Prevalence of rheumatoid arthritis
0.75% 0.49% 0.44% 0.56% 0.48% 0.49%
4.5. Transport and travel impact assessment
To ensure that the programme gives adequate consideration to transport and travel impact,
Mott MacDonald was commissioned to undertake a travel and access impact assessment.
The purpose of this assessment is to identify and assess impacts on travel and access for
the local community as a result of the option for change. This assessment focusses on the
travel and access impacts for patients, visitors, staff and local equality patient groups and
sits alongside the equality impact assessment.
The aim of the travel and access assessment is to explore the positive and negative
consequences of the change to the commissioning of elective orthopaedic services and
produce a set of evidence based, practical recommendations. These recommendations can
then be used by decision-makers to maximise the positive impacts and minimise any
negative impacts of the proposed change.
It is important to note that the principal purpose of this impact assessment is not to
determine the decision about proceeding with the change; rather to assist decision-makers
by giving them better information on how best they can promote and protect the wellbeing of
the local communities they serve.
A summary of the findings will be included in the consultation document with the full report
available on the consultation website.
4.6. Improving patient outcomes and experience
There is variation in a number of quality and performance indicators across north central
London. In some areas there is substantial deviation from national parameters. Our aim is
not to focus on variation between NCL organisations but to concentrate on the NCL picture
as a whole to support our rationale for change.
As the Royal National Orthopaedic Hospital NHS Trust provides super specialist intervention
and would not deliver the elective orthopaedic care within the scope of the review, its data
47 Public Health Profiles
46
has not been included in the information below. The data sets include data from North
Middlesex University NHS Trust, Royal Free Hospital NHS Foundation Trust, University
College London Hospital NHS Foundation Trust and Whittington Health NHS Trust.
4.6.1 Waiting times
The NHS Constitution48 sets out the principles and values of the NHS in England. It specifies
patients have the right to access certain services commissioned by NHS bodies within
maximum waiting times, or for the NHS to take all reasonable steps to offer a range of
suitable alternative providers if this is not possible.
For orthopaedic surgery, patients should wait no longer than 18 weeks from GP referral to
treatment. Referral to treatment (RTT) data is nationally monitored and reported monthly.
As of January 2019, over 10,500 NCL residents were waiting for planned orthopaedic
surgery. Between January 2018 and January 2019, the number of patients awaiting surgery
increased by 24% rising by over 2,200 patients (figure 6).
Figure 6: Patients waiting for elective orthopaedic surgery January 2018 to January 2019
On average between January 2018 and January 2019, 79% of NCL patients began
treatment within the target of 18 weeks, well below the national standard of 92%, as well as
the English (83%) and London averages (82%) for the same period. Figure 7 demonstrates
system-wide performance over 13 months.
Annual average performance varied considerably between trusts ranging from 71% and 94%
but dropping to as low as 65% in some organisations with pressures especially acute in the
winter months.49
48 NHS Constitution 49 Data from NCL Clinical Commissioning Groups
47
Figure 7: NCL waiting times January 2018 to January 2019 compared to English and London
performance
Between January 2018 and January 2019, the number of patients who waited more than 18
weeks to begin treatment rose by 74% from 1425 to 2477. In the same period, the number of
patients who waited over 52 weeks for surgery increased from two patients to 36 patients.
Figure 8: Patients waiting over 52 weeks for surgery between January 2018 and January
2019
4.6.2 Cancellations
Cancellation of surgery can cause distress for patients, relatives and carers. Operations are frequently cancelled at short notice, mainly due to emergency workload pressures taking priority. Some cancellations are unavoidable, such as late presentation of clinical issue resulting in patients not being fit for surgery.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19
Performance Performance Standard (92%) England London
2 35
8
3 4
1 2
11 12
1820
36
0
5
10
15
20
25
30
35
40
48
In 2018/19 across NCL there were 530 cancellations, equating to 10 cancellations a week,
over one per day. Data indicates 96% of procedures were cancelled on the day surgery was
planned.50
4.6.3 Length of stay
The benefits of reducing length of stay for patients are widely recognised. Reducing the risk
of acquiring hospital associated infections, preventing deconditioning, decreasing likelihood
of patient harm, and reducing functional decline have all been identified as the benefits of
timely patient discharge.51 For NHS organisations, there is the added value of improved
patient flows and reductions in unwarranted costs.52
Across NCL there is variation in a number of length of stay parameters with some
organisations performing better than the English average in a number of areas.27 Table 12
summarises length of stay. Data highlights:
Three NCL organisations exceeding expectations in terms of the proportion of day
cases undertaken as part of elective services compared to the English national
average
More patients than expected staying fewer than two days in two organisations
compared to the English average
Higher total length of stay than the English average in two out of four organisations
Higher number than expected of patients staying up to six days in one organisation
compared to the English average
Number of patients receiving surgery on the day of admission higher than the English
national average in three organisations.
Table 12: Length of stay following orthopaedic surgery
50 Data provided from each trust 51 Model Hospital data July 2019 52 NHS Improvement Guide to Reducing Long Hospitals Stays (2018)
Length of stay
parameter
North central
London Range National
Percentage of day
cases to elective
activity
68.5% 53% to 91% 58%
Average length of stay
(six-month rolling) 3.5 days 2.5 to 4.3 days 3.2 days
Elective admissions
with a length of stay
between one and two
days.
41% 20% to 59% 43%
Elective admissions
with a length of stay
fewer than six days.
12.5% 8% to 20% 8.2%
Length of stay greater
than six days 29% 13 to 39% 35%
49
4.6.4 Infection rates
Surgical site infection (SSI) is a type of healthcare-associated infection in which a surgical
incision site becomes infected after a surgical procedure. It is related to significant morbidity
and mortality if left untreated. Other surgery-related infections include postoperative
respiratory and urinary tract infections, infections secondary to wound sepsis, diarrhoea
related to antibiotics.
SSIs are monitored annually by Public Health England. The expectation is that less than 1%
for orthopaedic procedures would result in SSI.53 Infection rates vary across NCL, with one
organisation having an infection rate above 1% for hip replacement, knee replacement and
repair of fractured neck of femur. Infection rates ranged from 0 to 1.6%.54
4.6.5 Emergency readmissions following surgery
Readmissions to hospital within 30 days of an elective procedure is a marker of quality.
While average NCL readmission rates are above the national average for hip elective
surgery, there is variation between providers with some organisations achieving scores
below the national average.
Table 13: Emergency readmission following orthopaedic surgery55
4.6.6 Revisions
A small proportion of patients require emergency surgical revision following surgery.
Revision rates are a standard quality indicator. Data indicates:
Across NCL, revision rates in the first year after a procedure were marginally higher
than the national average for both hip and knee replacements.
Two trusts had higher rates than expected for knee replacements procedures.
53 NICE Quality Standards Surgical Site Infection (2013) https://www.nice.org.uk/guidance/qs49/chapter
/introduction 54 Public Health England Surveillance of surgical site infections April 2017 to March 2018 55 Model Hospital data July 2019
Length of stay greater
than 20 days
1% 0 to 1% 0.86%
Surgery on day of
admission
94.8% 87% to 98% 97.4%
Readmission
parameter
North central
London Range National
Emergency
readmission
secondary to hip
replacement
7.4% 3.5% to 12.2% 5.5%
Emergency
readmission
secondary to knee
replacement
2.5% 0% to 6.5% 6%
50
Three trusts had higher than average rates for hip replacements.
The inconsistency in revision rates across NCL, together with higher than average nationally
benchmarked outcomes, demonstrates quality of care could be improved.
Table 14: Revisions up to one year after orthopaedic surgery56
4.6.7 Patient reported outcome measures
Patient-reported outcome measures (PROMS) assess the quality of care provided from a
patient’s perspective. All patients undergoing NHS-funded hip or knee replacement are
asked to complete questionnaires before and after surgery to self-rate improvements in their
health improvements.57
The four patient reported measures used are:
EQ-5DTM index which combines five questions about health and quality of life
domains (usual activities, self-care, anxiety/depression, pain/discomfort, and mobility)
into an overarching measure of general self-reported health
EQ-VAS which is a single-item thermometer-style measure which asks patients to
rate their general health at the time of completion
The Oxford Hip Score and the Oxford Knee Score are closely related 12-item
questionnaires which combine questions about the patient’s specific condition and its
impact on their quality of life into a single measure.
Across NCL, with the exception of the EQ-5DTM for knee surgery, average PROM scores
were lower than the national average for England. Outcome scores varied between
providers, highlighting the opportunity to improve outcomes and consistency across NCL as
a whole.
Table 15: Nationally reported PROMs for elective orthopaedic surgery
Measure North central
London average Range England average
Oxford hip (all
procedures) 20.3 18 to 21.4 22.2
EQ-5DTM hip 0.42 0.4 to 0.47 0.46
EQ-VAS hip 13.4 11.6 to 14.6 13.9
56 NHS Improvement Guide to Reducing Long Hospitals Stays (2018) 57 Provisional Patient Reported Outcome Measures (PROMs) in England – Data Quality Note, April 2018 to September 2018
Revision parameter North central
London Range National
Hip procedure up to
one year after
replacement
1.9% 1.6% to 2.2% 1.8%
Knee procedure up to
one year after
replacement
4.5% 3.4% to 6.8% 4%
51
Measure North central
London average Range England average
Oxford knee
(all procedures) 15.0 13 to 17.5 17.0
EQ-5DTM knee 0.29 0.26 – 0.3 0.3
EQ-VAS knee 7.1 4.8 to 8.4 8.1
4.7. Fragmented commissioning landscape
Planned adult orthopaedic services for patients and residents in NCL are currently
commissioned from 10 separate hospital sites, which include three private hospitals. There
are also flows of residents from north central London accessing planned orthopaedic care in
hospitals outside of north central London and some sub-contracting of activity from acute
trusts to the private sector when services are operationally challenged, for example over the
winter months.
This fragmented commissioning picture has built up incrementally, with no overall strategic
approach to the commissioning of planned orthopaedic services, including a demand and
capacity analysis of the longer-term requirements to the service. Some of the flows –
particularly to the private sector – have been a practical response to the waiting time
constraints which are separately documented in the case for change.
Fragmented commissioning of the service impedes economies of scale, contributes to
variation in the quality of the service, variability in clinical outcomes and an inability to realise
the economic benefits of ring-fenced specialist services delivered at scale.
This review on the future of adult elective orthopaedic services sets out the long-term
strategic picture for those services delivered exclusively through a small number of elective
centres with the scale and capacity to deliver all the activity requirements for the NCL
population into the future. If approved following consultation, there may be consequential
contracting changes to reflect this new commissioning strategy.
5. Elective orthopaedic care model, services and expected
benefits
This section describes the potential new model of care, details how it could change, and how
the proposals could facilitate delivery of the new model. This section also highlights the
Following its clinical review panel, the London Clinical Senate stated the case for change
“clearly articulates the rationale and provides enough evidence that the change is justified
in terms of efficacy and patient experience”. Recommendations for development include
consideration of the wider musculoskeletal pathway to ensure that the intended benefits
can be maximised and that net activity projections were reviewed to ensure that they are
as realistic as possible”.
52
expected benefits and how the model meets the needs identified in the case for change
section.
The model described below was developed before the options appraisal process and
therefore the emerging preferred model of care. It was approved by the Joint
Commissioning Committee of the NCL CCGs on 2 May 2019 and was issued on 17
May 2019 to the five current NHS providers of adult elective orthopaedic services as
the basis for the submission of options to become an elective centre.
The outcome of that options appraisal can be found at section 8.
5.1. Aims and objectives of the service
We want to develop a clinical delivery model for a networked model of care which has an
international reputation for high-quality patient outcomes and experience, education and
research.
We propose to secure this through:
Excellent and timely diagnostics and outpatient care, both pre- and post-operatively,
at local base hospital sites, working seamlessly within local MSK pathways, including
both prevention and self-management
Elective centre(s) which would provide at-scale delivery of consolidated, high-quality
ring-fenced elective orthopaedic surgery with excellent perioperative care
A focus on consistent excellent patient education and rehabilitation, pre-operatively
and post-operatively
Appropriate flows to a super specialist centre for the most complex patients who
cannot be appropriately cared for in either the local (base) hospitals or elective
centres
Improvement in the delivery of local trauma services, by separating the delivery of
planned and emergency orthopaedic services, whilst maintaining a surgical
workforce who are trained to provide both, to best-practice standards
Improvement in staff experience, recruitment, retention, training, education and
research
An appropriate commissioning framework, which would facilitate expectations on
providers to deliver the expected improvements in the service model.
Our vision, developed and validated through a series of clinical design workshops, is to
deliver services from dedicated state-of-the-art orthopaedic elective surgical centres (also
known as cold or hub centres), separated from existing emergency departments, and co-
located with high dependency units (HDU), with the size and scale to enable a full elective
orthopaedic service. They would be staffed by the doctors, nurses, allied health
professionals and specialists delivering the right place at the right time. Trauma (ED) activity
would be maintained at local hospital trusts.
Freeing-up beds and theatres would also improve the experience for emergency patients
and the proposed separation of emergency and planned care is consistent in supporting the
North London Partners in Health and Care urgent and emergency care strategy. Efficiencies
as a natural consequence of these improvements, would offer better value for money.
5.2. Partnership for Orthopaedic Excellence: North London
A key feature of the planned model is the creation of a single elective orthopaedic network
across north central London: Partnership for Orthopaedic Excellence: North London. The
network is a standalone quality improvement initiative that aims to support the delivery of
53
higher quality elective orthopaedic care, improve outcomes as well as standardising practice
across the north central London footprint.
The network arrangements would continue to evolve as the arrangement for elective
orthopaedic services are defined. The initial outline governance principles of the orthopaedic
clinical network are:
There would be a single orthopaedic network in north central London: Partnership for
Orthopaedic Excellence: North London
The network would include the oversight of the wider elective orthopaedic pathway,
including outpatients and day surgery, but not including trauma, though close links
with trauma services would be maintained
The network would appoint a chair to act as clinical leader, individual sites would
identify a clinical lead who would work with the network leader, and clinicians would
also be identified to work on individual time-limited projects
The network would foster a culture of openness, transparency, shared learning,
clinical audit, research, service developments and continuous quality improvement
between all participating organisations, would work to improve MDT team working
across all tiers of hospital and ensure a focus on continuous quality improvement as
the network grows and matures
The network would work to an agreed work programme, seeking to reduce
unwarranted variation and set up standardised protocols based on best practice:
o Common quality standards and KPIs, including monitoring of surgical volumes
across sites and surgeons
o A best-practice common pathway for the delivery of elective orthopaedic care.
Specifically, in relation to the proposal set out in this document:
Partnership for Orthopaedic Excellence: North London would give oversight for
clinical and operational activity of the proposed elective centres offering peer-to-peer
review. It would have a mandate to support organisations to escalate areas of
concern affecting quality of care, and to support clinically-led early intervention rather
than the back stop of regulatory intervention
If there is more than one elective centre, the network would ensure protocols are
consistent and shared between all partners in the network, so that there is a unifying
pathway and treatment protocols and a continuous focus on unwarranted variation to
achieve best outcomes and experience for patients
The network would take an overview of the clinical governance of the proposed
elective centres in north central London. Operational clinical governance would be
the responsibility of the proposed elective centres.
Through the orthopaedic network, providers would work collaboratively to ensure that
patients receive an optimum patient experience. In addition, providers would adopt a
business model which ensures the financial and other benefits of consolidation are shared
between all providers and commissioners, rather than creating ‘winners and losers’.
The key design principles generated through clinical engagement and approved by the NCL
JCC in December 2018 are set out in table 16.
54
Table 16: Key design principles
Differentiation of levels or tiers of service at different hospitals. Incorporated
into the model
Partnership approach with all hospitals being seen as ‘base
hospitals’ with a stake in an elective centre.
Incorporated
into the model
Staffing model with clinical staff working into the unit from the base
hospitals, particularly surgeons following the patient to the elective
centre and providing continuity of care.
Incorporated
into the model
Development of common standards and pathways approach,
overseen by a clinical network with a standard set of outcomes to
which all organisations must adhere and are used to measure
success with clinical governance/oversight.
Incorporated
into the model
All outpatient care, pre- and post-operatively, to stay at base
hospitals (i.e. as at present).
Incorporated
into the model
Elective procedures on children and most adolescents (under 18
years of age), trauma, and spinal surgery to stay at base hospitals
(i.e. as at present). For children’s procedures, the base hospital
would act as a filter, with complex referrals continuing to go to Great
Ormond Street Hospital (GOSH) and the Royal National Orthopaedic
Hospital (RNOH).
Incorporated
into the model
Care-coordination function (care co-ordinators) to work across
base hospitals and elective centre(s), with a particular focus on
patients with vulnerabilities.
Incorporated
into the model
MDT team working to be a core component of the model. The
clinical network would develop expectations about how this would
operate. It is noted that there should be opportunities to do some of
this virtually.
Incorporated
into the model
High-dependency capability – the elective centre needs to be able
to manage a range of conditions and complexity; to do this they
would require appropriate back-up medical services and step-up
care.
Incorporated
into the model
5.3. Levels/tiers of service
Under the proposed model of care there would be three tiers of hospital provision for adult
elective orthopaedic services.
55
Table 17: Levels/tiers of service
Base hospitals Elective orthopaedic
centres Super specialist centre
These are the existing local
hospital sites.
They would act as the entry
point to elective orthopaedic
care for patients; support
the operation of the elective
orthopaedic centres as part
of a clinical network;
manage outpatients; and
post-operative follow-up,
some day-cases and all
trauma care alongside an
accident and emergency
department.
They would be the main
surgical centres, able to
undertake a mixture of some
complex and all routine
elective activity.
Able to treat medically
complex, as well as some
orthopedically complex,
patients, with appropriate
back up medical services
and step-up care.
This activity is (mostly)
commissioned by local
clinical commissioning
groups, although some
would sit with NHS England
(NHSE) specialised
commissioning.
Tertiary and complex
orthopaedic care is
undertaken here, that
cannot appropriately take
place at either the base
hospitals or the elective
centres.
This activity is (mostly)
commissioned by NHSE
with a national catchment
area and would be fulfilled
by the Royal National
Orthopaedic Hospital NHS
Trust (RNOH) in Stanmore.
This super specialist work
does not form part of this
review.
The overarching principle of this preferred model of care is that orthopaedic surgeons
would remain employed by their existing hospital with a job-plan that includes
programmed activities covering elective and emergency care. Their current (and
future) elective surgical commitments would move with them to the proposed elective
centres.
5.4. Number of proposed elective centres
The clinical delivery model is not prescriptive about the number of elective orthopaedic
centres required in north central London. This process may determine that there should be
more than one elective centre. If this is the case, each centre may manage different levels of
medical and orthopaedic complexity. The preferred model of care that was agreed as a
result of the options appraisal process is outlined in section 8.
5.5. The patient pathway
Our aim is to develop world class orthopaedic services in north central London, bound
together through the clinical network Partnership for Orthopaedic Excellence: North London.
These would deliver excellent patient outcomes and reflect the highest levels of productivity,
so that patients who require surgery receive a high-quality service with the minimum
possible wait.
The elective centre(s) would form part of the wider provision of elective orthopaedic care in
NCL and would be a collaborative arrangement between hospital trusts and reflected in
commissioner expectations of service provision. Patients would initially be seen at their local
or base hospital before receiving treatment at an elective centre. The elective centre(s)
56
would have dedicated theatres and beds to minimise the risk of cancellations. Following
treatment, patients would return to their usual setting of care and receive follow-up
appointments and rehabilitation at their local base hospital or in the community.
Figure 9 provides a high-level view of the envisaged pathway, how an elective centre could
work with base hospitals, and how patients could get their care delivered between base
hospitals and the elective centre for outpatients, treatment and rehabilitation.
57
Figure 9: High-level pathway view
58
5.5.1. Accessing the proposed elective centres
Trusts working within the clinical network Partnership for Orthopaedic Excellence: North
London would work in partnership with primary and community organisations to ensure all
patients requiring MSK services could access optimal end-to-end pathways to meet their
needs.
Base hospitals would work with their local MSK services to take referrals through established
primary and community care routes (single point of access, first contact practitioners and
referral management centres).
Transfers to the elective centre would be made through a patient’s base hospital in line with
protocols agreed by the clinical orthopaedic network, Partnership for Orthopaedic
Excellence: North London.
It is expected that each local hospital would transfer patients in a timely manner to the
elective centre(s), in order to allow the 18-weeks target of referral to treatment to be met.
Referrals must be in line with evidence-based thresholds of care. Arrangements for referral
targets and waiting times, including maximum transfer times, would be agreed through the
orthopaedic clinical network. Any breach of patient access targets would be required to be
reported through the appropriate commissioner arrangements.
5.6. Summary of service model specification
As set out in section 8, options put forward were assessed through an options appraisal
process. The criteria referred to in this section are those that were used for assessment in
the options appraisal process. The clinical delivery model sets out essential clinical and
other features of the service model. It was against these features that providers were asked
to demonstrate in the options which they put forward for consideration.
5.6.1. Essential requirements
There are a number of essential requirements which were assessed as part of criterion 1 to
fit with the clinical delivery model within the options appraisal process.
Each elective centre must deliver a minimum of 4,000 procedures a year58 (both
inpatient episodes and day-cases)
A defined ward (or wards) for elective orthopaedic patients with dedicated
orthopaedic beds59 and associated staffing (either in a separate building or
equivalent ring-fenced facility) must be provided
A dedicated ultra clean air theatre suite designed specifically to meet the needs of
orthopaedic surgery with appropriately trained orthopaedic theatre staff must be
provided, with capability to operate six or seven days per week, with three sessions a
day
Appropriate post-operative high dependency care must be provided, level two as a
minimum. Providers need to demonstrate the level three arrangements to manage
58 As set out in the draft case for change (August 2018) the review of literature evidenced that international centres of
excellence with high quality outcomes conduct a minimum of 4,000 procedures a year for each site. 59 The Getting It Right First Time (GIRFT) report (2012) confirms that a genuine elective orthopaedic ring-fence that is rigidly
enforced is essential if best outcomes are to be achieved. If there is a breach of any kind – including supposedly ‘clean’ surgical patients – of the ring-fence, then surgeons are advised to cancel their lists and require that the ward is closed and deep cleaned before joint replacement can begin again. It is worth remembering that when infections do occur, as is more likely in a non-ringed circumstance, it is necessary to go through the same deep clean procedures.
59
deteriorating or complex patients who require intensive care support for a short
period of time60
Arrangements for appropriate overnight medical cover, at sufficient seniority
supported by on-call arrangements (both medical and surgical), to enable the safe
care of medically complex patients must be provided.
5.6.2. Essential clinical requirements
There are also a number of essential clinical requirements which must be co-located with the
elective centre, which all options would need to meet. These would also be assessed under
criterion 1 of the options appraisal.
Adherence to safety standards as judged by prevailing standards
Deteriorating patients’ protocols
Compliance with NHS England service specifications for specialised orthopaedics
networks (case mix dependent)61
All surgical consultants and associate specialists have the required expertise.
Specialist nursing
Theatre inventory of appropriate equipment and a resilient supply chain and
decontamination arrangements
Theatre inventory of implant components
Transfusion service
Infection control services
Anaesthetists – specialising in orthopaedic care
Other standard hospital support services applicable to any elective site.
5.6.3. Essential services not required to be co-located
There is also a range of other essential services, including support services, which would be
required to be accessible on-site of the elective centre but not necessarily to be co-located:
Access to MSK radiology, including access to CT and MRI scanning equipment
Mental health – psychiatry
Plastic surgery (part of the MDT team available to support elective surgery, generally
would be required on a planned rather than emergency basis)
Vascular surgery (immediate telephone advice and on-site support must be available
within one hour of a request)
Medical support services (incorporating a range of general medical and medical
subspecialties) – e.g. cardiology, neurology, diabetes, infectious diseases, care of
the elderly
Clinical support services – e.g. pathology, nuclear medicine, interventional radiology,
microbiology
Acute pain management services.
Finally, there are features for innovation where, within the essential requirements, we have
looked for providers to describe their vision for delivery.
60 Level 2 – High Dependency Unit (HDU). Patients needing single organ support (excluding medical ventilation) such as renal
haemofiltration or ionotropes and invasive BP monitoring. They are staffed one nurse to two patients. Level 3 – intensive care. patients requiring two or more organ support (or needing mechanical ventilation alone). Staffed with one nurse per patient and usually with a doctor present in the unit, 24 hours per day. 61 NHS standard contract for Major Trauma service (all ages) and NHS standard contract for specialised orthopaedics (adult)
60
Intensive rehabilitation support for patients during their inpatient stay
Seven day a week service with extended hours. Presumption should be that patients would
be mobilised on the day of surgery (unless clinically inappropriate).
Clinical governance
Providers were asked to set out their proposed clinical governance structure for the elective
centre. Specifically:
How clinical governance and accountability would sit within the host organisation,
particularly the role of the medical director
How clinical governance would operate in a partnership arrangement between two or
more providers
How the elective centre would work with base hospitals to ensure robust clinical
governance arrangements, particularly tracking of readmissions and serious
incidents (SIs)
How patients would be involved in the clinical governance arrangements.
Multidisciplinary team (MDT) working
As part of the clinical orthopaedic network, the intention is to establish MDT working across
the elective centre, base hospitals and super specialist centre.
Providers were asked to set out how they would envisage the elective centre working within
the overarching governance of the clinical network (particularly if there is more than one
centre) to ensure consistency of clinical practice and patient experience, and a clear sense
that the elective centre is part of the delivery of a unified approach to elective orthopaedic
care.
Care co-ordination
There would be a need for a defined team to manage discharge at the elective centre
(including equipment needs). The team would focus on patients with vulnerabilities or those
with complex needs (non-medical). They would also:
Follow-up with the base-hospital to ensure that there is continuity and appropriate
ongoing patient care in the community
Have access to step-down facilities (if required)
Have effective links to social care to support discharge
Ensure that the discharge to assess team and protocols were in place (as required)
Ensure an emphasis on rehabilitation and reablement, be more explicit about taking
a more strengths-based approach with patients, maximising opportunities for
independence, including assistive technology as well as equipment.
Pre-operative assessment
Pre-operative assessment would be ‘owned’ by the elective centre as an important part of
the consent process, and to ensure consistency of practice to prevent on-the-day surgical
cancellations. Pre-operative assessment protocols would be developed to enable
standardised practice across the network.
61
Options for this include:
Base hospitals to identify complex patients who would require a more in-depth
anaesthetist managed pre-operative assessment
Digital solutions to enable base hospitals to start the pre-operative process, against
an agreed protocol, to enable screening tests needed before surgery e.g. an
echocardiogram, to be in place at the base hospital and take place there prior to
onward referral to the elective centre
Trusts to consider whether they want to deliver an outreach model with pre-operative
assessment delivered by the elective centre across a variety of sites, including base
hospitals.
Patient education
Patient education would be delivered to a consistent model developed by a single
orthopaedic clinical network with standardised core materials, including a website.
Face-to-face patient education would be co-ordinated by the elective centre, although could
be delivered across a range of sites (including base hospitals). To include consistent
prehabilitation assessment and support; joint school for hip and knee replacements; and pre-
operative patient education materials to be developed for the full range of orthopaedic
procedures.
Clinical case-mix
Providers were asked to set out their expectations in terms of the case mix they would safely
manage at the proposed elective centres, meeting all relevant safety standards. This would
include which day-case procedures they would undertake at the proposed elective centres
and which would take place at base hospitals. These assumptions were modelled into their
submissions.
Medical complexity
The proposed elective centres would undertake procedures on medically complex patients,
with appropriate back-up medical services and step-up care. Providers were asked to set out
their assumptions in terms of any specific cohorts of patient that they felt could not be
managed in the proposed elective centres and these assumptions were modelled into their
submissions. For instance, practice elsewhere would suggest that sickle cell or haemophiliac
patients would need to be treated at specialist units which may not necessarily be an
elective unit.
5.6.4. Interdependent services
The proposals for the elective orthopaedic centres have been assessed on how
interdependent services could be impacted by the establishment of a new model of care. To
do this all providers within the system, including those that would remain as a base hospital,
were asked to provide information as part of the submission of options process.
Paediatrics and adolescents (under 18 years of age)
Base hospitals would act as a filter through to specialist paediatric and adolescent
orthopaedic surgery at specialist tertiary centres (GOSH and RNOH)
62
For the small number of patients having surgery at base hospitals, as at present – base
hospitals would ensure separate list arrangements (cohorting on adult trauma lists should
not be the practice), surgeons available with appropriate skills set, and have appropriate
paediatric after care.
Trauma
Central to the model is the continuation of high-quality non-elective adult orthopaedic
services and trauma services (including fractured neck of femur services) at all base hospital
sites.
Base hospitals designated as trauma units would continue to meet the service specification
including the provision of operating theatre access and in-house rotas. Specifically:
Modelled theatre and dedicated bed requirements to manage current and projected
trauma workload
Management of trauma on-call arrangements to ensure full cover, and consideration
to whether job-plans would need to be reviewed to formalise any non-job planned
activities that currently take place as a result of the co-location of trauma and elective
surgery.
Major trauma is out of scope and would continue to be delivered at existing designated sites
(St Mary’s and The Royal London hospitals).
The robustness of the proposed base hospital arrangements was tested by the trauma
network as part of the assessment process.
Spinal surgery
Spinal surgery is not included within the planned scope of the elective orthopaedic centre,
although a base hospital which is also an elective centre could manage their own spinal
activity through the elective centre.
Base hospitals would have modelled their theatre and dedicated bed requirements to
manage their current and projected spinal workload
Specialist and tertiary spinal surgery would be provided at RNOH and National
Hospital for Neurology and Neurosurgery. Spinal surgery is also provided by
Whittington Health NHS Trust and the Royal Free London NHS Foundation Trust (on
both the Barnet and Chase Farm hospital sites).
The robustness of the proposed base hospital arrangements and proposed capacity was
tested by the spinal network as part of the assessment process.
Base hospital services
These are as follows:
Outpatient adult orthopaedic services
Access to MSK radiology, including access to CT and MRI scanning equipment
Contribution to the early pre-assessment screening using protocols agreed by the
clinical network, Partnership for Orthopaedic Excellent: North London.
Rehabilitation service including physiotherapists and occupational therapists
Emergency follow-up for post-surgical complications (e.g. infections or dislocations)
for all patients treated on both emergency and elective pathways.
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Community and primary care orthopaedic services
These are as follows:
MSK single point of access
First contract practitioners
Direct access physiotherapy
Community physiotherapy, occupational therapy (OT) and nursing services.
5.6.5. Enablers
Transport
Appropriate transport arrangements (for those meeting eligibility criteria) are vital for patients
with vulnerabilities and also the efficiency of the elective centre. Trusts were asked to
describe how they would manage transport arrangements for patients meeting eligibility
thresholds.
Digital
There are significant opportunities across the orthopaedic network to look to digital
integration of systems to support a new model of care, particularly by sharing information
across the whole care pathway, joining up pre-operative assessment and sharing images on
this and would continue through the clinical network in conjunction with the NCL digital
programme, the One London Project and the NCL Diagnostics programme.
Providers were asked to ensure that their level of digital maturity could support
interoperability with disparate systems across the north central London digital footprint and
the London-wide digital footprint. The following items are seen as a minimum to integrate
with the Health Information Exchange (HIE) and the planned centralised image exchange for
London:
All provider systems must be able to provide data using HIE standards such as
Health Level Seven’s Fast Healthcare Interoperability Resources (HL7, FHIR62) to
enable real-time integration with their electronic patient record (EPR) or their trust
integration engine. Where this is not possible, the provider should be able to provide
the data in near real-time utilising batch files from their data warehouse
An agreed minimum dataset from all participating care providers in the orthopaedic
pathway would be needed in digital format. The data needs to be coded data or in a
structured format
All providers involved in the care pathway would utilise the patient’s NHS number as
their primary identifier. To this end, all providers should ensure that they have at least
80% spine compliance with their NHS numbers. This would ensure appropriate
linking of patient’s records from multiple sources
Providers should support electronic workflow for patients on the pathway
All systems must be on the N3/HSCN network, or equivalent, to enable connectivity
To enable image sharing, HIE profiles such as the reporting workflow (RWF) and the
image exchange (XDSi), should be supported. This would facilitate linking-up
radiology events and PACS imaging
62 Health Level Seven® International (HL7®) is the global authority on standards for interoperability of health technology with
members in over 55 countries
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Providers’ PACS and RIS (diagnostic imaging networks) managers or vendors
should be able to facilitate historical data on-boarding by triggering the publication
information of documents and images onto the One London Central HUB platform for
an agreed period of time.
Provider systems should utilise SNOMED/NICIP as the standard vocabulary used for
metadata.
5.6.6. Workforce
The NCL adult elective orthopaedic review creates an opportunity to evaluate the adult
elective orthopaedic workforce. Developing new ways of working across the system is
crucial to developing a sustainable workforce model that builds local capacity, capability and
competency to deliver care across end-to-end best practice MSK pathways.
Robust education and quality improvement initiatives, led by the orthopaedic network, would
underpin system redesign, enabling transformation to happen at scale and pace. This would
support the development of a workforce model that is fit for purpose – for all clinical teams’
doctors, nurses and AHPs – and has the support of all key stakeholders and employers. It
would also ensure the workforce model has the ability to evolve over time to meet future
demands and challenges.
In January 2019, to support development of the NCL adult elective orthopaedic workforce
plan, the Health Education England (HEE) workforce observatory undertook an initial
baseline analysis of the current trauma and orthopaedic workforce. The report highlighted
the opportunity to attract staff to NCL together with challenges recruiting a number of key
disciplines. It has committed to carry out further evaluation and modelling as the workforce
plan evolves and the review progresses.
The NCL orthopaedic workforce plan is underpinned by national specifications set out by
HEE and the NHS Long Term Plan. It aims to drive development of integrated services and
working practices by facilitating changes in culture and practice.
The developing workforce plan for elective orthopaedic services is fully aligned to the wider
NCL workforce plan and aims to:
Make a significant difference to our ability to recruit and retain staff by making NCL
adult elective orthopaedic centres and base hospitals desirable and innovative places
to work for relevant staff, including training and non-training medical staff (including
GPs), allied health professionals and nursing staff
Enable productive working by enhancing digital capability and developing consistent
pathways
Utilise processes that are in existence (UCLH and Whittington passport) and being
developed across NCL to build flexibility and mobility (Cancer passport). This would
allow staff to work in different organisations and locations, particularly orthopaedic
surgeons, anaesthetists and other relevant clinical staff who would follow the patient
between base hospitals and the proposed elective centres
Develop consistent ways of working together with NCL-wide clinical protocols driven
by the orthopaedic network
Develop new roles where appropriate which are likely to include advanced clinical
practitioners and care navigators
Develop a robust research and education framework to attract national and
international funding and educational opportunities
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Deliver on the vision of 21st century care set out in the NHS Long Term Plan by
reviewing skills mix, creating new types of roles and utilising different ways of
working
Develop training models in partnership with the London Deanery that ensure
undergraduates have access to the highest quality education and training
Ensure there are no unintended consequences for interdependent staff groups and
services such as trauma, paediatrics and spinal
Develop NCL support networks including system-wide MDT team working structures
and defined escalation pathways to access clinical expertise for complex patients
Develop an NCL-wide recruitment strategy for orthopaedics.
The emerging plan is currently at a high-level with granular details to be incorporated into the
decision-making business case and implementation plan.
We asked trusts to detail how the workforce could be developed to ensure that:
Roles at the proposed elective centres are in place, including the care co-ordinator
role
There are mechanisms in place to enable staff to work cross site
The key principles (set out below) would be met
NLP STP workforce programme alignment would be achieved.
In addition, providers were asked to evidence how the workforce plan would ensure that:
The relevant essential requirements are met, i.e. how staffing would be identified and
established to provide a defined ward for elective orthopaedic patients
The relevant essential clinical requirements would be met, i.e. provision of specialist
nursing workforce
The relevant essential services would be delivered, i.e. how staffing would be
identified and/or established to provide vascular surgery support
The relevant interdependent services are provided.
In proposing a workforce plan that would meet these requirements, trusts were also asked to
consider how they would:
Develop and use new roles within the workforce especially the required care co-
ordinator role
Leverage the opportunity that portability of expert staff between organisations and
locations would offer
Address issues of workforce supply and turnover, particularly with expansion of key
roles in other areas including the impact on physiotherapy recruitment with the
implementation of the FCPs in primary care from 2020.
We asked them to demonstrate how they would:
Adopt the appropriate and relevant north central London workforce policies including
the NCL recruitment and selection policy which would enable future staff sharing
across sites
Ensure retention and recruitment of the workforce, particularly in light of national and
acute local shortages of clinical staff, for example operating department practitioners
(ODPs) – these strategies would also need to demonstrate alignment and integration
with the NCL workforce programme projects in these areas
66
Consider the appropriate use of new and emerging roles (and provision of training
for) roles such as trainee nurse associates (TNAs), advanced clinical practitioners
(ACPs) and physician associates (PAs)
Align and integrate with NCL workforce programme projects focusing on reducing
use of bank and agency staff
Consider the deployment of staff to maximise efficiency and staff experience, and
outline how they would support development of, and use, key portability options such
as the NCL employment license and NCL Mandatory and Statutory Training (MaST)
work (amongst others)
Outline plans to ensure a favourable experience for staff of working in the new
service.
Key principles
The overarching principle is that the current elective in-patient surgical commitments
of surgeons at base hospitals would move with them to the elective centre.
Surgeons would remain employed by the base hospital, with a job-plan that includes both
elective and emergency commitments.
We have drawn on the experience of the South West London Elective Orthopaedic Centre
(SWLEOC) model of staffing as our starting point for NCL. This includes a core team of
nursing and anaesthetic staff at the centre servicing the needs of orthopaedic surgeons from
the base hospitals working at the centre.
There are a number of key expectations around the management and engagement of the
workforce:
Providers were asked to set out how they would manage demand and capacity
modelling and job planning across the elective centre and base hospital. This would
include a key focus on how e-rostering and e-job planning would be deployed to
effectively manage the workforce across this to ensure that trauma capacity and
capability at the base hospitals is not undermined
In determining the roles need for an elective orthopaedic centre, providers were
asked to provide an example of the dedicated orthopaedic team expected to be
based at the elective centre and the staff who should be available, ensuring a ‘best in
class’ skills mix and capacity to be provided at different times across the extended
service
Orthopaedic surgeons would continue to be employed by the base hospitals and
would be expected to have job plans that include outpatients, trauma lists and on-call
arrangements at the base hospital site, alongside planned elective work at the
proposed elective centres
NCL has particular workforce challenges regarding cost of living and acute shortages
of professional staff (including middle-grade doctors and nurses), as well as staff in
lower paid roles. Providers were asked to detail the plans and infrastructure they
have, and would, put in place to address these challenges. This would include
minimising use of bank and agency staff and how they would ensure maximum fill
rates when such staff are deployed
Depending on the range of services provided from the centre, there may be a need to
provide specialist teams to deliver the appropriate standard of care. These may be
67
employed by the centre or drawn from base hospitals. Providers were asked to detail
their planned solution(s) to this, and outline steps to be taken to establish
agreements and relationships with partner organisations to provide these solutions
Given the partnership approach with all base hospitals having a stake in an elective
centre, orthopaedic surgeons would work across two sites. A proportion of providers’
additional staff would also work across two sites. Providers were asked to
demonstrate how they would limit the need for teams and individuals to work across
more than three sites as this could have a detrimental on patient and staff experience
Trusts were asked to consider how they might deploy their staff to maximise
efficiency and staff experience, including travel and London weighting considerations,
as well as the adoption of NCL approaches such as:
o Bilateral provider agreement(s) to share staff
o ‘Passporting’ of specified staff to work throughout clinical pathways and follow
the patient
o Recognition of other providers’ training – as a minimum Mandatory and Statutory
Training (MaST) and other clinical training (to be specified by providers).
Table 18: Roles at the elective centre
Clinical leadership structure for the elective centre, including a medical director.
Managerial leadership structure for the elective centre.
Appropriately established and staffed HDU and peri-operative care on-site to enable
the safe care of medically complex as well as orthopedically complex patients.
Arrangements for appropriate and fully staffed overnight medical cover, including
HDU, at sufficient seniority supported by on-call arrangements (both medical and surgical),
to enable the safe care of medically complex patients.
Orthopaedic trainees – The centre would operate on the principle that trainees would
continue to be aligned to the base hospitals. Trainees would follow their training consultant
to the elective centre on their consultant’s operating days to get their required exposure to
elective cases. The presumption is the elective centre would function without any reliance
on overnight or ward-based support from trainees.
Experienced anaesthetists in post – consultant anaesthetists, junior grade anaesthetists,
potentially further anaesthetist to cover anaesthetic issues.
Providers were asked to describe the model which they envisaged:
Pure model where all anaesthetic support is provided by the staff working
exclusively at the elective centre, or
Hybrid-model where some anaesthetic support is provided by clinicians from the
base hospital carrying out planned sessions in the centre.
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Nursing staff – theatre co-ordinator/sister, scrub nurses, staff nurses, recovery nurses,
anaesthetic nurses.
Medicines management support in post – including specialist pharmacists.
Experienced MSK radiologists.
Experienced physiotherapists, occupational therapists, radiographers and other allied
health professionals – offering a seven-day, extended hours service.
Infectious disease consultant cover.
Administrative and clerical staff.
Pathway co-ordinator/care navigation function to work across the proposed elective
centres and all feeder base hospitals, with a particular focus on patients with vulnerabilities
who may find it more difficult to navigate the pathway (these roles could draw on models
developed for primary care).
Business support – finance, HR, IT, procurement, logistics.
5.6.7. Teaching, training, education and research
A driving principle of the review is that the proposed workforce models at base sites, elective
centres, and super specialist centres, provide sufficient volume and opportunities for the
teaching, training and education of key clinical staff including therapists, nurses and doctors.
The proposed elective centres would have sufficient volumes to take part in research trials
and forge formal academic links with appropriate academic partners.
A further key principle of developing orthopaedic elective centres focuses on developing
research and education, particularly for complex procedures. Through this approach,
providers would improve capacity in this field nationally, become eligible to join the
International Society of Orthopaedic Centers (www.isocweb.org), and provide specialist
training for a new generation of doctors and allied health workers.
Trauma and orthopaedic education and training is a key dependency whose implications
need to be worked through in a collaborative way as part of the development and
implementation of a new clinical delivery model.
With regards to doctors in training, as in the SWLEOC model, the NCL model is based on
the principle that doctors in training would continue to be aligned to the base hospitals.
Doctors in training should then follow their consultant to the proposed elective centres on
their consultant’s operating days to get their required exposure to elective cases.
The London Deanery would be involved in the development of the training model to ensure
training requirements are fully integrated into delivery plans.
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This is likely to present challenges with regards to rota management and service provision
that should be addressed in detail within any education and training plan developed by
providers.
However, the model should also offer opportunities for training and education through
access to this range of activities and procedures and increases the benefits for doctors
working within this model.
It is also anticipated that therapists and nursing staff would also have increased
opportunities for intra-organisational rotations and training and development.
We asked providers in their education, training and research plan to include how they would
contribute to relevant continuing professional development, education and training, including:
How they built education and training capacity/capability/governance into the options
which they put forward for consideration
Show how, for clinical staff at the elective centre and the base hospital, they would
contribute to support orthopaedic education and training across other NCL providers
as part of the development of integrated care arrangements
Show how they would conduct and exhibit a commitment to clinical research,
specifically:
o Function as an academic centre (i.e. has residents or fellows in training)
o Five peer reviewed publications in top 10 journals per year as a minimum.
Health Education England would be asked to scrutinise implementation plans to ensure all
aspects for each discipline has been addressed.
5.7. Standards and performance of the elective orthopaedic service
Patient experience
The standards we would be aiming to achieve for patients in NCL would be:
To be compliant with all patient access targets
To reduce cancellations for elective orthopaedic procedures to zero for preventable
reasons (e.g. due to beds being unavailable)
To reduce on the day-cancellations due to anaesthetic review to zero (unless there
was a material change in the patient’s clinical condition between pre-operative
assessment and the day of surgery)
Develop a maximum transfer time between being seen at the base hospital and
referral to the proposed elective centres
To generate patient satisfaction scores in the top decile (PROMs, PREMs (patient
reported experience) and Friends and Family (F&F) test)
Patients would benefit from an accessible service and continue to have choice for
elective orthopaedic care
Active patient forums in the elective centre to define local patient experience, set up
broadly in line with the British Orthopaedic Association (BOA) Patient Liaison Group
standards
As part of the National Orthopaedic Alliance Vanguard, aim towards gold kitemark
against the quality standards for all procedures undertaken.
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Clinical standards
Specific clinical standards we would see in the preferred model of care:
Sites in NCL should demonstrate a critical mass for complex procedures to support
the safe and effective delivery of care
Individual surgeons would be supported to undertake a sufficient volume of
procedures each year to enable the safe and effective delivery of care, which would
reflect the BOA guidance on implementing GIRFT
Orthopaedic equipment on the shelf for a minimum of 90% of cases
Consistent use of enhanced recovery pathways across NCL
Overall deep infection rates of less than 1%.
Performance thresholds
Theatre utilisation – four primary joint replacement operations (or equivalent) in a
two-session day
Length of stay to be in upper quartile
Development of standard protocols for prostheses across NCL.
This section documents the governance structure that has been put in place to
ensure the consultation process is robust, accommodates relevant stakeholder views
and there is clarity on responsibilities for decision making and responsibilities for
approval of key documents and milestones.
The NCL adult elective orthopaedic services review has a clear governance structure in
which the north central London Joint Commissioning Committee (NCL JCC) is the decision-
making body for the programme.
The commissioning-led governance framework which underpins these adult elective
orthopaedic care proposals was established following agreement from the NCL JCC in
January 2019. The NCL JCC is a joint committee of the CCGs under s.14Z of the NHS Act
2006. All five of the CCGs’ governing bodies approved the proposals to establish the NCL
JCC and agreed its terms of reference.
Should the programme proceed to consultation and, following the outcome of that
consultation, the next stage of decision-making will be to discuss the Decision-Making
Business Case (DMBC). This will be taken by the North Central London CCG (a merged
organisation of the five NCL CCGs which is expected to come into being on 1 April 2020)63.
It will take forward and support any required implementation plans as part of its support to a
north central London integrated care system.
Before January 2019, a review group comprising of NCL provider clinical and managerial
representatives, patients and commissioners oversaw wider engagement around a draft
case for change and the creation of key design principles, developing a culture of common
purpose, collaboration and quality improvement.
63 Further information on the approval to merge can be found here
6. Programme leadership and governance
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6.1. North central London Joint Commissioning Committee (NCL JCC)
The NCL JCC has clinical and lay representatives from five NCL CCGs:
NHS Barnet Clinical Commissioning Group
NHS Camden Clinical Commissioning Group
NHS Enfield Clinical Commissioning Group
NHS Haringey Clinical Commissioning Group
NHS Islington Clinical Commissioning Group.
The NCL JCC also has other non-voting members from:
London Borough of Barnet
London Borough of Camden
London Borough of Enfield
London Borough of Haringey
London Borough of Islington
Director of Public Health, Barnet
Healthwatch Enfield and Healthwatch Haringey on behalf of the five Healthwatch
organisations in North Central London.
The committee’s role is to commission jointly a number of services that are most effectively
commissioned collaboratively across NCL. They include all acute services including core
contracts and other out of sector acute commissioning, this includes both elective and
emergency orthopaedic services64.
6.2. Programme board – adult elective orthopaedic services review
The NCL JCC is advised by a programme board for the adult elective orthopaedic services
review that oversees programme delivery, in particular:
To make collective recommendations to the NCL JCC
To connect local organisation-based accountability structures with the review
To consider and champion the interest of the public, patients, carers and staff
To provide feedback on the consultation plan and be responsible for communications
and engagement
To provide a forum where political and public engagement could be considered and
reviewed.
The programme board consists of:
Joint commissioner and provider senior responsible officers:
o Chief executive of the Royal National Orthopaedic Hospital
o NCL CCGs’ director of strategy
Clinical lead, who is chair of Partnership for Orthopaedic Excellence: North London
An executive director nominated by each of the five largest providers of elective
orthopaedic services in NCL
Two GP representatives
Two patient representatives
NCL CCGs’ chief finance officer
64 The five NCL CCGs are anticipated to merge by April 2020 into one NCL CCG. The NCL CCG will take forward further
decision-making and support any required implementation plans as part of its support to a north central London integrated care
system.
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Commissioner representatives from neighbouring sustainability and transformation
partnerships (STPs)
Director from NHS England specialised commissioning
NHS England strategy and reconfiguration representative
Nominee from adult social services representing the five boroughs in NCL
Independent clinical adviser (medical director of South West London Elective
Orthopaedic Centre).
Workforce executive director lead (director of HR from the RNOH, and chair of the
NCL HR Directors Group).
Finance executive director lead (director of finance, North Middlesex University
Hospital Trust)
North London Partners in Health and Care head of communications and
engagement.
The programme board is supported by the programme team and workstream leads, as
required.
6.3. Other workstreams
Underpinning the programme board are two workstreams:
Partnership for Orthopaedic Excellence: North London
This capitalises on the clinical engagement built through the original review group in the first
stage of the programme and aims to deliver system wide quality improvement. The network
also provides clinical expertise and advice to support the programme board. The role of the
network is set out in greater detail in section 5.2.
The clinical network consists of:
A clinical lead
Clinical representatives from each of the largest five provider organisations Nursing
and Allied Health Professional representatives
Patient representatives
Managerial representative from each of the largest five provider organisations
GP representatives
Patient representatives
AHP lead
Nursing lead
Finance steering group
A time-limited finance steering group was established to work through the finance and
activity elements of the programme providing advice to the programme board. The chair of
the group was recruited through an expressions of interest process.
The finance steering group consists of:
Director of finance North Middlesex University Hospitals NHS Trust (Chair)
Director of finance from each of the five largest provider trusts or their nominees
CCG acute commissioner and finance representatives.
The governance structure is supported operationally between workstreams and managed by
the programme executive.
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The programme executive includes:
Joint SROs
Core programme team (programme director and programme manager)
Operational support from each workstream
Chairs of workstreams (as required).
Communications and engagement
Communications and engagement are not a standalone workstream within this programme.
Instead, existing NCL STP structures have been used to support the programme, with adult
elective orthopaedic review a standing item on the following agendas:
STP engagement advisory board
Regular meetings with the five Healthwatch chief executives
Monthly STP/CCG communications and engagement group
Quarterly STP/CCG/Provider communications and engagement group.
Operational support has been provided through the head of communications and
engagement for the STP, who sits on the programme board and joins the programme
executive as required. The team was also supplemented by an additional resource to
support the higher levels of activity required during the engagement phase of the
programme, the ongoing involvement of resident representatives in the lead up to the
options appraisal exercise and the preparation for and delivery of a public consultation.
A time-limited communications and engagement task and finish group, involving CCG and
provider communications leads and patient representatives was established to support the
development of the consultation plan and materials.
Figure 10: NCL adult elective orthopaedic review governance structure 2019
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7 Stakeholder65 engagement
This section details the engagement undertaken to test and further develop our case
for change, how residents have had the opportunity to shape the future service
model, how this has informed the proposed consultation, how the consultation would
be undertaken, and the equalities analysis process.
7.1 Overview
Public and patient engagement has informed the planning process from its earliest stages
and would continue through consultation during late 2019 and early 2020 into future
planning phases, transition and the next era of service delivery.
A robust approach to engagement has been at the core of the adult elective orthopaedic
review from the outset and this principle has been applied to working with clinical partners
and providers, in the development of the service model, and with local residents, to ensure
that they are informed, involved and have a role in shaping the outcome of the review.
Resident involvement took several forms:
Two patient representatives sit on the programme board (see section 6.2)
An additional three local residents attended the clinical design workshops during
summer/autumn 2018. These residents were selected by local Healthwatch
organisations and acted as representatives for the wider community. Additional
representatives took part in two workshops in spring 2019 which refined the clinical
model and reviewed the options appraisal criteria and proposed weightings.
A two-month engagement period widened the involvement in testing the draft case
for change, through a series of conversations, events and engagement opportunities
working with a community groups and organisations
An open call to feed back on the case for change was also issued, with opportunities
to comment on the draft case for change being promoted through a range of media
channels
The options appraisal scoring panel had equal representation from local patients and
residents.
This ran in tandem with ongoing engagement with health and social care partners.
7.2 Legal principles
When developing proposals for public consultation, commissioners must consider section
242 of the NHS Act 2006 and section 142Z of the Health and Social Care Act 2012. Under
these, NHS Trusts and CCGs have a legal duty to make arrangements for individuals to
whom the services are being or may be provided, to be involved throughout the process.
The principle of section 242 of the consolidated NHS Act 2006 is that, by law, NHS
commissioners and Trusts must ensure that patients and/or the public are involved in certain
decisions that affect the planning and delivery of NHS services. While section 242 has far-
reaching implications, it is at heart about embedding good decision-making practice by
ensuring that service users’ points of view are taken into account when planning or changing
services.
65 Stakeholders refers to staff, public, patients, health and wellbeing boards, overview and scrutiny committees and voluntary
sector organisations, among others.
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Section 242(1B) of the National Health Service Act 2006 as amended by the Local
Government & Public Involvement in Health Act 2007, states that:
Each relevant English body must make arrangements as respects health services for which
it is responsible, which secure that users of those services, whether directly or through
representatives, are involved (whether by being consulted or provided with information, or in
other ways) in:
(a) The planning of the provision of services
(b) The development and consideration of proposals for changes in the way services are
provided
(c) Decisions to be made by that body affecting the operation of those services
Subsections (b) and (c) need only be observed if the proposals would have an impact on:
(a) The manner in which the services are delivered to users of those services; or
(b) The range of health services available to those users.
In order to meet these legislative requirements, public involvement must be an integral part
of service change process. Engagement should be early and continue throughout the
process using a broad range of engagement activities.
All public consultations should adhere to the Gunning principles, which are:
Consultation must take place when the proposal is still at a formative stage
Sufficient reasons must be put forward for the proposal to allow for intelligent
consideration and response
Adequate time must be given for consideration and response
The product of consultation must be conscientiously taken into account.
Additionally, all pre-consultation engagement should be undertaken in line with the NHS
England guidance Planning, assuring and delivering service change for patients (2018)66.
This states that service change (including changes in location) should be undertaken only
when a public consultation has been undertaken, which is;
Aligned to the local Sustainability and Transformation Partnership (STP) plans
Assured by NHS England prior to consultation
Led by service commissioners
Involves full and consistent engagement with stakeholders including (but not limited
to) the public, patients, clinicians, staff, neighbouring STPs and Local Authorities
Shown to have met the Secretary of State’s four tests for service reconfiguration (see
section 11.1)
Undertaken in line with section 242 of the NHS Act 2006 and section 142Z of the
Health and Social Care Act 2012 (as set out above).
7.3. Pre-consultation engagement on the draft case for change
In August 2018, a draft case for change was published for engagement with patents,
residents and wider stakeholders (from providers, commissioners and local authorities),
which took place between 17 August and 19 October 2018.
66 https://www.england.nhs.uk/wp-content/uploads/2018/03/planning-assuring-delivering-service-change-v6-1.pdf
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The draft case for change was deliberately presented at an early stage of the process to
enable participation by as many stakeholders as possible. It offered a mechanism by which
the programme could test the rationale for change, enter into structured conversations with
key stakeholder groups and offered a description of the key components of a theoretical
model that stakeholders could base comments upon.
The exercise helped to:
Surface crucial insights which helped to shape the next stages of the review
Define which elements required refining in the development of the clinical service
model
Support our aspiration to develop a future service which meets the needs of all
stakeholders.
During the pre-consultation engagement phase, meetings were held with all current
providers of orthopaedic services within north central London, both NHS and from the private
sector. The draft case for change was also shared in August 2018 with a broader range of
private sector providers, inviting them to comment. Feedback from the pre-consultation
engagement, design principles and the NCL Joint Commissioning Committee decision in
January 2019 around contract form, were formally communicated to all stakeholders,
including all the private sector providers who had been asked to comment on the draft case
for change.
During the engagement phase, our intention was to enter into more detailed conversations
and undertake quality engagement with local residents, as this would be the most effective
way to test ideas and derive information that could genuinely influence future thinking.
Targeted meetings were held across the five boroughs, with a total of 181 residents and
patients attending. Meetings were established in a number of different ways as a result of
the team directly approaching specific groups, being invited to pre-existing fora and the
receipt of invitations from interested parties.
Meetings took the form of a short presentation, which explained the aspiration of the review,
its key drivers and what current thinking was around the future service model. Depending
upon the forum and the time allowed, there was then a question and answer session and
comments were given. All feedback was captured in writing. At some meetings, participants
also chose to complete a printed questionnaire which they returned on the day.
Some of the more informal opportunities took the form of one-to-one conversations between
interested parties and members of the programme team. For example, the Islington Over
55s group is a social group that meets each week to enjoy social activities and entertainment
together. At this group, attendees enjoyed the entertainment and then individuals with an
interest in the review had one-to-one or small group conversations with the review team.
Others chose to give written feedback through the questionnaire.
The draft case for change and accompanying materials offered a good foundation for
conversations. However, it should be noted that for some, it was challenging to engage on a
topic in its formative stages (as opposed to a firm proposal).
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Table 19: Patient and public engagement events and attendance numbers
Public and patient engagement events Attendance
numbers
Camden CPEG – Patient engagement meeting 16
Islington Over 55s Group Clairmont Centre – Public event 23
Having A Say Group – Barnet Mencap- Learning Disability Group 10
Haringey Adult Social Care Joint Partnership Board – Patient
Public engagement 16
Enfield CCG Voluntary Community Stakeholder Reference Group
– CCG Stakeholder reference group – Patients/Public 11
Barnet Healthwatch – Patient and public event 11
Enfield CCG – Patient and public event 24
St Luke’s, Islington Group (with Healthwatch Islington) – patient
group 9
Haringey CCG open event 26
Camden Healthwatch Group – community event 7
Camden Carers’ Group – meeting with carers in Camden 3
Enfield Healthwatch public event – patient public event 23
Gendered Intelligence – patient group 2
TOTAL 181
In addition to these public events, stakeholder meetings were held. Members of the
programme team also attended external meetings to seek feedback on the case for change.
Table 20: Stakeholder meetings
Engagement Forum Meetings/Events (number of
events per stakeholder group) Numbers
Commissioners 7 54
Providers67 10 287
Local authority 6 22
Total 36 544
67 These are in addition to the clinical design workshop and included all current NCL providers of orthopaedic services
(independent sector and NHS)
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Alongside these in-depth engagement opportunities, wider reach was achieved by open calls
for involvement and the sharing of the case for change through organisational channels,
including electronic and print bulletins, mail outs, and social media. The case for change was
also available on the NLP website and included an online questionnaire. Communications on
the case for change reached a total of 58,710 people, most of whom lived in north London.
The engagement exercise was informed by an initial Equalities Impact Assessment (EIA)
which set out responsibilities of commissioners under the Equality Act 2010 and assessed
likely impact on groups sharing protected characteristics or others at risk of health
inequalities (deprivation, caring responsibility).
This identified groups with disproportionate need for elective orthopaedic surgery or
differential need. For example, females and males may have different needs to access a
service but there is no evidence to suggest that either females or males have a
disproportionate need. (See section 7.6)
Communication about the review and case for change and promotion of the engagement to
the scoped-in groups was through a mix of thirteen different community channels (e.g.
newsletters) provided by Healthwatch organisations and CCGs in each of the five boroughs
in north central London, plus a further four regular publications aimed at local patients
produced by four of the providers.
In addition, direct approaches were made to organisations and networks with reach to all of
the scoped-in groups. Invitations to participate in the engagement in a format appropriate to
each group were delivered. As a result, 26 organisations participated and there were nine
meetings and events relevant to equalities communities.
All groups scoped in through the equalities impact assessment participated in the
engagement exercise, with engagement methodology shaped in line with their preferences
for participation: some preferred one-to-one conversations, some preferred to be part of a
wider group conversation and others preferred to participate in an event established
especially for their group e.g. those with learning disabilities.
7.3.1 Engagement on key design principles
A series of five clinical design workshops between July and November 2018. The workshops
aimed to establish:
An outline pathway
Emerging design principles
Areas needing further attention during the subsequent stage of the review.
The workshops ran concurrently with the engagement on a draft case for change. Although
separate exercises, there was some overlap in those attending the workshops and those
attending engagement meetings on the draft case for change, and the two processes were
complementary.
Scope of the workshops
The five workshops took place between July and November. In total 63 people attended the
workshops, drawn from the review group, wider clinical teams in acute trusts, patient
representatives (nominated by the five Healthwatch organisations in NCL) and clinicians
working in a community setting (for workshop 4). All attendees were also asked to attend the
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final plenary session which summed up the outputs from all four workshops. A few additional
attendees, mainly clinical commissioners (including colleagues from neighbouring
CCGs/STPs outside north central London), were also asked to attend the plenary to enable
them to hear the feedback from the workshops.
The workshops covered the following areas:
Session 1 – Learning from others (18 July 2018): Speakers were invited from
south west London to talk about the operation of the South West London Elective
Orthopaedic Centre (SWLEOC), Greater Manchester Health and Social Care
Partnership and the Royal Free Group to share their experiences of similar
programmes of work separating planned and emergency orthopaedic activity
Session 2 – Developing the vision and high-level operating principles for NCL
service (12 September 2018): Session focused on the acute elements of the high-
level pathway and case-mix considerations
Session 3 – Managing dependencies and identifying factors that might
undermine a new model of working (19 September 2018): Session looked at
workforce considerations, alongside key dependencies (trauma, paediatrics and
spinal surgery)
Session 4 – Ensuring alignment with pre and post-operative pathways (31
October 2018): Session focused on the community elements of the end-to-end
pathway, particularly core components of a single point of access and the
arrangement of rehabilitation and follow-up in a community setting
Session 5 – Plenary session (7 November 2018): Fed back the emerging themes
from the first four design workshops and outlined key areas where further
consideration is required.
7.3.2 Feedback from engagement on the draft case for change
The following table sets out the main areas of feedback from the draft case for change
engagement process, and details how/where they have been addressed.
Table 21: Main areas of feedback68
Main area raised during engagement Addressed through
Patient experience: Patients with vulnerabilities (e.g. those with learning disabilities, dementia, and/or mental health issues) might find it difficult to travel to and find their way around an unfamiliar hospital, with unfamiliar staff. It was suggested that consideration could be given to having people available to assist them on arrival.
Clinical delivery model: Inclusion of care co-ordination function in the proposed model of care and transport section.
Options appraisal: Included a scored section on patients with vulnerabilities within the patient experience section (criterion 3).
Continuity of care: There were several points raised around the subject of continuity of care.
Clinical delivery model: This was specific about where pre-operative
68 Verve engagement evaluation report, North Central London adult elective orthopaedic services review’ pages 5-6, NCL
CCGs Joint Commissioning Committee 6 December 2018
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Main area raised during engagement Addressed through
In the majority of cases, these were about the location of pre-operative assessments and post-operative care/rehabilitation. These comments indicate that there is a need for the review to clearly explain where these activities would take place at the next stage of engagement.
assessment and patient education sit in the pathway.
Options appraisal: Detailed consideration was given to the fit with the clinical delivery model (criterion 1) and about how providers who put themselves forward to be an elective centre propose plan to manage patient education and pre-operative assessment.
Patients with complex needs: It was not clear where patients with complex needs (e.g. those with comorbidities) would have their surgery. This is a growing section of the population and it would be important for the review to produce clear and well justified recommendations.
Clinical delivery model: Included an essential requirement for all proposed elective centres to have an HDU to be able to manage medically and orthopedically complex patients safely.
Options appraisal: Criterion 1 included an assessment of providers’ proposals around inclusion of an HDU, case-mix and managing clinical complexity.
Integration: Contributors stressed the importance of joined-up working and integration between clinical, social care and rehabilitation services. The role of an integrated IT system was important if care is to be delivered across multiple locations.
Clinical delivery model: Included a section on digital requirements for the new system.
Options appraisal: IT and digital considerations were included as part of the deliverability score (criterion 2).
Travel (always a key concern for public and patients): With the assumption that future proposals could mean more time and money spent on travelling to appointments, as well as the potential impact on those with mobility impairments and/or economically deprived residents. There were repeated comments suggesting that an in-depth transport analysis should be considered so that the implications could be fully understood.
Clinical delivery model: Included a section on transport requirements.
Options appraisal: Criterion 3: patient experience specifically addressed transport considerations.
Public consultation: a detailed travel analysis is being undertaken to enable concerns and issues raised to be addressed throughout the proposed public consultation. It would be published as part of the proposed public consultation.
Across the system: A number of people mentioned the potential risk of unintended/indirect consequences for other parts of the local health economy. For example, loss of elective income could damage the viability of services at base hospitals, and the separation of trauma and elective orthopaedic work could have a
Clinical delivery model: Included sections on interdependent services.
Options appraisal: Hurdle criteria were included on whole system financial impact of any proposals. Criterion 4: impact on other services, looks at the impact on other services of options to be an elective centre.
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Main area raised during engagement Addressed through
detrimental effect on staff training, skills, job satisfaction and retention/recruitment.
System-wide sense check: Has been built-in to take place after the options appraisal process in order to take a step back and ensure that the preferred options are congruent when taken as a whole.
Patient choice: Some members of the public raised concerns about the potential restriction of patient choice through consolidating elective services onto a small number of sites.
Clinical delivery model: The clinical delivery model was developed with patients, clinicians, staff and residents, to ensure that referrals would continue to be made to base hospitals, with pre- and post-operative care managed locally. Surgeons from the base hospital would carry out surgery at the elective centre(s). Patient choice would still exist to enable patients to access care providers both within and outside north central London.
The model: More detail and reassurance were sought about the practicality of separating ‘hot’ and ‘cold’ work, based on the concern that staff might be pulled back to trauma work at times of high demand, winter pressures etc.
Clinical delivery model: The preferred model of care has been based on the successful model of care in south west London (SWLEOC).
Options appraisal: This would test the deliverability of the options put forward and any unintended consequences. Experts from the trauma network would provide an assessment of the viability of plans.
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7.4. Process for developing the criteria
Proposed assessment criteria were included in the draft case for change which was the
subject of an engagement process from August to October 2018.
Figure 11: Engagement process for developing the criteria
Drawing on the extensive engagement around the draft case for change, the adult elective
orthopaedic services programme executive developed an initial proposal for evaluating
provider options, including the clinical delivery model criteria. These proposals were then
tested with a range of key stakeholders, including through a workshop with clinical and
patient representatives. The proposed criteria and weightings were amended as a result of
this feedback (see section 8).
7.5. Governance and assurance for involvement and consultation
Collaboration to involve all groups of people who may be affected by the proposals is
enabled through existing and well-established NCL communications and engagement
channels and structures rather than setting-up a separate standalone workstream. This
delivers the strategy and action plan for involvement and consultation. Within the programme
governance structure, the communications and engagement lead reports to the programme
director.
Additionally, The Consultation Institute, a not-for-profit best-practice institute promoting high
quality public and stakeholder consultation, has been commissioned to work with the
programme team and provide assurance around the development of consultation approach
and materials. In addition, a time-limited task-focused consultation planning group would be
established to underpin the development of an inclusive, robust consultation.
The communications team relies on a number of key relationships to support delivery, which
include:
CCG and trust patient reference groups
83
Healthwatch organisations
NHS England and NHS Improvement communications and involvement teams
Voluntary sector agencies and advocates.
7.6 Public sector equality duty
The Public Sector Equality Duty (PSED) was created by the Equality Act 2010 to harmonise
the previous race, disability and gender equality duties and to extend protection to the new
protected characteristics listed in the act. The PSED replaced these duties and came into
force on 5 April 2011.
The duty covers age, disability, sex, gender reassignment, pregnancy and maternity, race,
religion or belief and sexual orientation. It applies in England, Scotland and in Wales. The
general equality duty is set out in section 149 of the Equality Act 2010.
In summary, those subject to the general equality duty must have ‘due regard’ to the need
to:
a. Eliminate unlawful discrimination, harassment and victimisation and other conduct
prohibited by the Act
b. Advance equality of opportunity between people who share a protected characteristic
c. Foster good relations between people who share a protected characteristic and those
who do not.
The equality impact assessment (EIA) process is designed to ensure that a project, policy or
scheme does not discriminate against any disadvantaged or vulnerable people or groups.
This ensures the NHS pays ‘due regard’ to the matters covered by Public Sector Equality
Duty.
7.6.1 Summary
The approach to undertaking an integrated health inequalities and equality impact
assessment has been described in detail in section 4.4. The stage 1 integrated health
inequalities and equality impact assessment, which was produced in September 2018, has
been shared with key stakeholders as well as being made publicly available, focused on
supporting the review process to ensure that North London Partners in Health and Care has
considered the potential impacts on those characteristics protected under the Equality Act
20102, including those who identify as carers. The pre-consultation equalities and health
inequalities impact assessment (stage 2 within the process) is due in December 2019 and
will be published alongside the consultation.
7.7 Local authority scrutiny
CCGs are under a duty to consult with the local authority about any proposals for a
substantial development or variation of service. Therefore, in line with scrutiny regulations,
the North Central London Joint Health Overview and Scrutiny Committee is leading a joint
scrutiny process for these proposals.
Since the start of the programme, the North Central London (JHOSC) has been engaged on
the development of the proposals:
23 March 2018 – initial presentation to the JHOSC setting out the rationale for the
review and proposed approach
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30 November 2018 – presentation setting out the feedback from the pre-consultation
engagement and next steps
March 2019 – written update to the JHOSC on the next steps for the review
21 June 2019 – presentation to the JHOSC updating them on the features of the
clinical delivery model and process for managing the options appraisal process
27 September 2019 – presentation to the JHOSC setting out the proposed model of
care following the options appraisal process and proposed approach to public
consultation.
There is also a local authority representative on the programme board. The Lead Member
for Health and Social Care (or committee lead) and Directors of Adult Social Services have
been regularly briefed about the proposals during their development and their input sought.
This section outlines the options appraisal process, the proposals submitted from
provider hospitals, how the options appraisal panel worked, the scoring criteria and
the final panel scoring decisions.
The process of assessing and selecting a preferred option is an important step before a
public consultation and we have involved our stakeholders, clinicians, patients and residents
fully.
The proposals were developed in an innovative, collaborative way between the providers of
health services in north central London. A number of steps have happened along the way
which have narrowed the number of options that could be considered and have led to the
proposed service model which is being put forward for consultation.
Over the summer and autumn of 2018, a series of clinical design workshops were held with
commissioners, clinicians, patients and residents. These clinical design workshops did not
start with a predetermined view of the service model that should be put forward; rather they
considered how similar service models have been implemented elsewhere, as well as
specific elements of the service model (the patient pathway, clinical interdependencies and
fit with primary and community services), and brought all these aspects together in a final
plenary session with conclusions for validation by a wider group of stakeholders. Full details
of the clinical design workshops are set out in section 7.1.3 of this document.
The output of the clinical design workshops was reviewed alongside the feedback from the
pre-consultation engagement exercise and a number of clinical design principles were
developed for the new service and agreed by the NCL JCC in December 2018.
The design principles agreed by the NCL JCC were:
Differentiation of ‘levels or tiers’ of service at different hospitals
Partnership approach with all hospitals being seen as a ‘base’ hospitals with a stake
in an elective centre
Staffing model with clinical staff working into the unit from the local trusts, particularly
surgeons following the patient to the elective centre and providing continuity of care
Development of common standards and pathways approach, overseen by a Network
with a standard set of outcomes that all organisations should adhere to and are used
to measure success with clinical governance/oversight over them
8. Options appraisal process
85
All pre-operative and post-operative outpatient care to stay at base hospitals (i.e. as
at present)
Paediatrics, trauma, spinal surgery to stay at base hospitals (i.e. as at present). For
paediatrics the base hospital would act as a filter, with complex referrals continuing to
go to GOSH and RNOH
Care-coordination function (navigators) to be included in the new model, to work
across base hospitals and elective centre(s), with a particular focus on vulnerable
patients
Multidisciplinary team working to be a core component of the model – need to
develop expectations about how this would operate. Noted that there should be
opportunities to do some of this virtually
High Dependency Unit – elective centre needs to be able to manage a range of
conditions and complexity, to do this they will require appropriate back-up medical
services and step-up care.
There were six areas identified where additional focus would be needed in the next stage of
the review:
System sustainability particularly the financial model
Keeping the focus on the patient, particularly travel, ease with which patients can
understand the model and development of integrated pathways
Developing a pathway that crosses organisational boundaries, particularly where
patient education (Joint School) and pre-operative assessment should sit in the
pathway and clarity about clinical responsibility at each stage in the process
Agreeing the clinical case-mix in the new model, particularly around day-cases and
complex patients
Modelling about the impact of any changes on the management of key dependencies
at base hospitals (trauma, paediatrics and spinal surgery)
System enablers, particularly IT interoperability and workforce considerations.
As a direct consequence of the clinical design principles, in January 2019 the NCL JCC
agreed that, because of the interdependencies with other services, particularly emergency
care and the need to provide high dependency support, planned orthopaedic services
should remain within the NHS by way of variations to existing annual contracts.
Between January 2019 and May 2019, further work was undertaken to develop and refine
the service model and address the areas that had been identified at the NCL JCC as
needing further consideration. Three more workshops were held, which again involved
commissioners, clinicians, patients and residents: a workshop in March to look at refining the
service model, a further workshop in March to consider digital interoperability, and a final
workshop in April to consider the options appraisal criteria.
Alongside these workshops additional expertise was brought into the programme team:
In the same way that a joint senior responsible officer for the programme was chosen
from commissioners and providers, it was felt that there should be a trust finance
lead trust. Expressions of interest were sought from acute providers’ directors of
finance to act as a single provider finance lead for the review and join the programme
executive. They would work with Simon Goodwin, STP chief finance officer as the
commissioner finance lead. David Stacey, director of finance at the North Middlesex
was appointed, and a finance workstream initiated to focus on the financial modelling
continued to meet until October 2019.
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In January 2019, expressions of interest were sought for an external clinical advisor.
Phil Mitchell, medical director of the South West London Elective Orthopaedic
Centre, was appointed to the role.
In May 2019, drawing on these additional inputs, the NCL JCC agreed a clinical delivery
model for the new service, based on the clinical design principles which had already been
agreed. This set out three tests which had to be met:
The provider must already be a provider of planned orthopaedic surgery
The dedicated operating theatres and supporting facilities for orthopaedic care must
be located on a site operated by members of North London Partners in Health and
Care
The option must demonstrate a favourable income and expenditure impact for the
system after two years of operation.
The clinical delivery model also set out in detail the full range of essential clinical criteria
which any option would be required to fulfil. This clinical delivery model can be found in
chapter 5.
Each of the five eligible NHS organisations in north central London was invited to put forward
options that would meet these requirements. The invitation set out the ambition for a system-
wide partnership approach to delivering services, rather than establishing a competitive
process in which providers compete with each other to deliver services. Providers were able
to submit proposals to become a base hospital, an elective centre, or both. There was,
however, no predetermined view about the option or options which should be put forward.
The deadline for proposals was noon on 5 July 2019, and two joint proposals were received:
North Middlesex University Hospital NHS Trust and The Royal Free London NHS
Foundation Trust
University College London Hospitals NHS Foundation Trust and Whittington Health
NHS Trust.
In putting forward these proposals, providers themselves discounted some remaining
options:
A single elective centre covering the whole of north central London
An elective centre at Whittington Health focusing on inpatient orthopaedic activity
An elective centre at the North Middlesex Hospital focusing on inpatient orthopaedic
activity.
The Royal National Orthopaedic Hospital chose not to submit a proposal to be a local
elective centre. It will continue in its role as a super specialist centre providing local and
national tertiary care and would be a key partner in developing local services, therefore
discounting itself as an elective inpatient centre.
The scoring of the non-financial criteria was carried out by a panel consisting of patients,
residents and clinical commissioners. The detail of the scoring is set out later on in this
chapter in section 8.7. In summary, the panel considered the two partnership options put
forward to be complementary and that both options not only met the criteria but were also
better than the status quo.
Following the options appraisal process, a collaborative system-wide sense check took place
with provider trusts, patients, residents and commissioners to ensure that there were no
unintended consequences arising from the preferred option.
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The outcome of the options appraisal and system-wide sense check were informally
reported to the NCL JCC and key stakeholders prior to being presented to the London
Clinical Senate for review.
It is this preferred option which would form the basis of a future public consultation.
8.1. The process for selecting a preferred option
Figure 12: Submissions of options process
Process for the submission of options
At the Joint Commissioning Committee meeting on 3 January 2019, a decision was made
that the services under the newly configured clinical delivery model would remain within the
NHS by way of variations to existing annual contracts to ensure providers could meet
essential criteria.
Following the NCL JCC meeting on 2 May 2019 each of the five eligible NHS organisations
was invited to submit a proposal to deliver adult elective orthopaedic services in NCL.
Organisations were able to submit proposals to be a base hospital, an elective centre or
both. The organisations approached were:
North Middlesex University Hospitals NHS Trust
Royal Free London NHS Foundation Trust
Royal National Orthopaedic Hospitals NHS Trust
University College London NHS Foundation Trust
Whittington Health NHS Trust.
The invitation set out the ambition for a system-wide partnership approach to delivering
services rather than a traditional competitive process focused on individual organisations.
To support organisations put together their submissions the programme team:
Offered support to providers to advise on bid writing and materials and capacity to
support finance and activity modelling
Hosted an expert event on 26 June 2019 involving Health Education England (HEE) and
wider stakeholders to help inform the education and training section of the submission
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Hosted a collaborative workshop on 12 June, approximately halfway through the
process, for providers to share their emerging proposals and gain visibility about any
intersections between provider submissions, particularly around key dependencies.
8.2. Proposals submission
The deadline for proposal submission was noon on 5 July 2019. Two partnership proposals
were received:
North Middlesex University Hospitals NHS Trust and Royal Free London NHS
Foundation Trust
University College London NHS Foundation Trust and Whittington Health NHS Trust.
The Royal National Orthopaedic Hospital chose not to submit a proposal to be a local
elective centre. It continues in its role as a super specialist hospital providing local and
national tertiary care and would be a key partner in developing local services.
8.3. Creating the shortlist
Each proposal was required to meet a number of hurdle criteria in the options that they put
forward. The shortlist was made up of all options that met these hurdles.
The hurdle criteria used were designed to ensure that they did not rule out options that made
use of any site available to the providers, or collaborations between providers or between
providers and the private sector, providing the options put forward supported delivery of the
requirements set out in the clinical delivery model.
Table 22: The hurdle criteria
Criteria Description
Existing
provider
That the provider is already a provider of elective orthopaedic services.
North London
Partners in
Health and
Care
Elective centres located on a site operated by member of the
Sustainability and Transformation Partnership, North London Partners
in Health and Care.
Financial
Demonstrate a favourable income and expenditure impact for the
system after two years of operation, against a counterfactual69 including
growth and cost of growth.
Within the health system70 we anticipate that:
Commissioners would continue to purchase the same volume of
activity regardless of the model that is adopted.
In the short term there would be financial winners and losers
amongst the providers of services resulting from these changes. It
69 A projection of how finances would appear if the proposals were not to go ahead 70 The methodology described for assessing the financial impact on the health system has been written on the basis that
Payment by Results (PbR) continues to be the framework by which money moves around the system and all organisations are held to account for separate control targets. We appreciate that this system is changing; PbR is likely to be replaced and system-wide control targets would be introduced. As the new framework becomes clearer the methodology for assessing the financial impact of each option may need to change. However, any new methodology would continue to concentrate upon the changes to the cost of the whole system, the efficiencies generated and the impact on legacy services.
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Criteria Description
may be necessary for providers to agree short-term financial
arrangements to mitigate for any temporary losses.
To meet this hurdle condition each proposal would need to be
demonstrate that:
The cost to commissioners would be no more than the cost of
orthopaedics if there were to be no development. It follows that: any
changes to the patient pathway do not result in new Payment by
Results (PbR) costs (such as additional outpatients attendances),
there is no net increase to the prices from Market Forces Factor
(MFF) variations or other factors and there are no new costs that
providers expect commissioners to fund.
The provider proposing the option is able to show that the elective
centre is a more efficient model of care with lower costs than the
current model of care. If there are new costs associated with the
model such as capital costs or patient transport costs, then these
must be offset against savings elsewhere.
Other acute providers impacted by the change to elective
orthopaedics should be able to show that the impact on the cost of
trauma and other legacy services is negligible, and that any
stranded costs associated with the loss of elective surgery could be
rapidly absorbed.
There should be no cost implications for community or primary care
services.
Both the proposals submitted were reviewed and assessed to have met the initial hurdle
criteria, they were therefore put forward for more detailed evaluation as part of the options
appraisal process, this consisted of two elements:
Assessment of non-financial criteria carried out on 17 July 2019.
Initial assessment of financial criteria carried out on 18 July 2019.
8.4. Assessment of non-financial criteria
The panel
The scoring of the non-financial criteria was carried out by a panel consisting of clinical
commissioners, together with patients and residents. The panel comprised of:
Planned care clinical lead, NCL CCGs and GP representative Camden CCG
GP lead, Enfield CCG
Lead Director of Quality, NCL CCGs
Director of Commissioning, Barnet CCG
Director of Finance, NCL CCGs, scoring together with the Director of Finance, Barnet
CCG
Director of Strategy, NCL CCGs
Director of Strategic Commissioning, North East London CCGs.
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Patient and resident panel representation
Ensuring there was effective patient and public representation on the panel was fundamental
to achieving our aim of putting patients and residents at the heart of the redesign process.
Drawing on the desktop equalities impact assessment, six patient and resident
representatives were recruited to the panel. They consisted of:
Two representatives who attend the programme board
Two representatives who had attended previous workshops
Two new representatives from NCL.
To recruit the new representatives, an NCL-wide recruitment campaign took place, delivered
in partnership with Healthwatch, providers and the voluntary sector. As a result of this
exercise, 18 residents expressed an interest in being part of the panel.
Not everyone who expressed an interest could be accommodated on the panel. To ensure
as wide a range of opinions and voices as possible could be represented during the non-
financial evaluation, all patients and residents who expressed an interest were invited to
attend a workshop. All views captured on that day were used to inform the patient and
resident contribution to the evaluation process.
To support patients and residents navigate the process, a training session was provided to
all participants prior to the options appraisal day. The event aimed to explain objectives of
the day and the evaluation process itself.
Additional support
On the day expert independent support to the process, including review and analysis of all
the provider submissions, was provided by NEL CSU. Two independent clinical advisers,
both orthopaedic surgeons, were also present: Phil Mitchell, Medical Director at the South
West London Elective Orthopaedic Centre; and Professor John Skinner, surgeon at the
Royal National Orthopaedic Centre and with an academic at University College London.
Expert specialist input and written advice was sought and shared with the panel to assist
their deliberations:
North west London spinal network and north London trauma network were asked to
provide written feedback around these key dependencies
HEE and a range of independent clinical inputs to review workforce implications
NCL estates and digital programme teams
NHS England Specialised Commissioning.
8.5. Options appraisal day
On 17 July 2019, a formal options appraisal day was held to evaluate the submissions
against the non-financial criteria.
At the start of the session, each partnership of providers was asked to present to the panel
focusing on:
How the option submitted would be an improvement on current service delivery
How the option submitted would be delivered and how risks around delivery had
been mitigated.
Scoring methodology
91
The purpose of the day was to assess each of the collaborative options against how services
work at the moment. As the two submissions received were not in competition with each
other, they were each scored against the status quo.
Voting panel members were asked to consider their score for each proposal and compare it
to the status quo for each sub-criterion (i.e. the continuing impact of not changing how
elective orthopaedics are delivered). For both options the panel agreed to score the status
quo at 2 for all criterion and sub-criterion, apart from deliverability which was scored at a 5
(as the status quo is by definition going to be straightforward to deliver).
The aim was to reach a consensus score with which all attendees were content. Where
consensus was not achieved, panel members’ individual scores were averaged. A scale of 0
to 5 was used with 0 demonstrating weak evidence that the proposal would improve the
quality of care and 5 demonstrating exceptional improvement compared to the status quo.
Table 23: options appraisal criterion scoring
Score Comments
0 Very weak or not answered
1 Poor
2 Satisfactory
3 Good
4 Very good
5 Exceptional
Before each criterion was discussed, the panel considered ‘score calibration’. It was made
clear that if the group felt that there was insufficient information supplied to agree a score, a
provisional score could be awarded, or no score given, and more information sought.
The differences in scores between different options was noted to enable the programme
board of the adult elective orthopaedic services review and the senior management
committee of the NCL CCGs to consider the robustness of the scoring as part of their
discussions to put forward a recommendation to the Joint Commissioning Committee of the
NCL CCGs.
8.6. Non-financial criteria
The following scoring matrix was approved by the NCL JCC on 2 May 2019 and used to
score both of the partnership options that were submitted.
To ensure complete transparency about the process that was going to be undertaken, it was
issued to providers with the clinical delivery model on 17 May 2019.
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Table 24: non-financial criteria
Criteria Detail of what was to be assessed Sub-section
weighting
Section
weighting
Criterion 1:
Fit with the
clinical delivery
model
How the provider proposes to deliver
the essential and innovation features
of the clinical delivery model to achieve
effective, safe care for patients?
50%
40% How well the provider’s workforce plan
supports the aspirations of the clinical
delivery model?
40%
The provider’s proposals for improving
education, training and research
capability in NCL?
10%
Criterion 2:
Deliverability
Material risks that could delay or
prevent a decision from being made 65%
20% Material risks that could delay or
prevent the scheme from being
implemented once a decision to
proceed has been taken.
35%
Criterion 3:
Patient
experience
How well does the option offer a quality
service tailored to the needs of patients
with vulnerabilities or those with
complex needs (non-medical)?
30%
25% How would the option deliver an
accessible service for all patients and
carers in north central London?
40%
How would the option improve patients’
experience of care? 30%
Criterion 4:
Impact on other
services
Trauma services 60%
15% Paediatric and adolescent surgery 10%
Spinal surgery 10%
Primary and community services 20%
The final scoring matrix was considerably amended following a workshop on 1 April 2019
involving clinicians and patients and resident representatives. The changes made to the
matrix are set out in Appendix B.1.
The detail to be considered in the evaluation of each criterion and sub-criterion follows:
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Table 25: Criterion 1: Fit with the clinical delivery model
Sub-criterion Description
How does the option deliver the
essential innovation features of the
clinical delivery model to achieve
effective, safe care for patients?
The assessment would take account of how the
essential requirements and innovation features of
the clinical delivery model would be met.
How well the provider’s workforce
plan supports the aspirations of
the clinical delivery model?
The assessment would cover how:
The roles at elective centres would be put in
place
The key workforce principles would be met
NLP STP workforce programme alignment
would be achieved.
The provider’s proposals for
improving education, training and
research capability in NCL?
Improved research outcomes [Pointers
high scoring options would demonstrate that
the quality and quantity of research would be
enhanced and that there would be patient
benefits accruing]
Impact on education and training [Pointers
Scoring would recognise that there could be
both positive and negative impacts on
education and training]
Criterion 2: Deliverability – definition: the relative difficulty associated with bringing the option
to completion.
Providers were not asked to submit a specific response in relation to this criterion. This
criterion was assessed holistically against all the information provided for each option.
Table 26: Criterion 2: Deliverability
Sub-criterion Description
Material risks that could delay or
prevent a decision from being
made.
The assessment would take account of:
The degree of support from key stakeholders
that the proposal is able to demonstrate
The complexity of the proposal including factors
such as whether the project would need to
obtain capital funding before it could receive
support
The complexity of the governance
arrangements for making a decision
If the demonstration that the proposal is
affordable is likely to be difficult and/or require
compromise and negotiation between
stakeholders.
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High-scoring options would demonstrate that there
would be no risk or that risk is not applicable to the
proposal.
Material risks that could delay or
prevent the scheme from being
implemented once a decision to
proceed has been taken.
The assessment would take account of
implementation programmes that involve:
Complex governance arrangements
High implementation costs
Significant change required to business
processes or IT systems
Significant disruption to the workforce and/or
ways of working
Major capital works
Challenges associated with maintaining safe
and efficient patient services during the
implementation stage.
While high-scoring options could demonstrate that
there would be no risk or that risk is not applicable
to the proposal, if a risk is acknowledged but
mitigated sufficiently it could still score well.
Table 27: Criterion 3: Patient Experience
Sub-criterion Description
How well does the option offer a
quality service tailored to the
needs of patients with
vulnerabilities or those with
complex needs (non-medical)?
Options would be assessed against the extent to
which they have considered patients with
additional needs, either through (non-medical)
complexity or vulnerability, in terms of planning of
the service model.
How would the option deliver an
accessible service for all patients
and carers in north central
London?
Options would be assessed against both the
design of the service model and plans to meet
transport requirements.
How would the option improve
patients’ experience of care?
Options would be scored on the extent to which
the proposed model of care would improve
patients’ experience of orthopaedic services. This
would include how options would meet the
performance measures in the clinical delivery
model.
Criterion 4: impact on other services was assessed by looking at all of the submissions
provided as part of the submissions of options process, including those from providers who
only envisaged a role for their organisation as a base hospital.
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Table 28: Criterion 4: Impact on other services
Sub-criterion Description
Paediatric and
adolescent surgery
Options would be assessed on the likely impact of the option on
paediatric and adolescent surgery in north central London as a
whole.
Trauma Options would be assessed on the likely impact of the option on
trauma services in north central London as a whole.
Spinal surgery Options would be assessed on the likely impact of the option on
spinal surgery in north central London as a whole.
Primary and
community services
Options would be assessed on the likely impact of the option on
primary and community services in north central London as a
whole.
8.7 Scoring against the non-financial criteria
On 17 July 2019, the options appraisal panel met for a full day of deliberation to assess both
the partnership options which had been submitted.
The panel welcomed the really positive engagement from clinicians and management. It was
clear that lots of thought and effort had gone into the collaborative submissions. The panel’s
view was that both submissions were clearly an improvement on the status quo and met the
aspirations of the clinical delivery model. The panel also recognised that research and
training opportunities had been positively articulated. The panel acknowledged the
importance of the clinical network in delivering change.
The panel was impressed by the thought that had been put into how the new models of care
would support patients with vulnerabilities and complex non-medical needs. It felt that this
represented a huge step change compared to current ways of working as a system. The
panel fed back that both models had the potential to improve the overall experience of care
for patients in north central London.
Table 30 is a summary and narrative of the scores for each submission. Tables 31 and 32
set out the scores in full for each partnership bid for each criterion and sub-criterion,
The only area where the panel was unable to score either submission was on the impact on
spinal services in criterion 4. This area was removed from the assessment, and further
information has been sought following the options appraisal process.
To assist the panel in its deliberations, external written feedback was provided by a number
of external stakeholders: spinal network, trauma network, NHS England specialised
commissioning, STP estates and digital programme teams and HEE and workforce
specialists. Stakeholders were all asked to provide detailed written comments as well as a
RAG rating to assess whether each option would enhance or detract compared to the status
quo. All of the external RAG ratings were either green or amber, suggesting that none would
result in a detrimental position compared to the status quo.
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Table 29: Submission scores - summary
North Middlesex/Royal Free
partnership
UCLH/Whittington Health
partnership
Overall
Overall the submission also scored
significantly above the status quo,
with the option scoring 39.92
unweighted against a status quo of
28.00 (the maximum score
achievable was 60.00). Weighted
these scores were 3.71 against a
status quo of 2.57 (with a maximum
score of 5.00). The panel felt that
many of the issues and
improvements were common to both
bids.
Overall the submission scored
significantly above the status quo,
with the option scoring 39.35
unweighted against a status quo of
28.00 (the maximum score achievable
was 60.00). Weighted these scores
were 3.71 against a status quo of 2.57
(with a maximum score of 5.00). The
panel felt that many of the issues and
improvements were common to both
bids.
Criterion
1
The option scored significantly better
than the status quo for criteria 1, fit
with the clinical delivery model,
indicating that the panel felt that the
option would deliver real
improvements to clinical outcomes,
workforce and education and training,
and that the trusts’ proposals met the
clinical specification. The highest
scoring area was education and
training where the panel felt that the
proposal demonstrated significant
opportunities to enhance clinical
practice and development across all
disciplines.
The option scored significantly better
than the status quo for criteria 1, fit
with the clinical delivery model,
indicating that the panel felt that the
option would deliver real
improvements to clinical outcomes,
workforce and education and training,
and that the trusts’ proposals met the
clinical specification. The highest
scoring area was education and
training where the panel felt that the
proposal demonstrated significant
opportunities to enhance clinical
practice and development across all
disciplines.
Criterion
2
The option scored marginally below
the status quo for criteria 2,
deliverability, indicating that the panel
felt that there would no significant
complications with implementing the
changes proposed.
The option scored marginally below
the status quo for criteria 2,
deliverability, indicating that the panel
felt that there should be no significant
complications with implementing the
changes proposed. The panel noted
that the service would require the
fitting out of new clinical space in the
new hospital phase 4 development
(under construction) and as a result
there could potentially be delays in
the implementation.
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North Middlesex/Royal Free
partnership
UCLH/Whittington Health
partnership
Criterion
3
Within criteria 3, patient experience
the option scored significantly better
than the status quo for the needs of
patients with vulnerabilities and the
experience of care, indicating that the
panel recognised significant
improvements that would be seen by
patients in areas such as reduced
cancellations. The score for
accessibility was only slightly better
than the status quo. Although it was
recognised that access to patient
pathways would improve the panel
had concerns about how patients’
travel would be impacted particularly
for those that relied upon public
transport.
Within criteria 3, patient experience,
the option scored significantly better
than the status quo for those patients
with vulnerabilities, indicating that the
panel recognised significant
improvements that would be seen by
patients in areas such as reduced
cancellations. The score for
accessibility was only slightly better
than the status quo. Although it was
recognised that access to patient
pathways would improve the panel
had concerns about how patients’
travel would be impacted particularly
for those that could not use public
transport for access to UCLH.
Criterion
4
The option scored only marginally
better than the status quo for criteria
4, impact on other services. The
panel felt that the changes would
have some positive impacts on the
trauma service and on primary and
community services. However, they
were not able to discern any impact
on orthopaedics services for
children. There was felt to be
insufficient information to score the
impact on spinal services and further
clinical information was to be sought
after the options appraisal process
about how spinal surgery would be
managed across the Royal Free
sites.
The option scored only marginally
better than the status quo for criteria
4, impact on other services. The panel
felt that the changes would have
some positive impacts on the trauma
service and on primary and
community services. However, they
were not able to discern any impact
on orthopaedics services for
children. There was felt to be
insufficient information to score the
impact on spinal services and further
clinical information was to be sought
after the options appraisal process
about the spinal surgery service at
Whittington Health following any
proposed changes.
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Table 30: Scoring for NMUH/Royal Free proposal
North Middlesex/Royal FreeUnweighted Weighted Unweighted Weighted
Weighting Average Score Average Score Average Score Average Score
Criterion 1: Fit with the clinical delivery model
Delivering features of the clinical model 20.0% 3.73 0.75 2.00 0.40
Workforce plan 16.0% 3.46 0.55 2.00 0.32
Education & Training 4.0% 4.46 0.18 2.00 0.08
Total for criterion 40.0% 11.65 1.48 6.00 0.80
Criterion 2: Deliverability
Risk to the decision making 13.0% 4.50 0.59 5.00 0.65
Risk to the implementation 7.0% 4.35 0.30 5.00 0.35
Total for criterion 20.0% 8.85 0.89 10.00 1.00
Criterion 3: Patient Experience
Needs of patients with vulnerabilities… 7.5% 4.62 0.35 2.00 0.15
Accessibility 10.0% 2.62 0.26 2.00 0.20
Improved experience of care 7.5% 4.35 0.33 2.00 0.15
Total for criterion 25.0% 11.58 0.93 6.00 0.50
Criterion 4: Impact on other services
Impact on Trauma services 9.0% 3.31 0.30 2.00 0.18
Impact on Child and Adolescent surgery 1.5% 2.00 0.03 2.00 0.03
Impact on Spinal surgery 1.5%
Impact on Primary and community services 3.0% 2.54 0.08 2.00 0.06
Total for criterion 15.0% 7.85 0.40 6.00 0.27
Total Scores 100.0% 39.92 3.71 28.00 2.57
Maximum Score 60.00 5.00 60.00 5.00
Status QuoProposal
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Table 31: Scoring for Whittington Health/UCLH proposal
Areas for additional assurance following the options appraisal process
As a result of the options appraisal process, areas were identified which needed further work
in September and October 2019 on some aspects of both bids – individually and as a single
proposition – to ensure that the two strong individual proposals would create a single service
feel for patients and staff across the whole of north central London. There were a number of
actions for all four providers after the options appraisal process to contribute to the preferred
service model, these were:
Review to be undertaken by the independent clinical adviser on three areas where
further clinical assurance or information is needed: (i) detail of how patients who
develop complications or require readmission would be managed (ii) assurance
around the management of some complex patients at base hospitals (iii) detail of
overnight cover arrangements and day-time staffing model in both proposed elective
centres
UCLH/WhittingtonUnweighted Weighted Unweighted Weighted
Weighting Average
Score
Average
Score
Average
Score
Average
Score
Criterion 1: Fit with the clinical delivery model
Delivering features of the clinical model 20.0% 3.73 0.75 2.00 0.40
Workforce plan 16.0% 4.00 0.64 2.00 0.32
Education & Training 4.0% 4.46 0.18 2.00 0.08
Total for criterion 40.0% 12.19 1.56 6.00 0.80
Criterion 2: Deliverability
Risk to the decision making 13.0% 4.50 0.59 5.00 0.65
Risk to the implementation 7.0% 3.85 0.27 5.00 0.35
Total for criterion 20.0% 8.35 0.85 10.00 1.00
Criterion 3: Patient Experience
Needs of patients with vulnerabilities… 7.5% 4.35 0.33 2.00 0.15
Accessibility 10.0% 2.65 0.27 2.00 0.20
Improved experience of care 7.5% 4.35 0.33 2.00 0.15
Total for criterion 25.0% 11.35 0.92 6.00 0.50
Criterion 4: Impact on other services
Impact on Trauma services 9.0% 2.92 0.26 2.00 0.18
Impact on Child and Adolescent surgery 1.5% 2.00 0.03 2.00 0.03
Impact on Spinal surgery 1.5%
Impact on Primary and community services 3.0% 2.54 0.08 2.00 0.06
Total for criterion 15.0% 7.46 0.37 6.00 0.27
Total Scores 100.0% 39.35 3.71 28.00 2.57
Maximum Score 60.00 5.00 60.00 5.00
Status QuoProposal
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Royal Free to provide assurance that level 2 HDU capacity would be in place at
Chase Farm and operational at the start of the new model becoming operational
Further work to be undertaken to ensure a single proposition around
o Detail of integration for post-operative community care Role of care navigators/co-
ordinators
o Requirements for digital interoperability prior to go-live – including the need for
image sharing as part of the One London programme or an NCL solution
depending on timescales
o Transport/access discharge arrangements
o Whittington and Royal Free to provide additional information about the proposed
model of care and arrangements for spinal patients, prior to further discussions
involving the spinal network.
Following feedback from the Clinical Senate in October 2019, further work is required in
partnership with trusts to explore workforce issues, how to embed quality indicators and
improvement metrics into standard operating procedures, consider the pathways into and
out of secondary care orthopaedics, shared booking systems and support for patients with
vulnerabilities. Progress to date can be found at appendix G.
8.8 Financial assessment
As part of the submission of options process, providers were asked to complete proforma to
explain the system-wide financial impact of their proposal.
The panel carrying out the financial assessment comprised of:
Chief finance officer, NCL CCGs
Director of finance, Haringey and Islington CCGs
Director of finance, Barnet CCGs
Director of commissioning, Barnet CCG.
The financial assessment of each option took into account for all of the information included
by providers in the proforma. The assessment was based on a rounded judgement looking
at all of the submissions, including those from providers who only envisaged a role for their
organisation as a base hospital.
The individuals tasked with carrying out the financial assessment did not score individual
financial responses, but used the information put forward by providers in the proforma to
report back on the expected financial impact of each option.
The driving features of this project remain the clinical and patient benefits rather than
financial savings. Consequently, the primary aim of the financial assessment was to
demonstrate that the project would not contribute to financial pressures in the health
economy and could, over the longer term, make a positive contribution.
During the initial evaluation there were constructive discussions with all parties. The panel
went onto conclude that, once fully implemented, the proposal would have no worse than a
neutral financial impact and should deliver modest cost savings. However, there was further
refinement of the financial forecasts required which has been carried out in preparation for
this PCBC. The output of this is described in section 10.
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8.9 System-wide sense check
To continue our partnership approach, following the options appraisal process a system wide
sense check took place on 22 July. The aim of the session was:
To take a step back and look from a whole system perspective at the two
submissions we have received and appraised
Check that aspects of both current service provision and potential improvements in
future services for residents of north central London have not been overlooked in the
two submissions
Review both submissions from a system perspective against both our vision for
change and the criteria by which we were judging each proposal individually.
The session provided a unique forum to share with stakeholders the emerging outcome of
the options appraisal day and receive confirmation from them that the initial vision and
aspirations of the programme continued to be met by the emerging outcome from the
options appraisal process. It helped to identify priorities for the clinical network, priorities and
impacts for other STP programmes as well as priorities/impacts to be drawn to the attention
of other programme stakeholders and further refinement of the two proposals.
8.10. Sensitivity analysis of options scoring
It is sometimes necessary in a decision-making process to test whether changes to the
some of the contentious scores would have changed the recommended preferred option.
However, this has not been necessary in this case as there was only one pair of options to
consider and there was very little variation between scores by individual panel members.
It should be noted that whilst the panel were unable to score the spinal surgery
interdependency, resolving the impact on spinal surgery services was not considered a
material impact on the conclusions of the scoring process.
9. Preferred model of care
This section outlines the preferred new model of care for adult elective orthopaedic
services, developed after the options appraisal process.
We are proposing a new way to organise planned orthopaedic surgery for patients in
north central London.
Two partnerships have been formed by local NHS hospital trusts – with University College
London Hospitals (UCLH) and Whittington Health working together, and The Royal Free
London (Royal Free, Barnet Hospital, Chase Farm Hospital) working with North Middlesex
University Hospital (North Mid). If the proposal is agreed, these partnerships would deliver
real improvements in how we provide planned orthopaedic surgery.
The partnerships would offer two hospitals with dedicated operating theatres and beds for
patients who need to stay overnight after their operation. They would also offer patients the
choice of which hospital they go to for day surgery, outpatient appointments and education
classes for patients prior to their operation. Appointments would be with a named surgeon;
the surgeon and their surgical team would stay with patients throughout their care.
Both partnerships would be overseen by a network of health professionals who would
ensure that, regardless of where patients receive care, it is of a consistently high standard.
102
Evidence from the UK and around the world shows that doing surgery in operating theatres
which only do orthopaedics, means better quality of care for patients. We believe that by
organising services in this way, we would be able to improve care and help more patients
before, during and after their operation.
The proposed change could affect anyone living in our five boroughs (and a small number in
neighbouring areas) who needs orthopaedic surgery in the future. To inform our decision-
making, we’d like feedback from anyone with an interest in these services.
Summary of the preferred model of care
Two NHS hospitals with dedicated operating theatres and beds, for patients who
need to stay overnight after their operation
A choice of NHS hospitals for those needing day surgery
Within each partnership, a choice of NHS hospitals for outpatient appointments
Improved education classes for patients so they understand their operation and what
to do to before surgery to support their recovery afterwards
Appointments would be with a named surgeon, who, with their surgical team, would
stay with patients throughout their care, regardless of where it takes place
Rehabilitation support for patients after their surgery
Access to high dependency or intensive care units for patients who need additional
care after their surgery
Care coordinators to support patients with conditions such as dementia or a learning
disability to understand their care and where it might take place
More complex surgery would continue at the Royal National Orthopaedic Hospital, a
super-specialist centre
Patients with other complex medical conditions, such as haemophilia, would have
their surgery at the hospital which specialises in their condition
Emergency orthopaedic care would continue at all local hospitals with an accident
and emergency department.
Table 32: Detail of the preferred model of care
North Middlesex University Hospital NHS Trust/The Royal Free London NHS Foundation Trust partnership
University College London Hospitals NHS Foundation Trust/Whittington Health NHS Trust partnership
Partnership for Orthopaedic Excellence: North London
Creates a quality improvement framework delivering a standardised approach to pre-assessment, post-operative procedures and protocols, joint school and patient education.
Providers in the partnership
A partnership between the
North Middlesex University
Hospital NHS Trust and The
Royal Free London NHS
Foundation Trust
A partnership between University
College London Hospitals NHS
Foundation Trust and Whittington
Health NHS Trust
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North Middlesex University Hospital NHS Trust/The Royal Free London NHS Foundation Trust partnership
University College London Hospitals NHS Foundation Trust/Whittington Health NHS Trust partnership
Inpatient elective orthopaedic surgery
A change: all inpatient
orthopaedic care would take
place at an elective
orthopaedic centre on the
Chase Farm site.
Approximate annual
number of patients
impacted by the changes:
400 inpatients who
currently use the North
Middlesex would in the
future have their surgery
at Chase Farm Hospital
225 patients referred to
the RNOH for non-
specialist care could be
suitable for treatment in
the elective centres
Up to 560 patients a
year currently treated in
the private sector would
over time have their
treatment in the NHS.
A change: all inpatient orthopaedic
care would take place in an elective
orthopaedic centre specialising in
inpatient care at UCLH’s new building
on Tottenham Court Road (known at
the moment as phase 4).
Approximate annual number of
patients impacted by the changes:
360 inpatients a year who use the
Whittington would in future have
their surgery at UCLH
75 patients referred to the RNOH
for non-specialist care could be
suitable for treatment in the elective
centres
Up to 40 patients a year currently
treated in the private sector would
over time have their treatment in
the NHS.
Day-case elective orthopaedic surgery
A change: In local NHS
organisations day surgery
would continue to take place
at both at North Middlesex
and Chase Farm hospitals.
Approximate annual
number of patients
impacted by the changes:
Up to 1,020 patients a
year currently treated in
the private sector would
over time have their
treatment in the NHS as
part of the new model of
care.
A change: as part of the partnership
approach, the Whittington would
become a centre specialising in day-
case orthopaedic surgery, with some
day-case surgery moving from UCLH
to Whittington Health.
Approximate annual number of
patients impacted by the changes:
Approximately 360 day cases
would move from UCLH and have
their surgery at Whittington Health
Day-surgery would also continue to
be carried out at UCLH
80 patients currently treated in the
private sector would over time have
their treatment in the NHS as part
of the new model of care.
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North Middlesex University Hospital NHS Trust/The Royal Free London NHS Foundation Trust partnership
University College London Hospitals NHS Foundation Trust/Whittington Health NHS Trust partnership
Pre-operative and post-operative outpatient care.
No change: patients would continue to be seen at the three Royal Free hospital sites and North Middlesex hospital both pre- and post-operatively.
No change: patients would be seen at UCLH and Whittington Health both pre- and post-operatively.
Pre-operative and post-operative outpatient care
No change: patients would continue to be seen at the three Royal Free hospital sites and North Middlesex hospital both pre- and post-operatively.
No change: patients would be seen at UCLH and Whittington Health both pre- and post-operatively.
Trauma – emergency orthopaedic care
No change: would continue to take place as now at both the North Middlesex, Royal Free and Barnet hospital sites.
No change: would continue to take place as now at both UCLH and Whittington Health hospitals.
This table shows how the location of care might change compared with today. In response to
the feedback we received from patients, care has been organised to minimise the number of
times that patients need to travel further away from where they would usually receive their
hospital care.
Patients who need very specialist care would continue to go to the Royal National
Orthopaedic Hospital – a super specialist centre in Stanmore.
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Figure 13: Where patients have their care today patients have their care now
Figure 14: Where patients would have their care under these proposals
Figure 15: How services may look in the future – the locations for orthopaedic care in north
central London under our proposals
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Figure 16: The proposed future pathway for day surgery
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Figure 17: The proposed future pathway for surgery requiring an overnight stay
Table 33: Benefits of the preferred model
Improved clinical outcomes including reduced cancellations, decreased waiting
times, reduced infection rates, decreased revisions and readmissions.
The delivery of at-scale orthopaedic surgery at dedicated facilities would deliver
consistently excellent clinical intervention delivered across end-to-end pathways. There
would also be a focus on patients with vulnerabilities. Patients would have access to high
dependency or intensive care units for those who need additional care, plus rehabilitation
support for patients after their surgery.
Increased research activity
Bringing the collective research elements together and supporting the development of all
clinical staff would strengthen research capabilities in the wider NCL orthopaedic network
for the continued improvement of orthopaedic care.
Increased staff satisfaction
The development of innovation into the workforce through the introduction of new roles
and effective ways of working would provide excellent opportunities for learning and
development via rotational programmes.
Increased patient satisfaction
Patient satisfaction would be increased by providing diagnostics and outpatient care in
local hospitals that are familiar to our patients. The inclusion of care co-ordinators in the
model would ensure a seamless transition along the pathway, a benefit especially to those
patients who have vulnerabilities.
Reduced patient time wasted
The physical separation of elective and non-elective care would eliminate the pressures of
high emergency demand on theatres and wards, which means patients would have their
surgery on the day that it is planned and reduce waiting times.
Improved clinical education
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The preferred model would provide an opportunity for students from across many different
professions to experience a collaborative delivery model within orthopaedics, achieve
competencies and develop knowledge, through a combination of class-based sessions,
online education, simulation training as well as clinically based sessions.
Long-term commissioning strategy for orthopaedics
Create a strategy and the long-term capacity, delivering all NHS-commissioned care as
part of a single model as set out in this pre-consultation business case. The proposed new
service model would be delivered solely by NHS providers and, following public
consultation, there may need to be consequential contractual changes with private sector
providers to reflect the changed commissioning strategy for orthopaedics.
10. Financial impact
This section describes the positive financial impact of the proposals on the health
economy as a whole and the impact on individual trusts.
10.1. Background
Section 8.8 described the initial assessment of the financial impact of proposals undertaken
as part of the options appraisal process. At that time, the evaluation panel felt there was
sufficient evidence to conclude that the financial hurdle – that the proposals would have no
worse than a net neutral financial impact on the health economy – would be met. However,
more work was needed to be done to refine the financial model to inform the pre-
consultation business case. This section describes the conclusions to this further work.
A group that has included finance directors of all the trusts involved, or their nominee, and
commissioners has been considering the financial impact of the proposals on the whole
health economy and on individual trusts. The group has looked at this from both the point at
which the proposals are fully implemented, and during the implementation period. Each of
the trusts has considered the future cost of the service based on a set of common
assumptions, which they have developed together. This has been compared to the current
level of expenditure and a counterfactual.
The counterfactual is a hypothetical projection of what expenditure would look like if no
change to the service model were made. It assumes that there would continue to be an
increase in demand (driven by population growth see 4.3.1) and that changes already in
train, such as the opening of the new Phase 4 building at UCLH, would take place with the
associated change in costs. The comparison with the counterfactual is important as it allows
the user to understand what element of forecast changes to costs are a result of the
proposed service change and what would have happened anyway.
It is worth noting that the analysis has been prepared applying the current financial
framework, Payment by Results (PbR), ensuring trust gains and losses take into account the
shift of PbR income at the current tariffs. However, all parties are aware that there are
significant changes anticipated to the commissioning landscape through the introduction of
borough-based integrated care partnerships and an NCL-wide integrated care system. PbR
would be replaced by an as yet unknown framework. Where possible, the analysis has
concentrated on the cost of providing orthopaedic services rather than the income and
expenditure impact.
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A feature of this exercise has been that the financial teams of all four trusts have worked
closely together to ensure that the approach taken to preparing costs is consistent and that
common assumptions have been used. It has also meant that there has been an opportunity
for peer review of each of the trusts’ conclusions and methodology.
10.2. General
The general conclusion is that the proposed changes would contribute a positive financial
benefit to the health economy from the second year of operation. The short-term costs of
introducing the changes could be managed internally within the sector without it affecting the
viability of the trusts involved.
At a partnership level there would be savings from the economies of scale and a better use
of available capacity, but also there would be some stranded costs and transition costs. The
savings would be sufficient to offset the additional costs. By 2023-24 the proposal shows a
financial gain to the health economy of £1.18m a year, when compared to the counterfactual.
The following show the net income and expenditure calculated for both the counterfactual
and the proposed model together with a breakdown of the movement between the two
forecasts. The movements come about from the following factors:
Efficiency gains above and beyond the gains that the growth forecast in the
counterfactual would bring through greater use of capacity. These gains include:
o The cost of cancelled operations
o A premium from the way that escalation beds are used in the winter
o Gains from procurement at scale
o Moving services to a provider where there is already a better level of efficiency
Both partnerships would benefit over the medium term from a shift of activity from the
private sector to the NHS. It is anticipated that, having consulted on a new model of care
for planned orthopaedics commissioners would look to cease directly commissioning
work from the private sector, as they would expect directly commissioned orthopaedic
work to flow through the new elective centres to gain the benefit of all the quality gains
set out elsewhere in this document. If approved following public consultation, we would
therefore anticipate consequential contracting changes to reflect the new commissioning
strategy
Stranded costs resulting from a period of double running when the elective centre is
incurring the cost of the new service, but the previous provider has not managed to save
all of the costs associated with the service before it moved
Transition costs associated with the impact of introducing a new service. There are
usually temporary costs of setting up and often a temporary loss of income before
systems are running smoothly
Operating costs associated with the operation of the elective centre.
The assumptions made in building the costing model are included in appendix C. It is worth
noting that the group of finance directors, or their nominees, felt that the methodology and
assumptions made used for costing much of this change was a prudent approach to
forecasting the possible gains from this programme and the likely transitional costs. The
consolidation of services onto fewer sites should lead to further economies of scale that may
be revealed when more detailed preparatory work is undertaken, e.g. to agree new working
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models and associated financials ahead of the decision-making business case. In addition,
there should be longer-term intangible gains from clinical improvements such as fewer re-
admissions or fewer joint replacement revisions.
The total value (based on PbR income) of elective orthopaedics across the four units is
around £39m. The changes would involve a net shift from North Middlesex University
Hospital to Royal Free Hospitals of around £2.1m, and a net shift of around £1.2m from
Whittington Health to UCLH.
10.3. Northern partnership: Royal Free and North Middlesex
At Chase Farm Hospital the service is already operating from a new dedicated elective
centre, which opened in the summer of 2018. Inpatient activity at Chase Farm is forecast to
increase with all activity currently at North Middlesex University Hospital shifting during
2020-21. This equates to 369 episodes of care in 2020-21. The Chase Farm unit has
sufficient capacity that the increase could be absorbed without investment in infrastructure.
No change to day case activity is proposed.
Table 34: Summary of financial impact of proposals by year in comparison to the
counterfactual: Northern partnership
By the fourth year of implementation, the proposed model is forecast to contribute an
additional £677k each year. Over the four years shown in the modelling the new proposals
would contribute £1.37m with a slight negative contribution in the first year of operation.
Both trusts currently make a net loss on elective orthopaedic services. The amount of PbR
income for orthopaedics does not cover the cost of providing the service. At Chase Farm this
is caused by underutilisation of capacity which is felt to be a temporary consequence of the
shift of work from Barnet and the Royal Free Hospitals in 2018 rather than a change in
demand. The trust is forecasting that utilisation at Chase Farm would improve regardless of
the orthopaedics proposals and this improvement is reflected in the loss shown on the
counterfactual improving over the four years shown. At NMUH there is also underutilisation
of capacity, but this is the result of increasing amount of emergency activity having to be
done at the expense of elective activity. At both trusts this has resulted in an increase in
patients waiting for operations since 2018.
There was discussion about whether the financial impact of clearing the backlog of
orthopaedic waiting lists should be included in the forecasts. It was decided not to include
this as the scale and phasing of this has yet to be agreed and arguable this would also be a
£000 2019-20 2020-21 2021-22 2022-23 2023-24 Total
Contribution from counterfactual (2,467) (2,333) (2,216) (2,033) (1,848)
Adjustments
Efficiency Gains 0 34 74 75 76 260
Impact of shift from independent sector 0 0 220 531 668 1,419
Stranded costs 0 0 0 0 0 0
Transition Costs 0 (46) 0 0 0 (46)
Operating costs 0 (67) (67) (67) (67) (267)
Total adjustments 0 (79) 228 540 677 1,366
Contribution from proposed model (2,467) (2,412) (1,988) (1,493) (1,171)
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factor in the counterfactual and therefore neutral to the analysis. However, the financial
benefit that this would bring to the trusts could contribute to the shortfall in the first year of
operation.
There are minimal levels of stranded costs anticipated at North Middlesex University
Hospital associated with spare capacity. NMUH Trust forecasts that increasing demands
from emergency services would mean that any capacity released would quickly be taken up
so that stranded costs associated with elective services would rapidly be absorbed.
The financial impact of the proposals is to increase the utilisation of capacity at Chase Farm
and remove a loss-making service from NMUH thereby improving the overall efficiency of
both trusts.
Contributing to this improvement is the assumption that in the medium term there would be a
significant shift of activity from private sector providers in the northern partnership to Chase
Farm to ensure that post-consultation all planned elective orthopaedic activity is delivered in
line with the proposed model of care. Enfield CCG is the principle user of private sector
providers in the sector. This gives the partnership a potential financial benefit of £668k a
year by 2023-24. This impact has been phased in over time to reflect the need for any
consequential contractual changes that may be required.
Modest levels of implementation costs, £46k in the first year, have been included in the
forecast. Operational costs for the elective centre have been forecast at £67k pa. These are
both significantly lower than those forecast for the southern partnership as an elective centre
is already operational at Chase Farm and the view taken is that there would be only modest
costs associated with transferring North Middlesex University Hospital activity into the unit.
For the Royal Free Hospital Trust the proposals would have a positive financial impact from
2021-22 created by the better use of underutilised capacity.
For the North Middlesex University Hospital Trust the proposals would also have a positive
benefit through the release of capacity for emergency activity.
10.4. Southern partnership: UCLH and Whittington Health
The proposal is to move elective inpatients currently treated in the main UCLH hospital and
from Whittington Health into a new cancer and surgery facility within UCLH that is currently
under construction (currently referred to as the Phase 4 development). The move of patients
from the Whittington equates to 362 inpatient episodes of care in the first full year of
opening. It also proposed that day case activity equal to 362 episodes would transfer from
UCLH to the Whittington. Phase 4 was planned long before discussions on orthopaedics
began and would accommodate the move of adult ear nose and throat surgery, inpatient
haematology and a new proton beam radiotherapy suite. The surgical facilities have been
reconfigured from the original building plan to accommodate the orthopaedic elective centre.
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Table 35: Summary of financial impact of proposals by year in comparison to the
counterfactual: Southern partnership
Table 37 shows that, in total, elective orthopaedics at the two trusts makes a net loss
(orthopaedics at the Whittington orthopaedics makes a positive contribution, at UCLH it
makes a loss). In both the counterfactual and the proposed model, the loss increases. The
main contributing factor to this is the treatment of overheads associated with Phase 4. As a
new building, Phase 4 attracts a high charge for overheads so the cost of orthopaedics at
UCLH increases as a result of the move. However, the view taken in this analysis is that this
cost would be incurred regardless of whether Phase 4 included orthopaedics or another
service and consequently this increase is neutral when compared to the counterfactual.
By the fourth year of operation the proposed model would contribute an additional £502k a
year to the health economy. Across the four years the proposal would contribute £59k more
than the counterfactual. During the first two years of operation, while there are stranded
costs still to be absorbed and transition costs, the proposed option would cost more than the
counterfactual.
There are full year efficiency savings projected of £219k.
There would be £465k a year of stranded costs anticipated at Whittington Health resulting
from two factors:
The cost of spare capacity resulting from the move of inpatients.
The loss of the contribution that inpatients makes to the trust (net of the opposite
effect of day cases moving to the Whittington).
The forecast is that these costs could be fully absorbed by 2023-24.
The southern partnership is also anticipating a shift of activity from the private sector to the
NHS with a full-year contribution of £53k a year. The likely impact is smaller than that
forecast in the north as Camden and Islington CCGs commission much smaller volumes of
activity from the private sector.
The southern partnership is forecasting £1m of transitional costs, over two years, associated
with the bedding-in of a new service in a new building. Currently this is a placeholder based
on the experience of other transformation programmes and further work would need to be
done on this in the decision-making business case following the proposed consultation.
£000 2019-20 2020-21 2021-22 2022-23 2023-24 Total
Contribution from counterfactual (1,098) (2,127) (2,743) (2,691) (2,639)
Adjustments
Efficiency Gains 0 14 186 259 219 678
Impact of shift from independent sector 0 0 35 42 53 130
Stranded costs 0 125 244 357 465 1,192
Transition Costs 0 (600) (400) 0 0 (1,000)
Operating costs 0 (235) (235) (235) (235) (941)
Total adjustments 0 (696) (170) 423 502 59
Contribution from proposed model (1,098) (2,823) (2,914) (2,268) (2,136)
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£235k a year of additional operating costs associated with running the elective centre have
also been included in the forecasts.
Once the transition phase is over the proposals would have a positive impact on finances. In
the interim the transition costs and stranded costs at the Whittington have the effect of
increasing net costs. Both UCLH and Whittington trusts are fully supportive of the proposals
and recognise the financial consequence on viability which it is felt could be managed.
There would be some capital expenditure required at UCLH but as this related to the fitting-
out of phase 4 it has been assumed that this is already included in the capital plan for UCLH
and would not require further capital funding.
10.5. Royal National Orthopaedic Hospital
The RNOH is proposing to make use of the elective centres in such a way that there would
be a positive financial contribution and provide a better experience to more patients. The
elective centres provide the RNOH with an opportunity to treat patients that currently cannot
be taken. At the moment the trust turns away around 2,700 referrals on the basis that these
are routine operations and the trust has limited capacity. This would have the impact of
improving the financial viability of both partnerships by bringing new income to the health
economy at only marginal cost.
However, it was felt prudent to exclude the impact of this change from the financial analysis
at this time. Whilst this would be a positive contribution to the local economy it relies upon
the PbR framework and would be neutral to the NHS as a whole. The positive financial
impact on the forecasts were these to be included is estimated to be £109k a year.
Table 36: Net impact of additional RNOH activity
Partnership 2019-20 2020-21 2021-22 2022-23 2023-24 Total
Northern partnership 0 24 38 40 42 144
Southern partnership 0 33 66 67 67 232
0 57 104 107 109 376
10.6. Cross-trust agreements and financial arrangements going forward
This financial analysis has been done at a sufficient level of detail to demonstrate a proof of
concept, thereby clearing the programme to move to the proposed consultation stage.
However, the financial analysis would need to be repeated in more depth before making a
final decision to proceed. At that time one or more formal agreements would need to be in
place, building on the MOU which has been agreed, between the trusts to ensure that losses
and gains across the health economy are smoothed out thereby ensuring that no trust’s
financial viability is impacted by these changes.
The STP has already put in place a set of principles that cover economy-wide initiatives such
as the one proposed here. In addition, trust chief officers have signed a memorandum of
understanding committing them to enter into formal agreements. The full text of the MoU is
attached as appendix D. The key commitments contained in the MoU are:
No trust would be financially disadvantaged by this programme. A compensation
package would be agreed between the trusts in each of the two partnerships that
corrects any financial imbalance
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Trusts would apply their best endeavour to minimise costs and absorb stranded costs
Trusts would act in good faith during the negotiation of compensation packages and
would continue to be open to peer review and scrutiny over their estimates of the
impact of the changes
Costs incurred in the implementation phase of the project would be absorbed by the
trusts collectively without requiring investment from the commissioners.
As well as agreements covering the interim period a longer-term financial agreement would
also need to be in place by the time that the decision-making business case is approved.
This would cover the:
Arrangements for sharing risks associated with the elective centre
Charging arrangements between trust for surgeons of one trust using the elective
centre of another
Non-financial matters such as responsibility for clinical risks.
This section outlines how our proposal has met NHS England’s assurance tests and
includes information on the Mayor’s five tests.
NHS England, in Planning and delivering service changes for service users’ guidance,
published in December 2013, outlined good practice for commissioners on developing
proposals for major service changes and reconfigurations.
Building on this, the 2014/15 mandate from the Secretary of State to NHS England, outlines
that proposed service changes should be able to demonstrate evidence to meet four tests:
1. Strong public and patient engagement
2. Consistency with current and prospective need for patient choice
3. A clear clinical evidence base
4. Support for proposals from clinical commissioners.
Reconfiguration proposals must meet the four tests before they can proceed. These tests
are designed to demonstrate that there has been a consistent approach to managing
change, and therefore build confidence within the service, and with service users and the
public.
From 1 April 2017, NHS England introduced a new (fifth) test to evaluate the impact of
proposals that include a significant number of bed closures. There are no plans to reduce
beds, therefore this test does not apply.
The adult elective orthopaedic services review has met these four tests in the following
ways:
11.1 Test 1: Strong public and patient engagement
This test evaluates how service users and the public are involved in developing the
proposals.
Public and patient engagement has informed the planning process from its earliest
stages and will continue through consultation during 2019 into future planning
phases, transition and the next era of service delivery.
11. NHS England assurance – Four tests
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A robust approach to engagement has been at the core of the adult elective orthopaedic
review from the outset and this principle has been applied to working with clinical partners
and providers in developing the service model, and with local residents, to ensure that they
are informed, involved and have a role in shaping the outcome of the review.
The options appraisal scoring panel had equal representation from local residents.
Engagement on the draft case for change received hundreds of individual pieces of
feedback and resident representatives have been part of our programme board.
Patients, residents and other stakeholders would continue working in many of the
programme’s workstreams, including patient advisory work on transport and access, resident
involvement in consultation planning and the delivery of a full public consultation in the
future.
A summary of activities includes:
Socialisation of the draft case for change with patents, residents and wider
stakeholders (from providers, commissioners and local authorities)
Calls for involvement and the sharing of the case for change via organisational
channels, including electronic and print bulletins and mail outs, and social media
Promotion of the review and case for change through three different community
channels provided by Healthwatch organisations and NCL CCGs, plus regular
publications aimed at local patients produced by hospital providers
26 organisations, from groups identified from the desktop EIA, were engaged through
meetings and events
Five clinical design workshops were held between July and November 2018
Regular ongoing engagement with local stakeholders following the end of the formal
pre-consultation phase and beginning of the formal consultation
Patient and resident representatives contributed to workshops in March and April
2019 refining the clinical delivery model and options appraisal criteria and scoring
Half of the panel for the options appraisal panel, which was held in July 2019, were
patient and resident representatives.
A log of engagement and involvement activities is detailed in appendix A. Further
engagement is planned (outlined in section 12.1) using the communications channels of all
health and social care partners involved, to include proactive and specific connections with
patients with vulnerabilities and seldom-heard groups.
Digital methods, including a dedicated website section and social media channels would
support face-to-face discussions, further focus groups and survey work.
Themes raised through pre-consultation engagement informed the planning for the formal
consultation and development of the pre-consultation business case; as well as feeding back
to the relevant workstreams and programme board.
A consultation planning group, comprising of local residents and representatives from
partner organisations and CCG engagement leads would inform the development of the
consultation plan and documents.
Stakeholders will have the opportunity to comment on the proposals and provide any
feedback on alternative options for the model of care.
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11.2 Test 2: Consistency with current and prospective need for patient
choice
This test illustrates whether any proposed redevelopment would maintain the availability of
service user choice.
In north central London we currently deliver adult elective orthopaedic services for NHS
patients from 10 separate NHS and private sector sites. While many of these services are of
good quality, we know that there is unwarranted variation in the quality of care we are
currently able to offer. Under our proposals, patients would continue to have a choice of care
providers both inside and outside north central London.
Clinical leaders in orthopaedics, locally and nationally, believe there is evidence that the best
clinical outcomes for patients, patient care quality, and efficiency benefits are improved
through ring-fenced orthopaedic elective care brought together in fewer sites and co-located
with appropriate clinical support services, such as rehabilitation services, in buildings fit for
purpose. This allows replication of standardised best practice pathways of care that are
responsive to individual patient needs. It also promotes the best workforce training, research
and learning environment for the recruitment and retention of staff.
The clinical delivery model ensures that predicated referrals would continue to be made to
base hospitals, with pre- and post-operative care managed locally. Surgeons from the base
hospital would carry out surgery at the proposed elective centres. Commissioners and
providers would continue to work together at a system-level to ensure that networks and
pathways are developed to improve how patients access elective orthopaedic care services,
how clinicians and staff would deliver those services, and how, by integrating research with
service delivery, this would create a huge benefit for clinical outcomes
Patient choice would be improved from a quality perspective as the proposal to move to the
two proposed elective centres would allow a more efficient patient journey time through and
improved outcomes, provide a higher quality experience for patients.
11.3 Test 3: A clear clinical evidence base
This test is to demonstrate sufficient clinical evidence and clarity on the case for change
(outlined in section 4).
The independent verification of the clinical case for change has been gained through
submission for consideration by the London Clinical Senate and engagement with a range of
clinicians.
11.3.1 London Clinical Senate: clinical reference panel
The London Clinical Senate’s clinical review of the proposals for adult elective orthopaedic
services reconfiguration in North Central London: case for change, clinical models and the
development of potential solutions, is conducted as part of NHS England’s assurance
process for a major service change.
In Planning, assuring and delivering service change for patients71, NHS England is required
to assure itself that a proposal for a major service change or reconfiguration satisfies all of
the four tests.
71 “Planning, assuring and delivering service change for patients,” (NHS England, March 2018)
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The role of the Clinical Senate is to establish if a proposal meets the third test, i.e. that it has
a clear, clinical evidence base. This is done this by conducting a clinical review of a draft of
the pre-consultation business case and other materials.
In conducting the review, the Clinical Senate examined a draft of the PCBC to establish if it:
Has a clear articulation of patient and quality benefits
Fits with national best practice and is clinical sustainable
Contains an options appraisal which includes a consideration of a network approach,
co-operation and collaboration with other sites and/or organisations.
The Senate’s review of a draft PCBC enables a commissioner to revise its business case
and integrate the Senate’s recommendations into the final version of the PCBC.
London Clinical Senate review panel meeting
The London Clinical Senate held a panel meeting in September 2019 involving discussion
with clinicians and representatives of patients and the public in north central London who
have been involved in developing the proposals and/or could be affected by them. The panel
reviewed proposals for adult elective orthopaedic services, focusing on the case for change,
clinical models and the development of potential solutions.
Specifically, the clinical review panel sought to establish:
1) Whether the new model of care would deliver safe, effective intervention that
significantly improves patient experience and outcomes
2) Whether there is sufficient evidence that the change proposed is justified in terms of
clinical efficacy and patient experience
3) That there is sufficient alignment with the wider musculoskeletal pathway to ensure
patients experience seamless care across the system
4) The NCL approach demonstrates the future demand is adequately addressed and
sustainable services developed
5) Workforce plans would ensure patients could access the right treatment at the right
time
6) Plans for digital innovation would facilitate seamless care across organisation
boundaries
7) There are no unintended consequences for clinical services that are out of scope but
key dependencies within the review (spinal surgery, paediatric surgery and trauma
services).
The review panel’s advice is based upon:
Its consideration of the documentation provided.
The presentations and discussion with clinicians, patients, commissioners, and
managers during the review panel hearing on 25 September.
The multidisciplinary panel members’ knowledge and experience.
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London Clinical Senate findings
The panel found that there was a “clear case for change, based on national best practice
and consideration of the local issues”. They also identified areas where work could be
developed and have generated recommendations to consider as plans are refined, and the
decision-making business case is developed.
The Clinical Senate had the following recommendations for the final version of the PCBC.
The panel recommends:
Quality indicators and improvement metrics are built into the standard operating
procedures. Where possible, these are collected digitally
Patient information literature is co-designed with patients and improvement metrics
are made available to patients
A sustained education model is developed for stakeholders of the service covering
topics such a discharge communication
Clarifying threshold and trigger points for readmissions
Clarifying the process for readmissions, considering identifying a single contact point
through which this is managed
Learning from pilots and best practice models already in existence considering rolling
out for consistency
Liaising with the London Ambulance Services regarding transport and discharge
arrangements across all sites
Exploring innovative models to support the pathway e.g. patient education, after care
and equipment
Further engaging community MSK triage and rehabilitation services to ensure a safe
effective and efficient pathway in and out of secondary care orthopaedic services
Considering the role and specification of beds on the Chase Farm site to clarify the
new model of care, commission the model and develop a practical understanding of
patient flow. This may include:
o Patient criteria e.g. high dependency unit or post anaesthetic care unit
o patient pathway
o anticipated length of stay
o arrangements with London Ambulance Service for patient transfer and
emergency conveyancing
Mitigating against avoidable growth in activity by ensuring that interventions are
provided to the right patients at the right time, through adhering to recommendations
relating to the musculoskeletal pathway
Reviewing activity projections to ensure that they are as realistic as possible.
Measure the rate of conversion to intervention from outpatient appointments to assist
with planning and projections
Implementing plans to recruit senior allied health professionals and nurses to the
programme board
Developing and articulating opportunities for all staff, allied health professionals and
nursing staff as well as doctors; giving attention to standards; pathways; education;
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mentoring and preceptorship; rotation; as well as practical employment issues such
as parking, childcare and maternity payments
Considering how roles such as first contact practitioner or single point of access/
triage practitioners might be integrated into the model; and develop a capability
framework for these
Considering the development of a workforce strategy that would address any rise in
activity
Undertaking a wider workforce scope, mapping the care pathway and points of care
for discussion with a wider forum of surgical trainees.
Considering how core surgical trainees gain exposure in areas other than
orthopaedics; looking at imaginative solutions
Considering the willingness and availability to flex staff across sites, paying attention
to passporting, rota and work schedules
Identifying within the model whether therapy services would operate five or seven
days per week and the workforce implications of this
Fully work up the proposals for care navigators/ co-ordinators, paying attention to:
o Articulating the outcomes of better care coordination within and outside the
hospital
o Gathering feedback from PPV groups to determine what the need is and therefore
influence how this could best be met
o The differing proposed models in the north and the south of the patch and whether
these could be standardised
o The role/ parts of role required to address the administrative aspects (perhaps
better called a navigator) and which would be clinical i.e. Nurse or allied health
professional consultant
o Development of a role description which includes a clear definition of clinical
responsibilities, if relevant
o Addressing how the care coordinator role would be funded – especially if it picks
up on parts of pre-existing roles
o Creating a development framework for these staff, potentially connecting to an
apprenticeship programme
o Identifying the interface with MDTs to manage patients across primary, secondary
and tertiary care pathways
o Identifying additional support that may be required for patients with additional
vulnerabilities e.g. mental health needs
Programme plan a time to explore the potential for shared booking to be available
across the system to smooth the patient pathway
Commissioners and providers consider managing the financial impact of gains and
losses across the health and social care system in north central London to enable
future sustainability. This could be enabled by network collaboration.
Feedback and responses to these recommendations are being addressed throughout the
PCBC; in particular in section 4 and section 5. Progress to date can be found at Appendix G.
The recommendations would continue to be reviewed and implemented as the programme
moves towards consultation and potential implementation of the preferred model.
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The report by the London Clinical Senate will be published by commissioners, once formal
consultation on the proposal is underway.
11.3.2 Clinical input
A wide range of clinicians has been engaged throughout the process to ensure proposals
have patient outcomes at their heart. There has been broad and varied communication with
a range of clinical staff.
Clinicians across north central London, together with patients and residents, have been fully
involved in the process of designing the proposed new clinical model of care for adult
elective orthopaedic services.
This process has put them at the heart of our planning, developing a model for future adult
elective orthopaedic services that works for patients, their families, staff and clinicians.
Drawing on local and global examples of best practice and building on the evidence, such as
GIRFT’s national review of adult elective orthopaedic services in England72, they have been
looking at how pathways could be redesigned, responding to local needs and opportunities.
The NCL sustainability and transformation partnership (NCL STP) Health and Care Cabinet,
which includes clinical leaders from all providers and clinical commissioning groups (CCGs)
in NCL, and the Joint Commissioning Committee for the NCL CCGs, believes that there
could be opportunities to achieve an enhanced quality of care for patients.
A key enabler to this work is the provision of enhanced advice, based on competency to
make sure everyone within the system, including patients, have the right access in order to
manage their conditions.
They have been involved in the process of assessing options and selecting a preferred
option as an important step prior to a public consultation. This process is designed to ensure
all of north central London has excellent high-quality services which would drive forward the
future of orthopaedics locally, nationally and internationally.
11.4 Test 4: Support for proposals from clinical commissioners
This test is to provide assurance that the proposals have the approval of local
commissioners.
NCL commissioners have supported the development of this business case, in principle and
subject to consultation. The NCL Joint Commissioning Committee, which comprises voting
members from the five NCL CCGs, lay members, local authorities, and Healthwatch, has
been fully informed and significantly involved in the development of these proposals:
Orthopaedic services review
At its meeting on 6 December 2018, they approved the design principles for a
preferred model of care and received the feedback from the engagement on the draft
case for change
At its meeting on 3 January 2019 they approved the overarching timeline, revised
governance and accepted the recommendation around final contract form
At its meeting on 2 May 2019, the NCL JCC agreed the clinical delivery model and
options appraisal process.
72 A national review of adult elective orthopaedic services in England, Getting It Right First Time
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Additionally, during the pre-consultation engagement phase on the draft case for change
during summer and autumn 2018 there was a discussion and feedback at CCG
governing body seminars. Following the pre-consultation engagement there has been
ongoing engagement with clinical commissioners through feedback in GP newsletters
and briefings scheduled at GP locality meetings over the summer and autumn 2019.
11.5 NHS England’s bed test
From 1 April 2017, NHS England introduced a new test to evaluate the impact of any
proposal that includes a significant number of bed closures.
There is not intended to be any significant change to the occupancy of beds associated with
this programme. We anticipate an increase in the number of beds occupied by elective
orthopaedic services associated with additional activity attracted by RNOH and a general
growth in demand. The trusts estimate that:
Across North Middlesex and Chase Farm Hospitals, approximately 47 beds are
currently used for elective orthopaedic surgery. By 2023-24 this would increase to 52
beds at Chase Farm
Across UCLH and Whittington Health hospitals approximately 21 beds are currently
used. By 2023 this would increase to 27 at UCLH.
11.6 Mayor of London’s six tests
The King’s Fund and Nuffield Trust published a report73 in September 2017 which
recommended that greater city-wide leadership is needed to successfully implement the five
NHS Sustainability and Transformation Plans (STPs) for London.
In response, the Mayor of London developed a six test framework for major hospital
reconfiguration. Each proposal is required to specify how it meets the requirements of each
test to enable the Mayor to give support for individual reconfigurations.
Following initial discussions and guidance from the Mayor’s health team, the evidence on
how the proposal fulfils the requirements of each test is set out below (Table 37). If the
planned public consultation proceeds, the Mayor’s health policy team will review tests 1 to 4
during the consultation period to ensure the specified criteria is met. Tests 5 and 6 would be
evaluated after public consultation has been completed.
Table 37: The Mayor of London’s six tests
Tests Evidence
Test 1: Health inequalities and prevention of ill health
The impact of any proposed changes on health inequalities has been fully considered at an STP level. The proposed changes do not widen health inequalities and, where possible, set out how they would narrow the inequalities gap. Plans clearly set out proposed action to prevent ill-health.
During the engagement phase of the programme, a desktop Equalities Impact Assessment was undertaken to identify the groups likely to be most impacted by the new model of care. Feedback from the engagement was used to shape the final model of care.
A full health inequalities and health equalities impact assessment has been commissioned prior to the planned public
73 Sustainability and transformation plans in London, an independent analysis of the October 2016 STPs (completed in March
2017)
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Tests Evidence
consultation. This would ensure there are no unintended consequences in terms of discrimination, access and that the interests of people with protected characteristics are addressed.
Further information can be found in Appendix E
Test 2: Hospital beds
Given that the need for hospital beds is forecast to increase due to population growth and an ageing population, any proposals to reduce the number of hospital beds would need to be independently scrutinised for credibility and to ensure these demographic factors have been fully taken into account. Any plans to close beds should also meet at least one of NHS England’s ‘common sense’ conditions
There is forecast a 16% increase in the number of beds (11) provided for patients requiring adult elective orthopaedic surgery in the new model of care. This includes:
An additional five beds at Chase Farm Hospital, with bed capacity within the northern partnership expanding from 47 beds to approximately 52 by 2023-24
An additional six beds at UCLH with bed capacity within the southern partnership increasing from 21 beds to 27 by 2023.
It is envisaged it would be possible for both sites to expand further should this approach be agreed with commissioners.
Further information can be found in section 11.5
Test 3: Financial investment and savings
Sufficient funding is identified (both capital and revenue) and available to deliver all aspects of plans, including moving resources from hospital to primary and community care and investing in prevention work. Proposals to close the projected funding gap, including planned efficiency savings, are credible.
The primary driver for changing the way adult elective orthopaedic surgery is delivered across NCL is to improve patient experience and outcomes.
Financial modelling indicates the proposed changes would have a positive financial benefit to the health economy from the second year of operation. The short-term costs of introducing the changes could be managed internally within the sector without it affecting the viability of the trusts involved. No capital investment is required: the Chase Farm Hospital site is already in operation and the phase 4 UCLH building where elective care would be delivered has already been commissioned and is due to open in autumn 2020.
A more detailed financial assessment would be undertaken as part of the decision- making business case which would be completed following the completion of the planned public consultation.
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Tests Evidence
Further information can be found in section 8.8
Test 4: Social care impact
Proposals take into account:
a) the full financial impacts on local authority services (including social care) of new models of healthcare
b) the funding challenges they are already facing.
Sufficient investment is available from Government to support the added burden on local authorities and primary care.
The reconfiguration of adult elective orthopaedic services focuses on a defined component of the secondary care surgical pathway. It is not envisaged that the proposals would have a significant financial effect on social and community care. However, it is recognised in terms of care quality that the proposed changes sit within the context of wider MSK, community and social care pathways. We therefore have engaged widely with our community and social care partners, through a variety of mechanisms including workshops and meetings, to ensure the programme aligns with current and future local plans and pathways. Should a decision be made to proceed with the proposal, further work would take place during implementation to join together key elements of community and social care including the discharge to assess pathways.
Further information can be found in section 3.3
Test 5: Clinical support
Proposals demonstrate widespread clinical engagement and support, including from frontline staff.
The original case for change, published in 2018, set out the rationale and evidence for changing the way elective orthopaedic services could be delivered in the best interests of patients. The refreshed case for change included in this document validates the proposition that by separating elective orthopaedic and trauma services and providing elective surgery from a smaller number of specialist centres, major benefits could be delivered for NCL residents.
A number of core principles underpinned the review including:
Co-production of an evidence-based service model to improve clinical quality, patient experience and outcomes
A clinically-led collaborative approach to design that ensured meaningful engagement with all local stakeholders particularly front line clinical staff, social care colleagues, the public and patients.
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Tests Evidence
To create a model of care, key stakeholders came together in five design groups to develop a shared vision for NCL adult elective orthopaedic services. The process was overseen by a multi-agency programme board including GP, patient, trust, social care, and commissioning representatives.
In parallel to the design process, an NCL engagement exercise was undertaken enabling feedback from key stakeholders to be incorporated into the emerging model of care. As part of an options appraisal process, local NHS providers were asked to submit proposals on how they could meet the agreed model of care. The process and proposals were developed into this document and submitted to the London Clinical Senate.
Further information can be found in appendix A. The clinical review panel of the London Clinical Senate took place on 25 September 2019. A panel feedback report found that there was a clear case for change, based on national best practice and consideration of the local issues. 23 recommendations were made, largely related to implementation.
Further information can be found in section 11.3
Test 6: Patient and public engagement
Proposals demonstrate credible, widespread, ongoing, iterative patient and public engagement, including with marginalised groups, in line with Healthwatch recommendations.
Two patient representatives were recruited through Healthwatch at the start of the review to sit on the review group, the programme board and the clinical orthopaedic network. Healthwatch organisations also supported additional patient and resident recruitment patients for additional workshops and the options appraisal panel.
Early engagement enabled strong links with a wide range of patient and resident groups to be established ahead of the public consultation. A consultation group has been established to oversee development of all the consultation documentation which includes Healthwatch, patient and resident representation.
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Tests Evidence
Further information can be found in appendix A
12 Decision-making and next steps
This section contains information on how we would make decisions to move forward
with the proposals, a timeline, what happens next, and an outline of the proposed
consultation plan.
After the consultation closes, the responses received from members of the public and
organisations will be independently analysed.
There are a number of factors that might influence the decision-making timescales including:
The quantity and detail of consultation responses received, and timescales required
to analyse those responses
The consideration of consultation responses by the consultation programme board
and subsequent update of analysis and evaluation as required
CCGs, as the decision-makers, need to consider the consultation responses and
make the decision about whether the proposals should be approved
Any ongoing CCG change programmes which are currently being discussed by
governing bodies.
However, to give an indicative timeline, the programme expects the following milestones for
this process. These may be subject to change.
9 January 2020 – Joint Commissioning Committee of the five NCL CCGs to be
asked to (i) approve the pre-consultation business case and (ii) consider the decision
to move to a public consultation
13 January 2020 Public consultation starts (12 weeks)
6 April 2020 Consultation finishes
April/May 2020 Following consultation, all responses from members of the public
and local organisations will be independently evaluated and a draft report produced.
Timescales for post-consultation decision-making, subject to the volume and content of
responses received:
May 2020 Stakeholders will have the opportunity to comment on the draft report of
the consultation evaluation together with the review of the equalities impact
assessment
June 2020 The evaluation of responses, feedback from stakeholders and impact
assessments will be shared with the Joint Health Overview and Scrutiny Committee
(JHOSC)
June 2020 A decision-making business case (DMBC) would be developed
outlining the recommended decision as a result of the consultation evaluation, impact
assessments and feedback from the JHOSC
June/July 2020 The final DMBC would be presented to NCL CCG for decision
(TBC).
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July to November 2020 – Assurance of implementation plans and trust internal
governance processes.
12.1 Consultation plan
When developing proposals for public consultation, commissioners must consider section
242 of the NHS Act 2006 and section 142Z of the Health and Social Care Act 2012. Under
these, NHS Trusts and CCGs have a legal duty to make arrangements for individuals to
whom the services are being or may be provided, to be involved throughout the process.
The principle of section 242 of the consolidated NHS Act 2006 is that, by law, NHS
commissioners and Trusts must ensure that patients and/or the public are involved in certain
decisions that affect the planning and delivery of NHS services. While section 242 has far-
reaching implications, it is at heart about embedding good decision-making practice by
ensuring that service users’ points of view are taken into account when planning or changing
services.
Section 242(1B) of the National Health Service Act 2006 as amended by the Local
Government & Public Involvement in Health Act 2007, states that:
Each relevant English body must make arrangements as respects health services for which
it is responsible, which secure that users of those services, whether directly or through
representatives, are involved (whether by being consulted or provided with information, or in
other ways) in:
(d) The planning of the provision of services
(e) The development and consideration of proposals for changes in the way services are
provided
(f) Decisions to be made by that body affecting the operation of those services
Subsections (b) and (c) need only be observed if the proposals would have an impact on:
(c) The manner in which the services are delivered to users of those services; or
(d) The range of health services available to those users.
In order to meet these legislative requirements, public involvement must be an integral part
of service change process. Engagement should be early and continue throughout the
process using a broad range of engagement activities.
All public consultations should adhere to the Gunning principles, which are:
Consultation must take place when the proposal is still at a formative stage
Sufficient reasons must be put forward for the proposal to allow for intelligent
consideration and response
Adequate time must be given for consideration and response
The product of consultation must be conscientiously taken into account.
Additionally, all pre-consultation engagement should be undertaken in line with the NHS
England guidance Planning, assuring and delivering service change for patients (2018)74.
74 https://www.england.nhs.uk/wp-content/uploads/2018/03/planning-assuring-delivering-service-change-v6-1.pdf
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This states that service change (including changes in location) should be undertaken only
when a public consultation has been undertaken, which is;
Aligned to the local Sustainability and Transformation Partnership (STP) plans
Assured by NHS England prior to consultation
Led by service commissioners
Involves full and consistent engagement with stakeholders including (but not limited
to) the public, patients, clinicians, staff, neighbouring STPs and Local Authorities
Shown to have met the Secretary of State’s four tests for service reconfiguration (see
section 11.1)
Undertaken in line with section 242 of the NHS Act 2006 and section 142Z of the
Health and Social Care Act 2012 (as set out above).
It is proposed that, subject to further engagement with patients, carers, staff and residents,
we will consult on our proposals to create a single adult elective orthopaedic service for
north central London (Barnet, Camden, Enfield, Haringey and Islington) with the following
key features:
A clinical network of orthopaedic specialists, to oversee the service
Two elective orthopaedic centres for inpatient care, in the south a centre based in a
new UCLH inpatient building on Tottenham Court Road in Camden and in the north a
centre, based at Chase Farm Hospital in Gordon Hill in Enfield
Enhanced post-operative care at Chase Farm Hospital, with a level 2 high
dependency unit (HDU)75
Day surgery would continue to take place at all four local hospitals, with an enhanced
day surgery offer at Whittington Health in Islington as part of the partnership with
UCLH
Highly specialist care delivered at the Royal National Orthopaedic Centre
A single, comprehensive approach to pre- and post-operative care and patient
education (joint school) delivered at a patient’s local hospital
Education, training and research as a core objective.
To define the scope of the consultation, the Programme Board signed off a consultation
mandate on 16 September 2019:
The five CCGs in NCL (Barnet, Camden, Enfield, Islington, Haringey) in partnership
with providers, intend to consult on the future configuration of adult elective
orthopaedic care. Our proposals are to create a single network, overseeing two
partnerships of providers, which would result in some changes to where patients
have surgery
Working through North London Partners in Health and Care, we would like to
understand the views of past, current and prospective patients and carers of adult
elective orthopaedic services, staff and stakeholders
Our aim is that, by April 2020, when the consultation has closed and feedback has
been evaluated, we would understand the impact of the proposals and be able to
improve them when implemented, to achieve better access and outcomes for
patients of adult elective orthopaedic care in NCL.
75 Patients in a level 2 HDU require a high level of monitoring and observation. One nurse looks after two patients.
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The aim of our consultation exercise is to understand stakeholder responses to our
proposals for the future model of adult elective orthopaedic services in north central London.
The proposed change could affect all patients and future adult patients of the five boroughs
with a need for elective orthopaedic care.
The aim of the proposals is to consolidate services from the current 10 sites onto fewer sites,
to improve the quality of care that patients receive, improve outcomes, reduce waiting times
and minimise the cancellations that patients currently experience.
Patients have been central to the development of our plans and we are committed to
continuing to listen to the views of diverse audiences – people who have used the service in
the past, people who may have a need for the services in the future, community
representatives and all partners in health and social care.
A full consultation plan is being collaboratively developed.
To inform our decision-making, through our consultation, we are seeking views about the
proposed change from:
• People who have experienced adult elective orthopaedic care in the past, at one of
the existing sites
• People who may need services in the future
• The families and carers of affected groups, including local residents and the public.
• Community representatives, including the voluntary sector
• Staff and partners in health and social care
• Relevant local authorities.
Our objectives are:
To inform stakeholders about how proposals have been developed
Ask their views on the service model we are proposing, and the ways in which it
might affect them
Find out what matters most to patients and how this might affect implementation
Understand the wider implications of the proposed change – and any unintended
consequences
Ensure that a diverse range of voices are heard
To run a process which maximises community support.
Following the consultation period, we will provide an evaluation of the responses, produced
by an independent organisation. Future decision-making and plans would be informed by
feedback on the issues laid out above and would influence the next steps of the programme
and how our plans would be implemented.
Our consultation documents will lay out our proposals clearly, explaining the thinking behind
them, how we arrived at them in light of the engagement already undertaken and how
people could feedback on them. The document will contain a questionnaire for structured
feedback, alongside quantitative responses. It will also give information about other ways to
feedback and engage in the process.
12.1.1. Drafting of the consultation plan
To ensure that the consultation plan is comprehensive, we plan to engage partners and local
residents in the drafting of the plan, and many of our consultation materials. To facilitate this,
a number of existing groups would be involved, and a time-limited group would be
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established, reporting into the NCL adult elective orthopaedic services review programme
board.
Their role would be to scrutinise and feedback on the consultation plan. In the drafting of the
plan we would involve:
A consultation planning sub-group would be established, with representatives of the
comms and engagement network (above) along with resident representatives who
have supported the review to date
A publications’ review sub-group would review the text and design of documents to
ensure that they are clear and easy to understand.
12.1.2. Public sector equality duty
We acknowledge that individuals who fall within the definitions of the 2010 Equality Act’s
protected characteristics groups use the services under review with no specific relation to
their membership of that particular group.
Our initial equalities impact assessment has identified a number of groups who may
experience an impact (positive or negative) through the implementation of our proposals and
as a result we are undertaking specific activities to ensure that we engage with these groups
during the consultation period.
A further integrated health inequalities and equalities impact assessment is due in December
2019 and looks more specifically at our proposals and the list of groups below will be
supplemented according. It will be published alongside the consultation.
We would be approaching local groups directly during the early stages of the consultation;
however, we intend to engage specifically with the following groups, who were identified
during our desktop analysis (stage 1):
Older people
Women
People undergoing gender reassignment
People from a white ethnic background
People from a black and minority ethnic background
People in economic and social deprivation
People with disability.
We would supplement this list with other groups identified as a result of the integrated health
inequalities and health equalities impact assessment (stage 2 report) which would be
published alongside the consultation.
12.1.3. Partnership working with service providers and other stakeholder groups
There is a good history of partnership working across NCL and we would work closely with
service providers and other organisations who work with those likely to be affected by
proposals. This includes:
Briefing meetings with staff and providers in all hospitals and the surrounding area
Meetings with politicians, community leaders and representative groups.
12.1.4. Engagement with political and statutory stakeholder groups
We are actively engaging with key statutory and decision-making groups to deliver the
consultation. The detail of this engagement is not described in the consultation plan;
however, we were keen to acknowledge the important role played by:
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Joint Health Overview and Scrutiny Committee
Relevant partnership groups via local authorities
Health and Wellbeing Boards
Healthwatch organisations
12.1.5. Consultation materials
We will produce the following tools to help people engage with the consultation:
Full consultation document
o Large print version
o Easy read version
o BSL version
o Versions available in Braille and other languages on request
Summary consultation document
Posters promoting the consultation
Short film explaining the proposals
Presentation outlining the proposals (versions could be created for different
audiences, around a core structure).
12.1.6. Consultation events
A diary of events and opportunities for engagement will be developed across all five
boroughs. These would comprise presentations, deliberative events, meetings and focus
groups where proposals would be presented, and feedback sought and captured using both
the consultation questionnaire and notes from meetings.
We would ask for responses to a specific set of proposals, rather than exploring desires and
issues. We would ensure an open approach to capturing feedback to our proposals and
would invite feedback in a number of ways:
Response using the printed questionnaire (freepost return)
Response using an online version of the same questionnaire
Feedback captured patient and carer groups and other in-person interactions
Feedback captured at deliberative events
Feedback given to our evaluation partner on the telephone
Submissions via letter or email, not using the structured questionnaire mechanism.
12.1.7. Close of the consultation
Following the closure of the consultation exercise, the project team will publish an
independent evaluation of the consultation which aggregates the major themes emerging
from the process and illustrates the likely outcome of consultation.
This will bring together the responses collected at each of the previous stages (online and
postal surveys, public event feedback, and also feedback gathered by the programme team
and partners in the course of its engagement of stakeholder groups) into one, synthesised
report. This would be produced by an independent third-party organisation.
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A&E Accident and emergency department
ACP Advanced clinical practitioner
AGM Annual General Meeting
AHP Allied Health Professional
APP Advanced Practitioner Physiotherapists
BAME Black and Minority Ethnic
BMD Bone mineral density
BOA British Orthopaedic Association
CATS Clinical Assessment and Treatment Service
CCGs Clinical Commissioning Groups
CHE Camden Health Evolution
CIC Community Interest Company
Committee in Common
CEO Chief Executive Officer
CIP Cost Improvement Programme
CPEG Camden Patient Engagement Group
CT Computed Tomography
D2A Discharge to assess
DHSC Department of Health and Social Care
DMBC Decision-making business case
EBITDA Earnings before interest, tax, depreciation and amortization
ED Emergency department
EIA Equalities Impact Assessment
EMAS European Male Ageing Study
FAQ Frequently Asked Questions
FBC Final Business Case
FCP First contact practitioner
F&F Family and friends
FHIR Fast Healthcare Interoperability Resources
FTE Full-time equivalent
FYFV Five Year Forward View
Glossary
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GIC Gender identity clinic
GIRFT Getting It Right First Time
GOSH Great Ormond Street Hospital
GP General Practitioner
HDU High Dependency Unit
HEE Health Education England
HIE Health Information Exchange
ICS Integrated care system
ICU Intensive care unit
I&E Income and expenditure
ISOC International Society of Orthopaedic Centers
JCC Joint Commissioning Committee
(J)HOSC (Joint) Health Overview and Scrutiny Committee
KPI Key performance indicator
LTP Long term plan
LSOA Lower Super Output Area
MaST Mandatory and statutory training
MDT Multidisciplinary team
MFF Market forces factor
MHRA Medicines, Healthcare Products Regulatory Authority
MRI Magnetic resonance imaging
MSK Musculoskeletal
MSOA Middle Layer Super Output Area
NCL North central London
NHS National Health Service
NHSE NHS England
NHSI NHS Improvement
NLP North London Partners in Health and Care
NMUH North Middlesex University Hospital
ODP Operating department practitioner
ONS Office for National Statistics
OT Occupational therapy
PA Physician associate
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PbR Payment by results
PCBC Pre-Consultation Business Case
PDC Public dividend capital
PREMs Patient reported experience
PROMs Patient reported outcomes
PSED Public sector equality duty
Q Quarter (meaning financial year quarter: Q1 is April-June, Q2 July-
September etc)
QIPP Quality Innovation Productivity and Procurement – Improving
Value
RNOH Royal National Orthopaedic Hospital
RTT Referral to treatment
SHAPE Strategic Health Asset Planning and Evaluation
SI Serious incident
SPA Single point of access
SRO Senior responsible officer
SSI Surgical site infection
STP Sustainability and transformation partnership/plan
SWLEOC South West London Elective Orthopaedic Centre
TNA Trainee nurse associate
TCI The Consultation Institute
UCLH University College London Hospital
YTD Year to date
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Appendix A – Engagement evaluation report
Engagement evaluation report: North Central London Adult Elective Orthopaedic
Surgery Review
Author: Clive Caseley
Date: 27/11/18
1. Overview
1.1 About this document
A review of adult elective orthopaedic surgery for the population of North Central London has
been established by the Joint Commissioning Committee of North Central London (NCL)
Clinical Commissioning Groups (CCGs).
This document contains the independent evaluation of an engagement exercise with
residents, staff and local stakeholders carried out between August and October 2018.
The purpose of the engagement exercise was to:
Share the draft case for change
Gather views to inform commissioners’ decisions following the first stage of the
review
Make recommendations for future involvement of residents, stakeholders and front-
line staff (should this be required).
Verve Communications was commissioned to conduct the evaluation. It was undertaken as
a desk exercise based on raw response data and information about the engagement
provided to us by the programme team. The purpose of this document is to provide:
Commentary on the process and its compliance with guidance and best practice
Analysis of comments, feedback and views on the case for change received through
the exercise.
1.2 About the engagement
Early engagement to support potential NHS service changes are an important opportunity to
involve local people in key decisions about their healthcare and services and to open a
large-scale dialogue about priorities and options for the future.
Engagement fulfils several different purposes:
Providing information
Obtaining feedback on proposals and evaluating the priorities among different groups
who may be impacted differently
Demonstrating accountability, scrutiny and open, transparent planning
Supporting a committee decision on specific proposals for change – which may be
subject to future consultation.
APPENDICES
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1.3 About the data analysed
The programme used a range of communication channels with significant reach to local
communities combined with targeted activity. This approach ensured notably high levels of
local involvement and inclusion of groups likely to be disproportionately represented among
elective orthopaedic surgery patients in north central London and those at risk of health
inequalities.
Similarly, the views of clinicians and other professionals were gathered using a variety of
methods to develop a rich picture of the views of provider staff, commissioners and
institutions.
1.4 Engagement summary
Table A1: Scope of engagement
Engagement Forum Meetings/Events Numbers
Patients and public 13 181
Commissioners 7 54
Providers 10 287
Local authority 6 22
Total 36 544
Meetings/Events Numbers
Workshops and plenary 5 63
Written communication
Channel Organisational Channels
Written feedback 7
Website feedback 78
Proactive promotion
Reach Organisational channels
(Electronic and print newsletters, mail outs,
bulletins)
Social Media (Facebook, Twitter)
58,710 28,796 29,914
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The collection of notes and comments by the programme team was comprehensive and
detailed. We were provided with a significant quantity and variety of free text comments as
the raw data for analysis.
These came in a variety of forms, but were chiefly:
Questionnaire responses
Comments noted at meetings
Formal responses from organisations or individuals (responding in an official
capacity).
This report also takes as a starting point an Initial Equalities Analysis conducted for the adult
elective orthopaedic services review to inform the engagement exercise. The analysis
identified key groups sharing protected characteristics likely to be significantly impacted or
groups at risk of health inequality enabling them to be prioritised.
Within this evaluation of the engagement activities we have aimed to:
Reference all substantive points made
Identify in broad terms themes and opinions including where the data suggests
variations between the different groups identified (i.e. patients/public, providers,
commissioners)
Focus on issues relevant to groups ‘scoped-in’ within equalities analysis where
possible.
1.5 Comments on the data received
The draft case for change was deliberately presented at an early stage of the process to
enable participation by as many key stakeholders as possible and to test the rationale for
change.
There is always a balance to be struck on the timing of engagement, and we have sought to
take this into consideration in the analysis in the following ways:
Respondents would not necessarily understand that the review is an iterative process
and, even if the milestones are set out clearly, there may still be comments based on
incomplete understanding of where, how and on what basis decisions would be
made.
Early engagement is likely to mean that there is not yet detailed, agreed answers for
how the new model may be configured. For example, it is not yet clear whether
imaging is proposed to be at the proposed elective centres or at base or local
hospitals because the model has not been developed in enough depth at this stage.
There may also be incomplete appreciation by respondents about the nature and
extent of communications and engagement or equalities work and, for example,
suggestions for dialogue which have already happened.
2 Headline findings
2.1 Rationale for the review
Describing the drivers for the review – Contributors recognised the pressures and issues the
review is seeking to address and these resonated with their experience of services.
However, questions were raised about whether the rationale for review could be articulated
more clearly, with suggestions that more evidence should be presented about the current
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scale and impact of cancellations/delays, and particularly the need for a clearer local case to
support the internationally suggested threshold of 5,000 cases a year and minimum numbers
of consultants per sub-specialism.
2.2 Opportunities to improve services in the preferred model of care
Patient experience Patients with vulnerabilities (e.g. these were learning disabilities,
dementia, and mental health issues) might find it difficult to travel to and find their way
around an unfamiliar hospital, with unfamiliar staff. It was suggested that consideration could
be given to having people available to assist them on arrival.
Continuity of care there were several points raised around the subject of continuity of care.
In the majority of cases these were in the form of questions about the location of pre-
operative assessments and post-operative care/rehabilitation. These comments indicate that
there is a need for the review to clearly explain where these activities would take place at the
next stage of engagement.
Patients with complex needs it was not clear where patients with complex needs (e.g.
those with comorbidities) would have their surgery. This is a growing section of the
population and it would be important for the review to produce clear and well justified
recommendations.
Integration contributors stressed the importance of joined-up working and integration
between clinical, social care and rehabilitation services. The role of an integrated IT system
was important if care is to be delivered across multiple locations.
2.3 Key dependencies or consequences that the preferred model of care would need to
manage
Travel – Always a key concern for public and patients, with the assumption that future
proposals might mean more time and money spent on travelling to appointments, and
potential impact on those with mobility impairments and economically deprived residents.
There were repeated comments suggesting that an in-depth transport analysis should be
considered so that the implications could be fully understood.
Across the system A number of people referenced to the potential risk of unintended/
indirect consequences for other parts of the local health economy. For example, loss of
elective income might damage the viability of services at base hospitals, and that the
separation of trauma and elective orthopaedic work might have a detrimental effect on staff
training, skills, job satisfaction and retention/recruitment.
Patient choice Some members of the public raised concerns about the potential restriction
of patient choice through consolidating elective services into a small number of sites.
The model More detail and reassurance were requested about the practicality of
separating ‘hot’ and ‘cold’ work, based on the concern that staff might be pulled back to
trauma work at times of high demand, winter pressures etc.
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2.4 Public and patients
Seen as benefits
Common responses included reference to clinical rationale, proposal seen as “a
good idea” which made sense with an ageing population and could achieve better
outcomes
Benefits for patients were seen as: consolidated expertise and the best equipment;
ability to ring fence beds for elective procedures; relatively rare procedures could be
concentrated in one centre, enabling clinicians to develop skills and experience;
reduced waiting times; fewer infections; speedier recovery; and reduced
cancellations
Other advantages were seen to include cost saving/cost effectiveness, better staff
retention and more scope for research and innovation.
Areas of concern
Most commonly mentioned were concerns about transport/travel, particularly for
patients with mobility impairments/disabilities car parking was a specific concern
How patients would navigate the system and the elective centre, especially for
patients with learning disability, dementia and/or mental health problems
Need more focus on the patient perspective (e.g. data from other areas about patient
experience/satisfaction, and information about current levels of cancellations and
delays should be cited)
That the driver for the review might lead to a focus too strongly on saving money –
there was a related concern that elective centres could lead to privatisation
Some doubt that elective capacity could be effectively ring-fenced
Staff might be reluctant to travel between sites, have less time to see patients and
may confuse/complicate processes
The impact on hospitals not selected as elective centres, particularly on trauma
surgery and consequent distribution of services across north central London
Some saw local hospitals as offering continuity of care – concern that an elective
centre may not be able to deal adequately with complex cases and maintain its own
Intensive Care Unit or High Dependency Unit
Assumption amongst those feeding back that physiotherapy/rehabilitation services
would also be located at the elective centre, with consequent additional journeys
required
A perception from some respondents that recent investment in Chase Farm means it
would automatically be selected as a specialist site, despite the perception of poor
transport links
A concern that patient choice could be reduced by having fewer sites carrying out
elective orthopaedic surgery
High-volume work within one specialism led some contributors to fear that staff could
become bored with the ‘conveyor belt’.
Other points for further consideration
Workforce issues/operational matters, e.g. recruitment and retention implications of
narrower career/training opportunities if elective work is split from trauma work
Social care/discharge, e.g. social care needs to be joined up with clinical care, and
concern that a very large elective centre may struggle to cope with the volume of
discharges across multiple boroughs
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The review: scope and timescale, e.g. explain the governance of the review, specify
the decision date. Does the review cover surgery on hands and shoulders?
Evidence-based medicine, e.g. is the review considering the Adherence to Evidence-
based Medicine Consultation and looking at procedures of limited clinical
effectiveness?
Financial/investment, e.g. where would the funding come from to fit out the new
designated centres?
Surgery vs non-surgical intervention e.g. calls for more non-surgical options for
patients, concern that new elective centres might drive a more interventional
approach.
2.5 Commissioners
The findings below are taken from seven meetings held with clinical commissioners. These
meetings were more focused on the technical aspects of a potential new service model
rather than a more deliberative approach used for other meetings.
Seen as benefits
Positive reactions to the key concept of establishing elective orthopaedic centres.
Awareness of similar reviews undertaken in other clinical areas (e.g. cancer or stroke
services), with many benefits cited: reduced length of stay, reduction in unwarranted
variation, procurement efficiency, and enhanced professional experience
Acknowledgement that although patients would not necessarily welcome any
potential additional travel, waiting times were seen as the paramount issue for
patients and anything that impacts positively on this was welcomed.
Areas for further development
Calls for the rationale for the review to be made clearer in the next iteration of the
case for change specifically whether the key motivation was improved clinical
outcomes or cost savings
View that the next iteration of the case for change should be transparent about the
potential downsides of a new service model and how they would be mitigated –
particularly any potential implications for financial viability of other local hospitals e.g.
interdependency between trauma and elective orthopaedic services
Need to consider how the system could be designed to ensure that high standards of
care are maintained across the whole patient experience, this should include social
services involvement
Workforce implications, such as whether clinicians might want to continue working on
both trauma and elective and any implications for training, retention and how
travelling time between sites would be managed
Recognition that it may not prove easy to separate hot and cold capacity in practice
Concern that the new model sets out clearly how patients with co-morbidities would
be managed.
Other points for further consideration
● Ways of working – practical implications, e.g. there would need to be clear protocols
across community services to ensure continuity of care, IT needs to be appropriate
for moving records across different locations
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● Engagement to achieve buy in from clinicians and public, e.g. needs to be
representative of boroughs, needs to inform GPs so that they could talk to patients
about it
● The need to work out and explain the patient pathway in the new system, e.g. how
would it fit with the wider MSK pathway, patients need to understand what it would
mean for them
● Further consideration of evidence/data to confirm the case for change, e.g. explain
the statistical evidence supporting the proposals, GIRFT programme needs to be
more prominent in communications
● Surgery vs. non-surgical intervention, e.g. calls for more non-surgical options for
patients, concern that new elective centres might drive a more interventionist
approach.
2.6 Providers
Seen as benefits:
The vision was well-received, though there was recognition that “the devil would be in
the detail”
A view that the public would accept extra travel if they were convinced about the
delivery of better outcomes
Benefits seen as: the opportunity to achieve more within current resources
economies of scale, improved efficiency through greater collaboration, better
outcomes through standardisation and reduced variation, research, and training
Could provide opportunities for staff to work across different sites and experience
both trauma and elective work.
Areas for further development:
That surgeons working across multiple sites might find the experience frustrating,
which could affect staff retention
Standardisation might lead to a levelling down of outcomes, rather than levelling up
The financial model was not yet adequately explained, specifically the potential for
some (especially smaller) hospitals to lose out
Whether resources would need to be shared e.g. pooled budgets across north
central London
Whether the proposed threshold of 5,000 cases per annum would be too high, and
might rule out some locations
Private hospitals were concerned about implications of the review for the private
sector
Need to test further some of the evidence presented e.g. whether GIRFT data is
sufficiently robust and how it would be taken into account
Question about where High Dependency Unit services should be located
View expressed that pre-operative assessment could be done at the site where
surgery would take place, because of considerations around anaesthetic and
perioperative care planning
Some concern that any implications for spinal services were not adequately
discussed in the proposal
Concern about the impact of extra transport/travel for patients and families
particularly challenging for deprived communities
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The process and proposals need to ensure a strong focus on patient experience and
continuity of care.
Other points for further consideration:
● Financial issues, e.g. would the necessary capital be available, how would the
income of smaller hospitals be protected?
● Workforce issues, e.g. are surgeons supportive or anxious about this, have
anaesthetists been consulted?
● Issues of scope and definition, e.g. where would day cases go, would it be a hub and
spoke model?
● Spinal issues, e.g. is RNOH spinal work included in the review, have you liaised with
the spinal networks?
● Local services/centralised services, e.g. where would rehabilitation take place, what
would happen to imaging?
● Pathways and relationships within the local health and care economy, e.g. would
there be unintended consequences, it needs good integration with social
care/housing/rehab to get patients home
● Communication, e.g. need to make the case to the public, consolidation at Chase
Farm could have been explained better
● Need to align with NCL work on discharge pathways for complex patients.
2.7 Participation in Enfield
Special mention should be made of the responses received as a result of work by
Healthwatch Enfield, who produced their own questionnaire and materials summarising the
draft case for change and ran a series of local events a number of which were attended by
members of the programme team. This generated a significant number of comments.
Enfield residents were therefore able to participate through both the programme feedback
routes and via Enfield Healthwatch. The raw data from the Enfield Healthwatch
questionnaire was shared with the programme team so that it could be included within the
integrated analysis framework and be reflected in the overall evaluation. Enfield Healthwatch
have also produced their own local report on the feedback received.
3 Meeting best practice
3.1 Policy and guidance relevant to the engagement exercise
When major changes to NHS services are proposed, communications and engagement
should be central at all stages of the process of developing proposals, considering options
and making decisions.
NHS change legislative framework
NHS Act 2006 (as amended by the Health and Social Care Act 2012) - s14Z2
(CCGs), s13Q (NHS E)
Where substantial development or variation changes are proposed to NHS services,
there is a separate requirement to consult the local authority under the Local
Authority (Public Health, Health & Wellbeing Boards and Health Scrutiny)
Regulations 2013 (“the 2013 Regulations”) made under s.244 NHS Act 2006. This is
in addition to the duties on commissioners and providers for involvement and
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consultation set out above and it is a local authority which could trigger a referral to
the Secretary of State and the Independent Reconfiguration Panel.
Equalities legislative framework
Equality Act 2010 s149 – Public Sector Equality Duty (PSED) and equality impacts.
Consultation best practice
The Consultation Institute (TCI): The Consultation Charter – The 7 Best Practice
Principles
For commissioner-led processes there are statutory requirements and best practice
guidance was published by NHS England in 2018 in Planning, assuring and
delivering service change for patients (NHS England) which sets out responsibilities
and the process, and separate guidance on equality and health inequalities legal
duties was published in 2015.
3.2 About the engagement process
Programme leaders, the review group and programme team made clear and positive efforts
to meet best practice, and in our view, the exercise meets the key criteria set out in guidance
by NHS England.
We have provided a commentary on relevant elements of the engagement process against
both NHS England best practice and the Consultation Charter standards (Appendix A)
NHS England
In Appendix A we have referenced key points from NHS England guidance relevant to pre-
consultation engagement and included observations on this exercise and appropriate
recommendations for engagement in future phases.
The Consultation Charter
The Consultation Charter (The Consultation Institute) identifies seven principles. Although
most commonly applied to consultation, these represent best practice at all stages of
engagement.
In our view, this engagement fully met the principles of the consultation charter. They are set
out in Appendix A alongside our comments relevant to this engagement.
3.3 Requirements of engagement to support the programme
If there is agreement to proceed, communications and engagement associated with later
stages of the review would be required to meet the statutory requirements set out above.
This would include:
The development of a pre-consultation business case (PCBC)
An options appraisal process
A formal consultation.
In later stages, other checkpoints and/or guidance may also become relevant for
communications and engagement. This includes:
Equalities impacts/Public Sector Equality Duty (PSED)
The Government’s four tests for reconfiguration, plus additional DHSC test on
reduction of hospital beds
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Department of Health Gateway (programme readiness)
Government Code of Practice (should consultation be required).
3.4 Approach to analysis
Principles
The analysis and commentary set out in this document are our views based on a review of
the data we received and the following approach:
Scale and scope of engagement is compared with guidance and best practice
(referenced where appropriate).
The analysis is a qualitative exercise, and we have therefore avoided drawing
‘quantitative’ conclusions. We note that participants and respondents are not
necessarily a representative sample of wider populations (or professional groups).
We have aimed to combine insights from a range of sources into a single framework
for an integrated analysis to support decision-making.
We have aimed to produce a comprehensive analysis of qualitative data (i.e. our
purpose is to capture within the analysis all of the substantive points raised in order
to provide the programme team with a rich but manageable checklist of views, issues
and concerns)
The views of providers, commissioners and public/patients are presented separately
so that the reader can appreciate the perspective behind the opinion or question
being expressed.
Questions
Questions were worded to reflect likely perspectives and experiences of different
stakeholders.
Public and patients
1. What are your views on our ideas?
2. What are the advantages and disadvantages of consolidating onto fewer sites?
3. What are the top three considerations to take into account when thinking about how
these services are delivered in the future?
4. If you have used these services (or know someone who has) please tell us whether
the challenges set out in this draft case for change reflect those experiences?
Providers
1. Do the challenges set out in this draft case for change reflect your experiences of
delivering adult elective orthopaedic services in north central London?
2. What are your views on our ideas?
3. What are the advantages and disadvantages of consolidating onto fewer sites?
4. From your perspective what operational considerations need to be taken into account
in designing the new service model?
5. Are there some services that would be best placed locally rather than at a centre?
6. Are there key clinical dependencies that need to be taken into account?
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Clinical commissioners
1. Do the challenges set out in this draft case for change reflect your experience of
elective orthopaedic services in north central London?
2. What are your views on our ideas?
3. What are the advantages and disadvantages of consolidating onto fewer sites?
4. From your perspective what operational considerations need to be taken into account
in designing the new service model?
5. Are there some services that would be best placed locally rather than at a centre?
6. Are there key clinical dependencies that need to be taken into account?
7. What are your views on our proposed assessment criteria?
3.5 The Public Sector Equality Duty (PSED)
The engagement exercise was informed by an initial Equalities Impact Assessment (EIA)
which set out the responsibilities of commissioners under the Equality Act 2010 and
assessed the likely impact on groups sharing protected characteristics or others at risk of
health inequalities (deprivation, caring responsibility).
This identified groups with disproportionate need for elective orthopaedic surgery or
differential need (for example, females and males may have different needs to access a
service, but there is no evidence to suggest that either females or males have a
disproportionate need). This is summarised in table A2.
Table A2: Summary of Scoped-In Groups (Protected characteristics in grey have not been
scoped-in by the EIA)
Characteristic Disproportionate need Differential need
Age: Young people
Age: Older people
Disability
Gender: Female
Gender: Male
Gender reassignment
Marriage and civil partnership
Pregnancy and maternity
Race and ethnicity: White
Race and ethnicity: Black
Religion and belief
Sexual orientation
Deprivation
Carers
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Communication about the review and case for change and promotion of the engagement to
the scoped-in groups was through a mix of 13 different community channels (e.g.
newsletters) provided by Healthwatch organisations and clinical commissioning groups in
each of the five boroughs in north central London, plus a further four regular publications
aimed at local patients produced by four of the providers.
In addition, direct approaches were made to organisations and networks with reach to all of
the scoped-in groups. Invitations to participate in the engagement in format appropriate to
each group were delivered. As a result, 26 organisations participated and there were nine
meetings and events relevant to equalities communities.
All groups scoped in by the equalities impact assessment participated in the engagement
exercise, with engagement methodology shaped in line with their preferences for
participation (some preferred one-to-one conversations, some preferred to be part of a wider
group conversation and others preferred to participate in an event established especially for
their group e.g. those with learning disabilities).
Equalities groups
26 organisations with reach to equalities communities (i.e. groups sharing nine
protected characteristics, caring responsibility, social deprivation)
Nine meetings and events relevant to equalities communities
17 channels (Five boroughs through Healthwatch or CCG plus four providers) to
communities across NCL.
4 Recommendations
Recommendation 1. Next stages of the review need to focus on the key concerns
frequently mentioned by patients, public, clinicians and commissioners, exploring issues in-
depth, identifying potential solutions and mitigations. In particular:
Transport/travel An in-depth transport analysis would need to be undertaken so
that the implications could be understood
Further examination of the impact of the proposed change in service model on the
local health economy and any unintended consequences for other services and
providers and how these may be mitigated.
Recommendation 2. Issues relating to equalities and accessibility of services, particularly in
relation to ‘scoped-in’ groups identified through the equalities impact analysis, should be
explored in more depth in the later stages of the review. This includes:
The potential benefit of elective surgery centres in developing real expertise relevant
to rare conditions and/or small cohorts of patients. For example, increasing
awareness and reducing the risk of treatment-related decreased bone density in the
transgender population.
Recommendation 3. The next stages of the review should articulate clearer and better-
defined messages about the benefits of centralising elective orthopaedic services for
patients and the public. Key areas of focus include:
Clinical evidence on the improved outcomes which might be achieved.
Explaining the whole care pathway, including rehabilitation, not only the surgical
element, and
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Assurances about how continuity of care and joined-up working would be delivered.
Recommendation 4. Through governance and operational structures, recruit clinicians in a
range of roles across north central London who are interested in representing and
advocating for the programme in future phases with stakeholders, media and face-to-face
with residents. This includes providing training, support and co-ordination.
Recommendation 5. Consideration should be given to how any potential options appraisal
and evaluation processes can be co-designed with patients, clinicians and other local
stakeholders. This would include applying patient experience and patient outcome criteria
during the evaluation process. Key themes identified as part of the engagement process
should be taken into account when designing any options appraisal criteria (i.e. sustainability
of the whole system, reducing health inequalities, improving health outcomes, accessibility,
managing interdependencies and improving the quality of the environment and experience
for patients).
Recommendation 6. Further thought should be given to how patients and the public can
have an effective role in governance and operating structures developed for the second
stage of the programme.
For providers as the review progresses
Recommendation 7. There should be clear and defined messages for staff. Key areas
include:
Further examination of the working practicalities of separating elective care – for example
the impact of pressure on clinicians through acute or trauma work during periods of high
demand e.g. winter pressures.
For communications and engagement leads in the sustainability and transformation
partnership
Recommendation 8. Consider opportunities at a system level (North London Partners in
Health and Care) to establish long-term forums for groups sharing protected characteristics,
and others at risk of health inequality, that could be drawn upon as part of engagement on
health and care services, rather than needing to reach out for each individual change
programme.
Sub-appendix A.A – Engagement channels and response
Scale of engagement and response received
In the tables below, we set out the scale of activity and – where possible – the level of
participation.
Forum Meetings/Events
Patients and public 13
Commissioners 7
Providers 10
Local authority 6
Total 38
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Engagement response
Design workshops Attendance Numbers
Design Workshop #1– Review Group: Multidisciplinary
design workshop – Engagement planning meeting 35
Design Workshop #2 – Institute of Sport, Exercise and
Health: Multidisciplinary design workshop 28
Design Workshop #3 – Whittington Health Education
Centre: Multidisciplinary design workshop 27
Design Workshop #4 – Institute of Sport, Exercise and
Health: Multidisciplinary design workshop 38
Plenary – Plenary Meeting Arlington 44
Patient engagement planning
Barnet Healthwatch – Engagement planning meeting 2
Public Voice Haringey – Engagement planning
meeting 1
Islington Healthwatch – Engagement planning
Meeting 1
Design workshops
Clinical Engagement: Attendance numbers
Provider engagement events
Royal Free Communications Team – Engagement
planning meeting 2
UCLH Surgery and Cancer Board – MDT clinical
board 13
UCLH Specialist Board – MDT clinical board 25
Royal Free Joint Audit Meeting – MDT clinical board 40
RNOH Clinical Meeting – MDT meeting 150
BMI Meeting Cavell Hospital – private sector
engagement 2
Aspen Health Care – private sector engagement 2
North Mid Orthopaedic Team – provider meeting 10
Whittington Health – provider meeting 18
UCLH orthopaedic audit meeting – provider meeting 25
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Clinical commissioners’ engagement events
Haringey and Islington Governing Body in Common -
commissioning forum 23
Camden Seminar Board – seminar board 10
North and East Herts CCG – CCG meeting 3
Enfield Board Seminar – seminar board 12
Herts Valley's CCG meeting 4
North West London STP – neighbouring CCGs 1
North East London CCG – neighbouring CCGs 1
Patient, resident and local authority engagement
Public Engagement: Attendance numbers
Public and Patient engagement events
Camden CPEG – Patient engagement meeting 16
Islington Over 55s Group, Clairmont Centre – Public
event 23
Having A Say Group – Barnet Mencap – learning
disability group 10
Haringey Adult Social Care Joint Partnership Board –
patient public engagement 16
Enfield CCG Voluntary Community Stakeholder
Reference Group – CCG Stakeholder reference group
– patients/public
11
Barnet Healthwatch – patient and public event 11
Enfield CCG – patient and public event 24
St Luke’s, Islington Group (with Healthwatch Islington)
– patient group 9
Haringey CCG open event 26
Camden Healthwatch Group – community event 7
Camden Carers’ Group – meeting with carers in
Camden 3
Enfield Healthwatch public event – patient public
event 23
Gendered Intelligence – patient group 2
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Local Authority engagement events
Islington Lead Member 2
Enfield Lead Member 2
Haringey Lead Member 2
Barnet Lead Member 3
Camden Lead Member 3
Enfield Health and Wellbeing Board 10
Sub-appendix A.B – Best practice guidance
NHS England guidelines
From NHS England guidance
on engagement
Observations of this engagement exercise
Front-line clinicians involved,
including playing a role in
communicating the benefits of
change (p.17)
Provider events attended by over 280 staff.
Design workshops were clinically-led.
Clinical leaders developed and presented the draft case for change throughout engagement.
Patients and public engaged
throughout development,
planning and decision-making
(p.17)
Engagement was conducted at early stage of development to gather views on the draft case for change and initial proposition for delivery models.
Early involvement with diverse
communities, Healthwatch and
the local voluntary sector (p 19)
Programme Equalities Impact Assessment clearly stated the ‘scoped-in’ groups most likely to be impacted.
Efforts were made to engage all scoped-in groups.
Involvement should be part of
an ongoing dialogue (p.19)
This exercise is part of a phased engagement with initial focus on the draft case for change.
Evaluation report provides a headline ‘checklist’ of priority issues to be considered at later stages, specifically with patient representatives/Healthwatch, LA Scrutiny, social care and voluntary sector.
A communications and
engagement plan should set
out objectives and methods,
and provide evidence at
assurance checkpoints
(p.19)
A communications and engagement strategy was developed to support the engagement phase of the review and beyond.
Face-to-face meetings were held with lead members for health and care in all five north central London boroughs.
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From NHS England guidance
on engagement
Observations of this engagement exercise
Early and continued contact
with local MPs and councillors
(p.19)
A briefing was prepared for MPs across NCL, for distribution by CCG communication teams.
One MP responded with some questions about the review and draft case for change.
Patient and public
representatives should be
involved in internal assurance
processes and structures (p.19)
Two patient representatives (recruited by Healthwatch) sit on the review group.
Structures for internal assurance in the next stage of the review are not yet developed – a recommendation is made in respect of this.
It is good practice for
commissioners to involve
stakeholders in the early stages
of building a case for change
(p.25)
At this early stage, a wide range of stakeholders were involved in discussions on the draft case for change including:
Healthwatch and patient representative groups
Equalities organisations and networks
Clinical commissioners
Front-line staff
Local politicians.
Service design and
communications should be
appropriate and accessible to
meet the needs of diverse
communities (p.14)
The engagement is designed to be accessible to
‘scoped-in’ groups likely to be disproportionately
impacted, with active inclusion for relevant third
sector and representative groups.
Draft case for change was made available for
download in large print.
A public-facing leaflet to accompany the draft case
for change was produced for distribution (5,000
run).
The Consultation Institute Charter
The Consultation Institute’s Charter and seven best practice principles have been adopted
for this project.
Best practice principle Project adherence to the
principle
Integrity
The process must have an honest
intention. The Consultor must be
willing to listen to the views
advanced by consultees and be
prepared to be influenced when
making subsequent decisions.
This engagement is being
conducted at scale and
independently evaluated.
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Best practice principle Project adherence to the
principle
Visibility
All those who have a justifiable right
to participate in a consultation
should be made reasonably aware
of the exercise.
There has been a high-level
of external communication,
public meetings attended,
and participation has been
widely promoted.
Accessibility
Consultees must be able to have
reasonable access to the exercise.
This means that the methods
chosen must be appropriate for the
intended audience and that
effective means are used to cater
for the special needs of ‘seldom
heard’ groups and others with
special requirements.
Engagement has focused
on accessibility, with issues
relevant to scoped in groups
specifically addressed and
involvement by people
sharing protected
characteristics actively
encouraged through a
process providing different
channels to respond and
accessible buildings.
Transparency
Many consultations are highly
public, and rightly so. Indeed, the
principle of Transparency and the
Freedom of Information Act 2000
requires that stakeholder invitation
lists, consultee responses and
consultation results be published.
But this should only occur with the
express or implied consent of
participants. Consultors who intend
to publish details of respondents
and their responses have a duty to
ensure that this is understood by all
participants.
A clear timetable and plan
for engagement and
consultation is in place.
At meetings and in the draft
case for change programme
milestones and the process
are clearly set out.
Disclosure
For consultation to succeed, and to
encourage a measure of trust
between the parties, it is important
to provide for reasonable disclosure
of relevant information.
Consultors are under a duty to
disclose information which could
materially influence the nature and
extent of consultees' responses. In
particular, areas where decisions
have effectively been taken already,
and where consultee views cannot
Clear and detailed
information has been widely
publicised in the draft case
for change, and a large
number of individuals have
been, and would be
engaged face-to-face to
answer the questions
posed.
152
Best practice principle Project adherence to the
principle
influence the situation, should be
disclosed.
Consultees are also under a duty to
disclose certain information. If a
representative body expresses a
view on behalf of its members, it
should inform the consultor of the
presence of any significant minority
opinion within its membership and
be prepared to estimate the extent
to which it is held.
Fair interpretation
Information and viewpoints
gathered through consultation
exercises have to be collated and
assessed, and this task must be
undertaken promptly and
objectively.
In general, decision-makers should
not normally be personally involved
with primary analysis and
interpretation of consultation data,
and the use of external data
analysts has many advantages.
Where consultors use weighting
methods to assist in the
assessment process, this must be
disclosed to participants and to
decision-makers relying on the
consultation output.
Specialist social research
expertise was deployed in
the analysis. The process of
capturing and interpreting
data from the various
feedback sources was
overseen by Graham Kelly.
Graham has worked in
social research for nearly 30
years and was previously
Head of Social Research at
a leading market research
company. From 2010-2018
he was a member of the
Standards Board of the
Market Research Society,
which sets and polices
ethical and professional
standards.
Publication
Participants in a consultation
exercise have a proper expectation
that they would see both the output
and the outcome of the process.
Except in certain Closed or Internal
consultations, the assumption
should be that publication in a form
accessible to the consultee would
follow within a reasonable time after
the conclusion of the exercise.
It is the responsibility of a consultor
to publish an adequate feedback
document, consisting of
The consultation report
would be made public.
153
Best practice principle Project adherence to the
principle
consultation output, preferably in
advance of decisions being taken.
154
Appendix B – Options appraisal
B.1 Options appraisal workshop – criteria changes
The final scoring matrix was considerably amended following a workshop on 1 April 2019
involving clinicians and patients and resident representatives. The changes are set out in
the table, below.
The text in blue indicates wording that was amended, or sub-criteria added, following the
workshop with clinical and patient representatives on 1 April 2019. Changes to the
weightings following the workshop are indicated in green.
Area Detail of what is to be assessed Sub-section
weighting
Section
weighting
Criterion 1:
Fit with the
clinical model
How does the option deliver the essential innovation features of the clinical delivery model to achieve effective, safe care for patients?
50%
40%
(was 45%)
How well does the provider’s workforce plan support the aspirations of the clinical delivery model?
40%
(was 35%)
The provider’s proposals for improving education, training and research capability in NCL?
10%
(was 15%)
Criterion 2:
Deliverability
Material risks that could delay or prevent a decision from being made
65%
(was 50%) 20%
Material risks that could delay or prevent the scheme from being implemented once a decision to proceed has been taken
35%
(was 50%)
Criterion 3:
Patient
experience
How well does the option offer a quality service tailored to the needs of patients with vulnerabilities or those with complex needs (non-medical)?
30%
25%
(was 20%) How would the option deliver an accessible service for patients and carers in north central London?
40%
How would the option improve patients’ experience of care?
30%
Criterion 4:
Impact on
other services
Paediatric and adolescent services 60%
(was 70%)
15% Trauma
10%
Spinal surgery 10%
(was 20%)
155
Area Detail of what is to be assessed Sub-section
weighting
Section
weighting
Community and primary orthopaedic
services 20%
Some elements of the clinical delivery model initially formed part of the hurdle criteria.
However, following further discussion after the workshop, it was felt that assessing some
aspects of the proposed model of care twice, once in the hurdle criteria and again at the
options appraisal stage could be an overly complex process. Therefore, these aspects would
now only be considered as part of the options appraisal.
156
Appendix C – Assumptions underpinning financial modelling
Proposal Counterfactual
Activity
Baseline used is 2019-20 planned activity
Growth based on
GLA population forecasts weighted by age
Commissioner plans for reducing demand for procedures of limited effectiveness
The net impact is that growth is forecast to grow by approximately 1% per annum, although this varies slightly for each CCG and provider
Activity exclusions
Activity includes adults treated under the orthopaedic specialty.
Excludes:
Patients under 18
Patients treated for spinal procedures
Patients treated for orthopaedic procedures performed by consultants other than orthopaedic surgeons (i.e. hand procedures done by plastic surgeons)
Outpatient activity excluded. Assumed that there would be no impact on outpatient attendances
Activity movement
All inpatients at North Middlesex Hospital move to Chase Farm Hospital Elective Centre (Royal Free Hospitals Trust). Approximately 400 episodes.
Most inpatients at Whittington Health move to UCLH – 360 episodes.
360 day cases from UCLH move to Whittington Health
No change to activity currently at the other NHS providers in NCL sector.
560 inpatients and1,020 day cases currently treated in the independent sector would be treated at Chase Farm Hospital
40 inpatients and 80 day cases currently treated in the private sector would be treated at UCLH.
All activity transfers assumed with no attrition
No shift of activity
Income
Payment by Results rules applied throughout (apart from Camden – see below)
2019-20 plan used as the baseline
2019-20 tariff applied to activity
No price inflation applied
Income (Camden)
Camden MSK contract is a block, so income remains constant until the contract expires in 2022 (note Camden have the option to extend by 2yrs), at which point it is assumed activity reverts to PbR.
157
Proposal Counterfactual
Market Forces Factor
MFF is at 19/20 rate, applied at the rate for the site the activity is delivered (i.e. assumed any activity transferred to UCLH receives UCLH MFF and vice versa for the WH)
No transfer of activity so does not apply
Expenditure
Baseline is 2019-20 budget informed by service line reporting (SLR) (UCLH and Whitt)
Baseline is 2018-19 actual uplifted 2.1% to 2019-20 price base (NMUH and RFHT)
Cost inflation is excluded
Medical staff costs
Northern partnership – bottom-up costing based on number of sessions required
Southern partnership – direct cost linked to activity movement
Ward costs (nursing etc)
Bottom-up costing using the estimated number of beds required
Theatre costs Unit cost per case from SLR applied to forecast activity
Support services (pharmacy, radiology etc)
Estimate based on local SLR systems
Overheads
Corporate services overhead using % uplift
Northern partnership 30%
Southern partnership 22%
Capital charges
Proportion applied based on the footprint of the elective centre
N/A
Travel No change to the cost of patient travel assumed
N/A
Phasing Changes are assumed to take place from October 2020
N/A
Contingency None applied N/A
158
Appendix D – North London Partners in Health and Care adult elective
orthopaedic services review – Memorandum of Understanding
159
160
161
Simon Goodwin Chief Finance Officer, NCL CCGs
David Stacey Director of Finance, North Middlesex University Hospital Trust
Peter Ridley Group Chief Finance and Compliance Officer, Royal Free London NHS Foundation Trust
Hannah Witty Director of Finance, Royal National Orthopaedic Hospital NHS Trust
Tim Jaggard Chief Finance Officer, University College London Hospitals NHS Foundation Trust
Kevin Curnow Director of Finance (Acting), Whittington Health NHS Trust
162
Appendix E – Initial equalities analysis – Desk research
To ensure the NHS has paid ‘due regard’ to the matters covered by Public Sector
Equality Duty, we appointed an independent expert to undertake an integrated health
inequalities and equality impact assessment (IIA), to ensure the project does not have
a disproportionate impact upon any groups with protected characteristics.
This appendix provides the detail of the initial desktop analysis undertaken, with the
full integrated assessment being published separately, alongside the consultation.
Author: Verve Communications
August 2018
North London Partners in Health and Care
North London Partners in Health and Care (NLP) is a partnership of health and care
organisations from the five London boroughs of Barnet, Camden, Enfield, Haringey and
Islington.
NLP have launched a review of adult elective orthopaedic services across North central
London (NCL) following agreement at the NCL Joint Commissioning Committee meeting on
1 February 2018. This review would be clinically led and initiated as part of the north central
London Sustainability and Transformation Partnership (NCL STP).
The decision to embark on a review has stemmed from recognising that whilst there are
many examples of good practice within their current service offer, the care is fragmented
with adult elective orthopaedic services available on ten different sites within NCL. The
review would consider potential options for change to both improve quality of care and
achieve better outcomes and value for patients. The ambition of NLP STP is to create
comprehensive adult elective orthopaedic services for NCL which would be seen as centres
for excellence with an international reputation for high-quality patient outcomes and
experience, education and research.
The first phase of this process will:
Establish the Adult Orthopaedic Services Review Group – with representatives from
trusts, CCGs and patients
Define the vision and case for change based on clear, detailed evidence including
issues/gaps
Develop, evaluate and shortlist options for improving services
Develop a pre-consultation business case (if options for change are recommended).
Our initial equality analysis scoping report (desk research) forms a necessary part of defining
the vision and draft case for change based on clear, detailed evidence including issues and
gaps.
The draft case for change document summarises the evidence which supports the adult
elective orthopaedic services review. This started in February 2018 and would continue to
March 2019 to assess whether there are steps which could be taken to:
Improve outcomes and experience for patients
Improve quality and efficiency of services by reducing unwarranted variation
Make efficiencies as a natural consequence of these improvements, improving value
for money.
163
The review would consider these opportunities and thoroughly assess the options for
change; options which would help define the future scope and model for the service and is
split into several distinct phases:
1. Set up and planning for the review (February-July 2018)
2. Public and stakeholder engagement (summer and early autumn 2018)
3. Reflection on inputs from the engagement phase and finalising proposed service
model (October-November 2018)
4. Development of a pre-consultation business case (November-March 2019)
5. Subsequent phases for consultation and decision-making. Implementation to be
informed by the service model decided on (dates to be determined).
This draft timeline is flexible as NLP want to ensure that they are engaging properly with
stakeholders and residents. NLP have committed to extending the timeline to achieve this if
necessary.
We understand that the views and ideas expressed in the draft case for change do not, at
this stage, represent the view of the commissioners as to the best way forward. The
development and refinement of the service model is an iterative process. Commissioners
would make a decision in respect of the final service model following phase three, and if
required, a formal consultation process.
Engagement
The fact that this scoping report has been launched and embedded so early in the process is
a positive statement of commitment – often such assessments are conducted late and their
potential helpful impact for patients and residents is reduced.
A critical success factor for the review process is around ensuring appropriate engagement
with patients, the public, clinicians and other staff. This scoping report would feed into the
further development of an existing engagement plan that involves listening to patients to
establish what they consider important about the services, and what could be improved into
the future, before developing options about what might change.
A key commitment of the NCL STP is to involve patients who share one or more protected
characteristic so that future plans are inclusive, eliminate discrimination, advance equality
and foster good relations between those who share one or more protected characteristic and
those who do not. The local approach to patient and public involvement is being developed
in discussion with the five local Healthwatch organisations and the Joint Health Overview
and Scrutiny Committee, this report should inform these discussions.
Good equality analyses are based on good insight and good engagement. Throughout the
engagement process, the capacity of current Joint Strategic Needs Assessments (JSNAs)
and approaches to engagement should be kept under critical review.
Current services
Secondary care orthopaedic interventions for NHS patients are currently delivered from NCL
on ten separate NHS and private sector sites within NCL (plus other NHS and private sector
sites outside NCL).
The sites are listed below and identified on the map below (figure E1) – the map at figure E2
also shows elective commissioner activity by Healthcare Resource Groups (HRG) (2014-15)
across the five boroughs.
164
Figure E1: Current hospital locations in NCL
Royal National Orthopaedic
Hospital
UCLH - University College
Hospital
UCLH - National Hospital for
Neurology and Neurosciences,
Queens Square
Whittington Health
North Middlesex University
Hospital
Royal Free London – Royal Free
Hospital
Royal Free London - Chase Farm
Hospital
Highgate Private Hospital (Aspen)
The Cavell Hospital (BMI
Healthcare)
The Kings Oak Hospital (BMI
Healthcare)
Figure E2: Elective commissioner activity by healthcare resource groups (HRG)
165
The elective HRG activity for NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG,
NHS Haringey CCG, NHS Islington CCG is: 245,972 admissions (68.1% of all admissions),
430,850 bed days (42.1% of all bed days), 1.8 days average length of stay
Equalities analysis overview
Equalities analysis
To support the review process and to ensure that North London Partners in Health and Care
has considered the potential impacts on those characteristics protected under the Equality
Act 2010, including those who identify as carers, Verve Communications was commissioned
to undertake an independent initial equalities analysis through analysis of the draft case for
change for elective orthopaedic services.
Through initial desk research, we have looked at existing data from other programmes
looking at elective orthopaedic services in other parts of the country, Strategic Health Asset
Planning and Evaluation (SHAPE), plus local Joint Strategic Needs Assessments, London
Observatory, local insight work, London Data, EDS2 documents across each CCG (where
available), earlier EIAs from Our Healthier South East London which draws on relevant
national research from NHS England and the British Orthopaedic Association
Scope and objectives
The objectives of this initial equalities’ analysis are to:
Identify positive and any negative impacts for the population to inform the discussion
towards service reconfiguration.
Identify which (if any) of the protected characteristics groups are more likely to be
affected by the proposals due to their propensity to require different types of health
services.
Set out how the core constituent public sector health organisations can fulfil the
Public Sector Equality Duty (PSED) through working to: eliminate unlawful
discrimination, harassment and victimisation and other conduct prohibited under the
Equality Act 2010, advance equality of opportunity between people who share a
protected characteristic and those who do not and foster good relations between
people who share a relevant protected characteristic and those who do not share it.
Provide recommendations on ways in which positive impacts could be maximised
and ways in which to mitigate or minimise any adverse effects.
The process of our equalities analysis is designed to be an interactive ‘work-in-progress’
which would be revisited or re-examined during the development of any potential
consultation process that may be required in the future and throughout the engagement
process. Our draft scoping report follows, if required the analysis could be extended to
include insight and advice through potential consultation and post consultation phase.
We are aware that the health and wellbeing of populations at large are enhanced when
patients, service users, carers, clinicians, practitioners and staff of services are actively
engaged within a joint effort to meet health needs and to reduce health inequalities through
proportionate, equitable and continuing means.
166
The approach that we have used to conduct this assessment has set out to seek evidence of
any evolving actions our partners are taking to meet their respective Public Sector Equality
Duties in pursuit of local commissioning strategies and equality objectives.
Overview of scoping report
The objectives of this scoping report are to:
Look at demand for elective orthopaedics services by each protected characteristic
group and identify groups for engagement throughout the review process.
Identify existing health inequalities, access barriers and equality issues to be
considered.
Identify groups who share one or more protected characteristics and might have a
higher need for orthopaedic services and may be impacted more by a change in the
delivery of service.
Provide recommendations about key groups that may be targeted if there is a need
for consultation.
Provide advice on equalities questions for inclusion for any potential public
consultation.
Evidence for this scoping report has been gathered through:
Demographic analysis which sets out the characteristics of the north central London
population, and particularly the distribution of residents from different equality groups.
An evidence review of available literature which identifies population groups who may
have a disproportionate need for services.
Feedback gathered by previous and related strategic and community engagement
(particularly through the work on MSK services)
North central London population profile
The total population and the density of the population provide a baseline from which to break
down the key socio-demographic trends in our study area.
Table E1: Total population
The table below shows the total population of each of the five boroughs, as well as wider
comparators:
Borough Resident population 2018 (ONS)
Population 2028
Barnet 395,021 433,082
Camden 249,481 262,350
Enfield 339,277 373,282
Haringey 285,060 307,131
Islington 233,562 244,068
Greater London 8,980,874 9,746,735
The table indicates that the largest of numbers of people live in the boroughs of Barnet (with
395,021 people) and Enfield (with 339,277) while the least populated borough is Islington
(with 233,562). The total population of the scoping area is 1.5m.
167
Where we refer to Lower Super Output Areas (LSOAs) please note that the average
population of an LSOA in London in 2010 was 1,722 compared with 8,346 for a Middle Layer
Super Output Area (MSOA) and 13,078 for a ward.
Population Density
Figure E3: Total population density of NCL
NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey CCG, NHS
Islington CCG's estimated population density in mid-2016 is 4831.51 per km² within a range
of 96.32 to 43788 across 795 Lower Super Output Area (LSOAs). The England-wide Lower
Super Output Area (LSOA) distribution is 1.71 to 72245.47 with a mean value of 3310.26 per
km².
Insight into protected characteristic groups
In this section each of the nine ‘protected characteristic’ groups are examined, as well
considering other disadvantaged groups, specifically deprived communities and carers. This
includes:
Age
Disability
Pregnancy and maternity
Race and ethnicity
Gender
Sexual orientation
Gender reassignment
Religion and belief
Marriage and civil partnership
Deprived communities
168
Carers.
For each group, we note whether there is evidence of disproportionate or differential need
for elective orthopaedic services and a summary of this evidence is provided. ‘Differential
need’ in the context of this report means that there is evidence that different subsections of a
protected characteristic group have different needs. For example, females and males have
different needs to access a service, but there is no evidence to suggest that either females
or males have a disproportionate need.
For each characteristic within scope, tables on the left-hand side of each page are provided
to show the total number of that characteristic in each CCG area and the percentage of the
total population. On the right-hand side of the page, socio-demographic maps are used to
demonstrate the density (or distribution) of these population groups across north central
London.
In the final sections, a summary of the in-scope groups is provided alongside a commentary
as to the profile of these population groups across north central London. Other equality
impacts are explored, and an overview and example of potential next steps provided.
Age (older people)
Table E2: Population aged 65 or over and 75 or over:
Aged 65 and over % Aged 75 and over %
Barnet 53,415 13.84 24,641 6.38
Camden 28,719 11.67 12,594 5.12
Enfield 42,030 12.68 19,491 5.88
Haringey 25,730 9.24 11,038 3.96
Islington 20,229 8.69 8,779 3.77
The analysis shows that Barnet has the highest percentage volume of those aged 65 and
over and those aged 75 and over. Barnet also has significantly more older people than any
of the other boroughs, with Islington having the least.
169
Figure E4: Population density aged 65 and over
Evidence to demonstrate disproportionate need for elective orthopaedic care:
Osteoporosis, a condition treated with elective orthopaedic care, becomes more likely as we
age. Around 50% of people over the age of 75 are affected by the condition and after the
age of 50 one in two women and one in five men will break a bone as a result of poor bone
health arising from osteoporosis76.
Evidence surrounding specialised orthopaedics services in adults also points towards older
people having a disproportionate need for revision joint procedures in later life, thereby
increasing the demand for elective orthopaedic care with older people. This is because the
average age for arthroplasty procedures is falling, and so people are likely to need revision
procedures as they are having initial surgery younger. The average age for knee arthroplasty
has fallen from 70.6 in 2004 to 67.5 in 2010, and from 68 in 2004 to 62 in 2010 for hip
arthroplasty patients. It is worth noting that these figures come in a time when the population
is ageing. NHS England (2013): NHS Standard Contract for Specialised Orthopaedics
(Adults).
19% of women and 18% of men undergoing a total knee replacement are under the age of
60.77 Nationally the average age for total hip replacement is 68 years (British Orthopaedic
Association, 2015)
76 Age UK (No date): Osteoporosis: Could you be at risk?. 77 http://www.mtg.org.uk/major-studies/
170
Examples of evidence to demonstrate disproportionate need for elective orthopaedic care78
Older people are more predisposed to osteomyelitis than the general population as they
disproportionally suffer from associated disorders (such as diabetes). (Biomed Central,
2010: Osteomyelitis in elderly patients).
Bursitis also disproportionately effects older people due to the joints, muscles and tendons
near the bursae being overused (NHS Choices 2014, Causes of bursitis).
The NHS website reports that most people who have a total knee replacement are over 65
years old. The most common reason for knee replacement surgery is osteoarthritis. NHS
Choices 2015.
Changing population trends of older people
Barnet has a higher proportion of its total population who are aged over 65 when compared
to London. The number of people aged 65 and over is projected to increase by 34.5% by
2030, over three times greater than other age groups.
Disability check stats below
Table E3: Population with long term illness or disability, learning disabilities, dementia,
osteoporosis and rheumatoid arthritis79 80
Long-term illness or disability
Learning disabilities
Dementia Mental health
Osteoporosis Rheumatoid arthritis
Barnet 55,302 1,469 2,887 4,140 691 1,592
Camden 17,325 744 1,363 4,002 235 1,015
Enfield 52,248 1,289 2,068 3,582 366 1,483
Haringey 39,908 1,050 1,203 3,808 298 1,158
Islington 36,435 993 1,210 3,774 170 1,021
201,218 5,545 8,731 19,306 1,760 6,269
Prevalence of learning disabilities across the five boroughs is lower than the England
average and in line with London at an estimated 3.36 per 1,000 people. The prevalence of
long-term conditions increases with age, in Camden for example, 60% to 65% of people
aged over 55 diagnosed with a long-term condition in each locality. The prevalence of having
at least one diagnosed long-term condition is highest among the Black population.
78 Please note, that although we are seeing a significant increase in joint replacement in the young population, it continues to
be the older population that is most reliant on orthopaedic services and driving the increasing workload. Briggs, T (2015) Getting it right first time. 79 Source for Long term illness and disability: UK Census 2011 80 Source for Learning disability, dementia, mental health, osteoporosis and rheumatoid arthritis: QOF results year 2016/17,
NHS Digital
171
Mental health: NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey
CCG, NHS Islington CCG's reported prevalence of patients with mental health is 1.25% for
year 2016/17. The England-wide GP distribution is 0% to 16.58% with a mean value of
0.96%. The value falls in the upper quintile.
Dementia: NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey CCG,
NHS Islington CCG's diagnosis percentage for ages 65+ is 4.85% for January 2018. The
England-wide GP distribution is 0% to 69.57% with a mean value of 4.32%.
Learning disability: NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS
Haringey CCG, NHS Islington CCG's reported prevalence of patients with learning
disabilities is 0.36% for year 2016/17. The England-wide GP distribution is 0% to 4.34% with
a mean value of 0.48%.
Examples of evidence to demonstrate disproportionate need for elective orthopaedic care
A UK report supported by the Department of Health states that people with learning
disabilities may have increased prevalence of osteoporosis and lower bone density than the
general population. Contributory factors include their possible lack of weight-bearing
exercise, delayed puberty, entering menopause at an earlier-than-average age for women,
poor nutrition, being underweight and use of anti-epilepsy medication. The report notes that
people with learning disabilities have a greater prevalence of some of the risk factors
associated with osteoporosis than other people (Emerson, E. et al. (2012): Health
Inequalities & People with Learning Disabilities in the UK: 2012).
Studies have suggested that people who take epilepsy medicine for long periods of time are
at higher risk of thinning and breaking bones than those who do not take epilepsy medicine.
In 2009, the Medicines, Healthcare Products Regulatory Authority (MHRA) advised that
people still taking the following older epilepsy medicines on a long-term basis were at risk of
osteoporosis or broken bones, carbamazepine, phenytoin, primidone and sodium valproate.
However, there is little research exploring whether some of the newer types of epilepsy
medicines can cause bone problems (Epilepsy Action (2013): Bone health).
Epilepsy is also more common in people with a learning disability than in the general
population. It is estimated that one in three people who have a mild to moderate learning
disability also have epilepsy and around one in five people with epilepsy also have a learning
disability. The more severe the learning disability it, the more likely that the person will have
epilepsy as well (Epilepsy Society (2016): Learning disability and epilepsy).
Orthopaedic surgery may also be necessary for people with cerebral palsy to correct
problems with bones and joints. (NHS Choices website 2015).
Although there is no direct correlation between mental health and a greater need for
orthopaedic surgery, those suffering with mental illness have a number of inequality issues
to consider. There are three main ways, as outlined by the Department of Health DOH
(2011) No Health Without Mental Health: Analysis of the Impact on Equality (AIE), that
inequality is important in mental health and impacts on other areas of the report:
People who experience inequality or discrimination in social or economic contexts
have a higher risk of poor mental wellbeing and developing mental health problems.
People may experience inequality in access to, and experience of, and outcomes
from services.
Mental health problems result in a broad range of further inequalities.
172
Finally, there is also evidence suggesting that people with HIV may have a disproportionate
need for elective orthopaedic surgery. Particularly: low bone mineral density is prevalent in
people with HIV81. Inflammatory arthropathy and avascular necrosis is common in HIV
patients82. Factors that may increase the risk of osteoporosis in people living with HIV
include HIV infection itself and some HIV medicines (for example tenofovir disoproxil
fumarate)83
Sex: Female
Nearly half the NCL population is female (49%). Women are at higher risk of requiring
orthopaedic services due to living longer and the subsequent risk of osteoporosis, hormonal
changes related to menopause, incidence of specific conditions such as Lupus, and
exposure to specific medications such as those prescribed to treat breast cancer84.
Table E4: Female breakdown by borough
Females %
Barnet 195,245 49.43
Camden 122,196 48.98
Enfield 169,597 49.99
Haringey 138,001 48.41
Islington 115,700 49.54
Total 740,739
81 McComsey, GA et al (2010) ‘Bone Disease in HIV infection 82 Reis MD, Barcohana B, Davidson A et al. Association between human immunodeficiency virus and osteonecrosis of femoral
head. J. Arthroplasty 2002; 17: 135-9 83 Brown T, Qaqish RD Antiretroviral therapy and the prevalence of osteopenia and osteoporosis: a meta-analytic review. AIDS
20 (17): 2165-2174, 2006 84 What Breast Cancer Survivors Need To Know About Osteoporosis National Institutes of Health Osteoporosis and Related
Bone Diseases National Resource Center (2018)
173
Figure E5: Population density of females in NCL
Females have been scoped in as having a disproportionate need. The evidence for this is
provided below.
Examples of evidence to demonstrate disproportionate need for elective orthopaedic care
Hip and knee operations have a clear role in getting patients back to work as more and more
patients receiving an implant are of working age. 20% of female and 25% of male patients
receiving a hip replacement are under the age of 60.85
Osteoporosis is more common in women than men. Women tend to live longer, with age
leading to an increased likelihood to develop osteoporosis (see section D.1). In addition, at
around the age of 50, women experience the menopause, at which point their ovaries almost
stop producing the sex hormone oestrogen, which helps to keep bones strong (National
Osteoporosis Society (No date): Risk factors for osteoporosis and fractures). A woman’s risk
of having osteoporosis is also heightened if she has an early menopause or a hysterectomy
with removal of the ovaries prior to the age of 45 (Age UK (No date): Osteoporosis: Could
you be at risk?).
Joint pain is a common symptom of the condition lupus, especially in the small joints found in
hands and feet. The pain normally moves from joint to joint and is often described as 'flitting'.
Joint pain and swelling are often the main symptoms for some people, although it is unusual
for lupus to cause joints to become permanently damaged or deformed. About one in 20
people with lupus develop more severe joint problems, and less than one in 20 have joint
hypermobility or a form of arthritis called Jaccoud’s arthropathy, which can change the shape
of the joints (Arthritis Research UK (No date): What are the symptoms of lupus?). Lupus is
more common in women than men, with around seven times as many women as men
having the condition. Whilst drugs are often prescribed to lupus suffers, some also undergo
elective orthopaedic surgery.
85 http://www.mtg.org.uk/major-studies/
174
Up to 50% of women develop carpal tunnel syndrome (CTS) during pregnancy. CTS in
pregnant women often gets better within three months of the baby being born, although it
may need surgical treatment if symptoms fail to subside. In some women, symptoms can
continue for more than a year. CTS is also common in women around the time of the
menopause. (NHS Choices, 2014, Causes of carpal tunnel syndrome). Evidence also
suggests that more women than men develop CTS, possibly because women naturally have
smaller carpal tunnels (Bupa (No date): Carpal tunnel syndrome). Occasionally, some
medications could also cause the condition. Exemestane and anastrozole are both
medications used for the treatment of breast cancer, thus taken by a disproportionately large
number of women. Both drugs are said to potentially cause carpal tunnel syndrome (Arthritis
Research UK (2012): Carpal tunnel syndrome).
Finally, as women are likely to live longer than men and therefore more likely to use elective
orthopaedic care (D.1.)19% of women and 18% of men undergoing a total knee replacement
are under the age of 60.
Gender reassignment
Population demographics are not available for the numbers of people undergoing, or who
have undergone, gender reassignment. However, stakeholders have noted that the number
of gender reassignment procedures is increasing. This is supported by figures obtained
under a Freedom of Information request, which shows that there have been increases in the
number of referrals to all the UK’s gender identity clinics (GIC). The London GIC in Charing
Cross is the largest adult clinic. The number of referrals has almost quadrupled in 10 years,
from 498 in 2006-07 to 1,892 in 2015-16. In 2015-16, NHS England has provided an
additional £3m towards funding adult GIC clinics. ‘Gender identity clinic services under strain
as referral rates soar’ Guardian newspaper 10 July 2016.
Examples of evidence to demonstrate disproportionate need for elective orthopaedic care
Trans men (female-to-male) and trans women (male-to-female) may be at risk of developing
osteoporosis because of the need to take hormones that change the balance of oestrogen
and testosterone in the body. After gender reassignment surgery, the level of hormones may
decrease, and this may also affect bone density. The degree to which either of these factors
affect the risk of breaking a bone, however, remains uncertain. Replacement sex hormones
(testosterone for trans men and oestrogen for trans women) are necessary to maintain bone
strength and are generally continued long-term. The risk of developing osteoporosis may
increase if sex hormone replacement is discontinued, or if levels of replacement are too low
(National Osteoporosis Society (2014): Transsexual people and osteoporosis).
Research has also found that the male-to-female trans population who have their testicles
removed can affect bone density as the body’s natural levels on testosterone are too low.
However, evidence suggests that taking oestrogen instead compensates for the decrease in
testosterone. Some trans men who are unable to take testosterone use Depo-Provera to
stop their periods from occurring, and, there is some concern that using Depo-Provera can
negatively affect bone density (Vancouver Coastal Health, Transcend Transgender Support
& Education Society and Canadian Rainbow Health Coalition (2006): Trans people and
osteoporosis).
It must be noted that the research available on this issue is limited, however due to the
evidence presented above, gender reassignment has been scoped in as a protected
characteristic that may have a disproportionate need. This would be explored further with
clinicians and representatives of those who are undergoing gender reassignment.
175
Race and ethnicity: White populations
Table E5: Population with a white ethnic background
Barnet and Camden have the highest volumes and proportions of people from a white ethnic
background.
Figure E6: Population density of white ethnicity
Examples of evidence to demonstrate differential need for elective orthopaedic care
It is important to note that this report is suggesting a differential need amongst ethnic groups,
rather than a disproportionate need. This is because there is evidence to suggest that those
from different ethnic backgrounds have need for different types of elective orthopaedic care
services. The evidence on this page highlights issues pertaining to those from a white ethnic
background.
The National Osteoporosis Society states that those from Caucasian background are at
higher risk of osteoporosis than Afro-Caribbean people. This is because people from an
Afro-Caribbean background tend to have bigger bones. National Osteoporosis Society (No
date): Risk factors for osteoporosis and fractures. See: https://www.nos.org.uk/healthy-
Population: White ethnic background (ONS, 2011)
%
Barnet 228,553 64.13
Camden 145,055 66.29
Enfield 190,640 61.01
Haringey 154,343 60.54
Islington 140,515 68.17
England mean value NA 86.74
176
bones-and-risks/are-you-at-risk. In addition, a US study founded that Afro-Caribbean
American women’s femoral neck bone mineral density (BMD) was 10% to 25% higher when
compared to US white women, thereby lessening their risk of developing osteoporosis or hip
conditions in their life course (Dempster, D. et al (2013): Osteoporosis Fourth Edition). Data
from a UK-cohort of the European Male Aging Study (EMAS) also compared White-British
men to a group of Afro-Caribbean British and South-Asian British men. The Afro-Caribbean
British group had higher BMD at all sites when compared to South-Asian British and White-
British, both before and after adjustment for body size (Zengin. A. et al (2015): Ethnic
differences in bone health).
Race and Ethnicity: Black population
Table E6: Population with a Black and minority ethnic background
NHS Barnet CCG, NHS Camden CCG, NHS Enfield CCG, NHS Haringey CCG, NHS
Islington CCG's population in the Black/African/Caribbean/Black British: All ethnic group is
12.83% within a range of 0.86% to 50.59% across 795 LSOAs. The England-wide LSOA
distribution is 0% to 64.96% with a mean value of 3.14%. The value falls in the upper
quintile.
The population is projected to become increasingly diverse, for example, with the BAME
population in Barnet projected to increase from 38.7 to 43.6% of the total Barnet population.
Population: Black and
minority ethnic background %
Barnet 81,118 12.13
Camden 18,060 8.2
Enfield 53, 687 17.18
Haringey 47,830 18.76
Islington 26,294 12.76
England mean value NA 3.14
177
Figure E7: Population density of Black ethnicity
Examples of evidence to demonstrate differential need for elective orthopaedic care
Scientists at the London School of Hygiene and Tropical Medicine discovered that people of
non-white ethnicity tend to have more severe disease and have suffered with arthritis for
longer by the time they undergo surgery. (Arthritis Research UK (2012): Sociodemographic
factors influence timing of joint replacement surgery). In addition, reports in the US on
differences in knee osteoarthritis between African-Americans and Caucasians report a
higher prevalence knee osteoarthritis in African-Americans, as well as more symptomatic
knee osteoarthritis in African-Americans than Caucasians. Gait patterns can also differ
between ethnic groups in osteoarthritis prevalence. A study has reported that that African-
Americans were possibly more prone to lateral compartment knee osteoarthritis than
Caucasians (Chaganti, R. et al. (2011): Risk factors for incident osteoarthritis of the hip and
knee).
Lupus is also more common in some ethnic groups as well, particularly those of African
origin (Arthritis Research UK (No date): Lupus)
Black people were one third as likely to receive a hip replacement compared to white people,
while Asian people were one fifth as likely to have the procedure. For knee replacement,
Black people were two thirds as likely and Asian people were just over four fifths as likely to
have surgery, compared to white people. Ethnic minorities are undergoing fewer than
expected joint replacement operations and it is likely a combination of different factors. One
possible explanation could be patient willingness to undergo surgery amongst the different
ethnic groups examined. This is often shaped by cultural factors, doctor-patient
communication, and even patient trust in the healthcare system. Secondly, osteoarthritis of
the hip is slightly less common amongst Black and Asian people and this may partially
explain the differences. It is also interesting to note the gender differences in rates of knee
178
replacement with Black and Asian males much less likely to undergo joint replacement than
Black and Asian females. These initial observations require further investigation. 86
Socio-economic status
Table E7: Population experiencing high levels of multiple deprivation:
Figure E8: Socio-economic status
Using the indices of multiple deprivation, the map highlights areas of high levels of multiple
deprivation with Islington and Haringey experiencing the most. Deprivation impacts life
86 Smith MC, et al., ‘Rates of hip and knee joint replacement amongst different ethnic groups in England: an
analysis of National Joint Registry data’, Osteoarthritis and Cartilage (2017)
Index of Multiple Deprivation score
(2015)
Health deprivation and disability (2015)
Barnet 17.81 13.5%
Camden 26.15 13.5%
Enfield 26.99 13.5%
Haringey 31.04 13.5%
Islington 32.53 13.5%
England mean value 21.67 NA
179
expectancy, for example, in areas of higher deprivation in Enfield, men live 8.7 years less,
and women live 8.6 years less than in more affluent areas.
Examples of evidence to demonstrate disproportionate need for elective orthopaedic care
Deprivation is associated with greater need for total hip and knee replacement surgery.
Moreover, more deprived patients remain in hospital longer, without morbidity, because of a
lack of social support available to them in the community. (Major elective joint replacement
surgery: socioeconomic variations in surgical risk, postoperative morbidity and length of stay,
Journal of Evaluation in Clinical Practice, 2009).
Scientists at the London School of Hygiene and Tropical Medicine also discovered that
people from lower socioeconomic backgrounds, tend to have more severe disease and have
suffered with arthritis for longer by the time they undergo surgery. The researchers looked at
data on 117,736 patients, all of whom underwent hip or knee replacement surgery in
England in 2009-10 (Arthritis Research UK (2012): Socio-demographic factors influence
timing of joint replacement surgery).
Evidence suggests that malnutrition increases the risk of developing osteomyelitis, as a
weakened immune system makes it more likely for infections to spread to the bones (NHS
Choices, 2014, Osteomyelitis – Causes). Moreover, osteomyelitis is more likely to occur if for
some reason an individual’s bones are susceptible to infection. Pre-existing health
conditions, such as diabetes, can cause this. In this instance bones may not receive a
steady blood supply, meaning infection-fighting white blood cells cannot reach the site of
injury within the bone (NHS Choices (2014): Osteomyelitis – Causes). Diabetes prevalence
increases with greater levels of deprivation. Public Health England (2014) Adult obesity and
type 2 diabetes.
In addition, obesity prevalence increases with greater levels of deprivation. Public Health
England (2014) Adult obesity and type two diabetes. Obesity is a strong risk factor for knee
osteoarthritis, with obese people 14 times more likely to develop the condition than those of
a healthy weight. ‘Osteoarthritis and obesity’ Arthritis Research Campaign 2013. Although
the main treatments for osteoarthritis include lifestyle measures, in some cases, surgery to
repair, strengthen or replace damaged joints is preferred.
Carers
Table E8: Number of people providing care per week across the five boroughs (Census
2011)
Barnet has a significantly higher volume of carers than any other area, however Enfield has
proportionately more individuals caring for another person for more than 50 hours a week.
Carers providing 1-19 hours care per week
20-49 hours
50+ hours
Barnet 21,448 5,584 6,224
Camden 11,551 2,457 3,318
Enfield 17,299 4,131 6,194
Haringey 11,812 2,904 4,171
Islington 10,044 2,505 3,762 72,154 17,581 23,669
180
Please note that while the most up-to-date data on carers is from the 2011 census, figures
may have changed since then. In addition, carer figures tend to be under-reported as data
requires carers to self-identify. A proportion of those whom the NHS would deem to be
carers do not identify themselves in this way.
Examples of evidence to demonstrate differential need for elective orthopaedic care
It is important to note here that we are not stating carers have a disproportionate need for
elective orthopaedic care, rather they have a differential need due to their caring
responsibilities, which is different to non-carers. As older people are more likely to require
carers, and they are the greatest users of elective orthopaedic care, carers are likely to be
impacted by any service changes. A report by Carers UK indicated that failing to consider
post-hospital support and carers’ needs had counterproductive consequences, such as
increased readmission (Carers’ UK, 2016: Response to the Public Administration and
Constitutional Affair Committee Inquiry into Unsafe Hospital Discharge). Carers can also be
disproportionate affected by longer waiting and recovery times for surgery, fitting this around
the needs of those they care for is a delicate balance.
Summary of scoped-in groups
The table below gives a summary of the groups scoped in and whether they have a
disproportionate or differential need for elective orthopaedic care. For each group, we note
whether there is evidence of disproportionate or differential need for elective orthopaedic
services and a summary of this evidence is provided. ‘Differential need’ in the context of this
report means that there is evidence that different sub sections of a protected characteristic
group have different needs. For example, females and males may have different needs to
access a service, but there is no evidence to suggest that either females or males have a
disproportionate need.
Table E9: Needs by characteristic
Characteristic Disproportionate
need
Differential need
Age: Young people
Age: Older people
Disability
Gender: Female
Gender: Male
Gender reassignment
Marriage and civil partnership
Pregnancy and maternity
Race and ethnicity: White
Race and ethnicity: Black
Religion and belief
Sexual orientation
181
Characteristic Disproportionate
need
Differential need
Deprivation
Carers
It is important to note that the report is not suggesting that other groups would not have need
of these services, rather it is to suggest that there does not presently exist a body of
evidence indicating a disproportionate or differential need. This could and should be,
continually examined through any potential further stages of the process.
Summary of the geographical distribution of scoped in groups
At the CCG level, volume and proportion are used as helpful measures to understand the
population of each scoped in group and to understand the relative presence of any particular
group.
At a pan north central London level, it is useful to look at density as a measure by which to
understand where the greatest concentration of scoped in groups are located. This is
important because this helps to indicate where impacts, both positive and negative, are more
likely to be realised across the study area without the analysis confined to administrative
boundaries.
In the case of this equality analysis and its ability to inform the decision-making process, it is
crucial to look at future service provision across north central London, rather than at a CCG
level. Travel time and accessibility impacts would need to be considered in any future
analysis, particularly as sites are selected to deliver more or less elective activity. Data on
how populations are changing has been excluded from this analysis.
182
Scoped in groups Volume Proportion Highlight
comments at CCG
level
Density Highlight comments at
North central London level
Age (Older people) Barnet has the highest
numbers of those aged
65 or over and aged 75
or over. Enfield also
has high volumes.
The greatest proportions of
older people are in Barnet
(13.84%) and Enfield
(12.68%), both of which are
slightly higher than the
greater London average
(12%).
Barnet and
Enfield are areas
with high volumes
and proportions of
older people.
Density of older
people is highest
in areas of
Barnet and
Enfield.
The north west of the study
area has the highest density
of older people.
Disability Barnet has the most
people living with a
long-term illness or
disability.
Camden has the lowest volume.
As a proportion of the
population, greater
proportions of disabled
people are in Islington
(15.6%), Enfield (15.4%)
and Camden (14.4%), all of
which are slightly higher
than the greater London
average (14%)
Barnet has high
volume and
proportion of those
living with a long-
term illness or
disability. Camden
and Islington have
higher proportion of
those living with
mental ill health.
Islington and
Camden have
higher densities of
those with a long-
term illness or
disability.
The inner London boroughs in the north west of the study area have the highest density of those with a long-term illness of disability.
Gender: Female
Race and ethnicity:
White
Barnet has the greatest
volume of people from
a white ethnic
background.
Islington (68%), Camden
(66%) and Barnet (64%)
have the highest proportion
of people from a white ethnic
background.
Barnet has the
highest volume and
one of the highest
proportions of
people from a white
ethnic background.
Islington has the
highest density of
those from a white
ethnic background,
Enfield the lowest.
Pockets of high density of
people from a white ethnic
background exist across the
study area.
Race and ethnicity: Black The greatest volume of
black communities is in
Barnet, followed by
Enfield and then
Haringey.
Haringey (19%) and Enfield
(17%) have the highest
proportion of people from a
black background.
Barnet has the
highest volume, and
Haringey, has the
highest proportion,
The greatest
densities people
with a black
background is in
Haringey.
Pockets of high density of
people with a Black ethnic
background exist across the
study area.
183
Scoped in groups Volume Proportion Highlight
comments at CCG
level
Density Highlight comments at
North central London level
of those from a
black background.
Gender reassignment
Deprived communities The volume of people
classified as deprived
is far greater in
Islington and Haringey.
According to the GLA report
on Indices of Deprivation in
the capital There is a
crescent of deprivation from
Enfield south through
Haringey to Islington,
Camden and Hackney
Islington (32.53) and
Haringey (31.04) also have
the highest levels of
deprivation, both of which are
significantly higher than the
greater London average and
national average (see
appendix 8).
Enfield and Camden
have very high
volumes and
proportions of
people classified as
deprived.
Islington has
higher densities of
deprivation, though
pockets also exist
in Haringey and
Camden.
The central of the study area
has the highest density of
people living in deprivation.
Carers Barnet has the largest
volume of carers and is
much higher than the
other areas.
Barnet has the highest
proportion of carers, though
all are similar or identical to
that of the greater London
average of 5%.
Barnet has
significantly more
carers than any
other area. It also
has the highest
proportion of carers.
This is consistent
with the fact that
Barnet also has the
largest volumes of
older people.
184
Concluding observations
Equalities analysis
This scoping report highlights the need for the following groups to be included in any
potential future engagements or if there is a need for consultation efforts: older people,
disabled people, females, people undergoing gender reassignment, people from a white
ethnic background, people from a black background, people in economic and social
deprivation and carers.
It is understood that disability is a heterogeneous category and that people with different
disabilities have different needs. This report focuses on those with learning disabilities,
rheumatoid arthritis, osteoporosis, epilepsy, mental health issues or dementia as this is
where most recent evidence exists to demonstrate disproportionate need. This would be
further explored with stakeholders representing disability as engagement continues.
It should be noted that individuals may be represented by more than one of the protected
characteristics as scoped in this report. This does not mean that their need would be greater
than an individual with one of the protected characteristics scoped into our report. For
example, a woman over 65 falls in to two of the protected characteristics (women and people
over 65) we cannot quantify that this example has double the level of need as a woman
under 65.
Recommendations for future engagement and consultation
Previous related consultation efforts have picked up on the following areas of focus that
might highlight variation in access, quality and outcomes relevant to equalities should any
potential plans require a consultation process:
Location of rehabilitation services.
Liaisons between community care services and planned care centres.
How planned care centres meet requirements of people with specific needs. This
would emerge throughout the engagement process.
As part of planning, along with any potential future engagement or consultation processes,
the report suggests that NLP considers examining issues such as the location and access of
services, the design of services monitoring and feedback. This would assist NLP in
understanding how factors such as location, the design of service and how they capture
feedback is important to patients and stakeholders. This is to be discussed further with NLP
should there be a need to move into a public consultation phase.
The social demographic analysis demonstrates difference in population groups across the
five boroughs represented by the NLP. Northern parts of the area represented by the STP,
Barnet and Enfield, have higher densities of the older people and carers. More central
boroughs, Camden and Islington, have higher densities of long-term disability or deprivation.
If NLP proceed to consultation phases it would be prudent to focus consultation activities on
certain groups in specific areas according to the trends identified in the report.
185
Next steps
Recommendations for current engagement and potential consultation
A continuing programme of engagement, these could take the form of face-to-face
meetings, one-to-one telephone interviews with stakeholders, focus groups and
presentations.
To date stakeholders have highlighted some potential overarching equality impacts,
which we would look to explore in more detail in any further stages.
Patient experience and quality of care: Some vulnerable groups find it more challenging
to understand and accommodate change in service provision, either due to challenges in
terms of comprehension, anxiety around unfamiliar journeys or venues and/or a lack of
independence. This may affect patient experience before and during service receipt.
Travel and access for certain protected characteristic groups. Centralisation of some
services would require longer journey times for some patients. Understanding the extent
to which these longer journey times affect the protected characteristics will be critical.
This is particularly the case because several equality groups have a higher reliance on
public transport than the general population which could compound any accessibility
impacts. It is recommended that NLP might want to consider this issue quantitatively
using travel and access analysis, based on different service options. We could discuss
the benefits of this with NLP in more detail.
Providing expert advice to NLP during any potential public consultation phase.
Undergoing staff engagement through one-to-one interviews.
Delivering an equalities training workshop to NHS staff on the data required to fulfil
Public Sector Equality Duty (PSED).
Recommendations for service design
Equalities recommendations should be considered at every stage of the service design.
Equalities monitoring whether through PSED2 or other mechanism should be built into
contract monitoring.
Commissioning of insight work to address gaps in equality data and information about
groups for patients with vulnerabilities and those who are isolated.
Collaboration with partner agencies to share information around particular groups to
strengthen and consolidate data capture and analysis.
Introduction of key equality questions at each stage of any procurement process to
ensure a stronger emphasis on provider requirement to provide specific responses
tailored to population.
Collaboration with system partners to agree more specific equality outcomes. measures
are supported by co-ordinated action by other partner organisations which address the
wider determinants that impact on health outcomes.
More comprehensive equality analysis and recommendations for best practice to be
written into equality analyses and provided as an important addendum for providers to
drive service change.
Building in a more explicit requirement for potential providers to evidence their ability to
flex and sustain required changes in services in light of new and existing changes to
equality data and population need.
Full appendices to the EQIA are available here.
186
Appendix F – Project implementation plan
Programme management arrangements
Following the outcome of the proposed consultation, if plans require implementation, this
would be co-ordinated and formally monitored by the NCL CCG 87 to ensure there are robust
reporting and assurance mechanisms in place. The STP management and governance
structure would ensure clear accountability and allocation of responsibilities and enable
issues to be rapidly identified and addressed. This appendix sets out a structure for
implementation and covers the following key areas, pending the outcome of the formal
consultation process and further consideration of the clinical senate recommendations,
where these would be reviewed and updated to take account of feedback received:
Project implementation budget
Project implementation team
Risk management arrangements
Implementation structure
Post-programme evaluation.
Project implementation budget
Project costs relating to the programme team and specialist advisors are included in the total
cost for the proposals. The budget for 2020/21 would need to be formally approved.
Project implementation team
The joint senior responsible officers for the project are Will Huxter, Director of Strategy for
NCL CCGs, and Rob Hurd, Chief Executive of the Royal National Orthopaedic Hospital, who
jointly chair the programme board and would move across to chair the implementation
board.
The programme team for the review would run a programme management office (PMO) to
oversee and co-ordinate the work of the project workstreams.
Risk management arrangements
There is an existing risk management process in place for the programme, and this process
would continue throughout the implementation and delivery phase of the programme to
ensure that risks are identified, monitored and where possible, mitigated.
Implementation structure
A 4-phase approach to implementation would be established:
Phase 1: Developing a structure for implementation
87 The five NCL CCGs are anticipated to merge by April 2020 into one NCL CCG. The NCL CCG will take forward further
decision-making and support any required implementation plans as part of its support to a north central London integrated care
system.
PHASE 1 Developing a structure for
implementation
PHASE 2 Planning for
implementation
PHASE 3 Implementation
PHASE 4 Evaluation
187
Phase 2: Planning for implementation
Phase 3: Implementation
Phase 4: Evaluation
Phase 1: Developing a Structure for Implementation
A governance structure would be established (figure E9). The structure would provide a
framework for accountability, reporting with clear lines of responsibility for each organisation.
The structure would support an open and transparent culture between the programme team
commissioners and trusts.
Figure E9: Implementation structure
The structure would be headed by an overarching STP-wide implementation board reporting
into the commissioning decision making body for all five NCL CCGs. Two partnership boards
would report into the Implementation board as well as the boards of each individual trust.
Phase 2: Planning for Implementation
Identify and set up workstreams including
o Procurement
o Workforce (including deployment and HR)
o Digital
o Communication and engagement
o Whole systems pathway development
o Education and training.
Develop implementation plan with key milestones and timescales.
Establish a series of phased implementation gateways.
Identify areas for further development/consideration.
Agree measurement and outcomes framework.
188
Phase 3: Implementation
Execute rollout plan
Perform gateway and regular check to ensure there are no unintended
consequences and provide a measure of project performance against project aims
including the realisation of benefits.
Define evaluation plan with mechanisms and timescales for post implementation
performance measurement.
Phase 4: Evaluation
Evaluate effectiveness both in terms of clinical quality and the delivery of cost-
effective care.
Implement mechanisms for system wide continual and shared learning including
through GIRFT.
Provide useful feedback and knowledge that could be shared with key stakeholders
as well as the NHS as a whole.
Recommend and implement an ongoing review process for ongoing quality
improvement and shared learning.
189
Appendix G – Progress against London Clinical Senate
recommendations
Key line of enquiry
Recommendation Action
Model of Care
Whether the new model of care will deliver safe, effective intervention that significantly improves patient experience and outcomes
Recommendation 1.
Quality indicators and improvement metrics are built into the standard operating procedures. Where possible, these are collected digitally.
Subject to public consultation, quality indicators and improvement metrics would be developed as part of the implementation process. Some suggested indicators are set out in Section 5.7. Indicators will be designed in partnership with the clinical orthopaedic network, Partnership for Orthopaedic Excellence: North London and, once agreed, embedded in the service specification.
Evidence
Whether there is sufficient evidence that the change proposed is justified in terms of clinical efficacy and patient experience
Recommendation 2.
Patient information literature is co-designed with patients and improvement metrics are made available to patients.
An overarching NCL-wide clinical orthopaedic network, Partnership for Orthopaedic Excellence: North London, has been established. The network is a standalone quality improvement framework to facilitate integration and drive care consistency. It is responsible for developing and embedding evidence based clinical materials, measures and protocols across the sector. Patient participation is a core component of the network with a variety of mechanisms in place to ensure patients and residents are involved in the design and evaluation of resources. An early focus of the network will be on patient information literature. The role of the network is set out in Section 5.2.
MSK Pathway
That there is sufficient alignment with the wider musculoskeletal pathway to ensure patients experience seamless care across the system.
Recommendation 3.
A sustained education model is developed for stakeholders of the service covering topics such as discharge communication.
An initial focus of the clinical orthopaedic network, Partnership for Orthopaedic Excellence: North London, will be the introduction of an NCL education programme for patients. The network will oversee the development of a new programme based on best practice principles and facilitate the delivery of an end to end MSK pathway.
190
Key line of enquiry
Recommendation Action
Recommendation 4.
Clarifying threshold and trigger points for readmissions.
Subject to public consultation, local thresholds and trigger points will be identified by individual partnership. The outputs from each partnership will be discussed at the clinical orthopaedic network, Partnership for Orthopaedic Excellence: North London, to support NCL consensus and implementation.
Recommendation 5.
Clarifying the process for readmissions, considering identifying a single contact point through which this is managed.
The protocols for the management of readmissions will be agreed via the clinical orthopaedic network, Partnership for Orthopaedic Excellence: North London. Subject to the outcome of the public consultation, local readmission pathways will implemented by each partnership based on the protocols agreed.
Recommendation 6.
Learning from the pilots and best practice models already in existence in the borough and considering rolling out for consistency.
The clinical orthopaedic network, Partnership for Orthopaedic Excellence: North London, provides a structure for quality improvement and is intended to be the forum through best practice and pilots are evaluated and system wide adoption is agreed.
Recommendation 7.
Liaising with London Ambulance Services regarding transport and discharge arrangements across all sites.
Subject to public consultation, transport, transfer and discharge protocols would be developed in partnership with the London Ambulance Service. The development of robust pathways is anticipated to be a key gateway for implementation.
Recommendation 8.
Exploring innovative models to support the pathway e.g. joint schools, aftercare and equipment.
The clinical orthopaedic network, Partnership for Orthopaedic Excellence: North London will provide a mechanism through which quality improvement initiatives will be agreed and taken forward. Patient education, procurement and discharge pathways have been identified as key elements the emerging work plan.
191
Key line of enquiry
Recommendation Action
Recommendation 9.
Further engaging community MSK triage and rehabilitation services to ensure a safe, effective and efficient pathway in and out of secondary care orthopaedic services.
The proposals set out in the pre-consultation business case focus on the proposed reconfiguration of planned adult orthopaedic services. It is recognised that these services sit within the wider MSK pathway and, to prevent fragmentation, system wide integrated pathways need to be developed. Through clinical orthopaedic network, Partnership for Orthopaedic Excellence: North London the new ways of working will be established that support the development of end-to-end pathways. Section 4.3.2 sets out current MSK improvement programmes that, subject to consultation, new pathways would link with.
Recommendation 10.
Considering the role and specification of beds on the Chase Farm site to clarify the new model of care, commission the model and develop a practical understanding of patient flow. This may include:
patient criteria e.g. high dependency unit or post anaesthetic care unit
patient pathway
anticipated length of stay
arrangements with London Ambulance Service for patient transfer and emergency conveyancing
Subject to public consultation, as part of the implementation process, a number of key gateways will be determined. The review will work together with the clinical orthopaedic network, Partnership for Orthopaedic Excellence: North London, to develop protocols and pathways to ensure there is a consistent, systematic approach to clinical care across NCL. This will include developing protocols for deteriorating patients and patients who require more intensive care post operatively.
Demand and Sustainability
Our approach demonstrates that future demand is adequately addressed and sustainable services developed
Recommendation 11.
Mitigating against avoidable growth in activity by ensuring that interventions are provided to the right patients at the right time, through adhering to recommendations relating to the musculoskeletal pathway.
Separate to the adult elective orthopaedic review, a significant number of quality improvement initiatives are underway to support access to the right intervention at the right time across the MSK pathway:
• Implementation of NCL-wide evidence based treatment and clinical standards
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Recommendation Action
• The introduction of physiotherapy first contact practitioners in primary care from 2020
• The development of consistent referral criteria
These will ensure patients access the timely treatment that meets their individual needs.
Recommendation 12.
Reviewing activity projections to ensure that they are as realistic as possible. Measure the rate of conversion to intervention from outpatient appointments to assist with planning and projections.
Subject to public consultation, activity assumptions and projections would be reviewed as part of the development of the Decision-Making Business Case (DMBC) and during the implementation assurance process
Workforce
Our workforce plans will ensure patients can access the right treatment at the right time.
Recommendation 13.
Implementing plans to recruit senior allied health professionals and nurses to the network board.
Both a nursing and an allied health professional representative have now been appointed to the Network Board.
Recommendation 14.
Developing and articulating opportunities for all staff, allied health professionals and nursing staff as well as doctors. Consider giving attention to standards; pathways; education; mentoring and preceptorship; rotation; as well as practical employment issues such as parking, childcare and maternity payments.
Subject to public consultation, a robust workforce plan would be developed in collaboration with partnership trusts as part of the implementation process. Plans would include innovative ways of working, new roles, and education and training programmes. The two partnerships would be responsible for any separate staff consultation that needed to take place prior to implementation.
Recommendation 15.
Considering how roles such as first contact practitioner or single point of access/ triage practitioners might be integrated into the model.
Subject to public consultation, current and future MSK pathways would be aligned with the new surgical pathways introduced as part of implementation to ensure there is integration across the system.
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Recommendation Action
Develop a capability framework for these.
Recommendation 16.
Considering the development of a workforce strategy that would address any rise in activity.
Subject to public consultation, a robust workforce plans would be developed as part of implementation, in collaboration with the two partnerships. Alignment with local initiatives such as the first contact practitioner programme will ensure patients receive the right intervention at the right time
Recommendation 17.
Undertaking a wider workforce scope, mapping the care pathway and points of care for discussion with a wider forum of surgical trainees.
Subject to public consultation, a work plan would be developed in collaboration with the London Deanery to provide a robust training programme for surgical trainees. It is likely that issues relating to training would be a key component of the implementation assurance process.
Recommendation 18.
Considering how core surgical trainees gain exposure in areas other than orthopaedics. Imaginative solutions may be required.
Recommendation 19.
Considering the willingness and availability to flex staff across sites, paying attention to passporting, rota and work schedules.
Subject to public consultation, a robust workforce plan would be developed in collaboration with partnership trusts as part of implementation. Plans would include innovative ways of working and the opportunity to work cross site.
Recommendation 20.
Identifying within the model whether therapy services will operate 5 or 7 days per week and the workforce implications of this.
A core component set out in the model of care submitted in both partnership proposals is the ability to deliver seven day therapy services to ensure patients are immobilised on the day of surgery.
Fully work up the proposals for care navigators/coordinators, paying attention to:
• articulating the outcomes of better care coordination
Subject to public consultation, a robust workforce plan would be developed in collaboration with partnership trusts as part of implementation. Plans would include specification of the core
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within and outside the hospital
• gathering feedback from PPV groups to determine what the need is and therefore influence how this can best be met
• the differing proposed models in the north and the south of the patch and whether these can be standardised
• the role/ parts of role required to address the administrative aspects (perhaps better called a navigator) and which would be clinical i.e. nurse or allied health professional consultant
• development of a role description which includes a clear definition of clinical responsibilities if relevant.
• addressing how the care coordinator role will be funded – especially if it picks up on parts of pre-existing roles
• creating a development framework for these staff, potentially connecting to an apprenticeship programme
• identifying the interface with MDTs to manage patients across primary, secondary and tertiary care pathways
• identifying additional support that may be required for patients with additional vulnerabilities e.g. mental health needs
competencies of the proposed care coordinator roles.
Digital innovation
Our plans for digital innovation will facilitate seamless care across
Recommendation 22.
Programme plan a time to explore the potential for shared booking to be available across the system
Scoping has identified London and NCL-wide programmes that could be utilised as building blocks for digital interoperability. Subject to public consultation, work would be
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organisational boundaries
to smooth the patient pathway.
undertaken to develop a clear digital plan, defining the programme elements that would be taken forward as part of the NCL digital programme and what elements would be undertaken at partnership level. These are likely to be key milestones in any implementation assurance process.
Unintended consequences
Recommendation 23.
Commissioners and providers consider managing the financial impact of gains and losses across the whole health and social care system in north central London to enable future sustainability. This could be enabled by network collaboration.
As part of the NHSE assurance process an NCL financial model was outlined with trusts working together to agree a single approach to modelling. A number of system-wide commercial principles that all organisations agreed were defined as part of the process of completing the pre-consultation business case. Subject to public consultation, further work would be undertaken to develop a sustainable financial model that all partnership organisations can agree and which would be set out in the DMBC post-consultation.
