“Meeting the Musculo-Skeletal Challenge”

Avril ImisonDept of Health:Access Policy Lead - Orthopaedics and Musculo-Skeletal

Services

ORTHOPAEDICS : THE BIG PICTURE

• Productivity - declining• Numbers of Long Waiters• Capacity Constraints• Raised as a “serious concern” with Top

Team

Orthopaedics has the biggest challenges:

AGREED PLAN - SEPTEMBER 2002

• Target capacity plans and LDPs

• Good practice guide - Published 2003

• Engage the BOA/College of Surgeons

• Set up support programme for challenged

TrustsDeveloped into Tailored Support Programme in 2004

Present Orthopaedic Services

• Large numbers of outpatient referrals - GP & Tertiary• Heavy demand on outpatient sessions to clear• Low conversion rates to inpatient listing - but high

numbers • Poor or absent pre-assessment (health or social care)

pre-listing• High removal rate at pre-assessment or admission• Actual treatment rates of approximately 20% of referred

patients• The “20%” is a higher demand than services are able to

treat in most places• Productivity in this specialty is lower than in any other

specialty

Orthopaedic Patient Flow In England

Average Flow is:

100% Outpatients

30% Decisions to admit10% (30%) removed after listing20% Receive surgery

NHS Plan Patient Access Targets

• 9 months maximum Inpatient waiting time:March 2004• 17 week wait for GP referrals to outpatients:March 2004• 6 month maximum inpatient waiting time:Dec 2005• 13 week wait for GP referral to outpatients:Dec 2005• Choice at 6 months for inpatient waiters:Aug 2004• Choice at GP referral:Dec 2005• Booking all day cases:April 2004• Booking all inpatient elective:Dec 2005• 3 month maximum wait:Dec 2008

PROGRESS: PERFORMANCEWaiting time for GP referrals - over 13 weeks Trauma and orthopaedics - England

GP referrals not seen waiting over 13 weeks

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

Jun Se De Ma Jun Se De Ma Jun Se De Ma Jun Se De Ma Jun Se De Ma Jun Se De Ma Jun Se De Ma Jun Se De

1998 1999 2000 2001 2002 2003 2004 2005

numbers waiting - quarterly Progressive reduction required since publication of the National Plan target

PROGRESS: PERFORMANCEWaiting time for inpatients - over 6 months

Trauma and Orthopaedics - EnglandInpatients and Day cases waiting over 6 months

8216583825 82993

78195

83444

86783

82923

78505

8171684424

80397

664716559264272

57128

34165

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

2000/0

1 Q

1

2000/0

1 Q

2

2000/0

1 Q

3

2000/0

1 Q

4

2001/0

2 Q

1

2001/0

2 Q

2

2001/0

2 Q

3

2001/0

2 Q

4

2002/0

3 Q

1

2002/0

3 Q

2

2002/0

3 Q

3

2002/0

3 Q

4

2003/0

4 Q

1

2003/0

4 Q

2

2003/0

4 Q

3

2003/0

4 Q

4

May 0

4

Jul 0

4

Sep 0

4

Nov 0

4

Jan 0

5

Mar 0

5

2005/0

6 Q

1

2005/0

6 Q

2

2005/0

6 Q

3

2005/0

6 Q

4

Qtr Wl Profile Target

CHALLENGE: PRODUCTIVITYOverall Productivity Trend - 13 year

periodFigure 3

Operations per consultant team England 1989/90 to 2001/02

0

100

200

300

400

500

600

700

800

1989/90 1990/91 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97 1997/98 1998/99 1999/00 2000/01 2001/02

Year

Op

erat

ion

s p

er y

ear

T&O Q1 2003/4 Benchmarking - Excess of Decisions to Admit over Admissions

April to J une 2003

- 200

- 100

0

100

200

300

400

500

600

Trusts

Exce

ss D

TA

s

Excess DTA's DC Excess DTA's I P

Line Analysis Chart - Adds and Admits by Quarter

0

20000

40000

60000

80000

100000

120000

140000

160000

Quarter

No

.

Decisions to Admit 138336 133558 135277 137558 143287 139217 146407 150309

Admissions 109526 106714 111666 111973 121870 112039 120522 120909

2001/2 Q4 2002/3 Q1 2002/3 Q2 2002/3 Q3 2002/3 Q4 2003/4 Q1 2003/4 Q2 2003/4 Q3

Trust

Specialty =

I P/DC (All)

110

(All)

T&O Q3 2003/4 Benchmarking - % of I npatients & Day Case Removed for Reasons Other Than

Treatment Q3 2003/4

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Trusts

% R

OT

T I

P & D

C

• 43 Nominated Trusts in the DH/MA

Orthopaedic Improvement Programme

• Diagnostic risk analysis and recovery plans

• Testing of process modernisation within

services

• Process modernisation can reduce over

50% of orthopaedic outpatients

attendencies

• Re-investment of time released in surgery

OPPORTUNITY: MODERNISATION &PRODUCTIVITY IMPROVEMENT

ORTHOPAEDICS : RECOMMENDED ACTIONS• Capacity plan by speciality

• SHA Orthopaedic Position Statement

• Primary care-led validation of orthopaedic

waiting lists

• Introduce health and social care

assessment at DTA

• Secure greater PCT and Trust Board

ownership of capacity and productivity

issues

RECOMMENDED ACTIONS• Contingency plans

• Broker surplus NHS capacity

• Consider options :

- overseas teams

- overseas treatment

- Supplementary procurement:(“GSUP”) 70% of

25,000 ‘free’ FCEs pa from 2004/05

- Share future vision of service

Orthopaedic Services - The Pathway, Problems and Solutions

PATHWAY

SOLUTIONS

EmergencyReferral

Electivereferral - GP, consultant, community

Outpatient waiting list

Outpatient attendance's

Inpatient / day case

waiting list

Elective admission from list

(Planned admission) - Discharge

Emergency Admission/discharge

Outpatient attendance/

discharge from consultant’s care

A&Eattendance

Poor Information, lack of understanding, lack of ownership

Insufficient primary carealternatives to hospital

Insufficient primary carealternatives to hospital

Numbers of patients currently waiting for surgery is increasing or remaining constant

Trauma/other specialities take

priority

Social care capacity not coping with demand from

service

Lack of consistency

Process bottlenecks.Inefficient use of resources

10The service is not

over reliant on agency staff

10The service is not

over reliant on agency staff

PROBS

9Post-op patients are only seen again in clinic when they

actually need to be

9Post-op patients are only seen again in clinic when they

actually need to be

4Elective care is

prescheduled and pre-planned across

the week

4Elective care is

prescheduled and pre-planned across

the week

Key

12The 6-month target is orthopaedics flagged as a priority for the coming

year in plans and personal objectives

12The 6-month target is orthopaedics flagged as a priority for the coming

year in plans and personal objectives

11There is evidence of role

extension/redesign so all members of the MDT are used to best effect

11There is evidence of role

extension/redesign so all members of the MDT are used to best effect

13The service is in balance and able to supply what is

needed to meet the 6-month target

13The service is in balance and able to supply what is

needed to meet the 6-month target

14There are no wider ‘whole system’ variations which are detrimental to the management of orthopaedics

14There are no wider ‘whole system’ variations which are detrimental to the management of orthopaedics

7There are no

avoidable factors extending LOS

7There are no

avoidable factors extending LOS

15There is high quality

performance information regularly available

15There is high quality

performance information regularly available

16The performance management

framework has clear lines of accountability for reporting, feedback

& dissemination

16The performance management

framework has clear lines of accountability for reporting, feedback

& dissemination

Secondary Care

Primary & Secondary Care

6There is

comprehensive pre-operative assessment in

place

6There is

comprehensive pre-operative assessment in

place

3There are effective

waiting list management

arrangements in place

3There are effective

waiting list management

arrangements in place

8The use of main and DC theatre

sessions has been maximised

8The use of main and DC theatre

sessions has been maximised

5Day case surgery is the treatment of choice wherever

possible

5Day case surgery is the treatment of choice wherever

possible

2The only patients

who see the consultant in clinic

are those who need a consultant opinion

2The only patients

who see the consultant in clinic

are those who need a consultant opinion

1There are agreed pathways of care which optimise

outcomes & resources

1There are agreed pathways of care which optimise

outcomes & resources

WHOLESYSTEMSIMPROVEMENT

CLINICALSYSTEMSIMPROVEMENT

Fall Services

Walk-in Clinics

Avril ImisonNational Access Policy Lead for Orthopaedics & M-SK

OutpatientConsultation

Pre-Assessment

Clinic

Primary Care Secondary Care

Primary CareActive Management

ofMusculo-Skeletal

Conditions

Facilitate Self Management

Physiotherapy andOccupational Therapy

Management

Rheumatology /Pain Clinics

Booked

BookedAdmission And

Discharge

Orthopaedics bookedAppointment inBooking System

(Adult and Children)

Physiotherapy asFirst Line - Self Referral

Interface with other Primary Care Services e.g

Podiatry, Orthotics,Equipment

Occupational Therapy in

Primary Care / Social Services

Less than3 monthsin 2008

Within13

weeks2005

Less than6 monthsin 2005

Surgical thresholds /

protocols and agreed by

Primary and Secondary Care

Musculo Skeletal Service (Consultation Draft)

Consultation

Consultation

Rehab & “Back to Work” Vocational Reintegration

Minor InjuriesTrauma/A&E/Day Case Outpatients

Trauma Inpatients

NHS Direct

Combined Clinics

Interface

Clinics

Choice

Intermediate Care

Child Health Services

THE NHS IN 2008•Patient chooses whether to make an appointment with a GP or

practice nurse, visit an NHS Walk-in Centre or Pharmacy Service

Centre, or contact NHS Direct for advice and diagnosis.

•Patients see a primary care practitioner within 24 hours when they

need to or within 48 hours for a GP.

•Patient chooses how, when and where they are treated from a range

of providers funded by the NHS and accredited by the Healthcare

commission.

•Patient books hospital appointment electronically for their own

convenience.

THE NHS IN 2008•Patient waits for specialist care are reduced to no more than 18

weeks from GP referral to treatment.

•Patient contacts NHS Direct or visits Minor Injuries Unit. If patient

needs to go to A&E, he/she is seen rapidly (Maximum four hours).

•Patient records owned by the patient; with secure access for

appropriate health professionals.

•Mixed sex wards abolished for older people and for all but a small

number of patients e.g. intensive care.

•Patients record their preferences in their personal; Healthspace on

the internet, linked to their patient record.

And so…...

….. to meet the access targets and to manage the demand and capacity, Primary Care has to manage this differently and INVEST IN ITSELF.

Thank you