Draft in progress | 1 1. Why planned care orthopaedic services need - - PowerPoint PPT Presentation

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• 1. Why planned care orthopaedic services need to change
• Discussion around the challenges
• 2. What could be done to improve planned care services

Discussions on:

• whether our thinking to date addresses the problems
• which services should be kept local (facilities to deal with emergency orthopaedic cases, orthopaedic
• utpatient appointments, orthopaedic day case operations)
• advantages and disadvantages of centralising inpatient elective orthopaedic work
• Overall, participants agreed that their experiences matched the challenges facing local planned care services

as highlighted during the meeting. But there was a desire to know the data/evidence behind them

• People noted that they would be prepared to travel if there were more certainty about the quality of their

care (procedures not being cancelled, higher quality services, more confidence in treatment given, better preparation and aftercare)

• When looking at future models of care the status quo should be included
• Careful consideration should be given to location of sites and transport/access links
• Further work needed to ensure that IT systems are compatible across the health and care system
• Provide a deeper level of detail about the challenges being faced and evidence behind the suggested solutions
• Further information on SWLEOC its effectiveness and how its quality has been measured
• More information about how decisions will be made

3 Draft in progress | Topic Time Introduction and welcome 0945 Elective orthopaedics in south east London

• Why do we need to change planned orthopaedic care?
• What are we changing?
• How these changes could happen?

1000 Expert panel Q&A 1020 South West London Elective Orthopaedic Centre (SWLEOC) – Presentation and Q&A 1035 Comfort/refreshment break 1100 Draft evaluation criteria and the Committee in Common (CIC) 1110 Table discussion 1125 Plenary 1210 Wrap up and next steps 1225

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– Mobile phones to silent – No jargon!- shout out if you don’t understand – Listen to others – one person speaking at a time – Information will also be shared on our website www.ourhealthiersel.nhs.uk for comment and you can share this with colleagues/contacts – We will be tweeting throughout the session #OHSEL @ourhealthiersel – We would like to take photos – please let us know if you would prefer not to be photographed

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• Why do we need to change planned orthopaedic care?
• What are we changing?
• How these changes could happen?

6 Draft in progress | Elective procedures delivered at these sites can be defined as either complex or routine:

• Complex procedures: Complex procedures are more
• challenging. They include revision surgery, hip

procedures with infections and ankle replacements amongst many others.

• Routine procedures: High volume procedures, such as

primary hip replacements, that have been standardised. For the purposes of this work any procedure not included in the complex category has been categorised as routine.

Orpington Hospital (as part of KCHT) is within 2-3 mile radius of PRUH

“If orthopaedic services, within a certain geographical area and with an appropriate critical mass were brought together, either onto one site or within a network… and worked within agreed quality assurance standards, not only would patient care improve but billions of pounds could be saved.”

Getting it right first time: Improving the Quality of Orthopaedic Care within the National Health Service in England

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• Demand for elective orthopaedics care (EOC) is increasing
• Waiting times for EOC are often longer than other specialties and more people wait longer than 18

weeks for their treatment

• Feedback from the public, patients and clinicians that experience and practice is variable across

SEL

• National work recommending different models for orthopaedic care- “Getting it Right First Time”
• Availability of evidence and good practice from other models such as SWLEOC (South West London

Elective Orthopaedic Centre)

• Trusts are struggling to manage existing capacity which impacts waiting times
• While length of stay has improved it remains below the London average at most sites in south east

London

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*Source: Orthopaedic related activity data is provided by the SEL CSU for the period Jan-Dec 2015. This data is used as a proxy for FY16 from which demographic and non-demographic growth is applied until FY21. PLEASE NOTE: The activity shown above is for all orthopaedic activity conducted by SEL providers.

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Source: NHS England, based on “Incompletes” Unify2 Data, September 2015.. *KCHT are not submitting data to Unify2, backlog numbers were provided by the CSU, but please note that these DO NOT included “non-admitted” patients, i.e. those who had an outpatient appointment. Overall patients were not provided so a percentage could not be calculated. Please also note that KCHT data is more recent (October 2015). **SWL waiting times are based on a weighted average of median/92nd percentile waiting times, weighted by number of patients at each trust.

378 (12.3%) 415 (9.8%) 102 (4.0%) 556 (*%) 100 200 300 400 500 600 GSTT LGT DGT KCHT* Number of patients

Number of incomplete (admitted and non-admitted) patients waiting more than 18 weeks by the end of September 2015 in T&O (Backlog)

SEL Trusts London average (11.6%)

5 10 15 20 25 GSTT LGT DGT KCHT* Waiting times (weeks) Waiting times for T&O RTTs at the end of September 2015 92nd percentile waiting time (weeks) Median waiting time (weeks) Target

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1.96 2.56 3.11 3.43 4.13 4.45 4.60 5.99 1 2 3 4 5 6 7 Orp. QMS GH DVH PRUH QEH UHL KCH Average length of stay (days)

Average length of stay for Elective T&O

SEL Sites London Average

Chart Data Source: HES, September 2014 – August 2015 (Latest 12 months of data available)

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 Consolidate elective inpatient services from the current eight sites to two sites while retaining outpatient, day case and trauma services locally at base hospitals  Create an orthopaedic network approach for procurement and service design  A business model which ensures the financial benefits of consolidation benefit all providers rather than creating “winners and losers”  All elective specialties are in scope apart from spinal This new model – devised to provide a higher quality and more efficient planned care pathway - to be evaluated against the status quo/ do minimum

• ption. We will explore the case for consolidating specialist and complex cases.

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Model Scenario Description Comment Multi-site model (As-Is) Multiple sites delivering complex and routine procedures A continuation of the current model of delivery with a range of complex and routine procedures delivered across multiple sites. This model will be considered alongside alternative

• ptions in order to provide a base case

Single site 1 Routine Routine procedures consolidated onto a single dedicated site. Complex and specialist procedures would take place at patients local hospital Based on the forecast demand and requirements it is unlikely that a single site in SEL will be able to meet the required capacity. This is on both space and capital expenditure. Discounted subject to sign-off /approval through the OHSEL governance process: The working group and Clinical Executive Group recommended to discount a single site option 2 Routine & Complex/Specialist Both complex, specialist and routine procedures delivered on a single dedicated site. Patients would continue to receive outpatient appointments locally. 3 Complex/Specialist Complex and specialist procedures consolidated onto a single site. Routine procedures would take place at a patients local hospital (the complex site may also be the local hospital for some patients and would therefore need to accommodate this activity) Two site model 4 Site 1) Routine Site2) Routine Routine procedures are consolidated across two sites. Complex procedures continue to be delivered locally. The working group agreed that this would not be appropriate clinically. 5 Site1) Routine, Complex/Specialist Site 2) Routine, Complex/Specialist Routine, complex and specialist procedures are consolidated across two sites. Only day case procedures are delivered locally. Agreed to progress these options to site identification and selection stage 6 Site 1) Routine Site 2) Routine, Complex/Specialist Procedures are consolidated across two sites. Site 1 would offer routine procedures and site 2 focuses on both complex, specialist and routine procedures. Complex and specialist procedures will only be delivered from a single site in SEL. 7 Site 1) Complex/Specialist Site 2) Complex/Specialist Complex and specialist procedures from SEL are consolidated across 2 sites. Routine procedures will continue to be delivered from local hospitals Discounted subject to sign-off /approval through the OHSEL governance process : Agreed that this model does not meet the case for change regarding consolidating routine activity >Two site model Discounted subject to sign-off /approval through the OHSEL governance process : It was agreed that there will be enough demand for consolidating services across more than 2 sites (See demand and capacity section for detail). This model would be too similar to the as-is and may not fully address the case for change. And, additionally, feedback from the EOC working group was that it would be impractical for clinicians to work across this number of sites.

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• Additional capacity in ring fenced beds
• Evidence-based treatments plans to improve outcomes
• Shared care arrangements between specialities for the management of co-morbidities
• Improvement in patient outcomes and experience, shared with colleagues in other

centres, enabling the sharing of best practice

• More complex operations, such as revision surgery, at specialist units with the

appropriate critical mass, by surgeons with a special interest in this field

• Providers working collaboratively to ensure that patients receive the best patient

experience

• Follow up care and rehabilitation after treatment at the patient’s home or in the

community.

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• Draft outline specification
• Site option identification
• Option appraisal
• Outline commercial

(operating model) and management case (implementation route)

• Public engagement on the

model and evaluation criteria

• Clinical and NHSE assurance
• Determine requirement for

consultation

5: Full Business Case /Implement 2: Consultation (if required) 1: Strategic & Pre Consultation Case 4: Outline business case 3: Confirm preferred model

• Run consultation (if required)
• Revise business case

to reflect outputs from consultation

• Agree preferred

model

• Initiated preferred

implementation route through agreed process

• Confirm plans for full

business case (if required)

• Initiate any capital work

Current phase: Present – September 2016 September-November 2016 January 2017 – Summer 2017 December 2016 – January 2017

• Develop Outline

Business case for each site (if required)

• Confirm detailed

clinical model

• Confirm and agree

detailed commercial model

• Alignment of business

cases across sites

• Relevant clinical and

regulatory assurance From Summer 2017

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• Patrick Li (Orthopaedic surgeon, Kings College Hospital)
• Laurence James (Orthopaedic surgeon Lewisham & Greenwich

NHS Trust)

• Peter Earnshaw (Orthopaedic surgeon, Guys and St Thomas’)
• Sarah Blow (Chief Officer Bexley CCG and Planned Care Senior

Responsible Officer)

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• Steve Thomas - Director of SWLEOC

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• Paul Minton (Independent Chair, Committee in

Common)

• Mark Easton (Director of Our Healthier South East

London)

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Health services in south east London are commissioned by six Clinical Commissioning Groups. A Clinical Commissioning Group (CCG) is a statutory organisation which plans and funds (commissions) most local health services. CCGs are led by GPs and other clinicians. All GP practices in a CCG area are members. Each CCG in south east London covers one of the six boroughs. The CCGs have decided to create a committee that allows delegates from each CCG to meet together and make strategic decisions- the Committee in Common The committee consists of:

• Paul Minton, Independent Chair
• 3 representatives per CCG
• 2 public representatives
• NHS England
• A local authority representative

Only the CCGs can vote (one vote per CCG) All decisions have to be unanimous The CiC meets in public- the first meeting is 17 March.

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The CCG Committee in Common will consider orthopaedics at its first meeting. It is being asked to sign off:

• The case for change
• The process for taking the project forward
• The criteria by which will review and consider different options for the delivery of

services (the evaluation criteria) Who will apply the evaluation criteria? We have established a group to apply the criteria with one representative from each CCG, and (non-voting) public and local authority participants. Expert clinical advice is available to the group.

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There will be a two stage process: 1. Any proposal has to pass certain tests- these are called hurdle (pass/fail) criteria 2. There is then a second stage used to assess the relative merits of the different options to arrive at scores for the proposals

The tests: 1

• Emergency departments can continue to be delivered from the current locations in SEL
• Trauma continuing to be provided in Trusts that currently do so
• Located in SE London

Pass/fail

2 It meets the clinical requirements set out in the model

Pass/fail

3 We have options in inner and outer SEL to be accessible to SEL patients

Pass/fail

4a The option makes a positive financial contribution

Pass/fail

4b The proposed option is consistent with the principle of being open to all/ no winners and losers financially

Pass/fail

5 The option is able to deliver the capacity requirements

Pass/fail

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Description Analysis Weight Section 2 – Non-Financial assessment 1 Travel and access Impact on transport times Travel time analysis (for patients by car and public transport including average travel times by mode of transport, and proximity to public transport) 2 Deliverability The option is sufficiently flexible to meet the requirements of growth or changes in future demand or change in national policy. Ease of implementation: the option can be delivered within a reasonable timescale with minimal risk around transition including impacts and disruption to existing services. Capacity and capability: The option demonstrates the appropriate capacity and capability to deliver the change/transition Where investment is required, the ease of obtaining required funding or financing is considered. Points scored for flexibility to increases/ decreases in demand Estimate of number of years for implementation Estimate of transition risk Assessment of financing/funding options 3 Quality The operating model provides evidence on how it will optimise outcomes for patients Quality impact assessment (e.g. governance and quality systems) Comparison of current clinical quality of sites which are expected to deliver future inpatient activity under each option 4 Patient experience The option allows the NHS in SEL to comply with the NHS equality duty The model demonstrates how it will optimise patient experience Equality impact assessment Friends and family and CQC inpatient survey performance against national benchmark 5 Research and education The model provides support the further development of research and education activity Assessment of impact on research and education 6 Workforce The option is staffable and is attractive to health care professionals working in SEL Estimate of future vs actual workforce Estimate of impact on current job roles Section 3 – Financial criteria 7 Affordability - The cost (e.g. capital and transition) of implementing the option represents good value and is affordable for the organisations impacted. An option will need to have a positive NPV to progress. Capex investment Productivity projections Revenue and cost projections Organisational sustainability - The option maintains or improves all organisational positions. Any option which could destabilise the ongoing financial and organisational viability of the individual organisations without a compensating strategy will be ruled out. Impact analysis on trust current vs future revenue and cost Pass/ Fail

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In your table groups please do two things: 1. Look at the hurdle criteria. Are these the right ones? Have we left any out? 2. Look at the second stage criteria. Are these the right ones? Have we left any out? 3. You have 100 points to distribute between the seven second stage criteria that are scored. Distribute these points between the nine criteria depending on how important you think they

• are. For example, if you think that patient experience is twice as important as travel times , you

would give outcomes 20 points and travel 10 points. You have 45 minutes to discuss this in your groups.

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Description Analysis Weight Section 2 – Non-Financial assessment 1 Travel and access Impact on transport times Travel time analysis (for patients by car and public transport including average travel times by mode of transport, and proximity to public transport)

12%

2 Deliverability The option is sufficiently flexible to meet the requirements of growth or changes in future demand or change in national policy. Ease of implementation: the option can be delivered within a reasonable timescale with minimal risk around transition including impacts and disruption to existing services. Capacity and capability: The option demonstrates the appropriate capacity and capability to deliver the change/transition Where investment is required, the ease of obtaining required funding or financing is considered. Points scored for flexibility to increases/ decreases in demand Estimate of number of years for implementation Estimate of transition risk Assessment of financing/funding options

17%

3 Quality The operating model provides evidence on how it will optimise outcomes for patients Quality impact assessment (e.g. governance and quality systems) Comparison of current clinical quality of sites which are expected to deliver future inpatient activity under each option

12%

4 Patient experience The option allows the NHS in SEL to comply with the NHS equality duty The model demonstrates how it will optimise patient experience Equality impact assessment Friends and family and CQC inpatient survey performance against national benchmark

12%

5 Research and education The model provides support the further development of research and education activity Assessment of impact on research and education 5% 6 Workforce The option is staffable and is attractive to health care professionals working in SEL Estimate of future vs actual workforce Estimate of impact on current job roles

12%

Section 3 – Financial criteria 7 Affordability - The cost (e.g. capital and transition) of implementing the option represents good value and is affordable for the organisations impacted. An option will need to have a positive net present value (NPV) to progress. Capex investment Productivity projections Revenue and cost projections

30%

Organisational sustainability - The option maintains or improves all organisational positions. Any option which could destabilise the ongoing financial and organisational viability of the individual organisations without a compensating strategy will be ruled out. Impact analysis on trust current vs future revenue and cost Pass/ Fail

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Key points from each table Agreement on points to be taken to the CIC meeting (17/3/16)

• 1. Is this a project we should be taking forward?
• 2. What are the key issues we should be keeping in mind
• 3. What is the PCRG’s view of the draft evaluation criteria:
• Confirm
• Challenge

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• Today’s work will be taken to the Committee in Common for

consideration and feed into programme development

• A full report will be written, following this meeting, and

circulated as well as being published on the website

• We would like to hold a third meeting in June (before the

second meeting of the committee in common on the 16th June), to look at possible consultation materials and process (if consultation is agreed)