Meeting the Musculo-Skeletal Challenge Avril Imison Dept 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 Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click Create from File Locate File name in File box Make sure Display as Icon is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click Object Action and select Edit Click OK 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 Trusts Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click Create from File Locate File name in File box Make sure Display as Icon is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click Object Action and select Edit Click OK Developed 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 Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click Create from File Locate File name in File box Make sure Display as Icon is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click Object Action and select Edit Click OK

Orthopaedic Patient Flow In England Average Flow is: 100% Outpatients Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click Create from File Locate File name in File box Make sure Display as Icon is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click Object Action and select Edit Click OK 30% Decisions to admit 10% (30%) removed after listing 20% Receive surgery

NHS Plan Patient Access Targets 9 months maximum Inpatient waiting time:March week wait for GP referrals to outpatients:March month maximum inpatient waiting time:Dec 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 month maximum wait:Dec 2008 Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click Create from File Locate File name in File box Make sure Display as Icon is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click Object Action and select Edit Click OK

PROGRESS: PERFORMANCE Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click Create from File Locate File name in File box Make sure Display as Icon is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click Object Action and select Edit Click OK Waiting time for GP referrals - over 13 weeks

PROGRESS: PERFORMANCE Waiting time for inpatients - over 6 months

CHALLENGE: PRODUCTIVITY Overall Productivity Trend - 13 year period

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

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 PATHWAYPATHWAY SOLUTIONSSOLUTIONS Emergency Referral Elective referral - 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 consultants care A&E attendance Poor Information, lack of understanding, lack of ownership Insufficient primary care alternatives to hospital Insufficient primary care alternatives 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 10 The service is not over reliant on agency staff PROBSPROBS 9 Post-op patients are only seen again in clinic when they actually need to be 4 Elective care is prescheduled and pre- planned across the week Key 12 The 6-month target is orthopaedics flagged as a priority for the coming year in plans and personal objectives 11 There is evidence of role extension/redesign so all members of the MDT are used to best effect 13 The service is in balance and able to supply what is needed to meet the 6-month target 14 There are no wider whole system variations which are detrimental to the management of orthopaedics 7 There are no avoidable factors extending LOS 15 There is high quality performance information regularly available 16 The performance management framework has clear lines of accountability for reporting, feedback & dissemination Secondary Care Primary & Secondary Care 6 There is comprehensive pre- operative assessment in place 3 There are effective waiting list management arrangements in place 8 The use of main and DC theatre sessions has been maximised 5 Day case surgery is the treatment of choice wherever possible 2 The only patients who see the consultant in clinic are those who need a consultant opinion 1 There are agreed pathways of care which optimise outcomes & resources WHOLE SYSTEMS IMPROVEMENT CLINICAL SYSTEMS IMPROVEMENT

Fall Services Walk-in Clinics Avril Imison National Access Policy Lead for Orthopaedics & M-SK Outpatient Consultation Pre-Assessment Clinic Primary CareSecondary Care Primary Care Active Management of Musculo-Skeletal Conditions Facilitate Self Management Physiotherapy and Occupational Therapy Management Rheumatology / Pain Clinics Booked Admission And Discharge Orthopaedics booked Appointment in Booking System (Adult and Children) Physiotherapy as First Line - Self Referral Interface with other Primary Care Services e.g Podiatry, Orthotics, Equipment Occupational Therapy in Primary Care / Social Services Less than 3 months in 2008 Within 13 weeks 2005 Less than 6 months in 2005 Surgical thresholds / protocols and agreed by Primary and Secondary Care Musculo Skeletal Service (Consultation Draft) Consultation Rehab & Back to Work Vocational Reintegration Minor Injuries Trauma/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. Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click Create from File Locate File name in File box Make sure Display as Icon is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click Object Action and select Edit Click OK

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. Instructions: Delete sample document icon and replace with working document icons as follows: Create document in Word. Return to PowerPoint. From Insert Menu, select Object… Click Create from File Locate File name in File box Make sure Display as Icon is checked. Click OK Select icon From Slide Show Menu, Select Action Settings. Click Object Action and select Edit Click OK

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