1. Trauma & Orthopaedic ACCESS Addressing Core Capacity Everywhere in Scotland Sustainably John Connaghan – NHS Scotland – Chief Operating Officer May 2015

2. Why are we here? To develop a national plan with focussed actions to Address Trauma & Orthopaedic Capacity Addressing Core Capacity Everywhere in Scotland, Sustainably

3. In fact we have to because of: –Demographic changes –£ pressures –The political climate, inc. waiting times –Patient expectations –Clinicians’ and managers’ frustrations

4. Hip & Knee Projections Estimated 42% growth 2013 to 2024 Estimated 49% growth 2013 to 2024

5. By 2031 - up to 75% increase in number of hip fractures (est. 6500 to 11,000 cases p.a.) And worse – 80% inc. in bed days as older with more co-morbidities (est. 216,000 to 389,000 p.a.) Demographic change cancels out effect of falling incidence Equates to an additional 475 hospital beds fully occupied with Hip Fracture patients Source : Paper by - Graeme Holt, Rik Smith, Prof. J Hutchison Hip Fracture Projections

6. NHS in Scotland is diagnosing and treating more patients than ever 53% increase in primary hip replacements from 2004 to 2013, while median wait has reduced from 156 days in 05/06 to 69 days in 13/14 – a decrease of 55.8% Primary knee replacement activity has increased by 69% from 2004 to 2013, while median wait has reduced from 165 days in 05/06 to 72 days in 13/14 – a decrease of 56.4% Day cases up over 45,000 (or 11.2%) since 2006/07 to over 451,000 in 2013/14 Inpatients up over 162,000 (or 17.8%) since 2006/07 to over 1.07 million in 2013/14 Outpatients up over 146,000 (or 3.3%) since 2006/07 to over 4.6 million in 2013/14 A&E Attendances up by over 51,000 (or 3.3%) since 2008/09 to 1,621,775 in 2013/14

7. But we have the right environment to take action… Skilled, knowledgeable and sensible individuals with enthusiasm for high quality patient care Momentum of change and the Quality Drive –e.g. 32 of 44 Orthopods rated a focus on Theatre Efficiency as a high priority - Trauma &Elective ( from SCOT Survey Jan ’15) Opportunity to embed more gains back into T&O

8. Rapid & Impressive Clinician-led change Enhanced Recovery – Hips & Knees (MSK Audit) 20102013 Patients managed as ERAS patients21%80+% Same day admission29%55% Urinary catheterisation35%16% Blood transfusion14%7% IV fluids stopped on day of surgery22%70% Use of PCAs 49%15% Restarting diet <12 hrs post-op60%87% Mobilisation of patients by end first day post-op84%95% Mean post-op length of stay (days)5.64.6 Patients discharged by 3 days post-op21%37% Patients discharged by 5 days post-op62%76%

9. Action Plan to Address T&O Capacity Optimise use of capacity –Embed and sustain Quality Drive pathway workstrands –Focus on further opportunities to optimise use of: Workforce; Beds and Theatres Calculate gap –between current and required activity (OP/IP/DC) to meet demand (recurrent activity and non-recurrent backlog) Board plans –How much of gap can be sustainably closed with optimised use of existing capacity? –Is additional capacity required? How can this be achieved? National Action Plan – What regional/national solutions are required?

10. There are always constraints Currently Impossible Currently Possible Choice A Choice B

11. Shifting constraints releases greater gain Workforce Theatres Beds Increase capacity through optimising use or increased volume Choice A Choice B