Strategy Meeting Trauma & Orthopaedics

Nish Chirodian

February 2013

Orthopaedic Strategy Meeting

• Paediatric Orthopaedics• Spinal Surgery• Shoulder surgery• Hand Surgery• Hip and Knee Soft tissue Surgery• Hip and Knee Arthroplasty• Foot & Ankle Surgery• Trauma Service• Academic Orthopaedics• Summary

Paediatric Orthopaedics

Paediatric Orthopaedics - Strengths

• 2 consultants, complimentary skills and interests, with excellent team approach

• Good range of services, support staff and MDT working

• Solid links to JPH and QEHKL, with NNUH as hub in sub regional service

• Regional and national profile increasing• Very clear understanding of service requirements in

Paediatric Orthopaedics by consultant colleagues, who have the drive to develop the service.

Paediatric Orthopaedics - Weaknesses

• Lack of paediatric out of hours support (only 2 consultants)

• Lack of dedicated separate children’s fracture clinic (NICE)

• Lack of a Paediatric ICU and Neurosurgery

Paediatric Ortho - Opportunities

• Ipswich – Impending retirement of Ivan Hudson.• Colchester and WSH – bring into sphere of influence.• Regional +/- national Child and Adult CP service,

capitalizing on RH’s experience (NSF guidance)• Academic opportunities, especially in nutrition of

surgical paediatric patients.• With a third surgeon, the opportunity to create a

Paediatric orthopaedic on call, for complex cases.

Paediatric Orthopaedics - Threats

• Centralisation of all services at Addenbrooke’s for political reasons

• Failure to expand sub-regional sphere puts all services here under threat.

Paediatric Ortho - Recommendations

• To expand paediatric orthopaedic surgery with the incorporation of work from Ipswich.

• At this time I anticipate a 50/50 investment pattern with Ipswich.

• Opening negotiations this year.

Spinal Surgery

Spinal Surgery - Strengths

• Strong performance in deformity surgery (scoliosis)

• Good reputation in other areas of spinal work, including cervical spine.

• Strong reputation as trainers.

Spinal Surgery - Weaknesses

• Lack of on call spinal service• Ipswich (5), Cambridge (6) • More developed with regard to an on call

service.• Lack of OOH spinal imaging (MRI), resulting

in any spinal on call having limited value.• Lack of a spinal lead.• Involvement of spinal surgeons in General on

call service (dilutional).

Spinal Surgery - Opportunities

• Enhancing spinal link to JPH, full internal cover of sessions as staffing allows.

• Building spinal link to QEHKL and possibly taking on all spinal responsibilities.

• Impending retirement of single surgeon, having 2 posts each 50% funded by QEHKL

• Aim for a partial on call service (4) within 6-8 months• Full on call service with (5) within 24 months.• Increasing the input of the triage therapists / nurse

practitioners to give earlier access to patients not likely to need surgical intervention (95%)

Spinal Surgery - Threats

• Addenbrooke’s and Ipswich

• 2 unit not 3 unit solution across the region.

• Risk losing cancer centre status due to lack of MCC cover

Spinal Surgery - Recommendations

• To Expand spinal surgery with 2 further joint appointments, a fully supported 1 in 5 on call service.

• Separate completely from General Orthopaedics and Trauma.

• Creation of such a service will need work and resourcing.

• It has significant service, financial and personal implications for those involved. 

Shoulder Surgery

Shoulder Surgery - Strengths

Currently able to provide satisfactory shoulder service for both scheduled and urgent patients, with 1.5 shoulder surgeons.

Shoulder Surgery - Weaknesses

• Single Arthroscopic surgeon, difficulty in attracting Shoulder fellows

• Patients with first time shoulder dislocations to undergo early primary repair.

• Increased move to fixation of proximal humeral fractures

• increased burden of unscheduled work for the shoulder surgeons.

Shoulder Surgery

• Opportunities– With the retirement of ADP in the next 3-5

years, probable development of full time Shoulder service, with 2 consultants and a fellow, to meet the above demand.

– May require some changes in working practices and investment in equipment.

• Threats– None

Shoulder Surgery - Recommendations

To support changes in working practices and investment in equipment.

Orthopaedic Hand Surgery

Orthopaedic Hands - Strengths

• 3 complimentary consultants, excellent team approach including therapies

• One stop service (hand surgeon / therapists) for many patients

• The new finger fracture service.

Orthopaedic Hands - Weaknesses

• Service constrained by transient loss of CE (Maternity Leave)

• Impossible to get a good locum, so various arrangements are being made to mitigate shortfall

• Loss of GK and potential degradation of plastics hand services are of concern

Orthopaedic Hands - Opportunities

• Hand fractures and wrist fractures into specialist clinics

• Transfer of all these patients from I/P emergency to D/C booked• improvements patient flow, • Reduced bed usage • financial and patient experience improvements

• Increasing input of therapists• Working with A&E, perhaps with investment in

equipment, to reduce risks of misdiagnosis

Orthopaedic Hands - Threats

• Loss of progress towards unification of services and training with plastic hand surgeons

• Risk to hand fellow appointment, which affect finger trauma service.

Orthopaedic Hands - Recommendations

• Continue service development with more emphasis on dealing with acute injuries.

• Some therapy and support staff needed, no requirement for additional consultant staff at this time.

Hip and Knee Soft tissue surgery

Hip and Knee Soft tissue - Strengths

• Concentration of expertise • STD with Patello-femoral problems • NPW with severe acute knee injury

• Overall, excellent service provision

• Regional leaders

Hip and Knee Soft tissue - Weaknesses

• Imminent retirement of Professor Donell

• No successor for complex knee practice.

• No surgeon capable of soft tissue hip surgery.

• Referrals increasing

Hip and Knee Soft tissue - Opportunities

• Integrated acute knee service, • Aim for one stop acute knee service, • direct GP referral• Prevent repeated opinions and investigations.

• Complex knee problem service• Appoint full time knee surgeon on STD’s retirement• Develop regional expert centre• Appointment of a soft tissue hip surgeon in due

course

Hip and Knee Soft tissue - Threats

None at the moment, but there is the risk of losing the access to Cambridge for hip arthroscopy, due to the nature of long term commitment to NHS work in this area.

Hip and Knee Soft tissue - Recommendations

• Will need a few additional resources, perhaps some freed up sessions.

• In the longer term, to develop a soft tissue hip service.

Hip and Knee Arthroplasty / Revision

Hip / Knee Arthroplasty - Strengths

• Excellent arthroplasty unit, national reputation

• Regional experese in both hip and Knee revison surgery

• High output in both quality and quantity (NJR, Dr Foster)

Hip / Knee Arthroplasty - Weaknesses

• Lack of capacity for Arthroplasty and revision work.

• Disproportionate number of patients who have migrated into area in retirement.

• Beds restrict capacity (ring fencing)• Falling efficiency, due to SDAU, later

starts, fixed end times to lists.• Lack of a functioning joint review

programme (under review)

Loss of output in lower limb surgery

• 2009 Almost 2000 THR / TKR’s per Annum• 2012 Down to 1400 TKR / THR = 30% reduction• But masked are

– 200 Revisions (unchanged)– 500 primaries equivalent time on lists (not transferable)

• Hence effective reduction of 2500 to 1900 is 24%• 3 Saturday Lower limb lists, 12 during the week was

20% of capacity• Added to the loss of productivity due to SDAU, late

starts and hard finishes explains shortfall.

Hip / Knee Arthroplasty - Opportunities

• To improve output, by investing to maximize efficiency in arthroplasty surgery

• Expansion affordable, as it brings pro rata income

• Expand ongoing collaboration with Spire• Treatment thresholds from CCG’s may result

in growth of ‘self funding NHS’

Hip / Knee Arthroplasty - Threats

• Revision burden of Metal on Metal hips from elsewhere.

• Early revision burden of patients done elsewhere due to C&B / transfers

• Unquantifiable risk of late revision burden of C&B patients.

• Burden of revision / failure (Briggs report – Getting it right first time)

Hip / Knee Arthroplasty - Recommendations

• Need to consider 1 -2 additional arthroplasty appointments in next 5-10 years IF capacity can be created.

• Must optimize capacity, productivity and efficiency in lower limb arthroplasty, even at the cost of additional resources.

Foot & Ankle surgery

Foot & Ankle surgery - Strengths

• 3 consultants, excellent team approach including therapies, multidisciplinary service (Diabetic feet etc)

• One stop clinic, MDT focus. 60-70% patients are managed non operatively

Foot & Ankle surgery - Weaknesses

• Forefoot surgery does not meet guidance re: usage of day surgery

• Lack of dedicated anaesthetic block facilities for surgery under regional techniques

Foot & Ankle surgery - Opportunities

• Anaesthetic expertise in Block techniques re-tasked towards dedicated services.

• F&A – increased day case surgery, nurse led services (dressings etc)

• Opportunities to take on services at NCH • An ambulant ankle fracture service to offload

the trauma list, as scheduled day cases.

Foot & Ankle surgery - Threats

• None at the moment

Foot & Ankle surgery - Recommendations

• To continue service development especially once our new colleague is appointed.

• Some therapy and support staff needed, no requirement for additional consultant staff at this time.

Trauma Service

Trauma Service - Strengths

• Above average performance NHFD

• Polytrauma- Sufficient resources to cope most of the time

• Sub-regional referral service for Pelvic and acetabular fractures and Limb reconstruction / salvage with 2 special interest surgeons.

Trauma Service - Strengths

• Succession planning for ADP in hand, on the trauma side.

• High quality service, no need for external referral.

• Continued national recognition as a centre of excellence

• International recognition via multiple faculty members delivering national and international teaching.

Trauma Service - Weaknesses

• Lack of flexibility on extra capacity for hip fractures when stretched.

• Continual increase in workload with increasing population age, osteoporosis and complications of elective orthopaedic surgery (infection, dislocation, peri-prosthetic fractures)

Trauma Service - Opportunities

• Enhanced MFE / NP service would capture 50% of missed income easily

• Development of O/P and DPU scheduled surgery for semi-elective trauma, especially wrists and ankles.

Trauma Service - Threats

• Disengagement of DGH’s from complex trauma and ‘simple’ high energy trauma (because they can)

• Potential loss of complex services to Major Trauma Centre either due to financial constraint or drift of referrals to “path of least resistance”.

• Currently, we are the path of least resistance.

Trauma Service - Recommendations

To work on more ‘scheduled’ and day case operating, in order to drive best practice tariff for both these cases, and freeing more capacity for hip fractures.

Academic Orthopaedics

Academic Orthopaedics - Strengths

• STD has made some progress, but started too late in his career.

• Portfolio and other nationally funded high quality studies are preferred over

local projects as they attract funding.

Academic Orthopaedics - Weaknesses

• Retirement of Professor Donell within 2-3 years

• No in-house successor likely

• Need for Handover period to ensure continuity

Academic Orthopaedics - Opportunities

• At least 1 local candidate who would be suitable as a proleptic appointment

• As it happens has a knee interest (desirable, but not essential)

• Possible external candidates already

established consultants.

Academic Orthopaedics - Threats

• Failure to appoint, with resultant complete loss of academic department

• Loss of quality candidates for research fellow jobs, which are pivotal in providing a safe on call service at junior level.

Academic Orthopaedics - Recommendations

• Proleptic appointment of academic post holder in 2013, to start in 2014.

• Will work as full time Orthopaedic / trauma consultant, dedicating SPA time and limited additional hours if funded by university, in order to manage and grow the academic department.

Summary

Limited Specialist Expansion –Hub and spoke services

• Vital to ensure the continuing success and stability of our Paediatric Orthopaedic services, plus all the other services they are linked into (such as paediatric anaesthesia)

• Creation of a distinct spinal service, again to ensure survival of our unit and the ability to provide a service up-to national standards.

Demand for all MSK services will rise: Little can be deflected

• While other services are restricted / transferred into the community, there is little alternative expected to Joint replacement for major joint arthritis.

• There are no expected technique changes that will improve efficiency, so it is likely that more capacity will have to be created.

Limited capacity improvement by (voluntary) flexible working

• Ability to maintain stable position limited by capacity.• Demand for services high, and falling OP waits only

increase this, by attracting patients who we have insufficient capacity to deal with.

• Voluntary flexible working not sustainable given the small number of participants.

• Extending the working week only acceptable if applied uniformly over all consultants and specialties.

Efficiency in the theatre space is a huge opportunity.

• It is possible to work in such a way as to improve the efficiency of theaters.

• There are ways of getting earlier starts, continuous lists and avoid the loss of momentum, even if it requires modest investment.

• As fixed costs remain static, the margin achieved per additional case performed is a major assistance to the trust. 

And Finally…

…Productivity growth is not everything, but in the long run it

is almost everything.

Paul Krugman, Nobel Laureate, Economics