FINAL MSK National Context

National Orthopaedic AllianceMusculoskeletal Disease

National Context

Professor Peter Kay Hip and Knee Surgeon WWLNational Clinical Director MSK NHS England

Past President Hip Society and British Orthopaedic Association

Data in this presentation has been anonymised to allow it to be shared. For further information please contact Ann Hoey, NOA Deputy Director via [email protected]

• More years lived with MSK disability than any other disease• 2nd cause of sever disability• More time off work• etc• Not Kids, Cancer, Cardiac• Is it a priority for payers?

• Under the Spot light Priority• Economy

• Expensive• Variation• Waiting times• Social care

• Work• Benefits

MSK in the NHS England (£7 -10bn)3-4th largest area of spend

Evidence-Based Interventions: Response to the public consultation and next stepsPublished by NHS England in partnership with NHS Clinical Commissioners, the Academy of Medical Royal Colleges, NHS Improvement and the National Institute for Health and Care Excellence

Carpal tunnel syndrome releaseThere was agreement to the inclusion of this proposal in the programme and general agreement to the clinical criteria, including from the British Society for Surgery of the Hand and the British Society for Clinical Neurophysiology.

We received requests for clarification which we responded to by: • Adding information provided by the British Society for Surgery of the Hand and

the British Society for Clinical Neurophysiology.• Amending the wording to reflect that while “service planning for the

management of Carpal Tunnel Syndrome should include early access to neurophysiological testing the use of nerve conduction studies to diagnose carpal tunnel syndrome” (clinician)., Nerve conduction should be carried out before surgery where possible as an aid to choosing appropriate treatment, for prognosis, and for reference in the event of a poor outcome.

The British Society for Surgery of the Hand and the British Society of Clinical Neurophysiology approved the changes to the recommendations and clinical criteria.

Where we are now…

Admitted Waiting List

Non EUR

Bunion

Dupuytrens

Carpal Tunnel

Scopes

Trigger Finger

Ganglion

Hyaluronic acid injections

Effective Use of Resource Procedures= 23% of the Admitted waiting list

Payment system reform proposals for 2019/20 A joint publication byNHS England and NHS Improvement October 2018

1.2 Our proposals ...................................................................................................... 5 1. 2.1 Duration of the tariff

................................................................................... 5 2. 2.2 A blended payment approach for emergency care

.................................... 5 3. 2.3 Outpatient attendances

.............................................................................. 9 4. 2.4 Market forces factor .................................................................................

10 5. 2.5 Centralised procurement..........................................................................

11 6. 2.6 Maternity pathway....................................................................................

11 7. 2.7 Other payment reform proposals .............................................................

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What about MSK

• Not a central NHSE priority• Stroke, Cardiovascular, Respiratory, Children Maternal, Cancer, Autism• 65% of CCGs and STPs say MSK is a priority• What have we got to help

• Internal knowledge• Nice Guidance• Right Care• GIRFT• Elective Care Transformation• Public Health• Personalised Care• Academic health networks• Research

How do we decide what to put in place in a local healthcare economy?

Support/ Resource

Prevention Broadly eg Obesity, smoking

Prevention: early detection eg osteoprosis, frailty

Referral pathways to appropriate secondary care (# or red flag symptoms)

Referral pathway to conservative treatment e.g. physio

Operative Intervention Non-operative Intervention PROMs Other Other

GIRFT

Orthopaedics, Spinal, Rheumatology. Eg.Joint replacement rates per 100k population

Revision, readmits, LOS, mortal, finance, litigation, hip implant type, reducing small no surgeons etc

PROMs

Shared Decision Making, Reduce Inequalities in access and outcomes, reduce unwarranted variation

GIRFT Guidance, Trust Data Packs, Good Practice Manuals, Data Portal, Recommendations, Site Visit Report, Logic Models

ECTPAdvice and guidance, MSK triage services. First contact practitioners

Reduce referrals to secondary care for MSK related conditions, Reduce Inequalities in access and outcomes, reduce unwarranted variation

MSK Handbooks, Evalutaion, Logic Models

RightCare

Promote primary and secondary prevention, work in collaboration with PHE, LA to address wider determinants of health and reduce inequalities

MSK Pathways, Falls And Fragility, Fraility, Population appraoch

Support FCP, MSK Triage, FCP

High Impact Interventions, e.g. Osteoporosis, Back Pain, Rheumatoid Arthritis, Support FCP, Advice & Guidance, MSK Triage Services, Integrated Care Models, Medicines Optimisation and Medicines Value Programme, Pain Management programmes,

Report PROMs in focus packs

Embed Shared Decision Making to ensure informed patient choice and appropriate referrals, Reduce Inequalities in access and outcomes, reduce unwarranted variation

MSK Optimal Pathways, MSK Focus Packs, GP Practice packs, STP Packs, MSK Logic Models, Bespoke analytics, Storyboards, Case Books, Patient Stories, working with Spec Comm

Choosing Wisely

Commissioning guidance: interventional Rx for backpain, Hip arthroplasty, Knee arthroscoplasty and arthroscopy, shoulder decompression.

Shared Decision Making

Public Health/

Local Authority

LifeCourse Approach, Wider Determinanants of health, reducing inequalities, risk factors, Work & health, Health and Wellbeing Boards

Public Health Outcomes Framework (PHOF)

Joint Strategic Needs Assessment, MSK ROI Tools, Knowledge and Intelligence Hubs,

STP Priorities

NHSI Op Prod Theatre productivity TBC TBC

Advice and guidance, MSK triage services. First contact practitioners

MSK Pathway Overview and Improvement Initiatives_V4

Pathway Prevention Problem Presents Intervention Outcomes

Support/ Resource






GIRFT



PROMs






RightCare








Choosing Wisely



Public Health/

Local Authority




STP Priorities





Support/ Resource






GIRFT



PROMs






RightCare








Choosing Wisely



Public Health/

Local Authority




STP Priorities





“We must not use data like a drunken man uses a lamp post: more for support than for illumination”.

Understand data and collectively act upon it

Wave 1 - Elective Care Transformation Programme MSK handbooks: A Spotlight

https://www.england.nhs.uk/elective-care-transformation/handbooks-and-case-studies/

• The handbook is a guide to ‘what, why and how’ ideas can be implemented locally to transform MSK services

• It is informed by Wave 1 of rapid testing and include early outcomes and links to further evidence

• The case studies are more detailed accounts of different interventions and the learning from Wave 1

Wave 1 Handbooks and Case Studies

Examples of Other Transformation Initiatives

• CCGs and STPs can use resources and learning developed by NHS England’s Elective Care TransformationProgramme to help address the steady rise in elective care referrals.

High Impact Interventions - specifications 2017

• MSK triage

• Clinical Peer review

High Impact Interventions - specifications 2018/19

• Ophthalmology

• First ContactPractitioner (MSK)

Re-thinking referrals

• Advice and guidance services

• MSK triage and clinical review

• Standardised referraltemplates

Self-management support

• Self-management education

• Self-management supportfor long term conditions

• Patient passports

Transforming outpatients

• Patient-initiated, rapid access and virtual follow-up

• Telephone follow-up

Alerts to referring GPs using thee-RS when a local provider haslong waiting times for theservice their patient needs.The system suggestsalternative local providerswith shorter waiting times.

High Impact Intervention: MSK Triage• What...

§ MSK conditions affect 1 in 4 of the adult population, approximately 9.6 million adults in the UK.

§ The NHS England RightCare programme has identified that 31% of total elective opportunities involve musculoskeletal pathways.

§ Clinical triage services provide specialist clinical review of referrals after a GP has made a referral for a musculoskeletal condition.

§ CCGs are delivering timely MSK triage with collaboration between clinicians in both primary and secondary care and clear referral criteria.

§ They are commonly delivered by NHS (hospital or community) or independent providers in a community setting.

§ Referrals are often reviewed by physiotherapists, advanced physiotherapy practitioners, or GPwSIs who specialise in MSK conditions.

High impact intervention: MSK Triage (2)• What…

§ MSK triage is designed to drive establishment of specialist triage services so that patients are seen by the right professional first time.

§ It does not require an integrated triage and treatment service, although these can be best practice arrangements.

§ The specification relates to all body parts and includes pain and rheumatological MSK-related conditions.

§ Exemptions will be defined locally e.g. urgent referrals for cancer.

§ MSK triage services can reduce referrals to secondary care by up to 30%, with patients often seen in other community based services.

§ This means that those patients who need to be seen by a hospital consultant are seen as quickly as possible.

High impact intervention: MSK Triage - Impact§ At the end of July 18, 90% of CCGs had rolled out MSK triage, with

all others making significant progress.

§ In order to articulate impact of the MSK triage the ECTP undertook an impact audit at the end of Q4 17/18. Provisional headlines:

Ø Across all MSK triage schemes approximately 50% of all patient referrals reviewed were diverted from secondary care.

Ø Those CCGs that were compliant with the MSK triage specification by the end of December 2017 had a significantly lower working day adjusted referrals seen rate per 1,000 population at 9.7 compared to those CCGs not compliant with the specification (11.3).

Ø When comparing the same 2 month epoch from 16/17 to 17/18 those CCGs that were compliant with the MSK specification saw a 10% reduction in referrals compared to a 3% reduction in those that were not compliant.

High impact intervention: First Contact Practitioner - a spotlight (1/3)§ The first contact practitioner (FCP) role should be situated at the beginning of the MSK

pathway and considered part of the GP team. They should be the first point of contact for patients and will be a real alternative to GPs for patients with MSK conditions.

§ They will be providing new expertise and increased capacity to general practice and providing patients with faster access to the right care.

§ They are qualified autonomous clinical practitioners who are able to assess, diagnose, treat and discharge a person without a medical input

§ All FCPs will demonstrate compliance with the Health Education England (HEE) and NHSE Capability Framework

§ Focusses on physiotherapists providing an FCP service in MSK care - where there is already a strong evidence base.

• What...

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GM Networked Orthopaedic ServiceGM Networked Orthopaedic Service

Network BoardMembership: Accountable Clinical Officer;

Clinical Directors; Directorate Managers;

Primary Care Practitioners; Patient

Representatives

Super-specialist centre (acts as Lead Provider –

responsible for negotiations with

commissioners)

Specialist centre

Joint centre

A&E / Local Hospital

GM Orthopaedic AllianceSupports the network in an operational delivery

role as an advisory body

Principles:

• Quality Standards

• Simplified commissioning

• Clinical leadership and common governance

• Surgeons to work at multiple sites

• Agreed research/innovation aims

• Coordinated training / recruitment

• Procurement at GM level

• MSK/Orthopaedics MDTs

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How should activity be coordinated?Unit type Suggested ‘baskets’ of activitiesSuper-specialist • Complex primary joint replacement

• Revision joint replacement for infection or complex revision• Pelvic reconstruction• Conditions requiring close multidisciplinary collaboration – e.g. inflammatory

arthritis, metastatic bone tumour, soft tissue sarcomaSpecialist • Primary elbows/ankles; uni-compartmental replacements; non-infected

revisions; complex soft tissue / osteotomy• High risk but non-complex activity – co-morbidities• Conditions requiring close multidisciplinary collaboration – e.g. inflammatory

arthritis, primary and metastatic bone tumour, soft tissue sarcoma• Specialist trauma

Joint centres • Primary hips/knees/shoulders (non-complex)• High volume procedures• Arthroscopies (low complexity)• Day surgery (23hr)• Simple soft tissue

Local hospitals • Outpatient diagnostics and follow-up• Injections• Routine trauma• Day case patient procedures

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Current activity

55,408 T+O procedures in

2016/17

Model configuration

A&E / local hospital = 10

Joint centre = 4

Specialist centre = 2

Super-specialist centre = 1

National Orthopaedic Alliance defined domains:1. Primary care/secondary care

interface referral (add GM info on social care interface)

2. Pre-operative assessment (need to add info for GM on ‘optimisation’)

3. Efficient theatre utilisation4. Enhanced recovery (need to add

specific info for GM re: evening & weekend physio provision)

5. Discharge process6. Patient outcomes and

experience7. Patient involvement shared

decision making8. Procedures of limited value9. Coding and costing)10. Referral to treatment time

management

11. Safety12. Appraisal13. New procedures/minimum

numbers14. Procurement15. Commissioning16. Spines17. Hip and knee18. Sports knee19. Foot and ankle20. Upper limb21. Cancer (bone)22. Bone Infection23. Anaesthetics, peri-operative

care and enhanced recovery24. Pain services25. Rehabilitation26. Rheumatology27. Paediatrics28. Tumour

Suggested GM specific standards:29. Integration with community30. Transition services (adult

services ‘pulling in’)

31. Mandate good data collection (coding) and system responsiveness

32. Patient information

33. Orthotic provision

34. AHP services

35. Consent

36. Infection screen

37. Ring fenced beds

38. Standards for recruiting & training (theatre staff, junior doctors, AHPs)

Quality Standards for GM – long-term

Priority Quality Standards – short-term

NOA defined domains selected for priority review and adoption in GM

1. Primary care/secondary care/social care interface referral

2. Pre-operative assessment and optimisation

3. Efficient theatre utilisation

14. Procurement

17. Hip and knee

GM authored domains selected for priority implementation

37. Ring fenced beds

Standardised processes

• Linked with Theme 2 to create standardised referral templates across GM• Recommended creation of ‘first contact’ physiotherapists/therapy services• Aim is for patients to be discharged back to ‘first contact’ physios in ‘wraparound’

service• Supported by standardised enhanced recovery pathways in use by providers

Theatre Utilisation - GM Orthopaedics has a 15% opportunity

There was a 15 percent opportunity across the elective orthopaedic operating lists undertaken during the calendar year 2017. This suggests that, after a 5% tolerance for On-The-Day cancellations is applied, there was a potential opportunity for an additional 5686 cases across the 16,954 elective sessions completed.

Opportunity by Trust

There was a 15 percent opportunity across the elective orthopaedic operating lists undertaken across 8 trusts in Greater Manchester during the calendar year 2017. Trust A had the lowest opportunity at 5% (112 cases after 5% tolerance for On-The-Day cancellations) and Trust D had the highest opportunity as a percentage of throughput at 28% (770 cases), whereas Trust C had the greatest opportunity in total capacity to undertake additional operations (1550 cases after 5% tolerance).

Nb. The number of additional cases (blue) reflects the opportunity before a tolerance for on-day cancellations is considered.

Trust A(5% Opp-112 cases)

Trust B18% Opp-854 cases)

Trust C(27% Opp-1550 cases)

Trust D(28% Opp-770 cases)

Trust E(13% Opp-282 cases)

Trust F(12% Opp –610 cases)

Trust G(7% Opp-169 cases)

Trust H(11% Opp-1340 cases)

304412

908

234

Downtime analysis by Trust

Trust Trust TrustA B C D E F G H A B C D E F G H A B C D E F G H

There is significant variation in late starts with Trust G demonstrating best performance on starting on time with an average 9 minutes late start compared to Trust D at an average 41 minutes. Trust D also has the greatest delays between cases when they happen, and the earliest finishes.

Update on MSK Clinical Networks: Improving theatre

efficiency and reducing variation in clinical practice

Professor Peter Kay Hip and Knee SurgeonNational Clinical Director MSK NHS England

Past President Hip Society and British Orthopaedic Association

Conclusion• You can’t consider theatre efficiency in isolation• Provider – commissioner• The Whole Pathway need to influence what comes in/goes out

• Individual theatre efficiency is the starting point• Best use of what you have

• Use of data to benchmark individual units• Rationalisation across units “a bigger foot print”• Equipment Loan Kits, low volume specialisation• Expertise and staff

• CCG, STP and regional considerations

Procurement• Proposal for GM level value-based procurement approach drafted as part of the

design of the new modelCategory Estimated spend P/A Estimated potential savings P/A

A. Procurement of implants – primary (assuming annual

volume of 7800)

£8.5m – implants

£37.5m other

pathway costs*

£425k - £850k (5-10%)

£900k- £2.8m (2.5-7.5%)

B. Procurement of implants – Revision (assuming annual

volume of circa 800 revision Hip/knee – cost data for

other revisions unavailable)

£1m

£9m other pathway

costs**

£75k - £150k (5-10%)

£225k - £675k (2.5-7.5%)

C. Procurement of consumables (Cement, procedure packs,

pulse lavage, “toga” gowns, drills/blades etc)

£1m £50 - £100k (5-10%)

D. Demand management/product selection – EG value

assessment of “Attune ® knee implant”

£400k £100k

E. Loan kits £240k £12k - £24k (5-10%)F. Buyer/supplier efficiency savings – Purchase to pay

efficiencies, inventory management, theatre support

scheduling

£50k

Estimated annual savings projection £1.8M - £4.8M

Identified areas for savingsIn opting for a primary supplier with 75% of activity rather than a sole provider, allows opportunities for innovation and a degree of clinical preference were total consensus cannot be achieved.

The proposal is to develop and award a five-year contract for the supply of 75% activity to one supplier in the following lots:

• Lot 1: Primary hip and knee replacements (est. value £7.3m)

• Lot 2: Revision surgery (est. value £1.6m)

• Lot 3: Shoulder surgery (est. value £850k)

• Lot 4: Ankle surgery (est. value £234k)

• Lot 5: Elbow surgery (est. value £86K)

Total annual contract value est. £10.1m (Data source - NJR)

Confidential

Clinical Supply Chain Context & AnalysisOrthopaedics | Primary Hip Arthroplasty | North West

Regional Activity, % Cemented (Region)

Source: Hospital Episode Statistics (HES) to date

All Patients >70’s

Confidential

Regional Supply Base (All Joint Reconstruction)

Risks• Monopolistic competition• Tacit collusion• Price Inflation

Opportunities• Brand / product

fragmentation• Supply-chain & logistics

consolidation• Admin Consolidation

Regional Brand Fragmentation (Hip Stem & Cup)Source: PPIB Data Collection

Some trusts are using numerous brands which leads to poorer outcomes and higher costs

Confidential

Cumulative Revisions by brand Combination

Cemented

Hybrid

Hybrid

Hybrid

Uncemented

Cemented

Cemented

Uncemented

High variety : Approx. 400 combinations where annual case volume is > 1000

£1000-£2000 (£1,365)

£900-£1700 (£821)

£480-£1100 (£707)

£700-£1700 (£736)

£800-£2000 (£823)

£1000-£2000 (£1,205)

£480-£1100 (£605)

£480-£1100 (£610)

Cost | Outcomes | % UncementedSource: NJR / PPIB Data Collection

Confidential

Cost Range: Standardised Primary HipSource: PPIB Data Collection

Confidential

Relative Component Pricing (Primary Hip)

Confidential

Opportunity (Primary Hips) £3.3M on £12M Spend

Confidential

Developing Long Term Plan - 10 year Plan

Networks and a changing systemYou have to build it yourself

“When you are done changing, you're done.”Benjamin Franklin

The Writing on the Wall

Shared decisions with patients, workforce, Networking, benchmarking are the future

You are not alone – MSK Support Network

FINAL MSK National Context

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