an orthopaedic plan for wales · driven by the emergency nature of the care required, and this has...

An Orthopaedic Plan for Wales

Getting Wales Moving

CONTENTS

Foreword 1

1. Summary 3

2. Introduction 5

3. Context 7

4. Strategic Approach 11

5. Key Actions 135.1 Managing Demand5.2 Using Our Capacity Efficiently5.3 Using Our Staff Effectively5.4 Adding Capacity5.5 Informing the Process

6. Responsibilities 31

7. Conclusions 33

Appendix 1 35Membership of the Orthopaedic Group

Welsh Assembly GovernmentHealth and Social Care Department


1

FOREWORD This plan follows a very extensive analysis of the need for

orthopaedic services in Wales. I have adopted the results

of that analysis and the recommendations flowing from it

as the vision for reducing orthopaedic waiting times and

improving access to trauma and orthopaedic services for

the people of Wales. This vision is based on partnership:

partnership between different organisations in providing

trauma and orthopaedic care, and partnership in terms of responsibility for

achieving the vision and improvement in service to patients. It will involve

concerted and continuous actions across the whole care system, involving Local

Health Boards and NHS trusts, primary and secondary care professionals,

community and rehabilitation services and the Welsh Assembly Government.

I am committed to driving down waiting times in Wales, especially for

orthopaedic services, where there are still long waiting times in some areas. We

have made significant improvements in recent years. The number of patients

waiting over 18 months for an orthopaedic inpatient/daycase operation has

reduced from 1,356 in April 1999 to 9 in April 2004. However, the numbers waiting

over 18 months for their first outpatient appointment has risen during this period.

This increase is despite the hard work of the NHS and its staff to address this

problem, and in part reflects the fact that demand for orthopaedic services is

continuously increasing. Thus, although we are actively tackling the long waiting

times, there are still large numbers of people who need to access our

orthopaedic services.

Because of my concerns, I commissioned this plan from health professionals and

Assembly officials to advise me of the way forward. The plan has been

developed by the Orthopaedic Group, which includes consultants and

professional advisors. It sets out the steps needed to rebalance our orthopaedic

service in Wales, and I am pleased to receive and endorse the strategic direction

and key actions that it contains.

Ensuring a sustainable orthopaedic service is not confined to adding capacity to

meet growing need. It is also about making better use of the resources that we

have, by improved management, and innovative ways of working that will ensure

that patients are treated by the right professional, in the right place, at the right

time, first time. For the plan to be implemented successfully, a strong partnership

between government and the NHS is required. I am therefore expecting health



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organisations to take forward their responsibilities to improve and develop their

services locally, with strong leadership and new ways of working.

For my part, I will increase investment for new capacity. I have already

committed substantial investment for South East Wales where the waiting times

are longest. This is part of a phased approach, and further investment will follow.

Jane Hutt AM

Minister for Health and Social Services



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1. SUMMARYThis plan is not simply about doing more of the same. It is about rethinking the

ways in which we provide trauma and orthopaedic services across the whole care

system, to ensure that we see the right people, in the right place, at the right

time. It is not confined to adding capacity; it is about managing demand and

increasing supply, whilst making full use of all the resources available to improve

patient access. This will ensure sustainable delivery of a high quality and timely

orthopaedics service for Wales.

Significant improvements have been realised in recent years, and considerable

investment has been made to impact on long waiting times. Despite these

achievements, currently the system is out of balance. Trauma and orthopaedic

demand is increasing and, in Wales, the activity rates are not keeping pace with

current levels of need. The impact of a growing number of elderly people, who

are significant users of trauma and orthopaedic services, added to the latent

demand, will continue to place increasing pressures on services. Added to this,

the impact of emergency trauma on elective orthopaedic care can cause an

imbalance in the service when emergency work displaces routine surgery.

The activity/capacity gap in trauma and orthopaedic services in Wales is

evidenced by the long waiting lists. Whilst the NHS, its consultants and other

staff have done much to address this problem, with a maximum wait of 18 months

for an operation now being guaranteed, access rates vary by region and by Local

Health Board area. There is also variation in the service models in place and

existing levels of capacity in each locality. These variations need to be overcome

to ensure optimal services in all localities and equity of patient care.

A whole systems approach is critical to the success of this plan, involving all

partners at all levels across primary and secondary care, with the Local Health

Boards playing a pivotal role in commissioning services. All elements of the plan

are set within the context of the wider strategic change agenda, specifically the

emerging Health, Social Care and Well Being strategies, the ‘Wanless action plans’

and the health gain targets for Wales.

This plan is based on three cross cutting themes to be applied across the whole

system. These are:

• Tighter management processes and good practice;

• Service improvement and innovation;

• Adding capacity where necessary, with an associated culture of working in

different ways.

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These concepts must be applied simultaneously for them to achieve maximum

impact. The themes will need to be addressed at the local level dependent on

local circumstances, based on the overall direction set out in this plan.

Within this context, the core elements of the plan are:

• Managing demand

Prevention;

Point of contact treatment;

Alternative referral pathways.

• Using our capacity efficiently

Trauma management;

Waiting list management;

Bed management and patient flows;

Theatre utilisation;

Discharge and rehabilitation.

• Using our staff effectively

Working differently;

Extended roles (particularly therapists);

General practitioners with a special interest (orthopaedics);

Increasing training numbers and skills mix.

• Adding capacity

Building upon existing NHS services, using local

expertise where possible;

Protected from trauma;

Culture of working differently and rethinking care pathway.

• Informing the process

Robust and timely data and management information;

Secondary analysis.

By adopting this approach across the whole system, the plan is intended to

secure long term sustainable solutions to meeting current and future levels of

demand for trauma and orthopaedic services, and to allow equity of patient

access. Some aspects have already been actioned in order to make some early

impact on identified hot spot areas with long waiting times.



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2. INTRODUCTIONThis plan is intended to bring about change: change in the way in which aspects

of trauma and orthopaedic services are delivered, and change in the time that

patients have to wait to access these services. Whilst a great deal has been

achieved in recent years, there is more to be done, building upon these

developments. Short-term actions are essential to achieving early gains, whilst

long term approaches will ensure sustainability. All need to be planned from the

outset and implemented incrementally in order to achieve steady and sustainable

improvement. They can only be delivered through common understanding,

partnership working and a whole systems approach. They will be delivered at the

local level dependent on local circumstances, with overarching policy direction

coming from the Welsh Assembly Government.

The aim of this plan is to develop a detailed methodology for the delivery of a

high quality and timely orthopaedics service across Wales, taking into account the

impact of emergency trauma on elective capacity. This includes early actions

towards providing a sustainable service solution, including compliance with

national waiting times targets.

The evidence in support of this plan is provided in a separate source document.

That document scopes the issues, including the epidemiology and the factors

governing demand. Copies of the Orthopaedic Plan: Source Document (Welsh

Assembly Government, 2004) may be obtained from the Waiting Times and

Emergency Care Branch of the Welsh Assembly Government (e-mail:

[email protected]) and will be available on HOWIS

(http://howis.wales.nhs.uk).

All elements are considered within the context of the wider strategic change

agenda, specifically the emerging Health, Social Care and Well Being strategies,

and the ‘Wanless action plans’. The plan will also contribute to the achievement

of the national health gain target to reduce the European Age Standardised Rate

for hip fractures in the 75 and over age group by 10 per cent by 2012.

The plan focuses on three themes: that better use should be made of the

resources available; that innovation in practice will have a positive impact and

should be encouraged and rewarded; and that where additional capacity is

needed, it must be provided but with an associated culture of working differently.

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The complexity of the orthopaedic service, identifying the range of aspects which

need to be managed, is well illustrated by the following diagram:

Culture ofstrong

managementand good practice

Trauma management & impact on

elective operations

Theatre utilisation & daycases

Inpatient waitinglists & bed

management

Rehabilitation & discharge planning

Education & training

Extended roles & new ways of working

Patient care pathways & flows

Access to diagnostic &

therapy servicesPrevention &

early intervention

Demandmanagement &

alternative referralpathways

Primary careled service &

point of contact

treatment

Outpatient systems &

waiting lists

Added Capacity

Management information

Service improvement

and innovation

Key:

Managing demand

Using our capacity efficiently

Using our staff effectively

Adding capacity

Informing the process

AnOrthopaedic

Plan for Wales

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3. CONTEXTMore detailed consideration is given to the epidemiological context, and its

impact on demand, activity and capacity in the Orthopaedic Plan: Source

Document (Welsh Assembly Government, 2004).

Demography

The population of Wales is increasing, with a projected growth of more than 1%

over the next ten years. The proportion of elderly people is increasing at the

greatest rate. The highest population density and therefore demand for services,

including trauma and orthopaedics, is concentrated in South East Wales.

Epidemiology

The elderly are heavily reliant upon the health and social care system. The 65+

age group are the most frequent users of health care and have a longer average

length of stay in hospital than other age groups.

Those aged 65+ suffer a high incidence of osteoarthritis and increased bone

fragility fractures and the age profile also suggests there will be an increasing

need for hip and knee replacements over the next decade.

Trauma

Treatment of trauma (emergency treatment of injury to bones or joints sustained

from an external force) is the key determining factor which drives the pattern of

care within the speciality of trauma and orthopaedics. For trauma, demand is

driven by the emergency nature of the care required, and this has a knock on

effect on elective care, i.e. waiting list cases.

In Wales the level of emergency trauma admissions is higher than in England, and

trauma accounts for approximately half the workload of orthopaedic surgeons,

and over two thirds of the bed use of allocated trauma and orthopaedic beds.

Demand

Demand is increasing. The level of referrals already exceeds the level of activity

that is commissioned and provided, and projections indicate that the growth in

the elderly population in particular will result in increasing levels of need for both

trauma and orthopaedic care. Therefore, if there is no change in the service

pattern, the gap between demand and supply will continue to increase.



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Latent demand (people with unmet need, who have not yet sought a medical

opinion) is hard to quantify. However, if latent demand is added, the system

could become further unbalanced.

Activity

As an indicator, Wales has a lower crude hip replacement rate than other

countries in Europe. The greatest activity gap is in South East Wales, which has a

much lower rate of hip operations than other regions. Consideration by Local

Health Board area shows further significant differences in the rate of hip/knee

procedures within each health community, which underlines issues of inequity of

access.

Capacity and its use

Whilst there is inadequate capacity in some localities, benchmarking indicators

suggest that the NHS is not optimising the use of its resource. Innovations in

Care’s A Guide to Good Practice (2003) reflects that ‘capacity is only the same as

activity when the whole system is operating at 100% efficiency – and experience

shows that this is rarely the case.’ There is a need to understand this in each

locality and to influence the factors that affect this, in order to bring about

change.

Limited capacity in general practice restricts the level of care that can be

provided in community settings. New ways of working and closer partnership

across the whole system offers scope for reshifting this balance. This could aid

the development of a truly primary care led service and allow more people to

receive certain treatment in their general practice surgery.

Analysis of the way in which available hospital capacity is used has demonstrated

that additional throughput could be achieved within the existing resource

envelope. Whilst more protected bed capacity is needed in some localities, bed

use figures highlight scope for better usage that could release a significant number

of bed days. Trauma too, uses a disproportionate amount of bed capacity due to

longer average length of stay. Similarly, although scheduling of additional theatre

sessions would be of benefit, particularly for trauma, efficient theatre

management and streamlining patient flows could significantly improve activity.

Likewise, outpatient clinics do not meet current waiting list demand but

alternative management of waiting lists, reduced follow up appointments, or

clinics run by other health care professionals, could release additional clinic time.



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Workforce limitations and the effect of the European Working Time Directive

affect the capacity of the workforce. This can be countered by expanded training

numbers, more sophisticated workforce planning, and working differently, e.g.

deploying extended scope therapy practitioners and general practitioners with a

special interest in orthopaedic care.

Long average length of stay and delayed transfers of care, especially among the

elderly, have a significant impact on trauma and orthopaedic capacity.

Strengthened rehabilitation and early supported discharge arrangements, with

advice and supervision from a consultant orthogeriatrician, could free up more

capacity in acute hospitals, thus allowing improved patient outcomes.

Activity/Capacity Gap

The current service for trauma and orthopaedics in Wales is out of balance. If no

changes are made to the way in which services are provided then, with increases

in demand caused by demographic and epidemiological changes, the activity gap

will increase.

The first challenge, therefore, is to make better use of the current resources. The

second is to add capacity where it is needed, with an associated culture of

working differently.



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11

4. STRATEGIC APPROACH Given the context set out above, a number of core themes and elements of the

plan have emerged, as illustrated by the following diagram:



KEY THEMES – Crosscutting

Tighter management processes and good practice

Service improvement and innovation

Adding capacity where necessary with an associated culture of working differently

Managing demand

Using our capacity efficiently

Using our staff effectively

Adding capacity

Informing the process

CORE ELEMENTS

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13

5. KEY ACTIONS This section documents the thirty nine key actions that have been identified to

deliver the orthopaedic plan. These have been drawn from the findings of the

Orthopaedic Group, which included professional advisors, and the evidence for

these actions is recorded in the separate source document that underpins the

plan.

Each key action has been given a rating based on an assessment of the likely

impact, as follows:

All should be regarded as high priority, but some actions will be initiated earlier

than others. Additionally, some will take longer to achieve than others.

Timescales have not been incorporated, as different health communities will be at

different starting points and an incremental approach will therefore be needed.

Partnership working is essential to delivering the key actions, and the

organisations with lead responsibility for the various elements are identified in the

analysis below. For a number of key actions, one organisation with lead

responsibility is identified; for other key actions a number of organisations are

equally responsible for different elements of delivery and respective roles and

responsibilities should be determined locally.

5.1 Managing Demand

Prevention and early intervention offer significant long term cost and quality of

life gains, and are likely to impact favourably on the available capacity for trauma

and orthopaedic services in the future. Key risk groups are those with low bone

mass and, within the elderly population, those at risk of falls, those who have

sustained a previous fracture and residents of care homes.



Early implementation; high impact 1

Longer term implementation; high impact 2

Longer term implementation; lower impact 3

Strategic Direction 1: Place increased emphasis on preventionfocused on high risk groups

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Key Action 1: Pursue fracture prevention programme focusing on key risk groups

Key Action 2: Consider calcium and Vitamin D supplementation for main risk

groups

Key Action 3: Develop lifestyle intervention programmes to improve bone

density and health and well being

Milestones WAG Trust LHB Priority

Routinely consider patients in residential and nursing homes for calcium & Vitamin D √ √ √ 2supplementation

Publicise the benefits of calcium and Vitamin D supplementation for other at √ √ 2risk groups


Commission locally based falls prevention programme in each health community, linking with √ 1local authorities and the National Public Health Service, where appropriate

Commission primary care surveillance schemes focusing √ 2on at risk individuals

Require secondary prevention to be a routine element of fracture √ √ 1management

Focus prevention strategies, including use of hip protectors, on risk groups √ 2living in care homes


Develop multiple lifestyle interventionprogrammes (diet, exercise, smoking cessation) for all age groups, building √ √ √ 2on relevant belief systems

Support the implementation of theHealth Promotion Action Plan forOlder People in Wales following √ √ √ 1final consultation phase

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Primary care capacity requires significant strengthening to allow increased

emphasis on a primary care led service. In order to increase the contribution of

primary care, further emphasis should also be placed on how secondary care can

support primary care with improved partnership working. Developments could

link with other policy work, advocating the concept of community-based Primary

Care Resource Centres, supported by general practitioners with a special interest,

clinical specialist therapists and extended scope therapy practitioners. This

would facilitate enhanced point of contact treatment.

Key Action 4: Link with other strategic development plans in Wales to introduce

the Primary Care Resource Centre model

Key Action 5: Review the potential within each Local Health Board to appoint at

least one general practitioner with a special interest in orthopaedics



Strategic Direction 2: Facilitate primary care led service, includingpoint of contact treatment


Emphasise and enhance point of contact care options in primary care √ √ 2

Link with other policy work in Wales to develop Primary Care Resource Centres that offer an √ 2additional range of services

Address methodologies of providing a primary care led service with a strengthened primary care team and √ 2secondary care outreach and support, e.g. prevention, surveillance

Commission general practice direct access to diagnostic and therapy √ 2services within the primary care setting


Develop plans and introduce a network of general practitioners with aspecial interest (orthopaedics) in each √ √ 2health community

Develop criteria for general practitioners with a special interest to refer major joints directly to inpatient √ √ √ 1waiting lists under protocol

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Managing demand is a key element of the solution to balancing supply and

demand for trauma and orthopaedic services in Wales. A whole systems

approach to orthopaedic care is needed, ensuring that alternatives to secondary

care referrals are available.

Key Action 6: Develop, using a whole systems approach, alternative referral

pathways as a fundamental aspect of demand management

Key Action 7: Utilise therapy services for demand management in primary care

Strategic Direction 3: Develop robust demand managementsystems, including alternative orthopaedic referral pathways


Develop and implement alternative referral options other than √ √ 2consultants’ lists

Jointly develop referral protocols and guidelines for specific conditions √ √ 1

Consider the benefits of piloting a central referral hub in each trust/health √ 3community


Commission general practitionerdirect access to mainstream √ 2physiotherapy and podiatry services

Ensure that therapies are engaged in the development and commissioning of services designed to manage demand at √ √ 2the primary/secondary care interface

Explore appropriate access to appliances and orthotic services √ 2for primary care teams

Initiate a pilot study to measure the value of using physiotherapy as the √ 2first point of contact in primary care

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Key Action 8: Develop enhanced demand management systems across each

health community, based on current and projected patterns of demand

5.2 Using Our Capacity Efficiently

A culture of tight management and good practice with strong leadership is

fundamental to improving the balance and ensuring continuous improvement and

high quality patient care in all aspects of the trauma and orthopaedic service.

Health communities should routinely assess their local services and introduce

changes that improve effectiveness and efficiency. A series of orthopaedic

imperatives (Just Do Its) have been developed to set out a standard good practice

approach to be followed. These will be issued to health organisations separately.

Key Action 9: Address the Waiting Times Strategy for Wales




Balance levels of activity commissioned by each health community to ensure it matches current demand, and monitor √ √ 1on a regular basis

Develop robust and timely referral monitoring systems to allow accurate information collection √ 2and evaluation of referral patterns and numbers

Strategic Direction 4: Ensure tight management of all processes,particularly relating to waiting lists, clinics, beds and theatres


Develop an approach to continue tosystematically reduce maximum √ 1waiting times targets in orthopaedics

Work with stakeholders to clarify and address inequity arising from √ 3cross border issues

Avoid reliance upon ad hoc waitinglist initiatives and short term contracts √ 2to reduce long waiting times

Develop arrangements for moving patients, not only between consultants, but also between trusts for their √ √ 2treatment

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Key Action 10: Adhere to A Guide to Good Practice (IiC, 2003) for the improved

management of orthopaedic, diagnostic and therapies waiting lists

Key Action 11: Mandate the orthopaedic Just Do Its (JDIs) to facilitate good

management and good practice, focusing on bed management, patient flows and

theatre management in particular




Ensure a stringent compliance with good practice management of waiting ,lists including booking systems, daycase √ 1rates and new-follow up ratios

Utilise the Clinically Prioritise and Treat Toolkit (CPaT) supported by Innovations in Care, to ensure that √ 2waiting lists are managed appropriately within clinical priority

Implement measures to ensure that outpatient and inpatient lists are reduced concurrently, rather √ √ 2than one acting as a ‘valve’ for the other

Schedule pre-operative assessmentsix weeks prior to surgery √ 1


Review, evaluate and promote deliveryagainst good practice standards in each √ √ √ 1health community

Develop, with partners, detailed plans for the delivery of all orthopaedic JDIs √ √ √ 1

Analyse bed use statistics, including pre-operative length of stay, and use as √ √ 1a catalyst for change, where appropriate

Establish clear protocols for protecting orthopaedic beds to safeguard √ 1elective capacity

Review theatre management and patient flows to optimise total knife- √ 1to-skin time

Stipulate daycase work without the intention to admit as the norm √ √ 1

Raise profile of infection control to reduce re-infection and length √ 1of stay

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Key Action 12: Apply performance management framework to facilitate

continuous improvement

Redesigning the care pathway and implementing innovative ways of working to

ensure patient-centred integrated treatment options, will enable the patient to

see the right professional, at the right time, the first time. This is likely to involve

doing things differently and streamlining processes and pathways for optimum

patient benefit.

Key Action 13: Introduce three regionally managed clinical networks for trauma

and orthopaedics to facilitate integrated patient pathways


Ensure that clean air theatres are used for all major orthopaedic surgery √ √ 2

Rationalise, where appropriate, prostheses used for standard procedures (including contract prices) √ 3in accordance with NICE guidelines.


Lead continuous improvement by introducing balanced scorecard √ √ √ 1methodology

Investigate those areas which are not running at optimum efficiency and implement specific action plans for √ √ 2improvement

Strategic Direction 5: Emphasise service redesign and innovation atall stages of the patient journey


Introduce formal managed clinical networks to facilitate continuity of approach and consistency of clinical √ 3care standards

Empower networks to take forward emerging issues and changes in clinical √ √ √ 3practice

Co-ordinate plans for tertiary services, e.g. spinal and neuro surgeons √ 2

Implement mechanisms for networks to play a key role in the common commissioning process with central √ √ 3funding streams

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Key Action 14: Examine the potential for redesigning aspects of the care pathway

The incidence of trauma continues to have a significant impact upon elective

work. In order to increase elective throughput, and to improve patient outcomes,

the organisation of trauma services should be strengthened and, where possible,

separated.

Key Action 15: Ensure tight management of trauma to minimise impact on

elective work




Review and develop the respective roles for each sector in providing integrated √ √ √ 3care pathways for elective patients

Develop and document non-surgical intervention pathways for appropriate √ √ 2patients

Consider the wider introduction of non-consultant led clinics √ 1

Maximise care pathway driven inpatient care, possibly with the introduction of √ 17-day working

Develop new ways of working to allow greater emphasis on extended scope practitioners and therapy based care √ √ 2pathways

Strategic Direction 6: Manage, and where possible, separate traumaservices to minimise impact on elective orthopaedics


Evaluate locally, the opportunities for management and redesign of trauma care, including configuration of trauma √ √ 1service, and separate planning of electives

Investigate the trends and reasons for high incidence of emergency trauma admissions in Wales to inform future √ √ 3service planning and delivery

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Key Action 16: Increase the number of dedicated staffed trauma lists in each

trust, as appropriate

Key Action 17: Develop trauma care pathways, e.g. fractured neck of femur

For elective patients, early discharge planning and supported community

discharge schemes can significantly reduce the length of stay and improve patient

outcomes. Early mobilisation and rehabilitation, with adequate social support and

appropriate care settings, will also assist the recovery of hip fracture and other

elderly trauma patients, and this should be planned from the day of admission.

The modernisation of trauma services by involving an orthogeriatrican is

recommended as a useful model.

Key Action 18: Strengthen pre-operative management and discharge planning for

elective patients




Review the trauma workload in each trust compared with theatre time available and implement staffed daily √ √ 1dedicated lists


Develop formal pathway and protocol driven care to fast track √ √ 1treatment for hip fracture cases

Review and extend the incidence of trauma liaison nurses to manage care of older patients with √ 2fragility fracture

Strategic Direction 7: Streamline discharge and rehabilitationsystems


Strengthen active management of patients on waiting lists √ √ 2

Plan home assessments and adaptations from the beginning of the care process √ √ 1

Encourage standardised care pathwaysfor elective orthopaedic patients √ √ √ 2

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Key Action 19: Implement early supported discharge and reablement schemes in

each health community for elective and trauma patients

Key Action 20: Pursue the geriatric hip fracture service and orthogeriatrician

model to modernise services in all health communities

Key Action 21: Collate an all Wales audit of hip fracture to provide an

information base to promote service improvements




Introduce early supported discharge schemes to reduce pressure on acutebeds, e.g. multidisciplinary hospital at √ √ 3home

Develop further community support systems, such as domiciliary hip √ √ 2assessment services


Assess the usefulness of introducing a geriatric hip fracture service for the care of fragility fracture patients in √ √ 1each trust

Enhance and formalise collaboration between geriatricians, surgeons, and multidisciplinary teams to improve the √ √ 1efficiency of trauma care

Ensure daily orthogeriatric presence for trauma patients to optimise patients medically and √ √ 2co-ordinate investigations

Ensure early initiation of rehabilitation and consider use of √ √ 1step-down schemes


Ensure that all health communities are involved in the Standard Audit of Hip √ √ √ 1Fracture in Europe (SAHFE)

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5.3 Using Our Staff Effectively

Additional activity required to improve access times will be reliant upon anadequate and skilled workforce to deliver care. Workforce planning musttherefore be closely linked to existing service models and future strategy.Solutions are also likely to involve new ways of working and extended rolesfacilitated by alternative patient care pathways.

Key Action 22: Strengthen existing planning systems to reflect actual and

predicted need within each profession, firmly linked to the national strategic

intent

Key Action 23: Develop clear plans for strengthening new ways of working, e.g.

extended scope therapy practitioners and general practitioners with a special

interest



Strategic Direction 8: Strengthen workforce planning systems anddevelop extended roles – specifically extended scope therapypractitioners, specialist nurses and general practitioners with aspecial interest


Introduce systems to ensure that all strategic and service plans factor in √ 2technical workforce requirements

Ensure inclusion of tertiary services, e.g. spinal work, in workforce planning models √ 2

Revisit accuracy and robustness of current workforce planning systems, to √ √ √ 1include speciality based forecasting

Develop systems to model precise staff requirements to deliver specific activity √ 2levels

Review the national service configuration and current/future service models in the √ 3context of workforce availability


Consider whether redefining roles and responsibilities of key workers will √ √ √ 1facilitate improved working patterns

Further develop extended roles within the care team: extended scope practitioners; specialist √ √ √ 2nurses; general practitioners with a special interest

Negotiate accredited higher training courses to allow extended roles √ 3

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Key Action 24: Support the further development and implementation of Wales’

recruitment and retention strategy for all NHS health provider organisations

Strengthening of the academic base will bring major benefits for teaching and

research and the recruitment and retention of a skilled trauma and orthopaedic

workforce. This should include multidisciplinary learning and basic training, higher

training and continuing professional development for all professions.

Key Action 25: Facilitate training place expansion for appropriate professions to

meet identified future demand

Key Action 26: Increase the number of Specialist Registrar (SpR) training places to

support future clinical manpower needs




Refine and roll out an all Wales recruitment and retention strategy √ √ √ 1

Strategic Direction 9: Increase training numbers and skills mix,linked with strengthened continuing professional development andresearch opportunities


Continuously review training numbersfor each profession, closely linked to √ 1the national workforce strategy

Expand the number of vocational training places in all professions to √ 2meet demand


Expand the number of SpRs in trauma and orthopaedics by 4 per year for √ 13 years

Review need for further increasing SpRnumbers in trauma & orthopaedics, √ 2anaesthetics & radiology

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Key Action 27: Strengthen continuing professional development programmes for

all professions

Key Action 28: Strengthen the academic base for trauma and orthopaedics

through a professional appointment

Key Action 29: Promote partnership working with the academic teaching and

research base for trauma and orthopaedics at the University of Wales College of

Medicine




Introduce appropriate higher training programmes for all professions as needed, e.g. extended scope √ √ 3practitioners

Link with University of Wales College of Medicine to establish a diploma course for general practitioners with a √ 1special interest in orthopaedics

Following needs assessment, develop aportfolio based continuing professional development programme for general √ √ 2practitioners to enhance core orthopaedic skills

Strengthen opportunities for multidisciplinary learning √ √ 2


Re-establish Chair in Orthopaedics atUniversity of Wales College of √ √ 1Medicine


Strengthen the research and development environment in trauma √ √ √ 2and orthopaedics in Wales

Evaluate wider research opportunities with private sector partners √ √ 3

Review the potential establishment of an Institute of Sports Medicine to strengthen the training and teaching √ √ 2environment

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Waiting times for diagnostic and therapy services suggest high levels of demand.

Access problems for a range of diagnostic services can result in bottlenecks in the

patient pathway, leading to longer surgical waiting times and some duplication.

Therapists have the potential to reduce demand on secondary care orthopaedic

services and support primary care in a number of ways, including enhanced health

promotion and primary care working, collaborative working within secondary care

at all stages of the patient journey, and facilitating early mobilisation and

discharge.

Key Action 30: Develop protocols that influence demand patterns for diagnostic

services

Key Action 31: Support the development and implementation of the Strategy for

Diagnostic Services in Wales

Key Action 32: Utilise therapy skills in outpatient and inpatient management in

secondary care

Strategic Direction 10: Encourage new ways of working fordiagnostic and therapy services, to offer alternative carepathways/patient flows


Develop protocols that address demand/requests for diagnostic √ √ 2services to avoid duplication

Promote systems and guidelines to allow general practitioners direct access √ √ √ 3to key diagnostic services


Support implementation of the national strategy currently in √ √ √ 1preparation


Ensure therapists are utilised in waiting list management approaches through triage of long waiting patients listed, √ √ 1e.g. physiotherapy, podiatry, orthotics, occupational therapy

Triage new referrals to orthopaedic services to identify more appropriate care pathways into surgical or non √ √ 2surgical management routes

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Key Action 33: Support the development and implementation of the Therapy

Services Strategy for Wales

5.4 Adding Capacity

Although it will be possible to implement a series of measures that will free up

capacity, there still remains an identified need to provide additional facilities to

cope with current and future demand. Additional dedicated elective capacity is

needed to provide sufficient orthopaedic procedures to meet incident and latent

demand, to reduce current long waiting times and to provide a platform for

developing new ways of working. This will also allow the separation of trauma

services and consequently lessen their impact on elective work.




Ensure therapy services are engaged, with nursing colleagues, in thepre-admission management of inpatient √ √ 2cases

Ensure adequate rehabilitation/therapy support to orthopaedic √ √ 1inpatient activity

Explore the potential for therapy contributions to early discharge schemes designed to shorten length of √ √ 2stay

Ensure therapy support to step down programmes to continue post-operative √ √ 2interventions


Support implementation of thenational strategy currently in √ √ √ 1preparation

Strategic Direction 11: Add protected capacity where needed, withimproved patient flows

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Key Action 34: Provide additional orthopaedic capacity commencing in the

South East Wales region to respond to highest levels of demand

Key Action 35: Evaluate the need and, where appropriate, develop plans for

adding equivalent capacity in Mid and West and North Wales

Key Action 36: Ensure that proposals for additional capacity include an

associated cultural change and new ways of working.

5.5 Informing the Process

Data sources and management information are often of poor quality and

therefore of limited value, and must be considerably strengthened in order to

provide a robust basis for service and strategic planning. It should also offer a

firm basis for audit, evaluation and daily management. Furthermore,

opportunities and resources for secondary analysis to model the current position

and map the impact of new approaches are limited. It is expected that many of

these issues will be addressed with the implementation of Informing Healthcare.

However, it is essential that information requirements are assessed and delivered




Provide a range of additional hospitalfacilities and extra staff strategically √ √ √ 1located across the region


Evaluate the need for and plan additional capacity for trauma and orthopaedic services to address current √ √ √ 2and future demand and reduce waitingtimes targets across the two regions


Consider service design and patientflows linked with new developments √ 2to optimise service efficiency

Consider the options offered by other models for adding capacity √ √ √ 2

Define the contribution of clinical networks to ensuring common √ √ √ 3approach and equity of access

Strategic Direction 12: Strengthen data capture processes to ensurerobust and timely management information

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as soon as possible to provide a suitable information base for management

action.

Key Action 37: Define ‘minimum data set’ needed to provide robust and fit for

purpose information for clinicians and managers

Key Action 38: Address the need for routine and targeted secondary analysis at

all levels

Key Action 39: Support the implementation of Informing Healthcare, in particular

its theme, ‘better use of health information’




Redefine data collection requirements (including timeframes) and systems, √ √ √ 2deriving from clinical processes

Develop methodologies for measuring non-consultant activity √ 1

Standardise methodologies and quality assurance to ensure robust, timely, √ √ √ 2accurate and meaningful dataset


Develop dedicated expertise for routine targeted, secondary analysis √ √ √ 3


Work with the Informing Healthcareteam to facilitate better √ √ √ 1availability and use of information

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6. RESPONSIBILITIES Responsibility for achieving this vision for improved trauma and orthopaedic

services in Wales must be shared by all stakeholders, and can only be delivered

through committed partnership working. Some elements require a firm policy

lead from the centre, whilst others must be delivered from within each health

community. Much work is already underway to improve service delivery and

clearly different organisations are at different stages in their organisational

development. Careful planning, along with concerted and continuous actions, are

needed by all partners to facilitate steady improvement. The key responsibilities

are set out below:

Welsh Assembly Government, including Regional Offices

• Waiting times policy and managing the backlog of long waiting patients;

• Health Promotion and prevention (primary and secondary);

• Primary care led service (point of contact treatment, general practitioners

with a special interest);

• A Guide to Good Practice (Innovations in Care);

• Management Information (common dataset and standard definitions);

• Workforce planning and policy (impact of European Working Time Directive,

numbers in training, staffing modelling and workload measurement, core

skills development, extended roles, education and training programmes);

• Performance management;

• Diagnostics strategy;

• Therapies strategy;

• Delayed transfers of care and discharge policies;

• Capacity.

Local Health Boards, trusts and general practice

• Demand management;

• Balancing activity with demand, and managing change;



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• Management information and data quality, e.g. waiting list management

information and service planning information;

• Surveillance and early intervention, e.g. falls, secondary fracture prevention;

• Outpatient systems and waiting list management, e.g. pre-assessment,

partial booking;

• Inpatient/daycase systems and waiting list management, e.g. scheduling.

theatre utilisation/day cases/bed management;

• Trauma management e.g. daily trauma lists;

• Bed management and patient flows, e.g. pre-assessment, physiotherapy, fast

track from A&E;

• Theatre utilisation;

• Organisational development and performance management culture of tight

management and good practice;

• Integrated elective care pathway, e.g. clinical networks, musculo skeletal and

backpain pathways, trauma care;

• Extended roles and new ways of working, e.g. nurse led clinics, waiting list

triage;

• Diagnostic and therapy services, e.g. requests, duplication, availability,

extended roles;

• Rehabilitation and discharge planning, e.g. step down/delayed transfers of

care, care pathway driven care, early supported discharge, reablement

schemes, aids and appliances, geriatric hip fracture programmes;

• Booking systems, e.g. reducing ‘Did Not Attends’ and ‘Could Not Attends.

Patient Responsibilities

• Health Promotion (lifestyle factors);

• Attending appointments.



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7. CONCLUSIONS• This plan is designed to ensure the sustainable delivery of a high quality and

timely orthopaedics service for Wales. This will allow improved patient

access and the continuous reduction in waiting times.

• It will need to be delivered incrementally, depending upon different starting

points in each health community. This will require carefully planned and

phased action.

• Successful delivery is reliant upon a whole systems approach, and a

combination of concerted health community management action with

central policy direction. This must revolve around:

• tighter management processes and good practice;

• service improvement and innovation;

• adding capacity where necessary, with an associated culture of working

differently.

• Not all elements will require new funding input but some further

investment will be required to support aspects of the Plan. The Welsh

Assembly Government has made a contribution to the new capacity by

committing capital investment of over £10 million, as well as a recurrent

revenue contribution of £10 million, with a possibility of further in 2005/06.

NHS trusts will need to contribute capital resources to achieve the

additional capacity, whilst Local Health Boards must contribute to the new

services through their commissioning plans.

• This approach will allow standardised good practice, enabling all

organisations to achieve change and to develop a service that is fit for

purpose. By facilitating optimal performance and adding new capacity

where necessary, it will be possible to match the total resource to demand

presenting over the next decade.

• Approaches will vary across the regions, depending on current activity,

service configuration and available capacity.



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APPENDIX 1

Membership of the Orthopaedic Group

John Hill Tout (Chair) Director of Performance and Operations Division, Welsh

Assembly Government

Roger Perks Head of Waiting Times & Emergency Care Branch, Welsh

Assembly Government

David Salter Deputy Chief Medical Officer, Welsh Assembly

Government

John Black Consultant in Trauma and Orthopaedics, Carmarthenshire

NHS Trust

Declan O’Doherty Consultant in Trauma and Orthopaedics, Cardiff and Vale

NHS Trust

Mel Jones Consultant in Trauma and Orthopaedics, North West

Wales NHS Trust

Maggie Parker Nursing Officer, Welsh Assembly Government

Zoe Goodacre Innovations in Care (to August 2003)

Marie Ward Patient Access Project Manager, Welsh Assembly

Government

Pat Tempest Head of Capital, PFI, Estate & Supplies, Welsh Assembly

Government

Sue Cromack Head of Workforce Management Branch, Welsh Assembly

Government

Rob Heaton Jones Head of Business Planning and Policy Team, Welsh

Assembly Government

Alex Bowerman Orthopaedics Project Manager, Welsh Assembly

Government

Maureen Potter Waiting Times and Emergency Care Branch

(to December 2003), Welsh Assembly Government

Margaret Foster Acting Regional Director, South East Wales (to March

2003)

Bob Hudson Regional Director, South East Regional Office (from May

2003)



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Jan Smith Therapies Advisor, Welsh Assembly Government (from

June 2003)

Advisors to the Orthopaedic Working Group

Marysia Hamilton Director of Public Health, National Public Health Service

Kirkwood

Anthony Johansen Consultant in Medicine and Trauma, Cardiff and Vale NHS

Trust

Hefin Jones General Practitioner, Merthyr Tydfil

Gof Cockell Statistician



Further copies of this document can be obtained from:

Waiting Times & Emergency Care BranchPerformance and Operations DirectorateHealth and Social Care DepartmentWelsh Assembly GovernmentCathays ParkCardiffCF10 3NQ

Tel: (029) 2082 3230E-mail: [email protected]

an orthopaedic plan for wales · driven by the emergency nature of the care required, and this has...

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