1 Musculo­Skeletal and Neurosciences Directorate Elective Orthopaedics at NUH Purpose of report This paper outlines the current waiting time performance of Elective Orthopaedics at NUH, the contributing factors to the current under performance and the current plans to recover the performance. 1. Current Performance The chart below shows Trauma and Orthopaedic referral to treatment (RTT) 18 weeks admitted performance. From March 2009­ November 2010. 18 Week % Performance Admit Spec Desc TRAUMA AND ORTHOPAEDICS Admit Directorate Musculoskeletal & Neurosciences 120.00% Count of Treatment Number 100.00% 80.00% More Bands 60.00% Under 18 18 and Over 40.00% Nov 10 Oct 10 Sept 10 August 10 July 10 June 10 May 10 Apr 10 Mar 10 Feb 10 Jan 10 Dec 09 Nov 09 Oct 09 Sept 09 Aug 09 July 09 June 09 May 09 Apr 09 0.00% Mar 09 20.00% Month# Admitted over 18 weeks RTT numbers Admit Spec Desc TRAUMA AND ORTHOPAEDICS 18 and Over 140 Count of Treatment Number 120 100 80 Adjusted W ait in W eeks2 18 and Over 60 40 Nov 10 Oct 10 Sept 10 August 10 July 10 June 10 May 10 Apr 10 Mar 10 Feb 10 Jan 10 Dec 09 Nov 09 Oct 09 Sept 09 Aug 09 July 09 June 09 May 09 Apr 09 0 Mar 09 20 Month# The graphs show an upward trend is evident from December 2009. The department has not achieved the 18 weeks admitted target since the winter in 2009/10, where there was a significant spike in trauma demand, due to the weather and increased associated activity. Nationally Trauma & Orthopaedics as a speciality continues to struggle to achieve 18 weeks.
2 Given the volume of patients seen in T&O the department’s failure to deliver 18 weeks in this specialty has a significant effect on the Trust’s overall delivery of the 18 week RTT admitted target. 2. Critical factor in underperformance The orthopaedic department experiences a fundamental mismatch in the demand for the service (as represented by additions to the waiting list) and the capacity to meet this demand (represented by numbers of operations per week). Mean Additions to NUH Orthopaedic Waiting List ­ 155 Mean Operations carried out in NUH Orthopaedics – 105 3. Compounding Factors causing underperformance
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The early and prolonged snow fall from the end of November 2010 and subsequent cancellation of elective patients. This was due to the need for both beds and operating time for trauma patients on the QMC campus.
The number of medical patients requiring surgical beds has had an adverse effect on the operating on both campuses.
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These cancellations (approximately 95 since the end of November) have had a double impact upon the service’s performance as they displace operating time for other patients when they are brought back in.
There is a shortfall in orthopaedic trained theatre staff of approximately 7.5 WTE on the City Campus due predominately to sickness absence. This has impacted on the Trust’s ability to run additional orthopaedic activity.
We are contracted to deliver orthopaedic outpatient services for the Treatment Centre and therefore we cannot balance the consequent impact on elective services at QMC. 4. Progress to date The weekly meetings led by the Chief Operating Officer have been centred on the delivery of this target and in particular overcoming the operational obstacles. This series of meetings has made good progress and already realised benefits in a number of areas.
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Ensuring all elective activity vacated due to leave is covered by a surgeon so that the theatre session is always used.
Sharing hand surgery patients with plastic surgery for suitable patients.
Sharing of ‘day case’ procedures between shoulder surgeons.
Negotiating to pay Tariff as a maximum at both local private providers. This means that we are spending the same as our income for cases that we send to the private providers. This is a reduction in price on previous agreements.
Improved validation of the data on dated and undated breaches. This means we report the waiting list more accurately.
Greater control over waiting list management through twice weekly review of major pressures and patients that are nearing their breach dates.
Opened 8 additional beds on the City Campus in January 2011 to support additional activity on the City Campus. This will also reduce the number of surgical cancellations due to ward bed unavailability. The Trust has consistently used the private sector to cope with the excess demand for the service. There is a budget for using the private sector that recognises the some of the shortfall in capacity to deliver elective orthopaedics. The directorate is looking to significantly reduce the amount it spends in the private sector in 2011/12 and has identified this as part of the directorates cost improvement programme. 5. Future Actions to Improve 18 Weeks RTT Admitted Performance
· Additional Elective Surgical Staff – The department has secured locum and industry funding to appoint a locum elective junior consultant and two advanced arthroplasty fellows. These will allow the department to continue to backfill lists as well as deliver additional operating sessions.
· Releasing consultant time to operate. The department is beginning to align outpatient and inpatient waiting times to release consultant PAs that can be delivered flexibly to cover additional operating sessions.
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Pathway improvement work – MSKN and Specialist Support are working together to deliver improved efficiencies in theatres. The department are currently reviewing the elective pathways to reduce inefficiencies and inherent delays.
Theatre New Build – The purpose­built orthopaedic facility that is planned to open in February 2012 will allow for innovations in clinical practice and administrative processes. This will facilitate the service working at optimum efficiency. The department is currently working on changing practice in readiness to move into the new theatres.
City Ward configuration – The ward renovation work and the centralisation of elective services on the City Campus will improve bed availability for elective orthopaedics. This will also reduce the amount of unproductive time in theatres due to ward delays. This work will be ongoing over the next 12 months and should be completed in February 2012. 6. Scoping the current problem as at January 24 2011 Current backlog of patients (undated over 12 weeks RTT + dated over 18 weeks RTT) Operating at 120 pathways per week, backlog of patients in weeks Additions to the waiting list per week – Mean 504 4 weeks 2 days or 907 hours 155 Current pathways per week – mean 105 Pathways per week – target 120 Additional hours per week operating time required to deliver current demand, excluding the backlog of patients (based on an average 1.8 hours per case) Additional hours per week operating to deliver current demand on top of targeted pathways, excluding the backlog of patients. 87 Hours or 24 additional theatre sessions. 63 Hours or 18 additional theatre sessions. 7. Conclusion This paper has demonstrated the ongoing pressures, both financially and performance related, which the specialty faces. Significant improvements
5 have been made in internal efficiencies and more are planned as part of a service improvement of the elective pathway when the QMC element of the elective service moves to the City Campus in early 2012. However, there have been issues outside the control of the specialty which have hampered achievement of the target. These include loss of beds due to medical outliers, loss of beds and theatre capacity due to high numbers of trauma patients, inability to manage the demand from the Treatment Centre and the difficulty in gaining additional theatre capacity due to staffing issues within theatres. As a result, once the specialty loses capacity it cannot recover that capacity and so consistently has to look at using the option of the private sector to match demand as far as possible. This can mean that the use of the private sector exceeds the budget for the private sector. Action to improve the position has been constant throughout 2010 and into 2011 and has the full engagement of the corporate team, theatres and the Head of Service. In addition to the internal efficiencies, action to improve the position also requires expenditure outside the Trust to increase our capacity to manage demand. This paper has highlighted the current position of the specialty and the detailed actions being taken to improve the situation. Mr Peter James – Head of Service, Elective Orthopaedics William Monaghan – Assistant General Manager, MSKN Damian Hughes – General Manager, MSKN Sue Cooper – Deputy Director of Operations