meeting the musculo-skeletal challenge avril imison dept of health:access policy lead - orthopaedics...
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“Meeting the Musculo-Skeletal Challenge”
Avril ImisonDept of Health:Access Policy Lead - Orthopaedics and Musculo-Skeletal
Services
ORTHOPAEDICS : THE BIG PICTURE
• Productivity - declining• Numbers of Long Waiters• Capacity Constraints• Raised as a “serious concern” with Top
Team
Orthopaedics has the biggest challenges:
AGREED PLAN - SEPTEMBER 2002
• Target capacity plans and LDPs
• Good practice guide - Published 2003
• Engage the BOA/College of Surgeons
• Set up support programme for challenged
TrustsDeveloped into Tailored Support Programme in 2004
Present Orthopaedic Services
• Large numbers of outpatient referrals - GP & Tertiary• Heavy demand on outpatient sessions to clear• Low conversion rates to inpatient listing - but high
numbers • Poor or absent pre-assessment (health or social care)
pre-listing• High removal rate at pre-assessment or admission• Actual treatment rates of approximately 20% of referred
patients• The “20%” is a higher demand than services are able to
treat in most places• Productivity in this specialty is lower than in any other
specialty
Orthopaedic Patient Flow In England
Average Flow is:
100% Outpatients
30% Decisions to admit10% (30%) removed after listing20% Receive surgery
NHS Plan Patient Access Targets
• 9 months maximum Inpatient waiting time:March 2004• 17 week wait for GP referrals to outpatients:March 2004• 6 month maximum inpatient waiting time:Dec 2005• 13 week wait for GP referral to outpatients:Dec 2005• Choice at 6 months for inpatient waiters:Aug 2004• Choice at GP referral:Dec 2005• Booking all day cases:April 2004• Booking all inpatient elective:Dec 2005• 3 month maximum wait:Dec 2008
PROGRESS: PERFORMANCEWaiting time for GP referrals - over 13 weeks Trauma and orthopaedics - England
GP referrals not seen waiting over 13 weeks
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
Jun Se De Ma Jun Se De Ma Jun Se De Ma Jun Se De Ma Jun Se De Ma Jun Se De Ma Jun Se De Ma Jun Se De
1998 1999 2000 2001 2002 2003 2004 2005
numbers waiting - quarterly Progressive reduction required since publication of the National Plan target
PROGRESS: PERFORMANCEWaiting time for inpatients - over 6 months
Trauma and Orthopaedics - EnglandInpatients and Day cases waiting over 6 months
8216583825 82993
78195
83444
86783
82923
78505
8171684424
80397
664716559264272
57128
34165
0
10000
20000
30000
40000
50000
60000
70000
80000
90000
100000
2000/0
1 Q
1
2000/0
1 Q
2
2000/0
1 Q
3
2000/0
1 Q
4
2001/0
2 Q
1
2001/0
2 Q
2
2001/0
2 Q
3
2001/0
2 Q
4
2002/0
3 Q
1
2002/0
3 Q
2
2002/0
3 Q
3
2002/0
3 Q
4
2003/0
4 Q
1
2003/0
4 Q
2
2003/0
4 Q
3
2003/0
4 Q
4
May 0
4
Jul 0
4
Sep 0
4
Nov 0
4
Jan 0
5
Mar 0
5
2005/0
6 Q
1
2005/0
6 Q
2
2005/0
6 Q
3
2005/0
6 Q
4
Qtr Wl Profile Target
CHALLENGE: PRODUCTIVITYOverall Productivity Trend - 13 year
periodFigure 3
Operations per consultant team England 1989/90 to 2001/02
0
100
200
300
400
500
600
700
800
1989/90 1990/91 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97 1997/98 1998/99 1999/00 2000/01 2001/02
Year
Op
erat
ion
s p
er y
ear
T&O Q1 2003/4 Benchmarking - Excess of Decisions to Admit over Admissions
April to J une 2003
- 200
- 100
0
100
200
300
400
500
600
Trusts
Exce
ss D
TA
s
Excess DTA's DC Excess DTA's I P
Line Analysis Chart - Adds and Admits by Quarter
0
20000
40000
60000
80000
100000
120000
140000
160000
Quarter
No
.
Decisions to Admit 138336 133558 135277 137558 143287 139217 146407 150309
Admissions 109526 106714 111666 111973 121870 112039 120522 120909
2001/2 Q4 2002/3 Q1 2002/3 Q2 2002/3 Q3 2002/3 Q4 2003/4 Q1 2003/4 Q2 2003/4 Q3
Trust
Specialty =
I P/DC (All)
110
(All)
T&O Q3 2003/4 Benchmarking - % of I npatients & Day Case Removed for Reasons Other Than
Treatment Q3 2003/4
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Trusts
% R
OT
T I
P & D
C
• 43 Nominated Trusts in the DH/MA
Orthopaedic Improvement Programme
• Diagnostic risk analysis and recovery plans
• Testing of process modernisation within
services
• Process modernisation can reduce over
50% of orthopaedic outpatients
attendencies
• Re-investment of time released in surgery
OPPORTUNITY: MODERNISATION &PRODUCTIVITY IMPROVEMENT
ORTHOPAEDICS : RECOMMENDED ACTIONS• Capacity plan by speciality
• SHA Orthopaedic Position Statement
• Primary care-led validation of orthopaedic
waiting lists
• Introduce health and social care
assessment at DTA
• Secure greater PCT and Trust Board
ownership of capacity and productivity
issues
RECOMMENDED ACTIONS• Contingency plans
• Broker surplus NHS capacity
• Consider options :
- overseas teams
- overseas treatment
- Supplementary procurement:(“GSUP”) 70% of
25,000 ‘free’ FCEs pa from 2004/05
- Share future vision of service
Orthopaedic Services - The Pathway, Problems and Solutions
PATHWAY
SOLUTIONS
EmergencyReferral
Electivereferral - GP, consultant, community
Outpatient waiting list
Outpatient attendance's
Inpatient / day case
waiting list
Elective admission from list
(Planned admission) - Discharge
Emergency Admission/discharge
Outpatient attendance/
discharge from consultant’s care
A&Eattendance
Poor Information, lack of understanding, lack of ownership
Insufficient primary carealternatives to hospital
Insufficient primary carealternatives to hospital
Numbers of patients currently waiting for surgery is increasing or remaining constant
Trauma/other specialities take
priority
Social care capacity not coping with demand from
service
Lack of consistency
Process bottlenecks.Inefficient use of resources
10The service is not
over reliant on agency staff
10The service is not
over reliant on agency staff
PROBS
9Post-op patients are only seen again in clinic when they
actually need to be
9Post-op patients are only seen again in clinic when they
actually need to be
4Elective care is
prescheduled and pre-planned across
the week
4Elective care is
prescheduled and pre-planned across
the week
Key
12The 6-month target is orthopaedics flagged as a priority for the coming
year in plans and personal objectives
12The 6-month target is orthopaedics flagged as a priority for the coming
year in plans and personal objectives
11There is evidence of role
extension/redesign so all members of the MDT are used to best effect
11There is evidence of role
extension/redesign so all members of the MDT are used to best effect
13The service is in balance and able to supply what is
needed to meet the 6-month target
13The service is in balance and able to supply what is
needed to meet the 6-month target
14There are no wider ‘whole system’ variations which are detrimental to the management of orthopaedics
14There are no wider ‘whole system’ variations which are detrimental to the management of orthopaedics
7There are no
avoidable factors extending LOS
7There are no
avoidable factors extending LOS
15There is high quality
performance information regularly available
15There is high quality
performance information regularly available
16The performance management
framework has clear lines of accountability for reporting, feedback
& dissemination
16The performance management
framework has clear lines of accountability for reporting, feedback
& dissemination
Secondary Care
Primary & Secondary Care
6There is
comprehensive pre-operative assessment in
place
6There is
comprehensive pre-operative assessment in
place
3There are effective
waiting list management
arrangements in place
3There are effective
waiting list management
arrangements in place
8The use of main and DC theatre
sessions has been maximised
8The use of main and DC theatre
sessions has been maximised
5Day case surgery is the treatment of choice wherever
possible
5Day case surgery is the treatment of choice wherever
possible
2The only patients
who see the consultant in clinic
are those who need a consultant opinion
2The only patients
who see the consultant in clinic
are those who need a consultant opinion
1There are agreed pathways of care which optimise
outcomes & resources
1There are agreed pathways of care which optimise
outcomes & resources
WHOLESYSTEMSIMPROVEMENT
CLINICALSYSTEMSIMPROVEMENT
Fall Services
Walk-in Clinics
Avril ImisonNational Access Policy Lead for Orthopaedics & M-SK
OutpatientConsultation
Pre-Assessment
Clinic
Primary Care Secondary Care
Primary CareActive Management
ofMusculo-Skeletal
Conditions
Facilitate Self Management
Physiotherapy andOccupational Therapy
Management
Rheumatology /Pain Clinics
Booked
BookedAdmission And
Discharge
Orthopaedics bookedAppointment inBooking System
(Adult and Children)
Physiotherapy asFirst Line - Self Referral
Interface with other Primary Care Services e.g
Podiatry, Orthotics,Equipment
Occupational Therapy in
Primary Care / Social Services
Less than3 monthsin 2008
Within13
weeks2005
Less than6 monthsin 2005
Surgical thresholds /
protocols and agreed by
Primary and Secondary Care
Musculo Skeletal Service (Consultation Draft)
Consultation
Consultation
Rehab & “Back to Work” Vocational Reintegration
Minor InjuriesTrauma/A&E/Day Case Outpatients
Trauma Inpatients
NHS Direct
Combined Clinics
Interface
Clinics
Choice
Intermediate Care
Child Health Services
THE NHS IN 2008•Patient chooses whether to make an appointment with a GP or
practice nurse, visit an NHS Walk-in Centre or Pharmacy Service
Centre, or contact NHS Direct for advice and diagnosis.
•Patients see a primary care practitioner within 24 hours when they
need to or within 48 hours for a GP.
•Patient chooses how, when and where they are treated from a range
of providers funded by the NHS and accredited by the Healthcare
commission.
•Patient books hospital appointment electronically for their own
convenience.
THE NHS IN 2008•Patient waits for specialist care are reduced to no more than 18
weeks from GP referral to treatment.
•Patient contacts NHS Direct or visits Minor Injuries Unit. If patient
needs to go to A&E, he/she is seen rapidly (Maximum four hours).
•Patient records owned by the patient; with secure access for
appropriate health professionals.
•Mixed sex wards abolished for older people and for all but a small
number of patients e.g. intensive care.
•Patients record their preferences in their personal; Healthspace on
the internet, linked to their patient record.
And so…...
….. to meet the access targets and to manage the demand and capacity, Primary Care has to manage this differently and INVEST IN ITSELF.
Thank you