Transcript Paediatric Orthopaedics

Strategy Meeting
Trauma & Orthopaedics
Nish Chirodian
February 2013
Orthopaedic Strategy Meeting
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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.
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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 retasked 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 23 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