Epsom & St Helier Hospital HMP High Down Orthopaedics Clinic

1. Epsom & St Helier Hospital HMP High DownOrthopaedics Clinic 6th RCGP Health & Justice Summit Presentation MISs Andrea Sott, frcs t&oRTH Dr Gareth Ruse, Lead GP HMP High Down Mr Christian Mubaira Clinical manager

2. Overview: • This presentation will: • 1. Give a brief background of the St Helier Hospital-HMP High Down Orthopaedic Service • 2. Present the problem and Solution • 3. Explore the running of the Orthopaedic Service in HMP High Down: • The Good: Give case examples & performance Data • The Bad: The challenges in the daily operational running of the service. • The Ugly: Strategic considerations in setting up the service. • 5. Discuss the future of the service • There will be Questions & Answers at the end

3. Background:

4. HMP High Down: • Is a male category B local prison located in Sutton, Surrey. • The prison holds adult remand and convicted prisoners and young offenders. • Has an operational capacity of 1163. • The prison also has a 23 bedded Inpatients unit. • Population churn rate is approximately 3 times per year

5. ProblemPrison health perspective • Context: • Operational difficulties: There were significant Prison staff shortages. • Bed watch and escorts pressures: In 2016 42 out of 75 (56%) appointments were being cancelled each month. • Novel Psychoactive Substances • Violence and aggression- Trauma There were poor outcomes for the patients

6. ProblemSt Helier Hospital perspective • High rate of re-referrals • High rate of cancelled appointments • Incomplete treatments • Missed complications from surgery • Limited access to urgent surgery /lack of compliance • System fails the young offenders

7. Case 1-Ryan, 19 male:

8. Solution HMP High Down & St Helier Hospital Trauma & Orthopaedics Dep to develop an in reach service within the Prison. • Epsom & St Helier Hospital Trauma & Orthopaedics Team • Prison Service • Prison GP & Primary Care Team • NHSE Health & Justice Commissioning • NHSE Specialist Services Commissioning • Orthopaedics Consultant(s) Link Nurse • Physiotherapist • Radiographer • GP Step 1: All stakeholders were invited to a meeting Step 2: Criteria was agreed Step 3: Pathway was developed Step 4: Service Level Agreement drafted

9. The Pathway GP completes referral & adds patient to waiting list on SystmOne (X-Ray referral where required) • Nurse: • Reviews waiting list • Sees patients • Liaises with Hospital Consultant • Books the Orthopaedic clinic • Sits in the Consultant clinic Post Op Care & Follow up • Consultant: • Reviews waiting list • Liaises with Nurse • Sees the Patients Physio + Review Onward referral to sub-Speciality RSCH Chronic Pain Service Surgery Further investigations

10. Clinic Performance:

11. Number of patients seenNov 2017-Oct 2018 • 282 referral were made and 257 patients were seen in the first 12 months of running the clinic. • This represents over 560% increase from the previous year!

12. Age distribution:

13. Non-attendance-DNAs

14. Percentage DNAs

16. POSITIVE IMPACT • 1. CLINICAL ASSESSMENT BY SURGEON IFDENTIFIED SEVERAL PATIENTS SUITABLE FOR REHABILITATIVE SURGERY • Knee Arthroscopy with meniscal surgery =/- ACL reconstruction • Specialist hand surgery for deforming Dupuytrens disease and debilitating Carpal Tunnel Syndrome • Osteoarthritis of the foot/Hallux Rigidus for Cheilectomy or fusion • Acute on chronic nerve root compression in LS Spine for caudal epidural pain relief

17. HAND CONDITIONS

18. FOOT CONDITIONS

19. ACL

20. POSITIVE IMPACT • Scheduled review of post surgical patients in prison • Patients after recent MSK surgery for wound inspection, change of plaster casts, removal of sutures and check Xrays • THIS HAS PARTICULARLY IMPROVED PATIENT CARE WHERE PREVIOUSLY WOUND ISSUES AND INFECTIONS REALLY COMPROMISED OUTCOME. • TACKLING PREVIOUSLY NEGELECTED PLASTERS AND BANDAGES AND MISSED CHECK XRAYS DUE TO TRANSFER PROBLEMS / MISSED HOSPITAL APPOINTMENTS

21. POSTOP ISSUES

22. INFECTED ANKLE

23. Positive impact • Assessment of acute pain and injury sustained in prison or on arrest • Immediate review of patient and their Xrays -> treatment plan • Fast tracking of prisoners to access MRI and CT or Ultrasound guided procedures by ESTH clinician • Facilitating urgent transfer for suspected cauda equina syndrome

24. POSITIVE IMPACT • AFTER SURGICAL REVIEW A ONWARD REFERRAL TO OTHER • IN PRISON HEALTHCARE SERVICE IS HELPFUL • PHYSIOTHERAPY • PODIATRY • ORTHOTICS/SPLINTS/BRACES • PAIN CLINIC • NHS EXTERNAL SERVICE/ CLINICS/DIAGNOSTICS • PLASTIC SURGERY • SPINAL AND OTHER SUBSPECIALTY SURGERY

25. The Bad • Laborious vetting process • Poor prisoner movements • DNAs • Prison transfers • Prison Lock downs • Acknowledgement of Clinic and therefore prioritisation • Radiologist post became vacant. • Equipment breakdown • Image reports • Supporting Nurse not always available due to other commitments

26. The Ugly • 2-hour clinic= 1PA • Costly • Efficient use of consultants time? • Labour & Time intensive: Following up patients • Short term increase in costs e.g. Equipment • Abusive patients. • High risk of failure: Especially if some stakeholders are not on board e.g. Prison Service. • Staffing implications e.g. Admin, Nursing, Radiology.

27. Lessons learnt • In summary we learnt that the success of running an “In reach” Service is dependent on a effective multidisciplinary team. • Communication is vital: – With the Patient-Prison GP- Hospital Consultants. • Specialist pain clinics • Engage key stakeholders early • Develop consistent working practice • It is important to have clear evidence based criteria and clinical pathway

28. Future • Radiology Link to St Helier Hospital • SystemOne Access at the Hospital • Video link for Virtual fracture Clinics