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“Meeting the Musculo-Skeletal Challenge” Avril Imison

“Meeting the Musculo-Skeletal Challenge” Avril Imison Dept of Health:Access Policy Lead - Orthopaedics and Musculo-Skeletal Services. Productivity - declining Numbers of Long Waiters Capacity Constraints Raised as a “serious concern” with Top Team. ORTHOPAEDICS : THE BIG PICTURE.

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“Meeting the Musculo-Skeletal Challenge” Avril Imison

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  1. “Meeting the Musculo-Skeletal Challenge” Avril Imison Dept of Health:Access Policy Lead - Orthopaedics and Musculo-Skeletal Services

  2. Productivity - declining Numbers of Long Waiters Capacity Constraints Raised as a “serious concern” with Top Team ORTHOPAEDICS : THE BIG PICTURE • Instructions: • Delete sample document icon and replace with working document icons as follows: • Create document in Word. • Return to PowerPoint. • From Insert Menu, select Object… • Click “Create from File” • Locate File name in “File” box • Make sure “Display as Icon” is checked. • Click OK • Select icon • From Slide Show Menu, Select Action Settings. • Click “Object Action” and select “Edit” • Click OK Orthopaedics has the biggestchallenges:

  3. AGREED PLAN - SEPTEMBER 2002 • Instructions: • Delete sample document icon and replace with working document icons as follows: • Create document in Word. • Return to PowerPoint. • From Insert Menu, select Object… • Click “Create from File” • Locate File name in “File” box • Make sure “Display as Icon” is checked. • Click OK • Select icon • From Slide Show Menu, Select Action Settings. • Click “Object Action” and select “Edit” • Click OK • Target capacity plans and LDPs • Good practice guide - Published 2003 • Engage the BOA/College of Surgeons • Set up support programme for challenged Trusts Developed into Tailored Support Programme in 2004

  4. Present Orthopaedic Services • Instructions: • Delete sample document icon and replace with working document icons as follows: • Create document in Word. • Return to PowerPoint. • From Insert Menu, select Object… • Click “Create from File” • Locate File name in “File” box • Make sure “Display as Icon” is checked. • Click OK • Select icon • From Slide Show Menu, Select Action Settings. • Click “Object Action” and select “Edit” • Click OK • 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

  5. Orthopaedic Patient Flow In England • Instructions: • Delete sample document icon and replace with working document icons as follows: • Create document in Word. • Return to PowerPoint. • From Insert Menu, select Object… • Click “Create from File” • Locate File name in “File” box • Make sure “Display as Icon” is checked. • Click OK • Select icon • From Slide Show Menu, Select Action Settings. • Click “Object Action” and select “Edit” • Click OK Average Flow is: 100% Outpatients 30% Decisions to admit 10% (30%) removed after listing 20% Receive surgery

  6. NHS Plan Patient Access Targets • Instructions: • Delete sample document icon and replace with working document icons as follows: • Create document in Word. • Return to PowerPoint. • From Insert Menu, select Object… • Click “Create from File” • Locate File name in “File” box • Make sure “Display as Icon” is checked. • Click OK • Select icon • From Slide Show Menu, Select Action Settings. • Click “Object Action” and select “Edit” • Click OK • 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

  7. PROGRESS: PERFORMANCE • Instructions: • Delete sample document icon and replace with working document icons as follows: • Create document in Word. • Return to PowerPoint. • From Insert Menu, select Object… • Click “Create from File” • Locate File name in “File” box • Make sure “Display as Icon” is checked. • Click OK • Select icon • From Slide Show Menu, Select Action Settings. • Click “Object Action” and select “Edit” • Click OK Waiting time for GP referrals - over 13 weeks

  8. PROGRESS: PERFORMANCE Waiting time for inpatients - over 6 months

  9. CHALLENGE: PRODUCTIVITY Overall Productivity Trend - 13 year period

  10. 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

  11. 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 ORTHOPAEDICS : RECOMMENDED ACTIONS

  12. 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 RECOMMENDED ACTIONS

  13. A&E attendance Emergency Admission/discharge Outpatient waiting list Outpatient attendance's Inpatient / day case waiting list Elective admission from list (Planned admission) - Discharge Orthopaedic Services - The Pathway, Problems and Solutions PATHWAY Emergency Referral Outpatient attendance/ discharge from consultant’s care Elective referral - GP, consultant, community Poor Information, lack of understanding, lack of ownership PROBS Social care capacity not coping with demand from service Insufficient primary care alternatives to hospital Numbers of patients currently waiting for surgery is increasing or remaining constant Trauma/other specialities take priority Lack of consistency Process bottlenecks. Inefficient use of resources Key 4 Elective care is prescheduled and pre-planned across the week 5 Day case surgery is the treatment of choice wherever possible 8 The use of main and DC theatre sessions has been maximised 9 Post-op patients are only seen again in clinic when they actually need to be 10 The service is not over reliant on agency staff SOLUTIONS CLINICAL SYSTEMS IMPROVEMENT Secondary Care Primary & Secondary Care 1 There are agreed pathways of care which optimise outcomes & resources 2 The only patients who see the consultant in clinic are those who need a consultant opinion 3 There are effective waiting list management arrangements in place 6 There is comprehensive pre-operative assessment in place 7 There are no avoidable factors extending LOS 11 There is evidence of role extension/redesign so all members of the MDT are used to best effect WHOLE SYSTEMS IMPROVEMENT 16 The performance management framework has clear lines of accountability for reporting, feedback & dissemination 15 There is high quality performance information regularly available 14 There are no wider ‘whole system’ variations which are detrimental to the management of orthopaedics 13 The service is in balance and able to supply what is needed to meet the 6-month target 12 The 6-month target is orthopaedics flagged as a priority for the coming year in plans and personal objectives

  14. Musculo Skeletal Service (Consultation Draft) Surgical thresholds / protocols and agreed by Primary and Secondary Care Primary Care Secondary Care Physiotherapy and Occupational Therapy Management Consultation Primary Care Active Management of Musculo-Skeletal Conditions Facilitate Self Management Fall Services Walk-in Clinics Interface Clinics Within 13 weeks 2005 Rheumatology / Pain Clinics Booked Choice Consultation Physiotherapy as First Line - Self Referral Interface with other Primary Care Services e.g Podiatry, Orthotics, Equipment Combined Clinics Less than 3 months in 2008 Child Health Services Booked Admission And Discharge Outpatient Consultation Pre-Assessment Clinic Orthopaedics booked Appointment in Booking System (Adult and Children) Occupational Therapy in Primary Care / Social Services Intermediate Care Less than 6 months in 2005 NHS Direct Trauma Inpatients Trauma/A&E/Day Case Outpatients Minor Injuries Rehab & “Back to Work” Vocational Reintegration Avril Imison National Access Policy Lead for Orthopaedics & M-SK

  15. THE NHS IN 2008 • Instructions: • Delete sample document icon and replace with working document icons as follows: • Create document in Word. • Return to PowerPoint. • From Insert Menu, select Object… • Click “Create from File” • Locate File name in “File” box • Make sure “Display as Icon” is checked. • Click OK • Select icon • From Slide Show Menu, Select Action Settings. • Click “Object Action” and select “Edit” • Click OK • 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.

  16. THE NHS IN 2008 • Instructions: • Delete sample document icon and replace with working document icons as follows: • Create document in Word. • Return to PowerPoint. • From Insert Menu, select Object… • Click “Create from File” • Locate File name in “File” box • Make sure “Display as Icon” is checked. • Click OK • Select icon • From Slide Show Menu, Select Action Settings. • Click “Object Action” and select “Edit” • Click OK • 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.

  17. 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

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