Orthopaedic summit: 15 February 2023

A second orthopaedic summit was held in February 2023 to discuss what progress had been made since the initial summit in August 2022. The aim was to review the progress health boards had made, regional developments and to share the latest developments from the National Clinical Strategy for Orthopaedic Services (NCSOS).

Nick Wood, Deputy Chief Executive - NHS Wales set out the expectations of the day, highlighting the progress made since August 2022 and actions health boards have put in place to address the backlog of patients and eliminate three-year waits. He highlighted that the discussions should cover theatre utilisation, progress on regional working and on ‘green’ or ‘ring-fenced’ orthopaedic capacity.

The delivery unit (DU) presented a number of slides that highlighted how waiting times had changed since August 2022. These are attached to this report.

Referrals into the orthopaedic service across Wales remain below the pre-pandemic levels. In each month since August 2022, referrals have been between 80% and 85% of pre-pandemic levels with the exception of December, where they fell to 63%. New outpatient activity, whilst it has increased, still remains slightly below the pre-pandemic levels at an all-Wales level, though some health boards are above pre-pandemic levels of activity. Inpatient / daycase activity also remains below pre-pandemic levels, with the December position being 56%.

The total size of the waiting list has fallen since August, reaching a peak in October 2022, with latest published information showing it has reduced to 98,555 at the end of January. There has been a reduction in the number of open pathways waiting for a first outpatient and since the middle of January, DU weekly data shows there had been a reduction seen in the total number of open pathways at stage 4, treatment, though it remained around 37,500. Reductions have been seen in the number of open pathways over 104 weeks, with the end of January position at 12,349, a reduction of just over 8,000 since the end of March 2022. The current forecast for the end of March 2023 is showing around 10,000 open pathways over 104 weeks, against the ministerial expectation of zero.

On new outpatients over 52 weeks, the end of January 2023 position shows 9,704 open pathways, 57% lower than the high of August 2023. It is important for health boards to continue to book patients from the cohort, to ensure the backlog of patients waiting is cleared as quickly as possible.

Professor Tim Briggs provided a brief update from GiRFT. He was pleased to note the improvements that have been made, but was clear there was still considerable work to do and an opportunity had been missed not to get ahead of the game in terms of outpatients, given that the referrals were still below pre-pandemic levels. He was pleased to note that BCU were considering a dedicated unit at Llandudno. He continued to support the work in Powys and was complementary of the work going on in South East Wales including the purchase of the former BA buildings. Professor Briggs was complimentary of the on-going work at Neath Port Talbot and the expansion to allow for more complex cases to be undertaken there, though there is a concern about having an ambulance based at the hospital in case of a need to transfer patients who may need a critical care bed following surgery. Professor Briggs highlighted a similar issue in St Albans, where the ambulance had been dispensed with within a month and suggested that colleagues from Swansea Bay speak to colleagues in St Albans.

In Cwm Taf Morgannwg, it was important to ensure the continued ring fencing of the elective beds at the Royal Glamorgan. The one area of concern was in Hywel Dda, where there did not appear to be a solution, though Professor Briggs did recognise the new day case unit was in place. However, when you look across Wales, it is the inpatient wait that is increasing and needs addressing. Professor Briggs highlighted the recommendations included in all reports, which was to maximise day case rates, maximise theatre productivity, getting to 85% and getting the protected hub sites up and running. He was clear that it is about using existing facilities better, ensuring that four joints a day were being carried out and about ensuring the right procedure was being carried out in the right place. The British Hand Society has produced guidance for some hand surgery to be carried out outside of a theatre.

Professor Briggs provided some information on England, highlighting that some organisations are now achieving 80% for day case rates and are increasing the numbers of right procedure right place, i.e. moving procedures from theatres to procedure rooms where applicable. NHS England is currently accrediting eight sites, looking at patient experience, clinician experience, outcomes, productivity and efficiency. There are a further 41 sites included in phase 2 during February and March, before being rolled out across the rest of England and they would be happy to share that with Wales. Professor Briggs advised that he had been promoted to not only National Director of Clinical Improvement, but also Elective Recovery working with Jim Mackey, who is the National Director of Elective Recovery. He would recommend the dyad of a senior manager and a senior clinician really holding systems and trust to account.

Mr Ian Smith noted that it was not easy to compare Wales with what had been achieved in England and there was a need for a reform to the consultant contract in Wales. Nick Wood confirmed that some initial discussions had taken place with workforce colleagues in Welsh Government. Suzanne Rankin agreed with the comments and offered any support she could and welcomed further support from Professor Briggs.

The Minister for Health and Social Services spoke to the group. She was clear about the need to address the backlog of patients waiting, recognising there are still too many people waiting over the target times. There is a need to improve day case rates and average length of stay and to implement the recommendations of the GiRFT programme and the NCSOS at pace. She wants to ensure the service is using the resources they have to their maximum and to develop regional solutions where possible. The Minister noted the additional orthopaedic capacity that was coming online and the need to maximise the use of resources available, workforce and job planning before we think about investing in new facilities. The Minister highlighted her recent visit to Abergele and her disappointment that there was no activity taking place at the time of her visit.

Officials have spoken with the GiRFT Theatre team to look at what metrics can be collected to monitor efficiency and the template the GiRFT Team use has been circulated to two organisations who are piloting it before it is rolled out across Wales.

Discussions should be taking place with patients as to whether an operation is the best option for that patient and if it is, then the patient should receive a proper pre-assessment prior to surgery and then have appropriate follow-up care. Health boards should have processes in place to remind patients of the dates for their appointments and treatment. The minister acknowledged the hard work of everyone working to reduce the backlog and improve services and noted that the next few years would be financially challenging. As a result, it is important that service change is expedited and that organisations work together across health board boundaries to deliver services.

Mr Navin Verghese provided an update on the work of the National Clinical Strategy for Orthopaedic Surgery (NCSOS). He agreed with the Minister that there was a big challenge ahead and it was a medium to long term issue to resolve. There are some actions that can be taken immediately to make some headway. The NCSOS had moved from project mode to programme mode, and everyone was dedicated to transform the way orthopaedic services are delivered. Every orthopaedic consultant across Wales has contributed to the strategy. Over the last six months some real progress has been made and there has been good engagement and this will hopefully help to flatten or calm down the curve over the next half a decade.

There are currently 183 orthopaedic consultants across Wales, working in 24 orthopaedic units. Some health boards have three or more orthopaedic units, all working differently which can lead to inefficiency and one orthopaedic pathway being totally different to another orthopaedic pathway. The GiRFT team have done a huge amount of work over the last decade and that has helped to standardise care across health boards.

The NCSOS programme has four pillars on which the programme is based: organisational reform, clinical networks, pathway transformation and the establishment of surgical hubs. All of these are intrinsically linked to each other. There has been good progress on reform in South East Wales. There were 155 recommendations from NCSOS and numerous recommendations from GiRFT and these haven’t been implemented as well as they should have. There needs to be a national roll out of this work and for there to be a regional link. There is a need to monitor surveillance data, KPIs and governance, and only then can we reduce the waste to duplication of variation and contradiction. Some of these things can happen, at pace, but some are a long-term commitment.

There is a need to get clinical networks in place. There are service delivery groups at each site and there is some national work through the planned care programme Board. There is funding to develop the orthopaedic network and have sub speciality CRGs and an MDT to look at the whole pathway to have standardisation of care. This will help in implementing GiRFT recommendations through support from the executive teams. It is essential to have regional working groups in place that will meet the needs going forward to implement national strategies down to service delivery groups.On clinical networks, this has been the main focus so far and it is clear there is a huge amount of inefficiency built into workforce. Certain health boards are lacking in some sub-speciality areas, but if work is done on a regional basis, those consultants can be shared across the region. It is important that health boards do not recruit for specific sub-speciality areas but look to work on a more regional basis.

Every part of the pathway is resource heavy, from triage, through outpatients, diagnostics and treatments and everything in between. By looking at the whole pathway, interventions can be put in place that either prevents surgery or makes it less complex. There is a need to bring consultants closer to the front of the pathway and in work that was undertaken on the spinal pathway in Swansea Bay at the start of the pandemic, they managed to reduce the referrals into the spinal stage one clinic by 50%, reducing costs by over £100k and the stage one waiting list was reduced by around 70% with no over 26 week waits.

NCSOS has been focussing on the establishment of surgical hubs. NHS England is leading the way on the development of hubs, and we need to develop higher throughput GiRFT accredited hubs across Wales. To address the hip backlog, we need to uplift activity by 192% across Wales. At current levels, to achieve this you would need 15 or 16 theatres in Wales running flat out with four cases per day to achieve that level. If they moved to working 2.6 session days, the requirement would be 10 theatres. Looking at the new facility for South East Wales, if there was a move from five days to six, the requirement for theatres falls to five and the bed requirement would be drastically reduced if there was a reduction in line with GiRFT recommendations on length of stay. It is about that pathway transformation. It is also around ensuring the patient is right for surgery.

A snapshot analysis of some data on elective against acute sites indicates that 41% of procedures had been cancelled, 53% across the acute sites, 36% in the elective site, which shows there is potential to improve with elective sites. It is important to ensure pre-operative guidance is followed correctly so that only those patients fit for surgery are listed. There are still large numbers of patients who are cancelled on the day, some due to pre-operative guidance not being followed, as well as lack of beds (even on elective sites). Nick Wood thanked everyone for their presentations.

There followed a number of presentations from the health boards, both individually and as part of the regional plan. Key points included:

• Although there had been reductions in numbers of open pathways, both at first outpatient and treatment stages, there was a recognition from health boards that activity levels need to increase for both areas if we were to achieve the ministerial targets.
• There are challenges across Wales in certain sub speciality areas, notably spines. Health boards need to protect bed capacity from urgent and emergency care pressures.
• Health boards are working to improve efficiencies, including theatre utilisation and reducing average length of stay.
• There are challenges with workforce requirements, both in terms of theatre staff and other staff.
• There is a reliance on WLIs and insourcing / outsourcing of activity to address the backlog of patients.
• Whilst health boards would like to move to do more high-volume low-complexity lists, at present this is hampered by the fact that the majority of cases in health boards are more complex due to the length of time they have already waited, meaning these patients are not suitable for that type of list.
• There is a need to have the right support services in place, including physiotherapy.
• Referrals into orthopaedics are still below pre-COVID levels.
• All health boards are building on and implementing the GiRFT and NCSOS work and continue to develop action plans for implementation, including new ways of working such as SoS and PIFU.

The discussion concluded that in order to reduce the waiting lists and sustain a realistic waiting time for patients that activity levels need to increase and be sustained.

Inefficiencies in the system need to be addressed, including theatres, as there is no real benefit in opening new facilities if the current ones are not being used to their maximum. It is essential that we all implement the actions and recommendations from the GiRFT reviews and the NCSOS report.

The following actions were set:

• WG officials to work with the GiRFT theatre team to implement the reporting tool they have in place in England in Wales, so that we can see where there are areas for improvement.
• All sites to continue to implement the GiRFT and NCSOS recommendations.
• Develop robust and refined datasets, building on work from GiRFT, so that surveillance of whole pathway can be carried out.
• Roll out of sub-speciality pathways.
• All heath boards to improve activity levels for both inpatient / day case and outpatients.
• Relentless focus on eliminating outpatient waits over 52 weeks and all waits over 104 weeks.
• Continue to explore opportunities to work more regionally.