REVIEW OFORTHOPAEDIC SERVICES

INGWENT

A REPORT TO THEWELSH ASSEMBLY GOVERNMENT

PROFESSOR BRIAN EDWARDSJANUARY 2003

SUMMARY

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FINDINGS

1. The current orthopaedic waiting lists in Gwent are far too long. The waiting timefor an outpatient appointment of up to three years represents an unacceptableservice..

2. In Gwent patients are being added to lists quicker than they are being seen ortreated. The problem overall is getting worse. A determined attempt to see moreoutpatients will quickly result in a longer waiting list for surgery.

3. The NHS in Wales and Gwent in particular does not have enough capacity in thisspeciality to handle current pressures and predicted future demand. In Gwent thegap between additions and removals is being partially bridged by specialinitiatives and referring patients to the independent sector for treatment with non-recurrent funds.

4. Some of the existing bed capacity is being used regularly for medical emergenciesand a significant number of other beds are occupied by patients whose dischargehas been delayed.

5. The orthopaedic service has been badly affected by surges in emergency medicaladmissions which has resulted in significant numbers of patients having theirelective admission cancelled at short notice. Work flows have also been disruptedby patients who do not turn up for their outpatient appointment or their surgery.

6. The Gwent health community needs to invest more in this specialty from theincreased funding they are expecting to receive from the all-Wales revenueequalisation process.

7. Joint replacement rates in Wales are significantly below those in England.

8. Whilst the Trust has worked hard to reduce its waiting times there is more thatthey can do to improve their own efficiency and waiting list management.

9. The number of joint replacement procedures could be significantly increased if theoperating theatre working practices at the Royal Gwent Hospital were moreflexible.

10. The demand on orthopaedic services could be managed better so as to ensure thatthe service is not swamped by cases that could be treated just as well by othermeans.

11. This problem cannot be solved by the Trust alone. It needs the whole healthcommunity engaged and committed to finding workable solutions.

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RECOMMENDATIONS

1. Tighter management

1.1 Waiting list validation needs to be significantly improved. The status of allpatients on the outpatient list needs to be checked at the six month point andthen quarterly. The existing outpatients lists need to be vigorously reviewedwith a view to re-referring suitable patients to alternative services.

1.2 A sample of patients who do not turn up for their appointment in the next threemonths should be reviewed with Local Health Boards to establish the reasonswhy and prompt a consideration of what action is required to improve matters.

1.3 The Trust should establish a closer relationship with patients on their inpatientwaiting lists involving much more regular contact particularly in the daysimmediately prior to admission. This will materially help with validation,reduce DNAs and be much appreciated by patients. The existing inpatient listsshould be validated much more intensively with special attention being paid tothose waiting longer than one year.

1.4 The Trust should review with their consultants the operation of the suspendedlist.

1.5 The Trust should monitor very closely the progress of the policy of referringpatients to the independent sector.

1.6 There should be a review of the use of day case facilities given the pressure oninpatient beds and main theatres. The waiting time target for day surgery shouldbe reduced.

1.7 Clinicians and managers need to manage existing resources more tightly. Asenior support team should work to the Clinical Head of Staff in creating anorthopaedics operations room which would provide a proper focus for thiscomplex and expanding service.

1.8 The support team should include an experienced manager, nurse,physiotherapist and General Practitioner. It would also be very helpful if amember of the Assembly’s staff could join the team so as to improve liaisonand understanding.

1.9 Operating theatre working practices at the Royal Gwent Hospital should bereviewed quickly in order to make it possible for two joint replacements to beundertaken per session.

1.10 The number of short notice cancellations by the Trust must be reduced.

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2 Capacity

2.1 Existing cold orthopaedic beds must have a higher degree of protection fromencroachment by other specialties.

2.2 Once the first stage of the new investment in acute medicine is in place, withthe recruitment of two new physicians at the Royal Gwent Hospital, 25 existingorthopaedic beds should be firmly ring-fenced and only accessed by otherspecialties in exceptional emergency situations.

2.3 The existing trauma work should be reviewed with primary care organisationsto establish whether there are acceptable alternatives to hospital referral.

2.4 Local Health Boards should work with the Trust in seeking to manage thedemand on orthopaedic services more tightly.

2.5 There should be immediate discussions about a protocol for outpatient referralthat would lead to only the most urgent or clinically important cases beingreferred to a consultant, at least for the time being.

2.6 Alternatives to consultant referral should be explored with primary careorganisations including more direct access to radiology, physiotherapy clinics,nurse specialists, chiropractors, GP specialists and orthopaedic equipmentcontractors. This will require targeted investment.

2.7 During the course of the next three years the overall investment in this specialtyshould be increased and additional capacity brought on stream at both NevillHall and the Royal Gwent Hospitals. Two capital schemes exist that wouldachieve this reasonably quickly.

2.8 The Assembly need to consider providing some level of additional capitalfunding and perhaps interim revenue support until such time as the Local HealthBoards can provide for it in their forward spending plans.

2.9 The proposed Orthopaedic Centre for South-East Wales should proceed inCardiff to serve its local community and not that of Gwent which, other than forthe most complex spinal work, should be self sufficient.

2.10 As the longer term plans for hospital services for the whole of South-East Walesare developed future provision should include a clear separation of trauma andcold surgery.

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3 Innovations

3.1 Once the waiting time position has improved, General Practitioners should beinvited to test with the orthopaedic specialists new referral protocols based onpredetermined slots which will allow them a far greater influence on patientpriorities.

3.2 The proposed trauma review is likely to open up new ideas for managingaccident cases. It should proceed quickly.

3.3 The better use of community hospital beds should be tested by the creation of asmall specialist orthopaedic facility at the County Hospital. If it works morecapacity of this kind should be developed.

3.4 The pioneering day case referral experiment at Caerphilly should be evaluatedand tested in other centres in Gwent.

3.5 The Trust should explore with colleagues in Local Government whether thecreation of a single social work focus within each of the large hospitals formanaging delayed discharge patients would be helpful.

3.6 The public should be made more aware of the waiting times to see individualorthopaedic surgeons and the option of being referred by their generalpractitioner to “the orthopaedic service” rather than a named consultant.

3.7 The orthopaedic service should seriously explore becoming a managed clinicalnetwork within the Trust with its own budget and Service Level Agreementswith other services.

MAIN REPORT

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THE PROBLEM

Outpatient Consultation

At the end on November 2002 there were 13,109 people waiting for an orthopaedicoutpatient consultation in Gwent. The time between referral and appointment could beas long as three years for non-urgent referrals. This is simply unacceptable in this dayand age.

Inpatient treatment

At the end of November 2002, 3,175 patients were waiting for treatment.

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More than 140 patients will have been waiting for surgery longer than 18 months.

This level of service is the worst in Wales and is far below the Assembly’s owntargeted standards, which I understand to be for 2001/2:

� Reduce significantly the number of people waiting over twelve months fororthopaedic treatment and eliminate waits over eighteen months

� Increase the number of joint replacements undertaken� Sustainably reduce the number of people waiting over six months for an

outpatient consultation.

The Trust does however face the dilemma in that that if they invest heavily in seeingmore outpatients this will inevitably work its way through to more patients beingadded to the inpatient and day case lists. For a few patients this means a wait of overfour years from the point of referral to treatment.

Despite this, the number of patients being referred for an outpatient appointment isexpected to increase this year from 11,778 in 2001/2 to 12,511 in 2002/3. The agreedoutpatient capacity through the LTA with commissioners is 7,066 in 2002/03.

The number of patients with long waits for surgery has reduced in the last ninemonths (it was 552 in March 2002). The Trust also achieved the target set for it bythe Welsh Assembly Government of ensuring that no patient had to wait longer thaneighteen months by July 2002 but as they correctly predicted this could not besustained. The waiting time is planned to reduce further, in the immediate future, tozero over eighteen month waiters by the end of February 2003 but again sustainabilityis in question. The Trust did deliver significantly more hip and knee replacements in2001/2 than in the year before.

The number of patients being added to lists (estimated for 2002/3 at 2,628) iscurrently higher than the number being treated or removed (estimated for 2002/3 at2,169). The problem overall is still getting worse. The gap between additions andremovals is being maintained purely through additional in house special initiativesand outsourcing of activity mainly from non-recurrent funds.

In addition to the official live list there is a suspended list with 362 patients on it.These are patients who have been deferred for personal or clinical reasons and will beexpected eventually come forward for treatment. When they are ready for treatmentthey will be returned to the active list although I doubt that many will do so. Inaccordance with Assembly guidelines they are not included in the waiting list count[1].

Over all level of Investment in Orthopaedic services

The existing level of provision is acknowledged to be inadequate to meet existingdemand and the inevitable growth in the future [4, 5, 6, 7]. The rate of jointreplacement in Wales is substantially below that in England and Scotland [6]. Theorthopaedic service is provided at present by fifteen Consultant Surgeons and oneOrthopaedic Physician, through 54 elective beds and 154 elective operating theatresessions per month at the Royal Gwent Hospital in Newport and Nevill Hall Hospitalin Abergavenny. Orthopaedic surgeons also access up to ten beds and theatres at

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Caerphilly Hospital for minor and intermediate cases. There are additional facilitiesfor trauma (accident) patients, which represent two thirds of the surgical work andwho have the highest degree of priority.

34% of non-emergency surgery in this specialty is undertaken on a day case basis andeven here we see a few patients with surprisingly long waits.

The principal problem at present is accessing the elective inpatient beds. Emergencydemands regularly exceed available capacity resulting in elective beds being takenover for emergency medical cases. The elective beds have also been closed onoccasion because of sickness or infection or occupied by patients awaiting discharge.As at the end of November 2002 there were 260 (up from 180 in the same month in2001) patients in this latter category delayed transfers of care most of whom werewaiting in community beds but 20 at least were occupying main acute beds and thuspreventing new admissions for surgery. Local managers estimate that the impact ofdelayed transfers of care in community hospitals could be affecting another 50-60acute beds. The majority of these delayed transfers of care are due, I was advised, toLocal Authority funding difficulties for placements in residential and nursing homes.

The capacity pressures and the policy of prioritising emergency services has led toinsufficient beds being firmly ring-fenced for elective cases and as a result the clinicalprocess is difficult to organise resulting in far too many cancellations at short notice (57 patients were cancelled in November 2002). It makes it almost impossible toguarantee admission dates for patients in advance, which almost certainly works itsway back to the high numbers of patients who fail to attend.

Gwent has significantly less acute beds than other communities [8]. The Gwenthealth community are presently operating with a financial deficit and a consequentialrecovery plan that allows little short-term room for financial manoeuvre. They dohowever have the prospect of growth money in future years as the Assembly equaliseshealth investment across Wales.

Managing the lists

The management of each consultant’s list is handled separately although medicalrecords staff often handle more than one list each. Most referrals in the south are tonamed consultants. There are more referrals to the “orthopaedic service” at NevillHall, which has the effect of adding these patients to the lists of those surgeons withthe shorter lists.

There is a substantial variation in the waiting lists of individual surgeons from 57 to400 patients [See appendix A]. Those patients added to the list of the consultants withthe longest lists must expect a significant delay before their treatment can be started.This information is available to General Practitioners but is not easily available to thegeneral public. It should be. The length of a consultant’s waiting list is not aninfallible indicator of best practice. The longest list in Gwent is for treatment by aconsultant who specialises in knees. It is important that patient choice is real which iswhy referral to a named consultant should be retained. Patients should however bemade more aware of the option of referral to the “orthopaedic service”, which for

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many patients will result in earlier treatment, as they will be added to the lists of thoseconsultants with the shortest lists.

If the lists were being managed optimally one would expect to see a high number ofcases from the end of the list being selected each week. In practice this does nothappen because consultants overlay the chronological list with their own judgementabout clinical priority and treat the more urgent cases first. Problems ariseimmediately if services are curtailed, as happened in the summer of 2002, due to acommunity D&V outbreak which significantly impacted on local hospitals,emergency pressures within Gwent and the need to support orthopaedic services inMerthyr, resulting in Nevill Hall taking Merthyr’s trauma for three weeks. Theconsequent loss of elective capacity resulted in an accumulation of urgent cases,which pushed the longer waiters even further back. In any case under currentprocedures each operating list needs a balance of major and minor cases to fullyutilise a theatre session which makes strict chronological selection impracticable. I examined the case selection for the first two weeks of December 2002 . The analysisbelow shows the section of the waiting list that patients were selected from.

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It is apparent that judgements about clinical priority significantly override thechronological list. This is entirely proper but unless patients waiting the longest aregiven some degree of special weighting they will never be treated. In practice somedegree of weighting becomes essential if the Assembly target of nobody waitinglonger than 18 months is to be achieved. A more detailed analysis is contained inappendix A.

Waiting list validation

The processes that govern the management and validation of waiting lists are properly

set out in the Trust’s procedure manuals [3].

Patients on outpatient lists are checked at six months on a rolling programme. Ifpatients do not reply after three weeks confirming that they still wish to see aconsultant they are removed from the list and their GP advised accordingly. Over onethousand such patients, who did not turn up for their appointment, were removed afterchecks in the last twelve months. There is something seriously wrong with thereferral process here if these numbers of patients simply do not turn up for aconsultation that could be very important to their health. This is not just an

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orthopaedic problem as 20% of patients on all Gwent outpatient lists were removedeither by patient election or for non-attendance in the 12 months to October 2002.Validation needs to be tightened up even further and undertaken at six months andthereafter on a quarterly basis. A review across all specialties undertaken in 2002showed that the most common reason for patients removing themselves from lists wasthat their condition “had cleared up” and the second highest was that they had beenseen privately. I suggest that a sample of patients who do not attend the orthopaedicservice in the next three months be followed up and interviewed as to their reasons. Ajoint study with the Local Health Boards might prove very constructive

The procedure for inpatients is slightly different and a distinction is made betweenthose patients who “could not attend” and those who simply did not turn up.Inpatients and day cases are validated after ten months on a rolling programme. Thepatients are further validated at 16/17 months when treatment plans are finalised. Iasked for an ad hoc telephone check to be made in December about a selection ofpatients waiting longer than one year. Of the 150 patients contacted seven wanted tobe removed. A further 49 patients could not be contacted. Efforts to talk to them arecontinuing and it looks like a further 17 patients will be removed from the active listas a result of these conversations. Regular validation is vital when lists get as long asthese. It should be routine and automatic and not based on one off occasional checks.The orthopaedic service should build a relationship with each patient on the inpatientlist and keep them in touch with their status. This will help with validation, reduceDNA’s and be much appreciated by patients.

The names of those patients who do not attend for their surgery are referred to theappropriate surgeon with a view to removal from the waiting list. In the last year only20% were authorised for removal, the majority (249) remain on the hospital’ssuspended list and in accordance with policy are not included on the active waitinglist. I suspect that most of these patients will never present for treatment. Thereneeds to be an early discussion with the surgeons about the application of the Trustsprocedures for dealing with DNA’s. The Assembly guidance does give consultantsthe discretion to override a cancellation but I am sure this was meant to be applied inexceptional circumstances. If there is an override it must be because treatment islikely and the patient should therefore remain on the main live list. Current practiceconfuses the picture and provides no practical benefit to patients. In the short termchanging this practice will make the current picture marginally worse but at least itwill be clear.

Patients who cannot attend (CNA’s) and who give the hospital notice are given asecond opportunity, but if they cancel on a second occasion they are removed fromthe list unless the consultant overrides. In Gwent many of these patients appear to goonto the suspended list rather than being removed.

All of these DNA and CNA cases need to be reviewed again, now, to establish clearlywhether the patient intends to proceed with surgery or not. A personal call or visit isalways more effective than a letter. There is little point in booking them in again ifthere is a significance chance of another non-attendance. When these patients areoffered a second admission date I strongly recommend that close contact beestablished with them in the days immediately prior to admission. This will be

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particularly important if they are amongst those selected for referral to another centre.

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The sheer volume of patients on these waiting lists is generating problems of its own.

Targets

The current target within the Gwent health community for a first outpatientappointment is that no patient should wait longer than three years. This is no serviceat all. The Gwent health community should be required to reduce this to a maximumof six or at the worst twelve months within three years and build the required financeand capacity into their spending plans. New investment in the orthopaedic service isclearly essential either by a process of reallocating existing investment within Gwentor with growth money provided by the Assembly or a combination of the two. Gwentclearly can expect new investment over the next few years if the recommendations ofthe Townsend report are implemented [7].

For inpatients the current Assembly target is that the “no over eighteen month waitinglist” target should have been achieved in July 2002 and then sustained month onmonth throughout the year. In Gwent the July target was not sustained and the currentcommitment is to achieve this by 28 February 2003. To do this the Trust will have tohave treated (or removed from the lists) 381 patients currently waiting at the end ofthe current list at 30 November 2002. Based on the agreed Commissioner LTA andpresent performance it is not possible to achieve this within the local NHS so asignificant number of patients (150 or more) will have to be referred to other centresfor their treatment. This will start in the New Year with 120 cases being treated, withNHS funding, at the BUPA hospital in Cardiff. Further contracts at other centres,some in England, are being negotiated. Some patients will no doubt be reluctant totravel and the Trust needs to be clear what will happen with regard to their status onthe waiting list if they do decline. In my experience most patients will travel if theyhave confidence in the centre to which they are being referred, transport is organised,and appropriate postoperative care arrangements are put in place. It needs superbclinical organisation, as many of these patients will require joint replacements. An allWales review in February 2002 showed the case mix at the end of lists in Wales to beas follows:

Shoulders 9%Feet and ankle 14%

Backs 9%Hips 20%Knees 45%Other 3%

Gwent will be pretty much the same.

The Trust are confident that the first fifty patients who are to be treated in Cardiff inthe coming weeks will present themselves but the position needs to be monitored veryclosely and action taken quickly if this should prove to be too optimistic. Theidentification of and booking for the next tranche of patients is underway but needs tobe accelerated if the agreed target is to be guaranteed. Given the importance of this

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action to the achievement of the target, day by day monitoring by the senior staff ofthe Trust would be appropriate.

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The Trust is unable to guarantee that this target of no patient waiting longer thaneighteen months can be held throughout 2003 without further funding. If it isachieved it is because of an investment of £1m by the Assembly, only half of which isrecurrent, a one off special investment of £300,000 by the local health community andan additional commitment to outsourcing by the Trust of a further £300,000 which iscurrently not covered (if indeed it can be committed at this stage in the year). I amadvised that further outsourcing capacity is available should funds become availableand suitable patients can be identified. This would materially help with next year’stargets.

Efficiency

Day case rates look to be at or around the Wales average as is the average length ofstay (ALS) in hospital. However the ALS for both hip and knee replacement looks tobe high [4]. Reported activity rates have been as follows but I am told there arereservations about the accuracy of the data for the earlier years and 1996 in particular.

Provider Spells 1996 1997 1998 1999 2000 2001 2002Day cases 1896 2034 1824 1798 1699 1351 1105Elective Inpatient 4100 3666 3302 3164 3201 3444 3775Emergencies 4867 4596 4480 4136 4183 3964 4276TOTAL 10863 10296 9606 9098 9083 8759 9156

NOTE: Year to end September I could obtain no really satisfactory explanation for the drop in day case work otherthan perhaps a change in clinical demand and change in medical staff. A moredetailed clinical audit would throw more light on this matter. There are 38 patientswaiting longer than twelve months. This target could be reduced to twelve months orless. Some patients who could properly be dealt with as day cases are being operatedon as part of major lists. This seems inappropriate given the pressure on inpatientbeds and main theatres.

Overall bed occupancy in the acute sector is 88% with the Royal Gwent operating at91.5%. This is high. Occupancy in the community hospitals is currently 87.1%.Further work needs to be undertaken to establish how these assets, totalling over 600beds, could be used to take some of the pressure off the acute wards.

If some of these the community beds were appropriately staffed it ought to be possibleto sharply reduce the time patients spend in the acute hospital, which is under suchpressure. If surgeons are to transfer suitable patients four or five days after majorsurgery they would want to be sure first that the community beds would be protectedfor their transfers, sufficient rehabilitation services were available on site and theenvironment was suitably sterile so as to prevent infection which has such seriousconsequences for patients who have had a joint replacement. I was advised that a six-bed unit could be created quickly at County Hospital at a minimal cost.

I did not myself review the trauma activity but given its size and importance a jointaudit with primary care would be valuable to see whether any of this caseload could

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be properly dealt with in ways that would avoid admission to hospital. Even a smallchange would have a significant impact on hospital resources.

Operating sessions at the Royal Gwent Hospital are currently not flexible enough topermit two major joint replacement procedures per session although this is possible atNevill Hall Hospital and in the private sector. Theatre policies need to be reviewedurgently with the surgeons and anaesthetists so that this is possible.

The continued growth in the number of medical emergencies remains a majorproblem but a good plan has been agreed locally to deal with it. A Bed Bureau is nowworking for General Practitioners. A new Medical Admissions Unit with ten bedscomes on stream at the Royal Gwent Hospital in September 2003 and two additionalPhysicians, with a particular responsibility for emergency care, start in the New Year.This should make a big difference. Other ways are, at last, being found of dealingwith surges in medical admissions other than encroaching into surgical beds.

Nevill Hall Hospital has also experienced increased medical emergency loads but hastraditionally been under less pressure although I am told this is changing.

Reducing the numbers of patients awaiting discharge from hospital would helpenormously in the whole sector. I wonder if a single social work co-ordination pointin each hospital would help matters.

POSSIBLE SOLUTIONS

In the short term the Trust can materially improve the present inpatient position by astricter policy of ring-fencing cold orthopaedic beds, greater attention to themanagement of the waiting lists and changes in the manner in which the operatingtheatres are utilised. The Trust will also need to ensure that the policy of referring asignificant number of patients to other centres actually works. Primary careorganisations could help by much closer attention to demand management so as toensure that specialist services are not swamped by minor cases whose needs could bemet in other ways.

In so far as ring fencing is concerned the Physicians to whom I spoke accepted theneed to do this for orthopaedic services as did the Health Authority. I suggest 25 bedsare firmly protected at the Royal Gwent Hospital as soon as the new Physicians are inpost. If these beds are to be used intensively the orthopaedic services will need to bemanaged much more tightly.

The outpatients problem is more difficult to resolve without a significant increase inthe number of orthopaedic Surgeons or Physicians. In the short term I suggest that,after discussion with General Practitioners, a referral protocol is established that leadsonly to the most urgent or clinically important cases being referred for the time being.(There might be one or two exceptions to this including perhaps the innovativescheme at Caerphilly for rapid access to day surgery).

General Practitioners might find an extended set of direct access Physiotherapistclinics helpful as a further alternative but the first priority for new clinics of this sortmust be an attempt to divert suitable patients from existing outpatient lists in order to

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reduce them to more acceptable levels. Current ideas, which seem sensible, centre onthe development of muskulo-skeletal pathways, particularly for back pain, but theyare not at present funded. Until recurrent funding can be found I suspect this willhave to be achieved by reprioritising existing work within the physiotherapydiscipline. In the short term the challenge will be to identify those orthopaedicpatients with the greatest clinical need and see that they are treated.

There may be other GP direct access options that could usefully be explored with theLocal Health Boards including extended radiology, orthopaedic equipmentcontractors and if available General Practitioner specialists and chiropractors.

The waiting lists need to be vigorously validated again for all patients who have beenwaiting longer than a year (and routine systems installed) and patients who do notattend referred back immediately to their General Practitioner.

Once the list is reduced to more manageable proportions some General Practitionersmight be persuaded to work within allocated outpatient slots, which gives themgreater discretion over priority setting.

In the longer-term more consultants is the only effective answer and this is providedfor in the proposals that follow.

For the medium term a decision needs to made about building additional capacity andemploying more consultant Orthopaedic Surgeons or Physicians. One option is tobuild a new orthopaedic centre for South-East Wales but there is no clear consensusabout where it should be located. This is an important issue because surgeons willhave to travel from all over South East Wales from the bases at which they undertaketheir trauma work. They will spend a lot of time travelling. The surgeons in Gwentdo not believe a centre planned to undertake the majority of the cold surgery for boththeir communitys and Cardiff’s is practicable (particularly if this centre is built on theassumption that lengths of stay will be short because of enhanced rehabilitation andnursing support in both the home and in the community hospitals). I think they areright.

For Gwent two intermediate solutions could be available quite quickly but the long-term answer will have to await the emergence of broader plans for the modernisationof hospital services across Gwent and the broader health economy in the whole ofSouth-East Wales. Whatever long-term plan emerges it should include a separationbetween trauma and cold surgery in this speciality. This is inevitably some yearsaway. Intermediate solutions are required.

The first solution involves creating additional bed capacity at Nevill Hall Hospital toensure the current operating theatres are used to maximum capacity. The capital costof this would be £1m and the revenue £2. 2m for 600 additional treatments and 1,000additional outpatients. This proposal could be implemented within eight months of adecision being made to support the plan.

The second intermediate solution is to create a dedicated cold orthopaedic centre withits own operating theatres at St Woolos Hospital, which is situated immediatelybehind the Royal Gwent Hospital in Newport. Revenue considerations will dictate

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whether this is a net increase in capacity or a replacement for some or all of the bedsin the main hospital (where the trauma beds will stay). The capital costs of thisscheme need to be worked out in some detail but £2-£2.5 million is the presentestimate for two demountable operating theatres and ward adaptations. The revenuecosts are estimated at £3-£3.5m IF they are a full addition to capacity. But even ifrevenue is tight this scheme still looks to be a good investment as it provides aprotected specialist facility for cold orthopaedics and releases beds in the mainhospital for other specialties. It could be available within a year provided noproblems are experienced with planning permissions. It would, it is thought enable anadditional 840 patients a year to be treated and 2,000 extra outpatients.

I have not myself checked any of these costs provided by the Trust and in any caseLHB’s will I am sure want the opportunity to review a more detailed business case.The revenue will need to be phased in over two or more years.

These new developments would together provide for the appointment of fiveadditional Orthopaedic Surgeons/Physicians, which should make a real impact onoutpatient and inpatient waiting lists.

At present the prospects of the capital to create this new capacity being available inGwent are poor given their overall financial position. The Assembly will have toconsider whether it can help with capital to get the change process working and thishelp may have to extend to transitional revenue funding until such time as recurrentfunding is included in the forward spending plans of LHB’s.

My advice also is to proceed quickly with a major new centre based in Cardiff(presumably at Llandough) to serve its local patients and perhaps provide a tertiaryservice for particularly complex cases from elsewhere in Wales. I support those whowill argue for an academic presence at such a unit and a partnership with thoseindustries involved in this field. If this unit does develop into a major centre forteaching and research consultants from outside Cardiff should be encouraged toparticipate in the work, teaching and research at the centre even if their main base iselsewhere.

I referred earlier to the need to manage orthopaedic services more tightly. It isalready a large service and is growing. Clinicians and managers need to work veryclosely together to maximise the existing investment and plan for the future. Usingring-fenced resources to maximum effect will require great skill and considerableorganisation. Orthopaedics needs to be run as a service with, at least in the short term,its own operations room under the direction of the clinical head of service where:

� Waiting lists are tightly managed � Case selection is co-ordinated and patients that are referred to the orthopaedic

service rather than an individual consultant are sensibly prioritised andallocated. Individual consultants must remain the final arbiter of the relativepriority of patients referred to them directly but some sensible reallocation ofcases by agreement and with the patients consent would help.

� Complex cases that require access to beds, theatres and high dependency careare pre-planned and the resources pre-committed

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� Connections between the beds in the main acute centres and the communityhospitals are co-ordinated and used to maximum effect

� Performance against service agreements is monitored and made know to allclinical teams

� Beds and theatre sessions that become free when surgeons or anaesthetists areunavailable (annual leave, study leave or sickness) are reallocated quickly andappropriately

� Ensuring diagnostic and rehabilitation services are properly aligned with otherservices

� Ensuring available theatre time is fully utilised� Ensuring the day case unit is used to maximum effect� Case managing patients who are referred to other centres � Acting as the principle day to day contact centre for primary care and

monitoring agreed demand management policies� Acting as the communication centre for patients on waiting lists� Monitoring outpatient clinics and any new direct access physiotherapy clinics� Ensuring annual leave and study leave for key staff is sensibly co-ordinated

and anticipated in patient scheduling.

In the short term I recommend that a senior support team be put in place to work tothe Clinical Head of Staff for this service comprising a senior manager, experiencednurse and physiotherapist and if one can be found a General Practitioner. The ChiefExecutive of the Trust might wish to provide close support. It would also be veryhelpful if a member of the Assembly’s staff could join the team so as improve liaisonand understanding.

The early priority is the management of the service based at the Royal Gwent Hospitalbut these services need to be closely co-ordinated with those at Nevill Hall. All ofthis might lead eventually to a fully functioning clinical network for orthopaedics withits own budget and service agreements and a working collaboration with the servicesin Cardiff in so far as the distribution of highly specialist work (e.g. complex spinalprocedures) is concerned.

The Local Health Groups need to think carefully about demand management forspecialist services and work closely with the Trust in moving forward. The solutionsto this problem needs the whole health community actively engaged.

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REFERENCES

1. Waiting list policies. Letter from RC Williams to NHS Chief executives11/03/1999.

2. Innovations in Care outpatient report end October 2002.3. Service standards and Protocols. Dept of Medical Records. Gwent NHS Trust.,

2001.4. Review of Orthopaedic Services, South-East Wales health economy July 2002.

Gwent and Bro Taf Health Authorities. 5. Report of Orthopaedic services in South Wales. VFM Unit July 1999.6. Review of Trauma and Orthopaedic Services for Gwent, Bro Taf and Iechyd

Morgannwg Health Authorities 1999. 7. Townsend report. Targeting poor health, 20018. A Question of balance. A review of capacity in the Health Service in Wales 2002.

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Appendix A

Waiting List case selection Gwent December 2002 [two weeks]This table shows the chronological place of the patient on the active list when theywere offered treatment in the first two weeks of December 2002.It also shows theirclinical category.

Consultant Total listsize

Place ofPatient

Category

1 227 2 Urgent2 335 314 Routine

121 Soon74 Soon1 Routine10 Routine201 SoonDeferredlist

Routine

2 335 32 Routine3 233 11 Routine

Deferredlist

Routine

221 Urgent6 Routine152 Urgent229 Urgent153 Routine210 Urgent230 Routine

4 180 176 Urgent5 57 4 Routine

19 RoutineDeferredlist

Routine

55 Soon6 104 11 Soon

13 Routine19 Routine

7 254 109 Soon115 Soon161 Urgent

8 400 20 Urgent9 271 170 Soon

258 Urgent10 81 7 Routine

20

79 Routine80 Routine74 Routine76 Routine55 Routine46 Routine178 Soon

11 2 Routine62 Soon180 Urgent

12 271 271 Routine13 187 28 Urgent14 332 159 Soon

50 Urgent121 UrgentDeferredlist

Routine

15 133 53 Routine116 Soon97 Urgent60 Urgent122 UrgentDeferredlist

Urgent

3065 55 cases

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Appendix B

DNA analysis December 2001/November 2002Patients who Did Not Attend; Consultant decision about removal or not from WaitingList.

Not removed Removed

Consultant IP DC OP IP DC OPMr Grant 17 6 3 2 - 96Mr Jones 30 3 3 6 1 90Mr Hariharan 29 2 2 10 2 105Mr Tayton 37 2 7 2 - 112Mr Alderman 17 1 1 4 - 74Mr Roberts 6 2 3 4 1 41Mr Kulkarni 8 - 2 7 - 61Mr Savage 23 18 8 1 5 73Mr Mintowt Czyz 13 6 2 3 - 85Mr Hannaford Youngs - - 3 - - 66Mr Nada 3 2 2 2 1 28Mr Davies 9 12 1 - - 37Mr Mackie 9 3 1 2 - 23Mr Rice 2 2 1 1 2 48Mr Walker 3 1 4 - - 51Mr Nathdwarawala - - - - - 20Shared patients - - 3 - - 36

TOTALS 206 60 46 44 12 1046

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Appendix C

Terms of Reference

Background

This year for the first time each health community agreed a SaFF with the WelshAssembly Government. As part of this process there has been significant discussionwith Gwent over their ability to meet certain waiting times targets.

The Welsh Assembly Government are aware of the difficult issues surrounding theTrust at the moment and the impact these appear to have on achieving the agreed keyelective targets. The work that the health community is doing to tackle these issuesthrough its strategic and operational management approaches is acknowledged andappreciated. However, meeting these targets is essential if we are to provide thepatient care that we are all striving for and the Minister is looking for this assurance.

It is clear that there are issues (e.g. emergency medical admissions, outbreaks ofD&V, Delayed Transfers of Care, impact from the Prince Charles Hospital) that thehealth community feel are having a serious effect on the delivery of key electivetargets. Assembly Officials are already working with the health community on tryingto resolve issues around emergency care and DToC.

Aims

1. To provide the Minister with early assurance that the Gwent health communitywill, as soon as possible, achieve and sustain the position in Orthopaedics where:

- no patient will wait over 18 months for inpatient or daycase treatment, and - work towards reducing the outpatient wait to 18 months.

2. To support the Gwent health community in identifying areas of development andgood practice to achieve its targets as soon as possible this financial year.

3. To provide a report with conclusions and recommendations as to position inGwent in relation to both short and longer term waiting times targets.

4. To inform the work of the all Wales Orthopaedic Project Group.

Terms and Reference

Taking account of issues affecting agreed elective targets:

To assess and report on the capability of Gwent Healthcare Trust to deliver waitingtimes targets for orthopaedics.To assess the Trust’s ability to maintain and improve such a position in the longerterm.To assess opportunities in mitigating other issues and pressures to support theachievement of targets.

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To assess the appropriateness and timeliness of waiting times information systems tosupport the delivering of targets.To confirm actual achievable targets for this financial year within existing resources.