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Business Case Reconfiguration of Trauma and Orthopaedic Services

CPG3 – Specialist Services

March 2011

Version 2.4

Reconfiguration of Trauma and Orthopaedic Services: Business case v2.4 1

Reconfiguration of Trauma and Orthopaedic Services CPG3 – Specialist Services

Document Authors

Names Mark Palazzo, Mick Pearse, Richard Mitchell, Julie Harper, Anne Hall, Lesley Powls, Jon Evans, Jenny Willis, Marvin Nyadzayo, Katie Denton

Job title Head of operations- specialist services Contact details 07795211370 [email protected]

Document Revision History

Distribution Version Date Issued Distribution v.1 21 Aug CPG 3 T&O board v.2 25 Aug CPG 3 T&O board v.3 31 Aug RM and JH v.4 01 Sept RM, JH and LS v.5 09 Sept Ortho board v.6 10 Sept Ortho board and LS v1.7 28 Nov RM and JH v1.8 29 Nov RM, JH and DN v1.9 1 Dec RM, JH, and DN v2.0 7 Dec RM, JH, DN and LS v2.1 8 Mar RM, JH, DN and JE v2.2 17 Mar RM, JH, DN and LS v2.3 19 Mar RM, JH and DN v2.4 22 Mar Trust Board Paper


Contents 1 Introduction ............................................................................ Error! Bookmark not defined. 2 Current engagement ............................................................. Error! Bookmark not defined. 3 Next steps ............................................................................. Error! Bookmark not defined. 1 Proposal ................................................................................................................................ 3 2 Current Position ..................................................................................................................... 3 3 Strategic case for change...................................................................................................... 5

3.1 Strategic fit..................................................................................................................... 5 3.2 Preparing for the future ................................................................................................. 5 3.3 Improving the service for patients now and in the future .............................................. 6 3.4 Objectives and benefits ............................................................................................... 10

4 Options ................................................................................................................................ 12 5 Options Appraisal ................................................................................................................ 12 6 Financial appraisal .............................................................................................................. 17

6.1 Pay costs ..................................................................................................................... 17 6.2 Capital spend .............................................................................................................. 18 6.3 Overall costs ................................................................................................................ 18 6.4 Sensitivity .................................................................................................................... 18 6.5 Net gain / loss .............................................................................................................. 18

7 Preferred option(s) .............................................................................................................. 20 7.1 Patient pathways for the preferred option ................................................................... 21

8 Stakeholders and communications ..................................................................................... 24 9 Commercial Aspects ........................................................................................................... 24 10 Workforce Implications ........................................................................................................ 24 11 Achievability ........................................................................................................................ 25

11.1 Programme .................................................................................................................. 25 11.2 Risk Analysis and Management .................................................................................. 25 11.3 Equality Impact Assessment ....................................................................................... 25


1 Proposal This business case proposes the reconfiguration of orthopaedic services by separating the provision of orthopaedic urgent (trauma) and planned (elective) surgery. The main objectives of this proposal are shown below:

• To improve the key dimensions of quality, clinical effectiveness, safety and patient experience

• To support the Major Trauma Centre (MTC) • To improve education, research and development opportunities • To improve productivity and eliminate waste

The Trust’s Specialist Service Clinical Programme Group (CPG3) also wishes to reconfigure services in order to ensure there is sufficient capacity for expected growth in the needs for the service as a result of demographic change. The total capital cost of the preferred option, to centralise the planned service on the Charing Cross (CXH) site and the urgent service on the St Mary’s (SMH) site, is £1.2m. The payback period is projected to be 2.4 years. The current service is loss-making and the projected annual EBITDA1 of the proposed service improves the balance sheet by £635,000. The target date for reconfiguring the service, should this be supported by the Board and the outcome of the public engagement, is Autumn 2011.

2 Current Position The service is currently provided to patients from the central, north and west London areas. The service is provided predominantly at Charing Cross Hospital and St Mary’s Hospital and is managed within the Clinical Programme Group for Specialist Services (CPG3). In 2009/10 procedures were carried out for some 5,100 inpatients in roughly equal proportions across both sites and almost 40,000 outpatient appointments took place, as shown in the table below. Trauma and orthopaedics procedures (day case and admitted) by site 2009/10 Source: Internal Trust Data

Type of procedure Hospital

Urgent Planned Total

St Mary’s 741 1670 2411 Charing Cross 764 1908 2672 Total 1505 3578 5083

Trauma and orthopaedics outpatient appointments by site 2009/10 Source: Internal Trust Data

New Follow up Total

St Mary’s 7350 12,350 19,700 Charing Cross 6450 13,400 19,850 Total 13,800 25,750 39,550

1 Earnings before interest, tax, depreciation and amortization


ICHT has developed a highly effective ortho-physician service, one of the first in London. It is the primary provider of spinal surgery in north west London and we are looking to develop and expand the service with spinal and neurosurgeons working together to provide excellent care for more patients. Charing Cross Hospital Site The Charing Cross site offers elective and urgent surgery in dedicated laminar flow theatres, a fracture clinic and outpatient appointments. There is also day case activity, but this is currently often carried out in main theatres, rather than a dedicated day case environment. Use is made of the robotics suite. Charing Cross is a tertiary referral centre for lower limb, pelvic and complex neck of femur procedures across north west London and the surrounding area. There are two orthopaedic wards on the CXH site, 7S and 7W. However, at present, the quality of ward infrastructure is inconsistent and does not provide single sex accommodation for all patients. One of the planned surgery specialties (hand surgery) at CXH was shortlisted for a Health Service Journal (HSJ) ‘Quality and Productivity’ 2010 award. St Mary’s Hospital Site The St Mary’s site offers elective and non-elective surgery, a fracture clinic, and outpatient appointments. Paediatric orthopaedics are also provided on the St Mary’s site. The orthopaedic ward is Valentine Ellis. In 2009, the Trust was designated to host the major trauma centre (MTC) to service north west London based on the St Mary’s site. The MTC has been operating on a 24/7 basis since January 2011. Current performance Compliance with the 18-week target is variable. Planned procedures on both sites have met the target in four of the 10 months data is available for this financial year. The service is loss-making.


3 Strategic case for change 3.1 Strategic fit

The key objectives for the proposed change are:

• To improve the key dimensions of quality; clinical effectiveness, safety and patient experience

• To support the Major Trauma Centre (MTC) • To improve education, research and development opportunities • To improve productivity and eliminate waste

These objectives link into the Trust’s mission of becoming one of the top five global academic health science centres within the next ten years and channelling excellence in research to provide world class healthcare for patients. The objectives link directly to the Trust’s principle objectives:

• To provide the highest quality of health care to communities we serve • To provide world-leading specialist care in our chosen fields • To conduct world-class research and deliver the benefits of innovation to our

patients and population • To attract and retain a high-calibre workforce, offering excellence in educational and

professional development • To achieve outstanding results in all our activities

3.2 Preparing for the future

One of the biggest challenges over the next ten to twenty years in London is likely to be caring for the growing and ageing population. Population projections suggest an increase in London’s population from 7.6 million in 2006 to 8.2 million in 2016. In addition to growing, London’s population is ageing. The fastest growing sections of the population are the 40-64 age group and the over 85’s, both of which are known to have higher health needs than younger age groups. A population that is both bigger and older will have a significantly greater need for healthcare, and specifically orthopaedic health needs. Total hip replacements are increasing at a rate of 20% per annum with demand for revision hips, total knee replacement and revision knees doubling over the last ten years. The increase is forecast to continue. The biggest challenge currently for many acute Trusts is meeting the 18 week referral to treatment target2 within planned orthopaedics. The Trust has not been able to consistently achieve the target. Achieving the target may be problematic in itself, however sustaining the 18 week pathway in the face of growing and changing service demand will not be possible without significant service delivery redesign. With demographic change and expected increase in market share, a modest projection of growth in demand for elective procedures is 10% year on year. The current configuration is unable to sustain this increase. This business case is not about doing more of the same, it is about rethinking the ways in which the Trust provides the service across the whole pathway/care system to ensure we see the right people, in the right place at the right time with the appropriate resources. This does not solely 2 Although the 18 week referral to treatment target has been suspended, this is being superseded by median waiting times.


relate to adding capacity. It is about making full use of all the resources available to improve patient access and ultimately clinical outcomes.

3.3 Improving the service for patients now and in the future • Improving clinical effectiveness Volume-outcome relationship – mortality, re-admission, post-operative complications and length of stay Separating elective and non-elective care means that surgeons are able to spend more time in their sub-specialty areas. A review of 18 articles3 which studied different orthopaedic surgical procedures, particularly total hip and knee replacements concluded that:

“They nearly all confirm that outcome, measured in terms of mortality, re-admission, post-operative complications (such as dislocation, embolism or infection) and length of stay after operation, improves with the volume of activity of hospitals and/or surgeons.”

A further literature review carried out in the USA in 20024 concluded that there is a positive volume-outcome relationship for orthopaedic procedures. A literature review of the volume outcome relationship in total hip replacement5 found that “a general correlation between high volume and low complication rate could be identified” There is a correlation between an increased number of procedures carried out by surgeons and a reduced length of stay. In 2005/6 the hip replacement patients of the consultants in the top 10 trusts in the country carrying out the most procedures had consistently lower lengths of stay than those of the consultants in the bottom 10 trusts in the country who carried out fewer procedures6. Improvement in the volume of procedures taking place as day case Because day case surgery generally provides timely treatment with less risk of last minute cancellation, a lower incidence of hospital-acquired infections (due to the reduced length of stay)7,8 and because it tends to use less invasive techniques, patients show better and quicker recovery9. Just as importantly, patients like it10. The British Association of Day Surgery recommends a target of 61% of all orthopaedic surgery to be done as day case. 3 Com-Ruelle L., Or Z., Renaud T. (2008), Volume d’activité et qualité dans les hôpitaux: enseignements de la littérature, Paris, IRDES 4 Halm, E. A., Lee, C. and Chassin, M. R (2002) Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature in Annals of Internal Medicine vol. 137 no. 6 511-520 5 Schräder P., Rath T. (2007) Volume-outcome-relationship in total hip replacement-literature review and model calculation of the health care situation Z Orthop Unfall May-Jun;145(3):281-90 6 NHS Institute for Innovation and Improvement (2006) Delivering Quality and Value – Focus on: Primary Hip and Knee Replacement, Coventry, NHS Institute for Innovation and Improvement 7 Fenn P: Variations in the frequency of MRSA infections across acute NHS hospitals, 2001-2006 8 Manian FA, Meyer L., Surgical-site infection rates in patients who undergo elective surgery on the same day as their hospital admission. Infect Control Hosp Epidemiol. 1998 Jan;19(1):17-22. 9 British Association of Day Surgery: Commissioning Day Surgery, A guide for Commissioners, Nov 2003 10 Audit Commission: Measuring Quality: The Patient’s View of Day Surgery, 1991


Improvement in 18 week performance When not separated, the unplanned misuse of elective resources by emergency surgical admissions can have a large impact on the use of beds, theatres and staff for elective work and in turn on the management of waiting lists. The Elective Orthopaedic Centre (EOC) in Epsom is one of the clearest examples of the benefits gained from separating the two. Their beds, theatres and staff are ring fenced for elective work and their throughput and 18 weeks performance is one of the highest in the NHS. Physical separation of services, facilities and rotas At present on both the CXH and SMH sites the planned and urgent services share theatres and staff. The separation of services, facilities and rotas is recommended by the Royal College of Surgeons (2007)11 Part of the elective hand surgery team at CXH was shortlisted for the prestigious HSJ ‘Quality and Productivity’ award 2010. If the elective part of the service is separated, elements of the hand surgery model such as high volume working with dedicated teams can be transferred into all elective surgery ensuring greater clinical effectiveness. Patient Recorded Outcome Measures (PROMs) Treating hip replacement and knee replacement patients in a dedicated elective environment would support an increase in PROMs scores. Currently the Trust’s average pre-operative scores are almost at the national average, but the average post-operative scores are lower than both the London SHA and national averages. Although PROMs are in their infancy and some data quality issues have still to be resolved, these figures give a good indication that the Trust needs to do better than it is now. • Improving safety

Reduction in healthcare associated infections (HCAIs) The rate of HCAIs for hip replacement, knee replacement and repair to neck of femur is 0.77%. Although this figure is low, and below the national average, it is still not acceptable for patients to develop infections whilst in hospital. The Royal College of Surgeons (2007) states: “Separating emergency and elective care has significant benefits for patients and can offer early investigation, definitive treatment and better continuity of care. Hospital-acquired infection risks are reduced and length of stay should be shorter. [...] Hospital-acquired infections can be reduced by the provision of protected elective wards and avoiding admissions from the emergency department and transfers from within/outside the hospital.”

The Association of Surgeons of Great Britain and Ireland states:

“There is consensus to separate ‘clean from dirty’. All patients with prosthetic implants should be nursed in ‘ringfenced’ post-operative environments to reduce the risk of HCAI acquisition.”

11 The Royal College of Surgeons of England (2007) Separating emergency and elective surgical care: Recommendations for practice, London, Royal College of Surgeons of England


The introduction of a ring fenced planned care orthopaedic ward and simple infection control measures allows 17% more patients to be treated and significantly reduces the incidence of all post-operative infections12. These findings are backed up by work at the Elective Orthopaedic Centre (EOC)13 which indicates that hospital acquired infections can be reduced by the provision of protected planned care wards and avoiding admissions from the emergency department. The Centre had no reported incidence of HCAIs in 2009/10. Presence of senior surgeons for planned and urgent work The Department of Health’s Musculoskeletal Services Framework Document14 states that the presence of senior surgeons for elective and emergency work enhances patient safety and quality of care. Seventy per cent of major trauma patients need orthopaedic intervention15. At present, there is no dedicated 24/7 consultant-led urgent orthopaedic cover working in conjunction with the MTC team which, if in place, would best meet the needs of the trauma patients. Availability of specialist critical care Evidence from a number of hospitals and critical care networks suggests that approximately 2% of trauma patients have some unexpected complication that requires specialist critical care support16. Orthopaedic trauma patients would best be cared for in a dedicated trauma facility which has dedicated ICU beds. • Improving patient experience

Reduce cancellations The rate of cancellations for non-clinical reasons is currently 2.4%. In addition to this being inconvenient and upsetting for patients and their families, this increases clinical and administration time spent rebooking. The Royal College of Surgeons (2007)17 states: “The unplanned misuse of elective resources by emergency medical and surgical admissions has a large impact on the use of beds, theatres and staff for elective work and in turn on the management of waiting lists. In particular, emergencies tend to overflow into elective resources...Streaming elective and emergency care should lead to fewer cancellations and improve supervision of trainees, this improving patient safety... Separating emergency and elective services can prevent the admission of emergency patients […] from disrupting planned activity and vice versa, thus minimising patient inconvenience and maximising productivity for the Trust.” With dedicated elective and trauma lists, elective patients would not be cancelled should a trauma patient need urgent surgery. 12 Biant, L. C. et al. (2004) Eradication of methicillin resistant Staphylococcus aureus by “ring fencing” of elective orthopaedic beds, British Medical Journal, 329 : 149 13 The Elective Orthopaedic Centre (2009) The EOC Annual Report 09 – One Step Ahead 14 The Department of Health (2006) The Musculoskeletal Services Framework, Leeds 15 Imperial College Healthcare NHS Trust Major Trauma Centre Business Case (2009) 16 The Royal College of Surgeons 17 The Royal College of Surgeons (2007) Separating emergency and elective surgical care: Recommendations for practice, London


Improve time to theatre for trauma patients and a reduction in the roll over rate ‘Trauma only’ lists would support the Trust in increasing the number of hip fracture patients who have surgery within 48 hours. According to the National Hip Fracture Database National Report 201018, nationally 81% of these patients had surgery within 48 hours and in London the figure was 80.4%. In the report both SMH and CXH were well below this at 64.2% and 52.6% respectively. However, there were data quality issues with the CXH figure, which is actually closer to 80%. The creation of a ring fenced trauma facility ensures emergency teams providing dedicated emergency care. The benefits to this include; higher trauma throughput, a reduction in the number of patients rolling over onto the next day’s operating list and a reduction in the length of stay. Single sex accommodation In line with national requirements, the Trust is committed to providing every patient with same-sex accommodation. At present trauma and orthopaedics are providing this for only 98% of our patients (2% ‘breaching’ the requirement) and we aim to guarantee same-sex accommodation for all patients. Patient experience I track scores19 for the elective only ward at CXH and combined elective and non-elective ward at SMH which both have similar staffing mix, experience and management, show that the elective only ward at CXH received consistently higher scores, as shown in the table below: Table: I track scores for orthopaedic wards at SMH and CXH Aug – Oct 2010 Month SMH score CXH score Aug 2010 81% 96% Sept 2010 74% 97% Oct 2010 86% 97% • Improving education, research and development opportunities The Royal College of Surgeons20 state that separating urgent and planned orthopaedics improves the training opportunities for junior staff, nurses and consultant surgeons. To run clinical trials of operative interventions requires planning of surgery. Every major orthopaedic surgical centre which is currently delivering such trials exists with functional separation of elective and emergency services. This enables the elective workflow, which is streamlined in a way that is impossible for emergency cases, to take place without interruptions for emergency cases. Splitting planned and urgent work would increase the number of trials taking place, which would support the Trust objectives of doubling the number and volume of commercially sponsored clinical trials by March 2014 and raising the proportion of patients enrolled in a research protocol by 1% each year for the next five years. 18 National Hip Fracture Database (2010) National Hip Fracture Database National Report 2010, London, London Hip Fracture Database/NHS Information Centre 19 I track is a programme of electronic patient surveys, which asks orthopaedics patients about 17 indicators. 20 Royal College of Surgeons, ibid.


• Elective orthopaedic centres and their benefits South West London Elective Orthopaedic Centre (EOC) opened in 2004 and has radically improved throughput in joint surgery and reduced waiting lists by delivering a redesigned service in a dedicated environment. Their performance and areas of note are as follows21: • Largest single site centre for joint replacements • High pre-operative, inpatient and overall patient satisfaction • Use of cutting edge technologies • 18 week compliance - 90% • Slot utilisation – 95% • HCAIs - 0% • MRSA – 0% • Same day cancellations non-clinical – 1%

Chapel Allerton Orthopaedic Centre (part of Leeds Teaching Hospital NHS Trust) opened January 2005. The NHS Institute for Innovation and Improvement22 used the centre as a case study, explaining that “The centre’s big successes have been: • Surgery on day of admission for virtually all patients • Reduced length of stay • Very low infection rates • Positive effects on mortality/morbidity rates • Virtually no complaints • No recruitment and retention problems”

3.4 Objectives and benefits

The objective of a reconfiguration of orthopaedic services is to improve on all the measures outlined above and do this at the same time as improving productivity and reducing the bed base, therefore saving money. The service is currently loss-making and this cannot continue. The table below shows the benefits realisation template:

21 The Elective Orthopaedic Centre (2009) The EOC Annual Report 09 – One Step Ahead 22 NHS Institute for Innovation and Improvement (2006) Delivering Quality and Value – Focus on: Primary Hip and Knee Replacement, Coventry, NHS Institute for Innovation and Improvement


Benefit Measure Current

Performance Planned Performance

To improve clinical effectiveness safety and patient experience

Reduction in length of stay (planned) 2.7 days 2.3 days (equal to Trust best site)

Reduction in length of stay (urgent) 6.5 days 4.7 days (best in peer) Improvement in the volume of procedures taking place as a day case

40% 56.6% (best in peer)

Improvement in the elective pathway as measured by 18 week performance (median wait in future)

69% (October 2010)

90%

Improved improvement measured by PROMs

Hip 0.352 Knee 0.274

Best in peer

Reduction in infection rates 0.77% (three procedures)

0

Presence of senior surgeons for planned and urgent work

Not always present

Always present

Availability of specialist critical care for urgent patients

Not always available

Always available

Reduction in the number of cancellations for non-clinical reasons

2.4% 1.0%

Improvement in time to theatre for urgent patients and a reduction in the roll over rate. (Current metric hip fracture to theatre within 48 hours)

86% CXH 53% SMH

95%

Increased proportion of patients in single sex accommodation

98% 100%

Improve i-track scores 86% SMH - mixed trauma and elective ward and 97% CXH – planned care only ward (Oct 2010)

98% across both sites

To improve education, research and development opportunities

Increase the % of patients involved in a clinical trial

2% Increase 1% year on year

Reduction in length of stay will be achieved by: 1. Increased day case 2. Less infection 3. Dedicated lists, leading to fewer cancellations 4. Operation on day of admission 5. Fewer complications 6. Critical mass


4 Options A number of options were discussed by clinicians and six were shortlisted for further analysis and consideration. Option 1 – Do nothing Option 2 – Co-locate urgent services at SMH, establish all planned inpatient services at CXH Option 3 – Consolidate the entire service at CXH Option 4 – Consolidate the entire service at SMH Option 5 – Consolidate the entire service at Hammersmith Hospital Option 6 – Separate planned inpatient and urgent services on both SMH and CXH sites Option 7 – Establish all planned inpatient services at CXH and ensure separate urgent services at both SMH and CXH

5 Options Appraisal The table below is an appraisal of the options under the headings: • To improve clinical effectiveness, safety and patient experience (inc availability of staff

for MTC) • To improve education, research and development opportunities • Space/achievability • Travel • Capital cost • Revenue cost

Do nothing (option one) has not been appraised as none of the clinical effectiveness, safety or patient experience indicators would improve.

Reconfiguration of urgent and planned orthopaedic Services v2.3 13

Benefit/ Indicator

Measure Option 2 - Centralise planned at CXH and urgent at SMH

Option 3 - Consolidate the entire service at CXH

Option 4 - Consolidate the entire service at SMH

Option 5 - Consolidate the entire service at HH

Option 6 - Separate planned and urgent services on CXH and SMH sites

Option 7 – planned inpatient services at CXH and separate urgent services at both SMH and CXH

To improve clinical effectiveness, safety and patient experience

Reduction in the complication rates for all patients

Dedicated facilities would support this (1)






Reduction in length of stay







Improvement in the volume of procedures taking place as a daycase

The Riverside day surgery unit at CXH is underutilised and increased number of patients could have their elective surgery carried out and be home the same day (1)


Limited use of Riverside day surgery unit at CXH (0)




Improvement in the elective pathway as measured by 18 week performance

Fewer planned patients are cancelled due to urgent cases needing theatre slots. Elective patients could be better managed with one single service located on one site (1)

Fewer planned patients are cancelled due to urgent cases needing theatre slots. Elective patients could be better managed with one single service located on one site. (1)



Fewer planned patients would be cancelled due to urgent patients, although there is a possibility that dedicated lists could be overtaken should the need arise. Co-ordination across two sites would make this more difficult (0.5)

Fewer planned patients would be cancelled due to trauma patients, although there is a possibility that dedicated lists at CXH could be overtaken should the need arise (0.5)

Physical separation of services facilities and rotas

This would be possible with planned and urgent care on separate sites (1)

This would be difficult to sustain and manage on one site (0.5)



This would be difficult to sustain and manage on both sites (0.5)

This would be difficult to sustain and manage on the CXH sites (0.5).


Benefit/ Indicator







Improved outcomes measured by PROMs







Reduction in infection rates

Separate planned and urgent wards would support this (1)






Reduction in the number of re-admissions to theatre within 72 hours

The increased volumes carried out by surgeons would support this (1)






Availability of specialist critical care for planned patients

All planned patients would have access to specialist critical care (1)






Reduction in the number of planned cancellations for non-clinical reasons

This would improve (1)






Improvement in time to theatre for urgent patients and a reduction in the roll over rate


This would improve, but patients would not benefit from MTC theatre located at SMH (0)


This would improve, but patients would not benefit from MTC theatre located at SMH (0)

This would improve, but there would be less frequent lists on each site and CXH patients would not benefit from MTC theatre (0.5)

This would improve, but there would be less frequent lists on each site and CXH patients would not benefit from MTC theatre (0.5)

Increased proportion of patients in single sex

This would be easier to achieve with dedicated urgent and

This would be easier to achieve with dedicated urgent and planned



This would be difficult to manage on both sites (0)

This would be easier to achieve with dedicated urgent and planned wards (0.5)


Benefit/ Indicator







accommodation planned wards (1) wards (1) wards (1) wards (1)

Improve i-track scores







Increased consultant support for MTC and presence of senior surgeons for planned and urgent work

Would support MTC (2) and dedicated urgent and planned rotas would support consultant presence for planned and urgent work (1)

Would not support MTC (0) but dedicated urgent and planned rotas would support planned and urgent work (1)

Would support MTC (2) and dedicated urgent and planned rotas would support planned and urgent rotas (1)

Would not support MTC (0) but dedicated urgent and planned rotas would support planned and urgent work (1)

Would provide limited support to MTC (1) and rotas for planned and urgent work would be very difficult to sustain on both sites (0.5)

Would support MTC (2) but would be difficult to sustain senior surgeon support on both sites (0.5)

Score - clinical effectiveness, safety and patient experience

/16 16 12.5 14.5 11.5 11 13.5

To improve education, research and development opportunities

Increased and equitable access to research

Yes (1) Yes (1) Yes (1) Yes (1) No (0) Yes (1)

Improvement in specialisation by dedicated surgeons

Yes (1) Yes (1) Yes (1) Yes (1) Yes, but more difficult to co-ordinate across two sites (0.5)

Yes, but more difficult to co-ordinate across two sites (0.5)

Increase the % of patients in a clinical trial

Yes (1) Yes (1) Yes (1) Yes (1) Yes, but more difficult to co-ordinate across two sites (0.5)

Yes, but more difficult to co-ordinate across two sites (0.5)


Benefit/ Indicator







Score – education, research and development

/3 3 3 3 3 1 2

Space/ achievability

Sufficient space, short timescales to make any change (2)

Sufficient space with some changes required (1)

Insufficient space to make the move (0)

Sufficient space, but time required for capital works (1)

Insufficient space at SMH for growth in service

Sufficient space, short timescales to make any change

Score – space/ achievability

/2 2 1 0 1 0 2

Travel Patients required to travel further than currently

Planned patients who currently use SMH and urgent patients who use CXH would travel further (outpatient appointments would remain as now) (1)

All patients who currently use SMH would have to travel further (1)

All patients who currently use CXH would have to travel further (1)

All patients would have to travel further (except those closer to HH) (0.5)

No change for patients (2)

Elective patients who currently use SMH and would have to travel further (except for outpatient appointments which would remain as now) (1.5)

Score – travel /2 1 1 1 0.5 2 1.5

Capital cost Expected capital cost

£1.2m £5.7m £8.1m £25m £4.5m £3.9m

Score – capital cost

/3 3 1 1 0 2 2

Revenue position

Improve or worsen

Improve a lot Improve a little Improvement Worsen Good improvement Good improvement

Score- revenue

/2 2 1 0.5 0 1.5 1.5

Total score 28 27 19.5 20 16 17.5 22.5


6 Financial appraisal The financial appraisal is focussed on the ability of the seven options to reduce the inefficiencies in the patient pathway compared to the capital cost required to deliver the savings. Three possible scenarios have been considered: a base or best case; a mid case and a worst case. The difference between these scenarios primarily being the amount of lost activity that would occur. The best case assumes no loss of activity. Whilst this may seem unachievable it needs to be remembered that planned surgery centres of excellence, such as the one we are proposing, commonly attract patients from a very wide geographical area – much larger than the current catchment. The appraisal does not take into account a number of assumptions that could have been used all of which would lead to an improved financial contribution for all the options (to a greater or lesser degree) compared to the current arrangements e.g. the appraisal assumes… • No improvement in theatre utilisation; • No reduction in readmissions; and • No reduction in rota costs (because there would be the same number of patients –

however this could be removed if the preceding efficiencies are made). To compare the options, the best case has been used because the mid case or worst case would affect all of the options to the same degree. More detailed breakdowns of the costs of the options can be found in appendix one. The assumptions used to test the sensitivity of the modelling can be found in appendix two.

6.1 Pay costs As detailed below, the best case scenario for each option would reduce the pay spend by £653,000 FYE. It is assumed that none of the options would deliver a saving in the rota provision.

Activity Analysis WTEs Value (£'s) Staffing costs: 1 - Band 8a 0 0 - Band 7 Nurse 0 0 - Band 6 Nurse -1.5 -74250 - Band 5 Nurse -8.5 -335750 - Band 3 HCA -3.25 -91000 - Band 2 HCA -3 -75000 - Band 4 Admin 1 28000 - Band 2 Admin 0 0 - Consultant -1 -115000 - SpR 0 10000 - Therapists 0 0 Total Pay Costs -16.25 -653000 The savings are based on a length of stay (LOS) reduction of 11.5 beds as detailed below: 1. Increase day case to best in peer of 56.6% - saving of 2 beds 2. Decrease in non-elective length of stay to best in peer of 4.7 days – saving of 8 beds 3. Decrease in elective length of stay to 2.3 days (current best site) – saving of 1.5 beds This would make a saving of 11.5 beds in total, from the current bed base of 75 NHS beds (29 at SMH, and 46 beds at CXH). There would be no reductions in the number of operating lists. There are minimal changes to non pay including a small increase in transportation costs for planned patients.


6.2 Capital spend

As shown below, all options for change require capital spend. Option two, ‘elective at Charing Cross Hospital and non elective at St Mary’s Hospital’, requires the least capital spend. The earnings before interest, tax, depreciation and amortisation (EBITDA) and NPV of the project for all options have been calculated using the best case scenario. Option five has a different EBITDA, because the large capital build would require an additional year to deliver the option compared to the other options.

6.3 Overall costs

As can be seen from the table above, only options two and option seven, ‘elective at Charing Cross Hospital and non elective at both Charing Cross Hospital and St Mary’s Hospital’, would provide a positive net present value (NPV) on the project over seven years. Option two provides a payback in 2.4 years which is within the five years the trust requires for all capital spend. Due to the poor NPV of options three, four, five and six, they are excluded from further calculations which are designed to test the robustness of the calculations on options two and seven – and what that might mean to the trust.

6.4 Sensitivity The activity assumptions for the best (or base) case, mid case and worst case scenarios are included with the capital investment in the table below. This shows that option two would provide a net present value within four years irrespective of the activity, which is within the five year target at the trust. None of the scenarios for option seven would provide a net present value within the five year target at the trust.

6.5 Net gain / loss

All sensitivity testing is shown in the appendices, however the charts below show the potential net gain for options two and seven in the best case scenario for year one. For option two, the loss of profitable elective activity is offset by the loss of unprofitable urgent activity. However the large loss of efficiency savings represents the reduction of urgent activity and therefore the loss in ability to deliver length of stay (LOS) reductions.


Option 2 - Elective at Charing Cross &Non Elective at St Mary's

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Option 7 - Elective at Charing Cross & Non Elective at both Charing Cross and St Mary's

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In option seven (below), the base case surplus is reduced (compared with option two). The graph shows the effect of losing profitable elective activity which is not offset by any loss of urgent activity. However there is a reduced loss in efficiency gains (compared with option two) because the majority of the beds that can be taken out are urgent care beds, where the biggest improvements are to be made. For comparison the approximate average annual surpluses of all the options (base case scenario) are shown below:

Option two: £ 550, 000 Option three: £ 200, 000 Option four: £ 50,000 Option five: £1 million loss Option six: £ 300, 000 Option seven: £ 370, 000


This annual surplus has been projected for a seven year period for options two and seven: Option two Option seven

7 Preferred option(s) The Trust considers that only two options are viable: Option 2: Centralise planned at CXH and urgent at SMH; and Option 7: Planned inpatient services at CXH and ensure separate urgent services at

both SMH and CXH As described above, these two options were the highest scoring in the options appraisal. Option four (consolidating all services at St Mary’s scored third in the appraisal (and in fact scored better on clinical quality than option seven). Nevertheless none of the options three, four, five or six showed a positive net present value (NPV) on the project over seven years and it was therefore agreed they should not be consulted upon. The Trust considers that the preferred option is: Option 2: Centralise planned at CXH and urgent at SMH; and Option two was the highest scoring option both clinically and overall. It also is the only option that provides a payback within five years, which the trust requires for all capital spend. Option 2 is the preferred option because it best meets the key objectives:

• To improve the three key dimensions of quality; clinical effectiveness, safety and patient experience

• To align the service with the Major Trauma Centre (MTC) • To improve education, research and development opportunities • To ensure the business case for the proposed change makes financial sense.


Implementation of this option would improve the financial position of the service by around £550,000 per annum (assuming the base/best case).

7.1 Patient pathways for the preferred option If all the Trust’s urgent orthopaedic surgery were to be located on the SMH site this would have an impact on the patient population for whom CXH is their local A&E. Discussions have taken place with London Ambulance Service (LAS) about which sites they would transport patients to, should CXH not accept these patients. The vast majority of the activity would go to Chelsea and Westminster or St Mary’s. We are in discussion with Chelsea and Westminster to ensure that quality can be maintained and capacity is available in the system. If patients presented to CXH A&E, whether by ambulance or as a ‘self-presenter’ and needed to be admitted, these patients would need to be transferred to SMH at an appropriate time. A set of protocols for management of these patients has been drawn up by clinicians. The protocols cover the following diagnoses: • Fractured neck of femur • Upper limb trauma • Lower limb trauma (excluding ankle) • Ankle trauma • Major orthopaedic trauma • Spinal trauma • Pelvic trauma

The protocols state that all urgent orthopaedic patients who present to CXH, who are medically stable, and who have a clear diagnosis requiring admission, would be transferred to SMH as soon as transport had been arranged. The only exception to this would be that patients with spinal fractures would continue to be treated at the site that they present to, whether SMH or CXH. The following sections: • set out the maximum number of patients who may ‘mis-present’ at CXH and would need

to be transferred to SMH; • explain all the assumptions which feed into the figures; • break down these patients by diagnosis and PCT or group of PCTs; • break down these patients by age (under 70 or 70 and over).

Maximum number of patients who would ‘mis-present’at CXH and need to be transferred to SMH 1. 767 patients were coded on the Trust’s PAS system (ICHIS)23 as urgent orthopaedic

admissions who were treated at CXH in 2009/10 and had a length of stay of one day or more.

2. Patients admitted through inter-hospital transfers or who were expected by the trauma and

orthopaedic (T&O) team through direct referral such as in-hospital falls were discounted, leaving only patients who were admitted through A&E or at consultant clinic. This reduces the total by 21 to 746.

23 The slight anomaly of three patients (compared to the total recorded on page 3 – is due to different coding on different hospital systems. There are separate recording systems for A&E (Symphony) and inpatient specialities (ICHIS). Looking at Symphony data for months 1-7 of 2010/11, a total of 38 patients were expected by the T&O team, so it looks like the ICHIS data under records inter-hospital transfers and other expected patients. However, for consistency’s sake this document will continue to use the data recorded in ICHIS.


3. It has been assumed that 30% of CXH urgent orthopaedic activity will attend Chelsea and Westminster Hospital’s A&E in the first instance, as they will be transported by LAS. This would bring the total to 522.

4. An assumption has been made that all major orthopaedic trauma and pelvic trauma patients

would be transported to SMH by LAS as they are easily identified. 5. Of the remaining diagnoses, an assumption has been made that 50% are self-presenters

and 50% arrive in an ambulance, except fractured neck of femur, where 10% are self-presenters and 90% arrive in an ambulance.

It has been assumed that, in the first instance, all remaining self-presenting patients will continue to self-present, and that LAS will bring 50% of the remaining neck of femur patients and 25% of upper limb, lower limb and ankle patients to CXH. This brings the total number of patients needing in patient care and transfer to SMH arriving at CXH (whether by LAS or self presentation) to 267.

6. These numbers would expect to decrease as it became well-known that SMH was the preferred site not only for major trauma but also urgent orthopaedic patients. For instance, at HH a very small number of orthopaedic patients present to the medical receiving room either as self-presenters or via LAS who subsequently need to be transferred to another site for treatment. Unfortunately, due to coding issues, this number cannot be accurately determined, but is believed to be between 10 and 20 per year. It is expected that if urgent orthopaedic patients were only treated at SMH, then the number of ‘mis-presentations’ to CXH would decrease to a similar level.


Breakdown of patient flows to A&E Charing Cross with urgent orthopaedic split by diagnosis Maximum number of patients with orthopaedic trauma requiring admission who would initially ‘mis-present’ at CXH and require transfer to ICHT’s SMH site (based on assumptions 1-5 described above) are presented in column 4 Diagnosis Total admitted

2009/10 Total through A&E or consultant clinic

Total less loss to other providers of 30%

Total not transported to SMH via LAS and self-presenters (initially)

Neck of femur 186 181 127 70 Upper limb 133 133 93 58 Lower limb 121 112 78 49 Ankle 210 205 144 90 Spine 25 25 18 0 Major orthopaedic trauma

47 45 32 0

Pelvis 45 45 32 0 Total 767 746 522 267 Maximum number of patients who may ‘mis-present’ by PCT Maximum number of patients who may ‘mis-present’ (column 4 in above table) separated by PCT or group of PCTs

Diagnosis H&F K&C Westminster Remaining NWL PCTs

SWL PCTs Remaining London PCTs

All remaining patients

Total

Neck of femur

27 7 2 19 12 1 3 70

Upper limb

23 4 2 13 6 3 7 58

Lower limb

11 3 2 18 7 3 6 49

Ankle 30 11 4 23 7 5 10 90 Total 91 25 10 73 32 12 26 267

Maximum number of patients who may ‘mis-present’ by age group

Diagnosis Under 70 70 and over Neck of femur 15 54 Upper limb 42 16 Lower limb 33 16 Ankle 71 18 Total 162 105 NB some totals on this page will vary slightly due to rounding. Examination of the current flows modified by assumptions outlined above would suggest that in the first instance some 267 patients, less than one per day, would require transfer to SMH for


definitive management. However with active engagement with LAS and a public information campaign it would be expected that the number of patients needing to be transferred would be significantly lower. While there remained a need to transfer patients it is clear that protocols and pathways would be in place to ensure timely and appropriate high quality treatment while awaiting transfer. The configuration of services would affect the patient pathway for some patients. All planned patients would be treated at the CXH site and all urgent patients would be treated either initially or for their entire stay at SMH.

8 Stakeholders and communications The summary communications strategy and plan (appendix three) identifies: • the communications principles and actions to be taken; • the legislative framework within which the engagement will take place; • the groups responsible for delivery of a successful outcome; • key deliverables and evaluation to be undertaken; and • the key audiences and the issues that are most likely to be important to them including:

o staff o patients and their representatives o commissioners and providers – GP’s , GP consortia, North West London

Commissioning Partnership and PCTs in London area o health partners including other Trusts and NHS London o Overview and Health Scrutiny Committees and councils in Westminster,

Kensington and Chelsea and Hammersmith and Fulham o London Ambulance Service o Local Involvement Networks (LINks)

Engagement with external stakeholders regarding the options has been initiated and further public engagement using the attached information and questionnaire (appendix four) will commence should this business case be approved by the Trust Board.

9 Commercial Aspects Not applicable to this business case

10 Workforce Implications The orthopaedics service is currently reviewing the workforce as part of the overall CPG 3

service reconfiguration. This will inevitably involve some changes to existing working practices and locations. Consultant rota and job planning changes will be ready for implementation in line with the timescales set out below. An additional consultant post is funded by CPG 3 and the MTC has funded an additional consultant and registrar post to support the orthopaedic trauma services provided to the MTC. A consultation with the nursing workforce, with the agreement of the trade unions, has been completed. The workforce implications are the on call service rota and not staff reductions for doctors. Other informal engagement and consultation will take place over the coming months with all other staff in the T&O service to assess the impact of the changes. We do not anticipate that as a direct result of implementing either of the two preferred options any compulsory or voluntary redundancies in the service.


11 Achievability 11.1 Programme

If agreed, changes required for the preferred option would be easily achievable in a short space of time.

11.2 Risk Analysis and Management Table 11.1: Key Risks for Implementation of Preferred Option and Mitigation Strategies Key Risks Risk Management Measures Board does not ratify reconfiguration plan

The service can still continue on separate sites but the benefits to quality of care, MTC and financial savings will not be realised

Public support is not gained for the changes

Robust communications and stakeholder engagement plans have been put into place so that the value of the proposals is communicated

High numbers of urgent patients still present at CXH A&E

We are working with LAS to ensure that patients would be transported to the most appropriate hospital. A public communications campaign will be put in place to ensure that the public know where to attend. Protocols have been drawn up to ensure that any patients who do attend CXH A&E and need to be admitted are transferred swiftly and safely.

Other trusts unable to take numbers of patients who will not be attending CXH or SMH

Working with LAS and other trusts to ensure that the effect of the change on them is minimised.

Financial savings are not realised

Regular reviews of savings against plan would take place and measures put in place to keep to these at the earliest opportunity if slippage if found.

11.3 Equality Impact Assessment

An initial assessment of the likely impact for minority groups has been carried out. Older people and women are disproportionately affected by the service reconfiguration as more of these groups would have to travel further for their treatment and more urgent patients in these groups would need to be transferred back to Charing Cross for rehabilitation. However, at this point, it is considered that the benefits of being treated at a specialist centre (whether urgent or planned) outweigh the drawbacks for patients: travelling further for their treatment; families and carers travelling further to visit patients in hospital; and transfer of patients for rehabilitation. However, a full independent impact assessment is being carried out as part of the stakeholder engagement workstream and will be available during the formal engagement period.

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