Improving planned orthopaedic surgery for adults in north central London
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Improving planned orthopaedic surgery for adults in north central London 13 January to 6 April 2020 We are proposing changes to planned surgery for bones, joints and muscles (planned orthopaedic surgery) for adults. This includes hip and knee replacements; and other surgery of hips, knees, shoulders, elbows, feet, ankles and hands. Any changes could affect residents of Barnet, Camden, Enfield, Haringey and Islington and neighbouring boroughs. We need your comments and advice. Closing date for feedback 6 April 2020 A consultation document published by North London Partners in health and care on behalf of Barnet, Camden, Enfield, Haringey and Islington clinical commissioning groups.
Introduction
Helen Pettersen Prof Fares Haddad
North London Partners in Clinical Lead for the review, Clinical Director of the
Health and Care Convenor and Institute of Sport and Exercise Health and a Consultant
accountable officer of NCL’s Orthopaedic and Trauma Surgeon at University College
five CCGs London Hospitals
Hospitals across north central London have North London Partners in health and care was established to tackle As a surgeon, who provides this kind of care every day, I know the
proposed a new way to organise orthopaedic
some of the big health and care challenges we face in the coming difference it makes to patients. Damage to bones, joints and muscles
years. We are a partnership of health and care organisations who are can be debilitating for people of all ages - whether it is a result of
working together to find solutions to address these challenges. Our ageing or trauma - but with the right care at the right time, the
surgery for adults. We believe that planning review of orthopaedic services is a good example of this. results can be life-changing.
together and sharing expertise and facilities will
We probably all know someone who has had a hip or knee replacement. Whilst the results of surgery are generally good, by working together as a
Such operations can be life-changing for those living in pain or who find it community of clinicians we can share knowledge and expertise to ensure that
difficult to get around. Demand for orthopaedic surgery is growing all the every patient in north central London has world-class orthopaedic surgery. In
result in vastly improved care for local people. time, but right now those who need care and treatment are not always seen
in a timely way.
our proposals, we have also committed to giving patients access to the latest
developments in orthopaedic care and clinicians, the opportunity to refine
their skills, through the best quality education and peer support. All of this
We want this review of orthopaedic services to be an example of how will result in a cycle of improvement for everyone.
we plan to work in future so that health and care professionals, working
alongside patients and residents, use their collective knowledge and expertise We have learned from our peers around the country and have included their
to improve health and care for residents who are using these services. I hope good practice into our plans. We have also spoken to hundreds of patients
that you will add your knowledge and experience to our work by taking part about their experiences of our services to ensure that the future is shaped to
in this consultation. meet their needs. I believe that our proposed plan for the future is a good
one, which offers the best solutions to the challenges the NHS faces today.
I hope you will agree.
3
What is planned
orthopaedic surgery?
Orthopaedic surgery treats damage to bones, Our proposals only affect Introduction................................................................................................. 3
joints, ligaments, tendons, muscles and nerves planned orthopaedic surgery What is planned orthopaedic surgery?.......................................................... 4
(the musculoskeletal system). Patients may be for adults About this consultation................................................................................ 6
referred to an orthopaedic surgeon for a long-term The following orthopaedic services are not Why are we suggesting changes to orthopaedic surgery for adults?.............. 8
condition that has developed over many years, such affected by our proposals:
as osteoarthritis or other non-emergency damage. • Emergency care Our proposals..................................................................................... 10
Surgery, such as hip and knee replacements, is • Children’s orthopaedic care Our ambition............................................................................................. 11
the most common orthopaedic surgery offered in Where would patients have their surgery under our proposals?.................. 12
• Spinal surgery
the NHS. However, other surgery of hips, knees, Where patients would have their care in the future..................................... 14
shoulders, elbows, feet, ankles and hands also falls • Specialist and complicated orthopaedic
What does this mean for patients?............................................................. 16
under this heading. surgery
How the proposals could affect travel and different communities................ 17
Planned surgery is when patients have an • Orthopaedic surgery for patients with
Benefits and challenges of our proposals.................................................... 18
appointment booked in advance. It is planned complex medical conditions such as
treatment, following a referral to hospital by a haemophilia
GP and an assessment by specialists. It is sometimes
The background to our proposals............................................... 20
• Local physiotherapy services for bones,
called ‘elective’ or ‘non-emergency’ care. How planned orthopaedic services work today........................................... 21
joints and muscles
Evidence used in developing our proposals................................................. 22
How our proposals were developed........................................................... 24
Developing our proposals collaboratively.................................................... 26
How much would it cost?.......................................................................... .26
What has happened so far, and next steps................................................. 27
How our proposed changes support hospitals in north central London....... 28
How to feedback on our proposals............................................. 30
How will a final decision be made?............................................................. 31
More detailed information about everything that
is discussed in this document can be found on our Ways to take part in the consultation......................................................... 32
website at: www.northlondonpartners.org.uk/orth_ Appendices................................................................................................ 34
consultation Consultation questionnaire (insertion)......................................................... 35
4 5
About this consultation To inform our decision-making, we’d like feedback
from anyone with an interest in these services,
By inviting people to take part in the consultation
we want to understand whether:
NHS services are better when patients and
healthcare professionals plan them together and in
We are holding a public consultation
between 13 January and 6 April 2020
“To inform our decision-
We are reviewing planned orthopaedic
including:
• We have developed the best possible solution
autumn 2018 we shared our reasons for needing
to change the services with patients and others to get feedback on our proposals. making, we’d like feedback
from anyone with an interest
surgery for adults in Barnet, Camden, • Anyone who is currently having or has had to the current challenges in providing planned with an interest, and asked for their feedback. As There are several ways in which you can give your
Enfield, Haringey and Islington and we’d experience of planned orthopaedic surgery orthopaedic surgery for those who need it in a result of these conversations, we have developed views during the consultation. Full details of each
in these services”
like your views on our proposals. north central London the proposals in this document. We’d now like
• Anyone who might need these services in future of these feedback routes are on pages 32 - 33. In
Two partnerships for orthopaedic surgery have • We are doing all we can to ensure that services your advice again to ensure that our proposals are addition to this detailed consultation document,
• Families and carers of people who use, have
been formed by local NHS Trusts - UCLH and are of the best quality right for the future. we have produced a summary document, large-
used, or might use these services
Whittington Health and the North Middlesex • In developing our proposals, are we doing the type, easy-read and audio versions. You can get
• Residents of Barnet, Camden, Enfield, Haringey, This consultation is being run by North London
University Hospital (North Mid) working with the right things to ensure everyone who needs care these on the website, but if you would like a
Islington and neighbouring areas who might use Partners in health and care on behalf of Barnet,
Royal Free London. These partnerships have been can access it in a timely way printed copy sent to you, a braille or audio version,
hospital services in north central London Camden, Enfield, Haringey and Islington clinical
working together to develop the plans about or a translation into another language, please
• There are more things we could do to make commissioning groups*
how services could be improved and we are now • Staff and professional representative bodies contact the consultation team.
seeking your views on these ideas. Should these services responsive and tailor them for those The independent evaluation of responses is being
such as trade unions, Local Medical Committees
with specific needs After we have heard people’s views, the North
be implemented, these partnerships would deliver and Royal Colleges carried by Participate.
Central London CCG*, the organisation which
the new improved services. • You have any alternative proposals, and what
• Community representatives, including the plans services on behalf of local residents, will
they are
We believe that by organising services in a voluntary sector decide whether to implement the proposals,
different way, we would be able to improve care • Staff and partners in health and social care update them, or find an alternative solution. This
and help more patients. The proposed changes consultation document and other related materials
could affect anyone who needs orthopaedic • Relevant local authorities were developed with the support of patients, and
surgery in the future, who lives in our five local Healthwatch groups.
boroughs or in a neighbouring area and has care
in one of the hospitals involved in our proposals.
Around 3000 could experience a change to where Camden
their surgery would take place in future, when
compared to current arrangements. Haringey
Enfield
Barnet
Islington
*On 1 April 2020 the five CCGs of Barnet, Camden, Enfield, Haringey and Islington will merge and become North Central London CCG.
Find out more at: www.haringeyccg.nhs.uk/ccg-news/north-central-london-clinical-commissioning-groups-ncl-ccgs-application-to-merge-
approved-by-nhs-england-and-improvement-london/98423
6
7
Why are we suggesting changes to orthopaedic surgery for adults?
Over 1.5 million people live in north central London and this number is expected to rise - as is the demand for planned Patients’ experiences vary, The amount of time a patient spends in hospital varies from
hospital to hospital. Infections aren’t very common, but numbers
orthopaedic surgery. Whilst current services are of good quality, we know that patients’ experiences vary and could be better.
depending on where they vary in different hospitals. The number of patients who need a
follow-up operation (known as ‘revision surgery’) also varies from
have their surgery
hospital to hospital.
Waiting times are too long NHS targets are being missed Too many operations Demand for planned
In January 2019, over 10,500 residents in north central
London were waiting for planned orthopaedic surgery.
The NHS expects 92% of patients to have started
treatment within 18 weeks of referral by their GP. However, are cancelled orthopaedic surgery is
on average between January 2018 and January 2019 only In 2018/19 across north central London 530 orthopaedic
expected to rise
10,500+
79% of patients referred for orthopaedic surgery in north operations were cancelled – 96% of these were cancelled on the
central London started treatment within 18 weeks of being day of surgery. This equates to 10 cancellations a week. The main The demand for planned orthopaedic surgery, such as hip and knee
patients on referred by their GP. In some of our hospitals, during the reason why operations are cancelled is the demands of emergency replacements, is expected to increase by around 9.5% by 2029. Within
waiting list very busy winter months this fell as low as 65%. services which can result in the beds not being available or key current arrangements, it would be very challenging for hospitals to cope
for surgery staff being called away at short notice. with this demand, and as a result, waiting lists could increase further.
65% 530
started treatment The changes we are proposing will deal with the current situation and
within 18 weeks also prepare for the future.
Between January 2018 and January 2019, the number of residents operations in
waiting for surgery increased by 24% rising by over 2,200 patients. 18W of GP referral in one year increase in
CANCELLED 9.5%
winter months demand over
next 10 years
10%
24%
NHS TARGET 92%
10 per week
JANUARY 18-19 79%
WINTER MONTHS 65% 0
Jan 2018 Jan 2019
2019 2021 2023 2025 2027 2029
8 9
Our The NHS in our area currently pays for patients to
be treated at 10 different hospital sites, both NHS
• Care coordinators to support patients with
conditions such as dementia or a learning Our ambition As a result of these proposed changes we would
be able to:
• Offer access to comprehensive training and
development opportunities to all staff working
proposals
and private. This is to ensure there is enough space disability to understand their care and where it in our partnerships including the chance to
for everyone who needs planned orthopaedic might take place There are a number of benefits for • Ensure all patients who need surgery could work in different environments and learn from
surgery. organising care differently. access the care they need without a long wait others
• More complex surgery would continue at the
We are proposing a new way to organise services Royal National Orthopaedic Hospital, a super- • Organise these services to meet current demand • Ensure that surgery offers patients top quality
in the future, that would change this. specialist centre * Access to consistently high-quality and any predicted future increases pre-operative and post-operative education and
• Patients with other complex medical conditions, care for all patients across north • Physically separate emergency surgery from care; this would be the same no matter where
Our proposals for the future of Our proposed service would have:
such as haemophilia, will have their surgery at central London planned surgery, so that planned surgery would patients receive care in north central London.
planned orthopaedic surgery.
• A choice of two NHS hospitals with dedicated the hospital which specialises in their condition not be cancelled due to unexpected emergency
* The capacity to meet current and These changes are not being proposed to save
operating theatres and beds, for patients who • Emergency orthopaedic care would continue hospital admissions money or spend less on this kind of care. We
future demand
need to stay overnight after their operation at all local hospitals with an Accident and believe that by organising services in a different
* A choice of two hospitals with • Have specialist staff with the right skills in
• Within each partnership, choice of NHS Emergency department * Physically separating emergency and the right place to provide the best care and way, we would be able to improve care and help
dedicated operating theatres and planned surgery, to avoid last-minute more patients.
hospitals for those needing day surgery experience for patients before, during and after
beds, for patients who need surgery cancellations
• Within each partnership, a choice of NHS their operation
that requires an overnight stay
hospitals for outpatient appointments We know that patients want to * Highly-specialist staff who focus on • Provide high-dependency or intensive care
* A choice of hospitals for those see the same surgeon throughout orthopaedic surgery, and become
• Improved education classes for patients so facilities for patients who need them
needing day surgery their care increasingly skilled at carrying it out
they understand their operation and what to
do to before surgery to support their recovery The new arrangement would ensure that • Learn from other services around the country,
* A named surgeon and team who patients always have care from the same so that the care and surgery that local patients
“We believe that by
will oversee a patient’s care, afterwards
surgical team, regardless of where their receive is based on the best, most up-to-date
wherever it takes place • Appointments would be with a named surgeon, appointment takes place. If a patient has their research and knowledge available
* A choice of hospitals for outpatient
who, with their surgical team, would stay with
patients throughout their care, regardless of
outpatient appointments at one hospital and
their operation at a different hospital, their
• Have beds allocated for planned orthopaedic organising services in a
appointments where it takes place surgeon and the surgical team would follow
them to the other hospital to carry out their
operations which would never be used for any
other kind of care. different way, we would be
able to improve care and help
* A single approach to planned • Rehabilitation support for patients after
orthopaedic surgery across north their surgery surgery. • Provide staff with different ways of working, to
more patients.”
central London, where staff learn • Access to high dependency or intensive care ensure care is more coordinated across north
Doctors will continue to work on emergency
from each other so patients receive units for patients who need additional care after central London, in and out of hospital
care at local hospitals, as well as planned
consistently high-quality care their surgery surgery, giving them broad experience and
improving their skills. This would ensure that
there would be no impact to the provision of
emergency care at local hospitals.
10 11
Where could patients have surgery under our proposals?
North Middlesex University Hospital North Middlesex University Hospital
Overnight stay: Usually hip & knee surgery / Royal Free London Partnership Day surgery: Usually shoulder, hand and foot surgery / Royal Free London Partnership
UCLH / Whittington Health UCLH / Whittington Health
Partnership Partnership
GP GP GP GP
GP & OUTPATIENT SURGERY FOLLOW UP COMMUNITY GP & OUTPATIENT SURGERY FOLLOW UP COMMUNITY
COMMUNITY APPOINTMENTS POST-OPERATIVE COMMUNITY APPOINTMENTS POST-OPERATIVE
CARE CARE CARE CARE
Barnet Hospital Barnet Hospital Barnet Hospital Barnet Hospital
Chase Farm Chase Farm Chase Farm Chase Farm Chase Farm Chase Farm
North Mid North Mid North Mid North Mid North Mid
Royal Free Hospital Royal Free Hospital Royal Free Hospital Royal Free Hospital
Outpatient Outpatient
appointment UCLH UCLH UCLH appointment UCLH UCLH UCLH
Overnight stay Whittington Health Whittington Health Day surgery Whittington Health Whittington Health Whittington Health
Two partnerships for orthopaedic surgery
have been formed by our local NHS Trusts –
regardless of where a patient receives their care, it is
of a consistently high standard.
operation, as would whether they need an overnight
stay, or have your operation and go home on the
This is a general guide – and there are some
exceptions to this. Examples of this are surgery for
minimise the number of times that patients need
to travel further away from where they would
“Your choice of hospital for
with UCLH and Whittington Health working
With the majority of orthopaedic surgery there are
same day (day surgery). (See page 14 for more patients with haemophilia, which would remain at
the Royal Free Hospital or patients with sickle cell,
usually receive their hospital care. your outpatient appointments
would influence where you
together, and The North Middlesex University information on this).
two elements to the care patients receive: the care which would remain at the North Mid. because Patients would be able to express their preferences
Hospital working with the Royal Free London
In most cases, hip and knee replacement surgery to their GP or physiotherapist, before a referral is
have your operation”
(Barnet Hospital, Chase Farm Hospital and The before and after surgery (outpatient appointments) these hospitals specialise in the care of these
needs patients to stay in hospital overnight. For some conditions. made so that they could choose the partnership
Royal Free Hospital). and then the operation itself.
people this might be two or three days. Shoulder, of hospitals that is most convenient for them. The
The partnerships would be overseen by a network A patient’s choice of hospital for your outpatient hand or foot surgery is usually day surgery, and In response to the feedback we have already exact locations are shown on the next page.
received from patients, we have organised care to
of health professionals who would ensure that appointments would influence where they have their patients can go home the same day.
12 13
Where patients could We believe that by all hospitals working together all patients would receive a significant
improvement in their care.
Day surgery:
Shoulder, hand and foot surgery
have their care in the North Middlesex University Hospital / However, if our proposals were taken forward, some patients would have surgery in a
different hospital, when compared with current arrangements:
• 360 patients a year who would currently go to
UCLH would have their surgery at Whittington
future
Royal Free London Partnership
Hospital instead.
UCLH / Whittington Chase Farm
Health Partnership Hospital • 80 patients a year, who would currently have
In the future, patients will have a choice of the NHS care in a private hospital, would over time,
two partnerships for their care. The table opposite have their surgery at UCLH instead.
shows where patients would go for different Barnet • 1020 patients a year, who would currently
elements of their care. Hospital have NHS care in a private hospital, would over
ENFIELD
The following orthopaedic services are not SSC time, have their surgery at Chase Farm Hospital
Royal National instead.
affected by our proposals: Orthopaedic Hospital OUTPATIENT DAY SURGERY OVERNIGHT STAY
• Emergency care North Overnight stay:
Middlesex
• Children’s orthopaedic care Hip and knee surgery
University NORTH
• Spinal surgery Hospital Barnet Hospital Chase Farm Hospital Chase Farm Hospital • 400 patients who would currently go to North
MIDDLESEX
• Specialist and complicated orthopaedic surgery, BARNET UNIVERSITY Mid. would have their surgery at Chase Farm
which will continue at the Royal National HOSPITAL / Hospital instead.
Royal Free Hospital Chase Farm Hospital Chase Farm Hospital
Orthopaedic Hospital in Stanmore ROYAL FREE • 360 patients who would currently go to
• Orthopaedic surgery for patients with complex HARINGEY LONDON Whittington Hospital would have their surgery
PARTNERSHIP Chase Farm Hospital Chase Farm Hospital Chase Farm Hospital
medical conditions such as haemophilia at UCLH instead.
• Local physiotherapy services for bones, joints
Chase Farm • 560 patients who would currently have NHS
and muscles North Mid North Mid
Hospital care in a private hospital, would over time, have
Outpatient Whittington their surgery at Chase Farm Hospital instead.
Royal
appointment Hospital
Free UCLH/ • 40 patients who currently have NHS care in
Day surgery Hospital Whittington Health
WHITTINGTON UCLH UCLH a private hospital would over time, have their
Overnight stay CAMDEN ISLINGTON HEALTH UCLH surgery at UCLH instead.
PARTNERSHIP
SSC
Super Specialist • 225 patients referred to the RNOH for non-
Centre Whittington Health Whittington Health UCLH specialist care could be suitable for treatment at
UCLH Chase Farm Hospital instead.
Change to current arrangements • 75 patients referred to the RNOH for non-
specialist care could be suitable for treatment at
UCLH instead.
14 15
What does this mean How the proposals • During our consultation, we should make sure
we seek the views of patients with disabilities,
We are keen to explore ways in which these
challenges can be addressed during the
for patients? could affect travel and
carers, those living in areas of deprivation, consultation. There are opportunities in the
people over 65 and transgender people. This consultation questionnaire to give views and
different communities
will make sure that any possible disadvantage ideas on this topic and we are actively seeking
can be minimised for these groups. opportunities to explore ways in which any
in north central London
negative impacts can be minimised.
Patient choice in the NHS • For all patients needing an overnight stay in
hospital, there will be a small increase in journey In developing the proposals, we already know
All NHS patients have a choice about where
time for the majority of residents across north that the impact of these changes for orthopaedic
to go for their care. This is enshrined in
When the NHS proposes changes to services, we central London. For most residents this increase patients, carers and staff could be offset in a
the NHS constitution and is your right.
need to make sure we take into account the needs is likely to be 15 minutes at most. number of ways:
Regardless of our proposals, patients would
of everyone who uses, or will use these services
still be able to choose which hospital they • For patients in Enfield and Haringey choosing
in future. We spoke to hundreds of local residents • All patients will have a choice of two
are referred to for orthopaedic surgery the North Mid/Royal Free London partnership
and shaped these proposals in response to their partnerships for their care and so could choose
– just as they can today. As long as the for their care in future, we know that these
feedback. the hospitals that are most convenient for them
hospital offers the kind of care the patient proposed changes will potentially have a greater
needs, they may choose to have surgery We also sought advice on whether the proposed impact on them than on others. • For patients and visitors longer journey times
at a hospital in another part of London or changes could affect some groups more than are only likely to be apply to one or two
• For those choosing to have outpatient
another area of the country. others. To do this, we asked independent experts journeys, getting from home to hospital and
appointments at the North Mid and surgery
to carry out an Integrated Health Inequalities and back for surgery, as outpatient appointments
If patients need to be referred for requiring an overnight stay at Chase Farm, this
Health Equality Impact Assessment and a Travel will continue to be available at a wider choice of
Nisha needs surgery on her hand John needs a hip replacement orthopaedic surgery, such as a hip or knee could mean a more difficult journey if using
Analysis on our behalf. hospitals.
This can be done in a day. She usually prefers He will need two nights in hospital. John speaks to replacement, their GP would be able to public transport. The transport analysis found
guide them, give them information about that there would be a maximum increase of • For staff, any travel implications could be
to go to UCLH and so chooses the UCLH/ his GP and they decide that the most convenient These will help us shape the proposals further and
the care at different hospitals and let them fifteen minutes to journey times using public countered by more consistent rotas meaning
Whittington Hospital partnership for her care. Her place for him to have his outpatient appointments help us to have conversations with specific groups
know how long they are likely to wait. Once transport for these patients. less travel during the day between sites.
GP explains that under the new arrangements, is North Mid. His GP explains that this means he’ll during the consultation, who might be affected by
she could also go to the day surgery unit at The have all of his outpatient appointments, before they have this information they would be the proposed changes. The analyses highlighted The reports set out a number of recommendations
The report suggests that this may particularly
Whittington Hospital instead. and after his operation, and his education class at able to make an informed choice. that: and further pieces of analysis that are needed to
affect:
North Mid, but his operation would take place at fully understand the implications of the proposals
Here is read more about patients’ right • Most equalities groups, the groups set out – those with a disability or a mental health
Chase Farm. This will mean that John has to travel and address the challenges which have been
to choose: in the Equalities Act 2010, will experience a condition, due to the challenges associated with
a little further when he goes to stay at Chase Farm identified. You can read these reports on our
www.nhs.uk/using-the-nhs/about-the- significant improvement in the quality of care new or different locations.
We’ve produced a short animation which tells for his operation, but there is virtually no risk that website. www.northlondonpartners.org.uk/
nhs/your-choices-in-the-nhs/ they receive as result of the proposals.
Nisha and John’s story and what the proposals his surgery will be cancelled last-minute. – some black and minority ethnic communities, orth_consultation
mean for them and other patients. and people living in the more deprived parts of
Enfield and Haringey, because of the location of
Watch it at: www.northlondonpartners.org.
existing hospitals and the transport links in the
uk/orth_consultation
areas where these communities live.
16 17
Benefits and challenges of our proposals
Benefits Challenges
We believe our proposals would improve services in the following ways: We know that with any change there may
be some disadvantages for some people. We
think these are:
Improvements for patients needing Improvements for staff working Improvements for the NHS Improvements in the consistency Improvements for joined-up care
an operation in orthopaedics • Hospitals would be able to manage of care Our proposals are focused on changes to
• Patients would have access to two • Surgeons would oversee the care of waiting lists better because they would Hospitals working together will result in a planned orthopaedic services, however it is • Some patients may have to travel
hospitals that would carry out operations patients who need planned care, but know exactly how many beds would consistent standard of care for everyone. recognised that this surgery is one element further to and from the hospital where
requiring an overnight hospital stay, Both also continue to work in emergency be available. This means patients would of the care that patients might receive. In they have their operation
The new arrangements in these proposals
hospitals would carry out high-quality departments. This would ensure that spend less time waiting for surgery and developing these proposals, attention has
would be overseen by a network of • Visitors may also have to travel further
surgery, in a relatively short distance from surgeons retain skills in both kinds of waiting lists would go down been given to how they will work with
specialist healthcare professionals.
where they live. surgery, and that our hospital emergency • The dedicated operating theatres would GPs and alongside musculoskeletal (MSK) • Some staff will have to work in a
• For some patients, these hospitals would departments have the specialist skills they enable improved access to the latest In practice this means: physiotherapy services so that patients different hospital to where they usually
be more accessible, due to improved need to care for patients who need them technology which would improve the receive the right kind of care, when they work, on some days of the week
access to parking or public transport – • The teams – for example anaesthetists results of surgery • Patients would all receive the same need it. • People with additional needs, (such
depending on where patients choose to and nurses – working in dedicated information before their surgery so that as those with a learning disability, or
• Hospitals would be able to learn from You can read more about this on our
go for their care. operating theatres would become highly they know what to expect and are aware dementia), could find it confusing
each other and share information website: www.northlondonpartners.org.
expert at what they do. This would result of the benefits and risks of surgery to go somewhere different for their
• Fewer operations would be cancelled uk/orth_consultation
in better quality care for patients and • The new arrangement would provide surgery.
because planned care would be flexibility in how staff work together • No matter where patients have their care,
completely separate from emergency care better results from surgery it would be to the same consistently high
across the area, creating more time On pages 17 and 24 of this document
• Everyone who needs surgery would have • Staff would be able to plan how they use and space to meet current and future standard we describe the plans we are putting in
equal access to services. Patients would their time better, meaning they would demands place to minimise the impact of these
spend more of their time caring for For further information visit our website:
have access to a high dependency or challenges. We are also asking for your
patients • The new arrangements would be www.northlondonpartners.org.uk/
intensive care unit if they need additional ideas when you answer the consultation
overseen by a network of specialist orth_consultation
support following surgery • Staff and local people could participate questions or come to one of our events.
healthcare professionals who would
• For patients having operations in research and education programmes ensure a consistent high-quality of care
requiring an overnight hospital stay, which could improve care for everyone
physiotherapists would be available seven • Staff would get better quality and
days a week, to support patients in their increased training as well as developing
recovery more quickly. new and innovative ways of working into
the future, as technology and practice
changes.
18 19The How planned orthopaedic
HERTFORDSHIRE
Where patients have In 2016/17, north central London hospitals carried
surgery today out 23,000 planned orthopaedic operations. Around
background
The Kings
services work today
Oak Hospital 12,000 of these were more routine orthopaedic
Chase Farm operations. This review is only looking at these more
Hospital routine operations.
to our
The NHS in our area currently pays for patients to be treated
The Cavell
Hospital at 10 different hospital sites, both NHS and private. Many of
these sites undertake all types of planned and emergency
proposals
care, including day surgery and surgery that needs an
ENFIELD
overnight stay.
Royal National
Orthopaedic Hospital • North Middlesex University Hospital NHS Trust
North
Middlesex • Royal Free London NHS Foundation Trust
University OUTPATIENT DAY SURGERY OVERNIGHT STAY
Hospital
– Chase Farm Hospital
* How orthopaedic surgery works
today BARNET – Royal Free Hospital
Barnet Hospital Chase Farm Hospital Chase Farm Hospital
– Barnet Hospital
* The evidence upon which our
proposals are based HARINGEY WALTHAM Royal Free Hospital Chase Farm Hospital Chase Farm Hospital • University College London Hospitals NHS Foundation Trust
Highgate
HARROW Private FOREST – University College London Hospital
* What local residents told us, and how Hospital
Chase Farm Hospital Chase Farm Hospital Chase Farm Hospital – National Hospital for Neurology and Neurosurgery
proposals were shaped in response
• Whittington Health NHS Trust
* How hospitals worked together HACKNEY North Mid North Mid North Mid
Whittington
Hospital • Royal National Orthopaedic Hospital NHS Trust
* The impact of our proposals
BRENT CAMDEN UCLH UCLH UCLH • The Cavell Hospital (BMI Healthcare)
Royal Free
Hospital ISLINGTON • Highgate Private Hospital (Aspen)
Whittington Health Whittington Health Whittington Health • The Kings Oak Hospital (BMI Healthcare)
UCLH
Private hospitals Private hospitals Private hospitals
National Hospital for
Neurology and Neurosurgery
WESTMINSTER
20 21Evidence used in Review by the London Clinical Senate
Further information on the evidence behind and other experts “Having to cancel a
developing our proposals
our proposals can be found on our website.
patient on the day
The London Clinical Senate supports development
This includes: of health services by providing independent,
of their surgery is
• A national review of adult elective advice from senior health professionals, patients
Evidence in the UK and around the world shows
orthopaedic services in England and other bodies.
that doing surgery in operating theatres dedicated
to orthopaedics, with specialist staff, is likely to
result in better quality of care for patients. This
• Getting It Right First Time (GIRFT 2015). While proposals were still in development, a probably one of the
worst bits of my job. It “I’d been in pain for
senate panel reviewed our suggestions and found
evidence also shows that the results of surgery • Separating emergency and surgical care: that there was a “clear case for change, based on
makes me feel like I’ve
are better for patients when surgeons carry out
over a year and having
recommendations for practice national best practice and consideration of the
operations regularly and in greater numbers, Royal College of Surgeons (2007) local issues”. They also made recommendations
One current example of this is
let the patient down to wait even a few more
allowing them to refine their skills. where our work could be developed. Their
• Reconfiguration of clinical services: what South West London Elective recommendations have informed further work.
is the evidence?
and haven’t done my hours is too long, let
Orthopaedic Centre
Evidence shows us that: The King’s Fund (2014) We also asked for advice from senior staff at
SWLEOC (South West London Elective
job properly.”
SWLEOC (see opposite) and other senior staff
• Care is improved when emergency and
planned care are physically separate, and
• International Society of Orthopaedic
Centers
Orthopaedic Centre) is a NHS centre providing
planned orthopaedic surgery services for patients
running orthopaedic services around the UK. alone being cancelled.”
delivered in places designed specifically in south London. This includes inpatient, day cases More information can be found on our website
for the purpose. This also results in less • Examining new options and opportunities and outpatient care. at www.northlondonpartners.org.uk/orth_ Staff nurse in north London Patient in north London
hospital-acquired infections for providers of NHS care. consultation
The Dalton Review (2014) It was established by four south west London
• M
ore operations in one place – with acute trusts in January 2004, and has earned a If we do not change these services, it is unlikely
clinical staff seeing more patients with reputation as a centre of excellence for planned that local hospitals will be able to reduce waiting
similar conditions – leads to in better orthopaedic surgery with outstanding results, low lists, the number of cancellations will continue to
results for patients complication rates and high patient satisfaction. grow and we will not be well-prepared to deal
SWLEOC is recognised as the largest joint with the expected increase in demand for services.
replacement centre in the UK and one of the Access to services and the quality of those services
largest in Europe, performing around 5,200 each will continue to be variable with some patients
year. It was rated as outstanding by the Care having to wait a long time
Quality Commission in November 2015. for surgery.
For more information, visit www.eoc.nhs.uk The NHS is currently experiencing staffing
challenges, however our proposals could help
to ensure that staff who currently work in
orthopaedic services can use their skills more
effectively.
22 23How our proposals were developed What local residents told us How our plans changed
We have worked with patients and residents, doctors and nurses
and other health care professionals, like physiotherapists, from
People with additional health and social care needs, such as learning
across our boroughs, to design and agree the way in which we’d We developed a new role of ‘care coordinator’ to support these Rosemary Arnold,
difficulties, might need some extra help to understand the different and
like planned orthopaedic surgery to work in the future. patients throughout their care. patient representative
new places they would go for their care.
We talked to a wide range of people and staff to test our reasons for “As a patient rep, I have found the process
changing. We developed our ideas through workshops with the healthcare We need to carefully consider how the right information about a patient’s
Hospitals are joining up their digital patient records securely so that fascinating as I had no idea the NHS thought
professionals and patients who currently run and use these services. In health and social care needs is shared to make sure care is well managed
information can be shared more easily. so carefully about change. I have been able
these workshops we looked at how services could be improved and heard and coordinated across different hospitals.
to ask questions at every stage and felt
from other parts of the NHS from across the country about how they run there was a real effort to think about the
similar services. We also looked at the impact that any changes might have In our proposals, the hospitals that would undertake surgery requiring an
Some patients needing orthopaedic surgery might also have other health process from a patient’s point of view.”
on NHS services that work alongside orthopaedics, such as trauma care and overnight stay would also have high dependency or intensive care units. This
conditions that might have an impact on their surgery. This could mean means anyone with complex medical needs would get the care they need.
paediatrics. Patients told us about how the current way in which services that their surgery comes with additional risks or that they need other
work has impacted on them and their thoughts on how services could A small number of patients with very complicated health conditions would
specialists to be involved in their care.
be improved. be cared for at the most appropriate specialist hospital for their needs.
We are continuing to test and refine our ideas with local people and staff. We are looking carefully at the transport options available to patients who
All of the hospitals involved are in agreement with the proposals in this Some patients may need to travel further than previously for their surgery Helen Andrews,
cannot get to hospital independently to see how any inconvenience could
consultation document and each of the hospitals involved are signed up to or education before surgery. This additional travel could also affect visitors, patient representative
be minimised. We have commissioned a travel and transport report to help
them. You can read more about our partners in appendix 1. family and carers.
us understand the potential impact of our proposals. “When looking at the options for the future,
The feedback we received has helped to shape the proposals that we have we ensured that patients’ voices were heard.
The money that supports planned orthopaedic surgery would be fairly
put forward in this document. A full report of what we heard from local For me, it was important that those who
distributed across all hospitals whether they undertake surgery or not.
people between August and October 2018 can be seen on our website. By moving services around, some people were concerned that their local find it difficult to use NHS services were
Hospitals who will delver planned orthopaedic services in future are considered.”
A summary is provided opposite. hospital might lose services or money.
supportive of these proposals and do not believe there would be any
significant financial impact in making these changes.
From August - October 2018 we spoke to over 600 patients to help us
develop our plans. Patients would always have choice of where they have their care – this is
Moving services would result in less choice for patients. part of the NHS constitution.
Patients also participated in 13 workshops alongside potential service The full report of what we heard from
providers, to develop ideas for how the services could work in future. local residents during the planning of our
There were concerns about the practicalities of separating emergency and We asked specialists in emergency care to look carefully at our plans and
Patients made up 50% of the panel that evaluated the proposed partnerships. planned orthopaedic surgery, such as how staff might work. confirm that these would not undermine emergency care. proposals as well as background to how
these proposals were developed, can be
found at: www.northlondonpartners.org.uk/
orth_consultation
24 25Developing our proposals • The option must demonstrate a favourable
income and expenditure impact for the system
In July 2019 a panel of patients and residents,
healthcare professionals and commissioners What has happened so December 2018
• The JCC approved the principles of how services
January to April 2020
• Consultation: We will ask local people and
collaboratively far and what are the
after two years of operation considered the proposals. They decided that the could work in future and heard feedback from stakeholders their views on the proposals
two options were complementary, that both met the earlier public engagement exercise that have come out of the pre-consultation
In May 2019, NHS Trusts were asked to put
next steps?
the criteria and were better than current services. and business case stages
forward options for the future. Two were received
The proposals in this consultation document were It is this preferred option which forms the basis of January 2019
– both partnerships:
developed in an innovative, collaborative way this consultation. • The JCC reviewed the timeline for next steps,
between the providers of health services in north • North Middlesex University Hospital NHS These are the phases and timeline for the revised governance arrangements and how the Summer 2020
More detail can be found on our website:
central London. Trust and The Royal Free London NHS development of our proposals to change NHS would contract and oversee the services in • The outcome of the consultation and the
www.northlondonpartners.org.uk/orth_
Foundation Trust health services for patients who need planned future development of a decision-making business
Drawing on the feedback from clinicians, consultation
NHS Trust, local patients, stakeholders, and a • University College London Hospitals NHS orthopaedic surgery. case. The NHS will consider the responses to
May 2019 the consultation and decide about progressing
How much would
number of workshops with all of these groups Foundation Trust and Whittington Health
participating, an agreement about how services NHS Trust. 1 February 2018 • The JCC agreed plans for how services might the proposals or changing them. This includes
should look in future (clinical design principles) • The Joint Commissioning Committee (JCC) of look and the process for making decisions on consideration of our equalities impact
it cost?
The trusts who had put together these proposals the five CCGs in north central London, agreed who might provide them, and where they
were developed and agreed by the JCC in assessment and travel analysis.
had looked at all of the options available within that orthopaedic surgery should be reviewed could be
December 2018.
the criteria, and ruled out a number as not being to see if there were opportunities to improve Assurance and implementation from autumn
In January 2019 the JCC agreed that because possible, including: a single centre for north • Hospitals were asked to develop proposals for
We believe that by organising services in a services for local patients 2020 onwards
of the interdependencies with other services - central London; a centre at Whittington Health the future
different way, we would be able to improve care If permission is granted to implement our
particularly emergency care high dependency for planned orthopaedic surgery that required and help more patients. August to October 2018 July 2019 proposals, we would begin to put our plans
provision - that these services should remain an overnight stay; and centre at the North Mid • We undertook an analysis of which patients • A panel made up of local patients and residents, in place.
within the NHS as a variation to contracts. for planned orthopaedic surgery that required an If our proposals were approved, we would could be affected if the service changed in
overnight stay. The Royal National Orthopaedic continue to spend the same amount of money doctors and NHS managers looked at the
In May 2019 the JCC agreed both the essential future Future developments
Hospital chose not to submit a proposal, preferring (around £37 million) on orthopaedic services as hospitals, proposals and agreed the potential
clinical elements of the proposed future service • Local patients, residents and other stakeholders new way in which services would be organised We will continue improve these services in future,
to focus on supporting local hospitals as a super we currently do. By changing the way we deliver
and three key tests which needed to be met: were asked their views on a draft case for in future and maximise the benefits of our proposals, if
specialist centre. orthopaedic services we would make better use of
change: our thoughts on why services needed implemented. We will monitor:
• The provider must already be a provider of this money and improve patient care. Over time,
planned orthopaedic surgery to change and some ideas for the future August to December 2019 • Waiting Times
this new way of working should be able to
save money. • A document called a pre-consultation business • Cancellations
• The dedicated operating theatres and • Patients, doctors, nurses and other NHS staff
case (PCBC) was developed to test proposals, • Length of stay
supporting facilities for orthopaedic care, must took part in five workshops to explore how
You can read more about this on our website: whether they would be affordable and would • Surgical site infection Rates
be located on a site operated by members of services might look in the future
www.northlondonpartners.org.uk/orth_ meet the needs of our communities. The PCBC • Emergency readmission within 30 days
North London Partners in Health and Care consultation takes account of feedback already received from • Revision rates
patients and stakeholders • National patient reported outcome measures
• Friends and family test results to ensure that the
• We worked with NHS England as they tested
proposed changes have been effective.
whether our plans would provide safe and
effective care for patients and would make sure
public money is spent wisely.
26 27How our proposed North Middlesex University Hospital/Royal Free UCLH/Whittington Health Partnership
changes support London Partnership
hospitals in north
central London
Chase Farm Hospital North Middlesex University University College London Hospital Whittington Health
As well as significant benefits (part of the Royal Free London Hospital NHS Trust UCLH is in the process of building a new facility The Whittington’s day treatment centre is a new
for patients, each of the NHS group of hospitals) The North Mid. has a well-established day- on Tottenham Court Road, which will be complete healthcare facility, providing planned surgery for
hospitals in our partnership
The new Chase Farm Hospital was completed in surgery unit and an active A & E department. Our in late autumn 2020. This will contain dedicated NHS patients. The centre has four state-of-the-art
would see other benefits as a proposals will improve bed capacity at the hospital facilities for planned orthopaedic surgery, as well operating theatres and provides orthopaedic day
July 2018 and is at the forefront of pioneering new
result of our proposals. ways of working to deliver better, safer and more and therefore minimise cancellations for a range of as a new proton beam therapy for cancer patients surgery for patients in north central London.
efficient care to the local population. The addition care that the Trust offers patients. and a centre for the treatment of blood disorders. These proposals would widen access to this
of a dedicated orthopaedic operating theatres modern facility.
would make even better use of the investment
made by the NHS.
28 29How to feed How to give your views How will a final decision Complaints
There are several ways to join in this consultation Timescales for post-consultation decision-making,
and give us your views on the proposals which subject to the volume and content of responses
be made?
back on our
include completing the consultation questionnaire, received: If you have a complaint relating to the way
We want to receive the views of as many patients, attending one of our meetings or drop-ins in which this consultation is being managed
residents, staff and partners as possible to inform or writing to us with your own feedback or This consultation will start on 13 January and May 2020
please contact the North and East London
proposals
our plans during our public consultation – running proposals. finish on 6 April 2020 (subject to volume and Stakeholders will have the opportunity to
Commissioning Support Unit (NEL CSU) Patient
between 13 January and 6 April 2020. content of responses). This consultation period comment on the draft report of the consultation
Experience and Effectiveness Team, which is an
All feedback will be evaluated by Participate may be extended if it would be helpful to hear evaluation together with the review of the
Taking into account your views, as well as other NHS organisation who manage the complaints
Ltd, an independent company who have been more views. The phases of the programme will equalities impact assessment.
evidence for service change and value for public process on our behalf.
engaged to receive and evaluate feedback depend on what decisions are made at several key
money, commissioners will decide whether the regardless of how it is submitted. June 2020
stages but the following outlines what the timeline They can be contacted on 0203 688 1666 or by
proposals should proceed to the next stage of The evaluation of responses, feedback from
may look like: email: nelcsu.complaints@nhs.net
planning. We would like to hear your views on: Please let us know your comments and views on stakeholders and impact assessments will be
these proposals by completing the consultation 9 January 2020 shared with the Joint Health Overview and NEL CSU will retain personal information for the
• Whether we have developed the best possible questionnaire and returning it in the post using Scrutiny Committee (JHOSC). purpose of this complaint investigation only. In
solution to the current challenges in providing Joint Commissioning Committee of the five
the Freepost address provided. NCL CCGs to be asked to i) approve the pre- order for us to make improvements to the services
planned orthopaedic surgery for those who June 2020
consultation business case and ii) consider the you receive, anonymous information about your
need it in north central London, as described in You can also complete the consultation questions A decision-making business case (DMBC) will be
decision to move to a public consultation. complaint may be shared as part of our reporting
this document using our online survey at: developed outlining the recommended decision
process. Should you have any concerns with this,
www.northlondonpartners.org.uk/orth_ 13 January 2020 as a result of the consultation evaluation, impact
• Are we doing all we can to ensure that services please contact us on: nelcsu.complaints@nhs.net
consultation Public consultation starts (12 weeks) assessments and feedback from the JHOSC.
are of the best quality
Information on how to make a complaint
• In developing our proposals, are we doing the If you attend any of the public meetings or drop-in 6 April 2020 June/July 2020
can be made available in other languages, on
right things to ensure everyone who needs care events, your views will also be captured and fed Consultation finishes Patients and NCL CCG will have the opportunity
audio cassette or CD, in large print, Braille and
can access it in a timely way into the evaluation. to review the evaluation together and discuss any
in illustrated format. Interpreters can also be
April/May 2020 implications. The final DMBC presented to NCL
arranged, including sign interpreters. Please
“We want to receive the
• Whether there are more things we could do to Following consultation, all responses from CCG for decision (TBC).
make services responsive and tailor them for contact us if you need this support:
members of the public and local organisations will nelcsu.complaints@nhs.net.
views of as many patients,
those with specific needs be independently evaluated and a draft report July to November 2020
produced. Assurance of implementation plans and trust
We are also interested to receive alternative
residents, staff and
internal governance processes.
proposals to the solutions we have laid out
in this document. After 1 April 2020 there will be a single CCG for
partners as possible to north central London.
inform our plans”
30 31You can also read
