Orthopaedics & ENT - June 2017

In the summer of 2017, we consulted patients in Liverpool, Sefton and Knowsley about a proposed reconfiguration of Liverpool's hospital-based Orthopaedic and Ear, Nose and Throat (ENT) services for adults. 

You can find out more by watching this short film here:

 

  

The findings from the consultation can be viewed here and further background information which was published during the consultation can be found below.

The consultation outcomes are currently being considered and further updates will be available shortly.

 

Key Documents

Orthopaedics Feasibility Study (downloadable Word Document, 9MB)

Map showing travel times to Aintree Hospital (PDF)

Map showing travel times to Broadgreen Hospital (PDF)

Map showing travel times to Royal Liverpool Hospital (PDF)

Orthopaedics & ENT Booklet (PDF)

Easy read version of consultation information (PDF)

Frequently Asked Questions (June 2017) 

Why do orthopaedic services need to change?

Doctors have identified a number of reasons why these services need to change:

  • To make the most of Liverpool’s orthopaedic expertise:There is strong evidence that orthopaedic patients receive better care when they are treated by a doctor who specialises in their particular condition, and who carries out a procedure more regularly. Currently, Liverpool’s orthopaedic services are delivered by two separate teams in two different hospital Trusts, across three sites, which reduces opportunities to bring expertise together for the best possible care.
  • To meet existing clinical guidelines for the best orthopaedic care:‘Getting it Right First Time’, a national review of planned (elective) orthopaedic services for adults, made a number of recommendations for improving care; not all of these are possible under current arrangements at Aintree and the Royal Liverpool & Broadgreen. These recommendations include ‘ring-fencing’ hospital beds so that they can only be used for people undergoing planned – rather than unplanned – care, to reduce the risk of infection.At certain times, particularly over winter when hospitals receive more emergency admissions, it can be difficult to maintain this ring fence currently.”
  • To meet new clinical standards and protect local services:New national standards for specialised orthopaedic services are expected soon. We anticipate that current orthopaedic services at Aintree and the Royal Liverpool & Broadgreen will be unable to meet all of these new standards, along with many other orthopaedic services nationally. This means that people won’t always receive the best possible orthopaedic care. It also means there is a risk that in the future some specialist services might be moved to other hospitals outside of Merseyside that can meet these standards, if we do nothing.
  • To make sure that services are value for money:At the moment, two separate orthopaedic services are run by two separate hospital Trusts, across three site, in the city. This means there is some duplication, which creates unnecessary waste. The NHS needs to make sure services are efficient if it is to protect them for the future.
  • To make sure that the right staff are in the right place:All hospitals need to make sure they have the right number of doctors and nurses with the right skills, so that care is safe and of high quality. Aintree is the Major Trauma Centre for Cheshire and Merseyside, meaning it receives seriously injured people from across the region, so it also has to follow additional guidelines for safe staffing numbers. Making sure that there are enough doctors to cover orthopaedics rotas is increasingly difficult. Demand for local orthopaedic services has been steadily increasing, and is expected to continue to rise as the population ages. Working in a different way would be an opportunity to find better ways of dealing with this demand, both now and in the future.

What is being proposed for orthopaedics?

Orthopaedic specialists from both Aintree and the Royal Liverpool & Broadgreen believe that in the future they should operate as a single team, working across all three hospitals, rather than continuing to work as separate teams. This is known as the ‘preferred option’.

This proposal involves separating the majority of planned and unplanned operations and procedures so that they happen on different sites. At the moment, most people needing planned orthopaedic operations or procedures go to either Aintree or Broadgreen. Under this proposal the majority of planned orthopaedic care in Liverpool would instead take place at Broadgreen. This, in turn, would allow Aintree to focus on caring for people who need un-planned operations straight away, for example after a car accident or a bad fall.

As Aintree is the Major Trauma Centre for Cheshire and Merseyside, ambulances already take the most seriously injured people there directly (this applies to all types of injuries, not just orthopaedics). In Liverpool, people with less serious injuries are currently taken to the Royal Liverpool, if that is nearer than Aintree. Under these proposals, ambulances would take all orthopaedic injuries – not just the most serious – to Aintree, even if the Royal Liverpool was nearer. People could still visit the accident and emergency (A&E) department at the Royal Liverpool themselves if they had an orthopaedic injury that needed urgent attention, but if once they were assessed it was decided that they needed an operation they would be transferred to Aintree.

Outpatient services are those which don’t require a hospital bed. All orthopaedic outpatient services, including preoperative care (the care you receive ahead of having an operation), and follow-up appointments and treatment would continue at all three hospitals, which would mean that most care would still take place as close to people’s homes as possible.

This proposal does not include inpatient spinal services which take place at the Royal Liverpool.

Why can’t orthopaedics move without impacting on ear, nose and throat (ENT), general surgery or urology?

Moving all planned orthopaedics procedures from Aintree to Broadgreen would mean that extra operating theatres would be needed at Broadgreen. Currently, ENT services use three theatres at Broadgreen – for the preferred option to go ahead this space would be needed for orthopaedics. However, moving ENT services from Broadgreen to Aintree would bring benefits for ENT too as Aintree is a regional centre of excellence for head and neck care.

Similarly, moving urology services and general surgery services from Broadgreen to the new Royal Liverpool Hospital would put them in the same location as related services, for example the new Clatterbridge Cancer centre which is due to open next to the new Royal in 2019. 

Has a decision about what will happen to orthopaedics and ENT already been made?

No. Doctors have developed proposals for how these services could be delivered in the future, including a ‘preferred option’, but now we need to gather the public’s views on what is being proposed. The public consultation is an important stage of the process and no final decisions will be taken until it has taken place. 

Who has been involved in developing the orthopaedics proposals?

This has been a clinically-led process - the work to improve services was initiated by orthopaedics doctors from Aintree University Hospital and the Royal Liverpool & Broadgreen University Hospitals, and during the last 18-months a range of staff involved in delivering orthopaedic care have been involved in developing the proposals.

This process first involved looking at what was needed from a clinical perspective, before considering what resources were available within the existing workforce, what could be achieved financially, and what would best support national best practice and standards.

Would these proposals affect all types of orthopaedics care?

The proposals to focus planned orthopaedics care at Broadgreen Hospital and unplanned orthopaedics care at Aintree Hospital only apply to in-patient care (where a hospital bed is needed). If the proposals went ahead, all pre-operative care (the care you receive ahead of having an operation), and follow-up appointments and treatment, would continue to be delivered across all three hospital sites at Aintree, Broadgreen and the Royal Liverpool, ensuring that the majority of orthopaedic care can be delivered as close to home as possible for patients.

What impact would the proposals have on the quality of care that patients receive?

Under these proposals, orthopaedic services would be able to meet more clinical standards for improving patient care, and ENT patients would benefit from access to more specialist care by being treated at Aintree Hospital, which is a regional centre of excellence.

There is strong evidence that specialist services are better concentrated in fewer centres, where medical staff will see more patients with the same condition. This way of working is linked to better results for patients because doctors, nurses, and other clinical staff get better at doing things when they do them more often.

What about patients who have complex care needs?

Planned orthopaedic procedures for higher risk patients with very complex health needs currently take place at Royal Liverpool Hospital or Aintree, where they also have rapid access to more specialist support – should they need it. Each patient is assessed on a case by case basis as part of their pre-operative care to identify any risk factors, and whether they might need more specialised care. Under these proposals, any patients with complex care needs would receive their care at Aintree so they would continue to have access to this specialist support.

Why are spinal services not part of this consultation?

The majority of spinal services are specialised services commissioned by NHS England (in the NHS, ‘commissioning’ is the process of planning and buying health services), rather than local clinical commissioning groups, and while they are connected to orthopaedic services they are also part of neurological services.  Discussions about future options for these services are currently taking place with the hospitals who provide them, NHS England and local commissioners (clinical commissioning groups). 

Why might services move to hospitals outside of Merseyside if change doesn’t happen?

New national standards for specialised orthopaedic services are currently being developed, and it is expected that these will be published soon. Specialised services are those provided in relatively few hospitals, accessed by comparatively small numbers of patients but with catchment populations of usually more than one million. These services are commissioned by NHS England (in the NHS, ‘commissioning’ is the process of planning and buying health services). Increasingly, they are being concentrated in fewer centres, which do greater volumes of work and can meet higher standards. Local doctors anticipate that current orthopaedic services at Aintree and the Royal Liverpool & Broadgreen will be unable to meet all of these new standards, along with many other orthopaedic services nationally. This means that if things don’t change there is a risk that in the future some specialist services might be moved to other hospitals outside of Merseyside that can meet these standards. 

Is this about saving money?

These proposals are about making services better for patients, and the process has been led by local doctors looking at ways to improve care. Although working as a single team – rather than two separate teams – would reduce duplication and present opportunities to be more efficient, this work is not being driven by the need to save money. In fact, for these proposals to go ahead there would need to be an initial investment to upgrade operating theatres. 

How much would these proposals cost?

Putting these changes into place is expected to cost around £2.3 million. This would be a one-off cost which would mainly come from upgrading operating theatres.

In the longer term, it is expected that running a single service will present opportunities to save money, for example through improved efficiency, better procurement (the buying of goods and services), and less need for agency staff.

Why is it better to have fewer hospitals offering particular types of care? Surely it’s better for patients if they can have their planned operation at either Aintree or Broadgreen?

Evidence tells us that care is better when doctors and other medical staff do the same procedures more regularly. By having Broadgreen focus on planned care, while Aintree focusses on unplanned care, doctors would see more people with the same condition. This is about making sure that people are treated by the specialist best able to meet their particular needs. Spreading out expertise between a greater number of sites makes this harder to achieve.

How will this impact on travel times?

Under these proposals, in most cases, Aintree would no longer carry out planned orthopaedic operations. This means that some people might have to travel further to receive their in-patient care. Equally, people taken to Aintree with orthopaedic injuries might be further from home than if they had been transported to the Royal Liverpool.

If inpatient and day case ear, nose and throat (ENT) services moved to Aintree from Broadgreen, some people using these services would also need to travel further for their care. Although we can’t know the home locations of all future patients, we have used referral information from GP practices in Liverpool, Knowsley and south Sefton to understand more about the impact that these changes might have on patient journeys. This indicated that if the preferred option was chosen, 59% of patients attending for inpatient or day case surgery would either travel the same distance or less for their care than they would currently; 41% of people would have to travel an average of an extra 2.3 miles to access services.

This would only apply to the operation itself, as the preoperative care (the care you receive ahead of having an operation), and follow-up appointments and treatment would continue to be delivered at Aintree, Broadgreen and the Royal Liverpool.

The questionnaire for the public consultation includes questions about travel. People are encouraged to share their views so that they can be considered as part of the decision-making process. 

If the proposal went ahead would it mean jobs being lost?

These proposals are about making what we have better, and using resources – including staff – in a more effective way, which improves patient care. There are no plans to reduce the number of staff. Equally, bringing teams from two hospital Trusts together would create a bigger service which would be more attractive to potential staff as it would present more opportunities. 

Why do two hospital Trusts need to create a single team? Can’t you just work closer together?

Orthopaedics teams at Aintree and the Royal Liverpool & Broadgreen already work closely together – and these proposals have developed as a result of this partnership – however doctors believe that this has been taken as far as it can while they remain two separate teams. 

How many people would be affected by these proposals?

In 2015/16, there were a total of 3,300 planned inpatient (elective) admissions for orthopaedics across Aintree and the Royal Liverpool & Broadgreen (this doesn’t include planned spinal admissions, which are not part of this proposal). There were also 6,395 day case admissions. This makes 9,695 planned admissions in total. Over the same period of time there were 3,634 admissions for orthopaedic trauma – this means they were unplanned, perhaps as the result of an accident or fall.

Have you considered other options?

A number of other potential solutions were considered for orthopaedic services, but when they were assessed none scored as highly as the preferred option. Details are set out in the consultation booklet.

For ENT, doctors agreed that, other than the preferred option, there are no other options that could be identified for their service, other than the ‘do nothing’ option of leaving inpatient and day case services at Broadgreen.

If these proposals go ahead which other services might come together in the same way?

Since early 2016, as part of Healthy Liverpool, we’ve talked about bringing teams from different hospitals in Liverpool together, to provide single services for things like cancer, stroke and cardiology. In conversations with the public, the majority of people supported the idea of reviewing services to look at the benefits of specialist teams working closer together. Orthopaedics is the first service to go out to formal public consultation; we’ll share more information about other services when those proposals are ready.

The work on single services is also linked to discussions taking place between Aintree University Hospital NHS Foundation Trust and the Royal Liverpool & Broadgreen University Hospitals NHS Trust about how they might become a single organisation in the future. A single orthopaedics service would help pave the way for closer working between other teams at Aintree and the Royal Liverpool & Broadgreen. In the future we could also see more care and treatment happening outside of hospital, closer to people’s homes, with hospital specialists working in partnership with GPs and other services to share skills and provide the very best care.

What happens next? When will a final decision be made?

A 12-week public consultation is running from 26 June to 15 September so that we can gather views about these proposals.

Once completed, all of those views will be drawn together into a final report with recommendations. We will share this later in the year, along with further details about the next steps being taken and timescales.

Who makes the final decision?

A final decision will be agreed by the Boards of both Aintree University Hospital and the Royal Liverpool & Broadgreen University Hospital, with approval from NHS regulators, local commissioners (clinical commissioning groups) and local authorities.

Do these proposals affect orthopaedic services at Southport & Ormskirk or any other local hospitals?

These proposals only relate to services provided at Aintree University Hospital and the Royal Liverpool & Broadgreen University Hospitals.

The consultation document talks about the need to meet new and existing standards – what are these?

In 2012 Professor Tim Briggs published the ‘Getting it Right First Time’ report into orthopaedic surgery in England. This was built upon in 2015 by a national review of adult elective (planned) orthopaedic services in England, which involved a national pilot funded by NHS England. You can read more on the British Orthopaedic Association’s website: https://www.boa.ac.uk/pro-practice/getting-it-right-first-time/. The report identified widespread variation in orthopaedics practice across the country, and made a series of recommendations for improving care. Current orthopaedic services in Liverpool meet some but not all of these recommendations; local orthopaedic doctors believe that the preferred option would allow all of these recommendations to be met.

In addition to the Getting It Right First Time guidance, work to set out new national standards for specialised orthopaedic services has recently been taking place, and it is expected that these will be published soon. Specialised services are those provided in relatively few hospitals, accessed by comparatively small numbers of patients but with catchment populations of usually more than one million. These services are commissioned by NHS England (in the NHS, ‘commissioning’ is the process of planning and buying health services). Increasingly, they are being concentrated in fewer centres, which do greater volumes of work and can meet higher standards. Local doctors anticipate that current orthopaedic services at Aintree and the Royal Liverpool & Broadgreen will be unable to meet all of these new standards, along with many other orthopaedic services nationally. Not only does this mean that our hospitals aren’t able to offer the very best standards of care, it also means that if things don’t change there is a risk that in the future some specialist services might be moved to other hospitals outside of Merseyside that can meet these standards. 

Why does using beds for both planned and unplanned care increase the risk of infection?

Patients undergoing planned surgery such as a knee or hip replacement wouldn’t usually be able to have that surgery if they had, for example, a chest infection. Some illnesses increase the normal risks of being put under anaesthetic, and there would also be a risk to other patients on the same ward, so the procedure would be postponed until they were well. Although beds for elective – or planned – care are normally only used for these patients – at times when a hospital is receiving a greater number of patients this arrangement might be suspended so that all beds can be used. This can be a particular issue in winter, when the NHS is generally under greater pressure, and more people are admitted as an emergency. Admitting patients receiving unplanned care into wards normally used for planned care means there is a greater risk of infection being introduced into wards. As people undergoing operations are more vulnerable to this, often these operations are cancelled as a result. If planned care took part on a separate site – Broadgreen – as is proposed in the preferred option, this wouldn’t happen as the hospital does not have an accident and emergency department and unplanned admissions don’t go there. 

 

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