North London Partners in health and care

Review of adult elective orthopaedic services

We are reviewing Adult Elective Orthopaedic Services

In 2016/17, north central London hospitals carried out over 23,000 adult elective orthopaedic operations across 10 sites. Adult elective orthopaedic surgery is planned (non-emergency) surgery of bones and joints, such as hip and knee replacements. 

We think there may be opportunities to improve adult elective orthopaedic surgery in north central London by consolidating services onto fewer sites and we are undertaking a review of these services to see if these improvements can be achieved.

Our review was launched, following agreement at the NCL Joint Commissioning Committee meeting on 1 February 2018.  It has been established by North London Partners in health and care

The review has had extensive clinical involvement with nurses, doctors, surgeons, physiotherapists and other allied health professionals - alongside members of the public - involved in shaping how this kind of care could be delivered in the future. Our thinking is presented in our draft case for change.

A Programme Board made up of all key stakeholders is overseeing the work of the review.  Clinical commissioners in Barnet, Camden, Enfield, Haringey and Islington will make the final decisions on where and how future services are shaped.

Engagement on the draft case for change

In our engagement phase from August 2018 to October 2018 we invited written feedback via our online questionnaire, email and in writing.  We also worked with NHS colleagues at CCGs, local hospitals, other healthcare providers and voluntary sector partners to promote the opportunity to feed back.  We attended community events in all five boroughs and co-hosted a number of open public meetings.  In total we talked to over five hundred people and reached out to thousands more via social media.  The feedback we received has been independently evaluated, and what we heard informed the next steps of our review. 

We formally fed back the evaluation of our engagement and our thinking to the Joint Commissioning Committee of the five NCL CCGs in December 2018 and January 2019.  You can read more about what was taken to these committees, and see copies of the reports on our engagement phase feedback page.

Design principles and contract form 

What could services look like in the future, and how might they be delivered? 

Adult Elective Orthopaedic Review

A number of design principles were shared with the Joint Commissioning Committee December 2018, these were drawn from the outputs of a number of clinical design workshops.  These principles will act as our guide to how services could be delivered in the future.  These are:

  • Differentiation of ‘levels or tiers’ of service at different hospitals
  • Partnership approach with all hospitals being seen as a ‘base’ hospitals with a stake in an elective centre
  • Staffing model with clinical staff working into the unit from the local trusts, particularly surgeons following the patient to the elective centre and providing continuity of care
  • All pre-operative and post-operative outpatient care to stay at base hospitals (i.e. as at present)
  • Paediatrics, trauma, spinal surgery to stay at base hospitals (i.e. as at present). For paediatrics the base hospital would act as a filter, with complex referrals continuing to go to GOSH and RNOH
  • Multi-disciplinary team working to be a core component of the model – need to develop expectations about how this would operate. Noted that there should be opportunities to do some of this virtually.
  • High dependency Unit – elective centre needs to be able to manage a range of conditions and complexity, to do this they will require appropriate back-up medical services and step-up care.

These emerging design principles create the backbone of a service that in order to deliver high value quality outcomes for patients needs to be embedded within the operation of wider and interdependent NHS services, specifically the requirement for:

  • HDU support at sites with an elective centre;
  • staff working between the base hospital and elective centre(s) – specifically clinical staff delivering elective orthopaedic services would need to continue to have job plans that include trauma lists and elective lists, and to work between base hospitals and elective centre(s) to deliver this range of activity;
  • and Multi-disciplinary working across sites.

The partnership model, described in the design principles, is the model that is successfully operated in South West London (SWLEOC), underpinned by a financial partnership agreement.

Being able to manage trauma activity is a vital component of any hospital running an emergency department. There is a very real risk that a delivery model that does not include integrated clinical teams who deliver elective and trauma services would undermine what are already fragile emergency services across north central London.

All these considerations have led to the conclusion that it would not be possible to deliver the establishment of adult elective orthopaedic centre(s) as a standalone service. At their 3 January 2019 meeting the Joint Commissioning Committee therefore made the decision that in taking forward the second stage of the review, and any options appraisal, the services should remain within the NHS by way of variations to existing annual contracts.

The detailed clinical delivery model will need is being finalised and it is intended that this will go to the Joint Commissioning Committee meeting on 2 May for approval. In developing the final clinical delivery model and options appraisal process, the CCGs will refer to and document their considerations around the requirements of the NHS (Procurement, Patient Choice and Competition) (No 2) Regulations 2013.

Next steps

The clinical delivery model will be reviewed and agreed at the JCC in May.  Following this, potential providers of the service will be invited to make proposals about how they might deliver the service in future.   Over the summer an options appraisal process will determine the final options for consultation.   Our current plan is to consult in Autumn 2019, however timelines may be adjusted in response to the unfolding process. 


Download the draft case for change

Download a large print version of the draft case for change

The draft case for change document contains links to a series of illustrative graphs and tables hosted on our website. If you read the case for change on your computer or device, the link will take you to the relevant graph or table.

However, if you intend to print the draft case for change, you should also print the accompanying graphs and tables.

If you would like a printed version of the document sending to you in the post please contact us at , including your full name and address in the email.  

If you have questions or comments please 

You can read the papers presented to the North Central London (NCL) Clinical Commissioning Committee meeting on 1 February 2018 here.

If you have any concerns or feedback about any specific personal orthopaedic treatment you have already received, or you are waiting to receive, please speak to your GP or the hospital who provided this service.