What could services look like in the future, and how might they be delivered?
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
- 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
The overarching workforce approach in this model of care is that orthopaedic surgeons will remain employed by their existing base hospital; with a job-plan including both elective and emergency care. For surgeons at base hospitals, their current elective surgical commitments would move with them to the elective centre.
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 has been approved at the Joint Commissioning Committee meeting on 2 May 2019. 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.