Orthopaedic surgery

We want you to tell us what you think about our preferred change proposal to develop:

• A ‘centre of excellence’ in Lincolnshire for planned orthopaedic surgery at Grantham and District Hospital, along with
• A dedicated day case centre at County Hospital Louth for planned orthopaedic surgery​​

Orthopaedic surgery relates to planned surgery (e.g. hip and knee replacements) and unplanned surgery (e.g if a patient has been involved in an accident).

Planned surgery can be provided:

• As a ‘day case’, where the patient is admitted to and discharged from hospital following their surgery on the same day; or
• As an ‘inpatient’, where the patient stays in hospital overnight after their surgery

In August 2018 the orthopaedic surgery service provided by United Hospitals Lincolnshire NHS Trust (ULHT) became part of a national orthopaedic pilot to look at how service quality and patient outcomes could be improved.

Prior to the pilot beginning, planned and unplanned orthopaedic surgery was carried out at three hospital sites; Lincoln County Hospital, Pilgrim Hospital, Boston and Grantham and District Hospital. In addition, planned orthopaedic surgery was provided from County Hospital Louth.

Under the pilot all unplanned orthopaedic surgery is now carried out at Lincoln County Hospital and Pilgrim Hospital, Boston, and as much planned orthopaedic surgery as possible is carried out at Grantham and District Hospital.

​​​​​Lincoln County Hospital and Pilgrim Hospital, Boston continue to provide some planned orthopaedic surgery for high risk patients with multiple health problems, which is comparatively small in volume.

In addition, throughout the pilot Louth hospital has focused on day case planned orthopaedic surgery.

A summary of orthopaedic surgery provision prior to the pilot changes and after the pilot changes in August 2018 (pre COVID-19) is set out above.

This section sets out the challenges and opportunities for orthopaedic surgery and what we hope to achieve by making changes.

Challenges (pre pilot)

• A lack of ‘protected’ planned orthopaedic surgery beds across United Lincolnshire Hospitals NHS Trust (ULHT) meant that the high volumes of medical emergencies experienced all year round resulted in fewer beds being available for planned orthopaedic surgery
• On average, around 10 patients each month had their planned orthopaedic surgery cancelled on the day of surgery due to a lack of beds. This is a very poor experience for patients and their families
• Failure to consistently meet nationally set referral to treatment time targets – limited separation of planned and unplanned orthopaedic surgery made attainment and sustainment of the target a challenge
• The orthopaedic service had high doctor and nurse vacancies
• Over 3,000 patients from Lincolnshire each year received a planned orthopaedic procedure in the private sector (funded by the NHS), much of which took place outside of Lincolnshire. This is because sufficient capacity is not available in the NHS locally. The money that is spent with these private providers could go towards the delivery of local NHS services

Opportunities

By making changes, we can look to ensure:

• Improvements in the quality of patient care and outcomes evident during the pilot become permanent
• Reductions in the number of patients who have their planned orthopaedic surgery cancelled on the day due to lack of beds
• Reductions in the time patients wait for their planned orthopaedic surgery is reduced, so they are treated quicker
• Best practice for the length of stay for patients in hospital after surgery
• Overall patient experience and satisfaction is improved, including reducing the amount of time spent in hospital after surgery
• More Lincolnshire patients choose to have their orthopaedic surgery in Lincolnshire
• The number of patients going to the private sector for planned orthopaedic surgery, paid for by the local NHS, is reduced
• The need for temporary staff to cover vacancies is reduced
• The orthopaedic service is able to attract and retain talented and substantive staff to build an effective, high quality, successful team
• Orthopaedic services are provided to Lincolnshire’s patients in line with national best practice and care standards

There has been ongoing engagement with the public throughout the Lincolnshire Acute Services Review programme, particularly through the ‘Healthy Conversation 2019’ engagement exercise.

Some consistent themes in relation to orthopaedic surgery have been shared by the public and stakeholders throughout our engagement to date:

• Acknowledgement of the problems with the current situation e.g. the number of cancelled operations and the number of patients travelling out of county for treatment
• The principle of separating planned and unplanned care is considered sensible if it will enable a reduction in the number of cancelled operations and allow staff to become more specialist
• A desire for information about where any planned and unplanned sites would be located, and to better understand how different sites would be utilised in future if services changed
• Concerns about the distances needed to be travelled, with the transport infrastructure and rurality identified as major challenges. The ability for family members to visit the patient was also seen as important
• The process of being discharged from secondary care, specifically the link between ‘bed blocking’ and the cancellation of planned operations, and the need to improve ‘step down’ care and integrate more closely with social care
• Working with existing resources by making use of our smaller hospitals as diagnostic treatment centres
• We have consistently taken into account all of the public and stakeholder feedback throughout our work
• In addition to the feedback received through our engagement exercises, the orthopaedic surgery pilot has sought feedback from its patients.
• The overarching theme from the patient experience and feedback is how impressed and happy people are with the level of care and treatment received from all staff involved. Just prior to the onset of COVID-19, 95% positive feedback was achieved in the NHS Friends and Family Test (a post treatment survey)

Our proposal for change (which reflects the pilot arrangements) is to establish a ‘centre of excellence’ in Lincolnshire for planned orthopaedic surgery at Grantham and District Hospital, and a dedicated day case centre at County Hospital Louth. Outpatient clinics would be unaffected.

This would mean Grantham and District Hospital would not provide unplanned orthopaedic surgery.

Lincoln County Hospital and Pilgrim Hospital, Boston would continue to provide unplanned orthopaedic surgery, and some planned orthopaedic surgery for high risk patients with multiple health problems, which is comparatively small in volume.

It is anticipated the change would affect on average:

• Between 3 and 4 patients a day for planned orthopaedic surgery, these patients would receive treatment at either Grantham and District Hospital or Louth hospital; and
• Around 1 patient a day for unplanned orthopaedic surgery, these patients would have previously received care at Grantham and District and would now be treated at a different site

If more planned orthopaedic surgery capacity became available at Grantham and District Hospital and County Hospital, Louth, more patients could be seen at these sites and benefit. This includes seeing more of the patients who receive their planned care in the private sector (much of which takes place outside of Lincolnshire) paid for by the NHS.

A key part of our evaluation of options to tackle the service challenges, was to hold a clinically led health system stakeholder workshop and four workshops with randomly selected members of the public.

For orthopaedic surgery, where only one solution remained following the shortlisting of options, attendees at these workshops were asked whether they agreed or disagreed that the changes proposed would help to improve the current situation and meet the challenges identified.

The table below summarises the level of stakeholder and public support for the change proposal.

As we have developed our proposals we have considered the quality and equality impact of the preferred option for orthopaedic surgery.

We have also benefited from the evidence collated through the pilot (pilot evaluation is based on data for the period August 2018 to February 2020).

Through our equality impact assessment we identified three groups of people, two of which are defined by protected characteristics that may be more likely to be impacted, positively or adversely, by this proposal.

These three groups are age, disability and those who are economically disadvantaged.

Our observations from the pilot evaluation and these assessments are set out below. We will continue to review and develop these, including the impact on different groups of people within our population, with independent support, through our public consultation in light of the feedback we receive.

Potential positive impacts

 Evaluation of the pilot pre COVID-19 identified:

• A reduction in waiting times for planned orthopaedic surgery, which means patients were getting treated quicker
• Cancellations on the day of planned orthopaedic surgery due to a lack of beds reduced:
  • From 10 a month to 3 a month across United Hospital Lincolnshire NHS Trust (ULHT)
  • To 0 at Grantham and District Hospital
• Length of stay reduced:
  • From 2.9 days to 2.3 days across ULHT
  • From 2.7 days to 1.7 days at Grantham and District Hospital
• ULHT performed better than many other hospitals in terms of the length of time patients stayed in hospital after their planned surgery
• An improvement in overall patient experience and satisfaction. In February 2020 a score of 95% was achieved in the ‘Friends and Family Test’
• The number of patients going to the private sector for planned orthopaedic procedures, funded by the local NHS, reduced
• The pilot workforce model successfully removed the need for temporary staff to cover vacancies, and the service is more attractive to junior doctors which supports long term service sustainability

• Receiving planned orthopaedic surgery at Grantham and District Hospital or County Hospital Louth, would mean treatment is received at an alternative hospital site for some patients (3 to 4 a day on average).
• As the pilot has demonstrated, these patients would receive high quality care and outcomes; however it is acknowledged that needing to travel further for this care may be seen as an adverse impact by some people.
  • Of those receiving planned orthopaedic surgery at an alternative hospital site it is estimated around 1 a day, on average, will travel more than 75 minutes by car for their surgery, the threshold agreed by the local health system for this type of activity
  • The friends and family of those patients receiving treatment at an alternative hospital, may have to travel further to see them
• For those patients who were previously admitted to Grantham and District Hospital for unplanned orthopaedic surgery (around 1 a day on average), care would be received at an alternative hospital site
• These patients would receive the specialist input they need at the right time, in the right setting; however it is acknowledged that needing to travel further for this care may be seen as an adverse impact by some people.
  • Of those receiving unplanned orthopaedic surgery at an alternative hospital site it is estimated none will travel more than 60 minutes by car for their surgery, the threshold agreed by the local health system for this type of activity
  • The friends and family of those patients receiving treatment at an alternative hospital, may have to travel further to see them​​​​​