Trauma and orthopaedic reconfiguration

We need to make changes so we can:

• provide on-site, orthopaedic consultant cover seven days a week for major trauma work (for example fractured hips following a fall or broken bone injuries that require an operation and stay in hospital)
• provide dedicated staff, beds and theatre time for urgent trauma operations to reduce delays for patients
• create a centre of excellence for hip and knee joint surgery (known as arthroplasty)
• significantly reduce the number of patients whose operations are postponed due to emergencies, particularly in the winter months, by separating it from urgent trauma and surgical work which often has to be prioritised over non-urgent (routine) operations
• reduce the waiting times for planned (elective) orthopaedic operations as a result of less operations having to be postponed and re-scheduled
• reduce the time frail elderly people are in hospital following orthopaedic trauma operations, through dedicated rehabilitation therapy and specialist ortho-geriatric doctors and specialist nurses.
• Improve outcomes for patients being treated for a hip fracture (often called a fractured neck of femur)
• respond to recommendations made by the National Clinical Director of Clinical Improvement (Professor Tim Briggs) that were made following a review as part of the ‘Getting it Right First Time’ programme
• Continue our plans to have services local where possible, whilst centralising services where necessary (for example where it is clinically appropriate or a specialist requirement).

The key elements of our proposed new service model are listed below.

• Trauma patients whose injury requires an operation and stay in hospital would be re-directed from Royal Hampshire County Hospital (RHCH) for treatment in Basingstoke and North Hampshire Hospital (BNNH), as it is already a level 2 trauma centre, or an alternative acute hospital with the right specialist consultant capability and capacity.
• Trauma and orthopaedic consultants will be available at BNNH seven days a week specifically to see and treat trauma patients, with ring-fenced beds and theatre time.
• Arthroplasty patients will be treated at RHCH, where a dedicated centre of excellence unit will be developed. This change may be phased to allow time for additional bed and theatre capacity to be available.
• Elderly frail patients will receive treatment for fractured hips at BNNH and then have their inpatient rehabilitation service in The Firs with additional ortho-geriatric support and advanced nurse specialists to enhance their rehabilitation and reduce the time they spend in hospital.
• Trauma and orthopaedic consultants will still be on-site at RHCH five days a week, and there will be provision for on-call cover for inpatients and the emergency department when it is needed at night and weekends.
• Patients will still be treated in both Winchester, Basingstoke and Andover for minor trauma that doesn’t require a stay in hospital (including simple fractures and sprains requiring a splint or plaster cast).
• Patients will still be able to have their outpatient and follow-up appointments at Andover, Basingstoke or Winchester .
• Rehabilitation services will still be available for patients at Andover, Basingstoke and Winchester.
• Planned operations, except for hip and knee replacement, will still be carried out at Winchester and Basingstoke.
• There will still be an Emergency Department at BNNH and an Emergency Department at RHCH.

We would like to start testing the service model in parallel with wider engagement this winter, ideally starting in December 2019.

Our extensive engagement around the concept of a critical treatment hospital showed that there is public and stakeholder support for the principle of centralisation of acute services.

The principle of centralising some services is already in place for patients in need of cardiology (centralised in Basingstoke) and stroke care (centralised in Winchester).

Centralisation of trauma and orthopaedic services has already been successful in many other Trusts, including Cheltenham and Gloucester, East Kent and the United Lincolnshire Hospitals.

While there is a case for a complete hot / cold split (with all trauma done in one hospital and all elective (planned) operations done in a separate hospital), additional work and engagement has already shown that this will not be possible without the significant investment of a new hospital building, which is not financially viable. We have therefore refined the service model to propose an option that will enable as much specialist centralisation as is practical (in line with recommendations from NHS England’s Director of Clinical Improvement, Professor Tim Briggs, the NHS long term plan and our clinical strategy) whilst still retaining local services where possible.

We are currently consulting with our staff and updating our practical operational procedures so we can be very clear about how we will see and treat the patients whose pathway into our trauma and orthopaedic services will change. We hope to have completed this work by early December so we can, ideally, start using the new service model before Christmas.

In practical terms, this means that:

• ambulances will take trauma patients who need an operation and stay in hospital straight to Basingstoke and North Hampshire Hospital, which is already a tier 2 trauma centre
• patients needing treatment for fractured hips (who are most often frail, elderly patients) will receive their surgery at Basingstoke and North Hampshire Hospital and then have their inpatient rehabilitation service in The Firs. The Firs is a dedicated unit on the Basingstoke and North Hampshire Hospital site that will have additional ortho-geriatric support and advanced nurse specialists to enhance the rehabilitation and reduce the time patients spend in hospital
• trauma patients who arrive at the Royal Hampshire County Hospital Emergency Department (either by ambulance or through their own transport) and are assessed as needing an operation and stay in hospital, will be transferred to our dedicated trauma ward at Basingstoke and North Hampshire Hospital
• trauma patients who arrive at the Royal Hampshire County Hospital Emergency Department (either by ambulance or through their own transport) and are assessed as being able to go home and come back at a later date for an operation, will be given an appointment with our trauma ward at Basingstoke and North Hampshire Hospital
• patients who attend Basingstoke’s hip and knee school, ahead of hip or knee replacement surgery, will start to receive appointments for their operations which will be done by our specialist orthopaedic surgeons in Winchester.

There will be no change for patients having other orthopaedic surgery or appointments, including outpatients, physiotherapy and occupational therapy.

There are a number of things we just won’t know until we start working in this new way. By testing the proposed service model first, we can:

• closely monitor the impact – both positives and negatives
• act quickly to refine, change or stop the new service model if necessary
• give additional support to staff from senior managers and clinicians
• encourage staff, patients, partner organisations and the public to give feedback based on real experience
• ensure we are able to listen to feedback more quickly
• expand our new procedures so they cover a wider range of scenarios.

We will monitor the quality of the service through a range of quantitative and qualitative measures to ensure that any unforeseen consequences are recognised and addressed at the earliest opportunity. The national ‘Getting it right first time’ team has also recommended some performance indicators that will demonstrate a range of benefits to patients that we will be able to compare against our past and current performance.

These include:

Yes.

We are very clear that if the changes do not bring about the anticipated benefits, we will stop and revert back to our current service model until we can find a way that works. We will do this by working with the national ‘Getting it right first time’ team and other Trusts where centralisation of trauma and orthopaedic services has already been successful, including Cheltenham and Gloucester, East Kent and the United Lincolnshire Hospitals.

We will agree transfer arrangements between our hospitals on an individual basis. This could be through our own Trust ambulance (which we are arranging specifically for trauma patients who need to be transferred to our trauma ward). These patients will also be able to make their own arrangements but only if it is clinically safe / appropriate.

We believe the proposed changes will be better for patients, with services local where possible and centralised where necessary (for example where it is clinically appropriate or a specialist requirement).

We understand, however, that people may have concerns about the practicalities of visiting a different hospital. We therefore want to engage with patients, their families/carers, the public and community and voluntary groups to understand those concerns and how we can overcome them – by changing elements of the proposed new service model, with support from partner organisations or through additional or new information, signage and support.

Both Winchester and Basingstoke hospitals, and Andover War Memorial Hospital, are run by the same NHS organisation. These new arrangements will ensure our patients receive assessment and treatment by senior trauma and orthopaedic doctors – 24 hours a day, seven days a week.

We want to engage with a wide range of stakeholders (staff, patients, carers, partner organisations and the public) as each group will have a different perspective and may therefore have different ideas and queries.

We want to:

• find the right balance of specialist centralisation and local services
• ensure any changes will work practically and safely
• get feedback from a wide range of stakeholders so we can fully understand the potential impact, so these can be addressed or minimised.

We will publicise engagement opportunities and make it as easy as possible for people to use their experiences to give their feedback and help shape the proposals.

An overview of our engagement plans were included in the paper that went to the Health and Social Care Select Committee on 16 September.

We haven’t got all the answers yet and that is why engagement is so important.

There will also be formal consultations with directly affected staff and directly affected medical staff.

We plan to consider all the feedback together so that we are not considering any points in isolation, especially as they could collectively provide better ideas and options.

We will, however, regularly monitor the responses we receive in case there are any questions that we can helpfully answer straightaway, either individually or through FAQs.

We will use the insight we get from the feedback from the wide range of people and groups we engage with to shape the details of the final proposals. We will also use the information we receive to carry out an equality impact assessment.