Business Case Title: Shoulder Unit Consultant
circa TOTAL £196k Annual Revenue Contribution
Clinical Leader / Corporate Dept: Mr Simon Lambert
Clinical Director: Mr Marco Sinisi
Lead Director: Mrs.Sheila Puckett
Lead Manager / Author: Mrs Shane McCabe
Funding Year: 08 – 09
1. Rational, Introduction and Strategic Context
Mr Ian Bayley will be retiring on 31st May 2008. This business case is in recognition of the
current in-patient waiting list and the requirement for an additional Shoulder Consultant to
enable the 18 week target to be achieved and maintained given projected future demand.
The Shoulder Unit is a key element of the RNOH and provides upper arm and elbow
orthopaedic surgery for complex cases. The RNOH aim is:
Advancing care for patients with neuro-musculo-skeletal disease/disability through research,
teaching and excellence in clinical practice and to be endorsed by others as a world class leader
in this field.
The RNOH business plan also accepts the 10 year NHS Plan (published 2000) as the main NHS
strategic and performance driver. The following NHS Plan priorities are key to this business
case and the need to recruit another Consultant Shoulder Surgeon:


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Provide fast and convenient care for patients – reduced waiting, improved infrastructure
Developing professions and the NHS workforce
Improving performance – implementing clinical governance and meeting financial targets
There is a growing body of evidence that hospitals providing high volume of complex care have
the best outcomes. A recent meta-analysis in the British Journal of Surgery has found that there
is a positive relationship between volumes of specialist surgery and three key outcome
indicators (mortality rates, reduced lengths of stay and complication rates).
Healthcare for London - A Framework for Action’ Professor Sir Ara Darzi 2007
The report also sets out the need for Academic Health Science Centres: internationallyrecognised centres of excellence where research and clinical practice is considered to lead
within the UK. The RNOH is well placed to take up this accolade; however, investment is
required across the Trust.
These priorities and targets underpin the direction of the RNOH and enable the Trust to
progress its strategic direction knowing we are positively contributing to the strategic direction of
the whole NHS.
2. Current Service Profile
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There has been an exponential growth in the understanding of the shoulder and elbow and an
increase in the number and type and complexity of surgical procedures available to improve
mobility, reduce pain, and repair and reconstruct joints, muscles and nerves. In addition, a
range of non-surgical procedures are now being used both for detailed assessment of
shoulder/elbow problems and for conservative treatment (particularly to deal with shoulder
instability and the manifestation of shoulder problems within the joint hyper-mobility syndrome,
again aimed at increasing functionality. The application of the principles of rehabilitation is a key
factor for the complete recovery and retraining of the shoulder/elbow both post-operatively and
in patients treated non-operatively. The surgical and rehabilitation (therapy) elements of the
service are fully integrated with joint ward rounds and clinics, and provide a model for service
provision in similar units at the RNOH. The shoulder service is recognised as an exemplar
service in the multidisciplinary management of a complex group of patients requiring a variety of
therapeutic inputs within the context of an holistic approach to individual patients.
The Shoulder surgeons collaborate closely with the Director of Rehabilitation, Dr J Cowan, who
provides electro-physiological assessments and leadership of the Pain Management
Programme, and who also collaborates in the electrophysiological research portfolio; Dr J.
Berman (chronic pain service); the Bio-Medical Engineering Department (under Professor
Blunn); the Centre for Tissue Engineering and the Centre for Academic Orthopaedics (Professor
Marsh). There is collaboration with the Nuffield Orthopaedic Centre, University of Oxford and
with the University of Liverpool Shoulder & Elbow service Joint clinics are held with Dr R.
Wolman (Consultant in Sports Medicine and Rheumatology), and Professor F. Muntoni
(Dubovitz Neuromuscular Centre, Hammersmith Hospital), and ad hoc clinics with the
Rheumatology department, and the Spinal Injuries Unit.
Current Shoulder Unit Consultants:
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


Mr Ian Bayley 6 sessions per week. (Mr Bayley will be retiring in May 2008)
Mr Simon Lambert - 11 PAs per week.
Mr Mark Falworth - 11 PAs per week.
Mr Simon Grange - 4 clinical sessions joint appointment with The Institute of Orthopaedics
(he requires supervision in undertaking clinical operative sessions)
The number of patients treated has increased dramatically year on year with an increasing
conversion rate. The number on the in patient waiting list is currently 241. The maximum
waiting time is 21 weeks for in-patients and 12 weeks for out-patients. This needs to
significantly reduce in order that the Trust can achieve and maintain an 18 week maximum
waiting time.
3. Service Demand and Market Analysis
The RNOH provides tertiary specialist shoulder and elbow surgical and non-surgical care for
neurodegenerative, skeletally degenerative, post-traumatic and developmental conditions, and
specific pain syndromes around the upper limb. There are very few Consultant Shoulder
Surgeons and Physiotherapists with the expert knowledge, skills and experience of the shoulder
service clinicians currently at the RNOH. The referral rate is steadily increasing and the type of
complex patients cannot be seen at a local DGH as expertise is not available, or the providers
are unwilling, to treat them. In addition, the conversion rate is increasing as the range of
surgical and rehabilitation options available for treating patients increases.
4. Proposed service profile
The new Consultant will initially work closely with the current Consultants in the following outline
weekly pattern. Theatre and outpatient sessions will be required.
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Other members of the Shoulder Unit team are:
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

Senior Clinical I Specialist Physiotherapist
Senior I Physiotherapist
Junior Specialist Physiotherapist
There is also a range of clerical/administrative and secretarial staff supporting the unit.
The weeks will alternate between the new post-holder and Mr Lambert
Week 1
AM
PM
Monday
Ward Round
Theatre
Theatres
3
Tuesday
Ward Round
Out-Patient Clinic
2
Wednesday
Out-Patient Clinic
Admin/Teaching
1
Thursday
Ward Round
Theatre
Theatre
3
Friday
Research
Administration
Programmed
Activities - PA
2.5
On-call for the hospital – equivalent to 0.5 PA
Week 2
AM
PM
Monday
Administration
Ward Round
0
Tuesday
Ward Round
Pre Assessment
Out –Patient Clinic
2
Wednesday
Out-Patient Clinic
Out-Patient Clinic
3
Thursday
Ward Round
Theatre
Theatre
3
Friday
Research
Administration
Programmed
Activities
2.5
5. Case for change
There has been a significant increase in the number and complexity of patients referred to the
shoulder unit. In order to provide a service to meet the NHS Plan waiting time targets for both
outpatients and inpatients, an additional Consultant Shoulder Surgeon is required. Without the
additional Consultant the RNOH will not achieve or maintain (or reduce) the 18 week target
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when Mr Bayley retires. Mr Bayley is an experienced, skilled surgeon who is able to operate at
a good pace with excellent clinical outcomes. A new Consultant would work at a slower pace in
order to ensure accuracy and competence will increase with ongoing experience. The Shoulder
unit only managed to achieve the 20 week in-patient waiting time target by March 2007 through
the recruitment of Mr Falworth who commenced on 11th September 2006 and has worked
additional theatre sessions. There are currently 241 patients on the in-patient waiting list. The
current Consultants operate on circa. 46 patients per month. The 20 week wait is only just being
achieved. There are on average 60 additions to the in-patient waiting list each month. This is
out of balance with the actual existing surgical capacity by 14 patients each month. Therefore,
with the money released by Mr Bayley reducing his sessions, this business case is aiming to
secure a full-time Consultant Shoulder Surgeon to work alongside Mr Lambert, Mr Falworth and
Mr Bayley. Mr Bayley would be willing to provide expert knowledge around very complex cases
for 6 months to enable all of the Shoulder Consultants to continue to develop their clinical
knowledge and skills whilst receiving clinical supervision and expert assistance. Mr Lambert
would specifically lead on the training of the new consultant.
6. Resource & other implications
Financial implications
The medium term implication is an estimated additional 84 cases per annum – additional annual
income of £462k. This activity is built into the 2008/09 financial plan.
The extra work generated will not require extra resources across the board – the new consultant
will take up the time made available by working a realistic work plan for SL and MF and we can
build the case for the extra operating time, clinic time etc as his/her competence increases to the
point where they can take an independent role, say at about 18/12. The business case for the
additional resources can be built in as an on-cost over that period not necessarily from the start.
It is proposed that the following costs be funded from the Trust’s 2008/09 activity reserves
available from additional income agreed with PCTs for additional activity to meet the 18 week
target. It is considered that activity will continue at these levels after the 18 week access target
has been met.
Consultant
Medical Secretary
Theatres – MTO
Theatres – Nurse
Theatres – Nurse
Radiographer
OT
Physio
Orthotics
MC72
4
6
6
5
6
6
6
6
1.00
0.40
0.32
0.32
0.32
0.50
0.50
0.50
0.50
109,639
10,048
11,916
11,916
9,581
19,126
19,126
19,126
19,696
Non pay
Non-pay – additional activity
7,760
92,400
4.36
330,333
Less current budget for Mr Bayley
TOTAL
(63,867)
4.36
266,466
Therefore the business case provides an estimated contribution of £196k (42%), consistent with
the assumptions built into the financial plan.
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7. Service benefits and risks
Benefit to purchasers / patients:
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Ability to meet the NHS Plan waiting time targets
Improved patient satisfaction and access to service
Continuing provision of a high-volume specialist care not readily available elsewhere in
the UK, and rarely in the EU.
Enhanced recruitment & retention opportunities
Enhanced reputation for the Trust as a world class leader in treating patients with
complex shoulder conditions, carrying out research and teaching.
The opportunity for the new Consultant to develop excellent clinical skills under the
guidance of Mr Simon Lambert and Mr Mark Falworth
Risks of undertaking change:
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

Failure to meet NHS Plan 18 week maximum target
The Trust would have to turn away this work which is very lucrative (the shoulder service
performs more joint replacements than any other unit in the UK, and all such cases will
be coming out of tariff by the start of the financial year 2008-9);
The profile of the RNOH would be adversely affected if this work had to go elsewhere in
high numbers
8. Timetable and deliverability
All relevant paperwork (job description, weekly job plan and person specification) has been
completed and is available for consideration prior to commencing formal recruitment. This
process will be commenced as early as possible in the new financial year. It is anticipated that
the process is likely to take some time and the new appointment may not be in post until early
autumn ‘08.
9. Recommendation
The urgent nature of the capacity and waiting list issues requires that this post is approved and
recruitment processes commenced without delay.
Signed
Lead General Manager ____________________________________
Date: ____________
Director of Operations ____________________________________
Date: ____________
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