Planning for achievement of 18 week targets in spinal surgery
The November Trust Board requested a plan for the achievement of 18 weeks’
targets for spinal surgery. This was an acknowledgement of the importance for
the RNOH to achieve access targets monitored by the Healthcare Commission
as part of the strategy to become a Foundation Trust and secure the
redevelopment of the site.
This paper therefore sets out the current position and key elements of the plan
for ensuring the spinal unit achieves compliance with the 18 week targets.
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Overview and context
The Trust currently carries out a third of scoliosis surgery in England which is the
largest amount carried out by any of the spinal units. On this measure, the work
undertaken is the most complex in the country.
The Trust has experienced a significant increase in referrals from summer 2008.
Although the number of patients is small in comparison to other specialties, the
nature of the operations brings particular problems in scheduling treatment.
Operations are lengthy, and often only one can be scheduled for each half day
session. About a third of the scoliosis cases require 2 long operations a week
apart.
The service is almost entirely delivered by senior and experienced consultants.
The work is physically and mentally demanding and the risks of the surgery
cause stress, especially as a high proportion of the scoliosis patients are children
and adolescents.
An additional consultant surgeon was appointed last year and will start on 1st
February. This post will support the lower back pain service and will not provide
additional scoliosis capacity. The Trust has advertised for 2 full time consultant
spinal surgeons with an interest in spinal deformity (including scoliosis) on 13th
December. A short listing workshop takes place on 21st January and interviews
scheduled for 30th January. General expectation would be that new appointments
would be likely to start 3 – 6 months after appointment.
Consideration needs to be given to the evidence base that the Trust can provide
to the Healthcare Commission for extenuating circumstances as to whether a
tolerance level of 10% of admitted patients and 5% of non-admitted patients is a
robust reflection of the proportion of patients for whom it is clinically appropriate
to have a pathway of more than 18 weeks in spinal surgery. Patient case note by
case note evidence will be needed rather than general statements to evidence
this case.
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Current 18 week position for spinal surgery
The admitted performance for the unit has been from 35% - 40% and the nonadmitted performance is similar. The proportion that are meeting the target
relate to urgent cases or where a new clock has started after active monitoring,
or for relatively simple procedures such as injections.
There are long waits for all sub-specialties for new outpatient appointments,
follow up appointments (for example after diagnostic scans) and for inpatient
treatment.
Tertiary referrals are usually breaching 18 weeks before first OP appointment.
Admitted backlog: There is currently a backlog of 150 cases which is 50% of
the Trust’s total backlog. This is approximately 5 weeks’ work. The expectation
would be that we need to reduce this to 10 -15 cases as a baseline for achieving
18 weeks, with the tolerance representing 3-4 cases breaching each week.
Non-admitted backlog: again, this is about 50% of the backlog and it is
currently harder to quantify how many weeks’ work this would be for spinal. This
will need to be incorporated into the plan as capacity is identified.
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Potential 18 week pathway
Up to 4 weeks:
1st OP appointment assessment with previous diagnostic material
supplied, diagnostics and follow up booked at end of first
appointment
Up to 6 weeks:
scan and report completed
Up to 7 weeks:
follow up clinic appointment, decision for treatment, watchful wait etc
Up to 18 weeks:
treatment, either surgery, physiotherapy, bracing etc.
Tertiary referrals would need to be accelerated through the final treatment phase.
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Current waiting times and opportunities
10 – 28 weeks
18 – 36 weeks
20 – 38 weeks
46 – 64 weeks
1st OP appointment
scan and report completed if necessary
follow up clinic appointment, decision for treatment, watchful wait etc
inpatient admission for surgery; physiotherapy, pain management or
bracing would be very much sooner
Despite the length of the above, often a decision not to treat is taken by consultant and
patient at the follow up appointment, or active monitoring begins.
Both of these decisions would stop the clock. This opportunity is not being fully used
currently by the surgeons. There is a concern that such patients will be “lost” in the
system and need to be kept on the waiting list to allow tracking to continue. The surgeons
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need reassurance that new waiting list tracking systems allow this to be done without any
impact on the manner in which their waiting lists are managed. Clinical Directors have
had discussions with the surgeons on this point but there remains a resistance to
changing waiting list practice in this area. The Department of Health’s Intensive Support
Team (IST) have provided spinal surgeon contacts at other Trusts with a view to
facilitating some of the discussions and providing reassurance that decisions not to treat
and pursue active monitoring will not result in patients being “lost”. This will continue to be
actively progressed in December and January.
A new clock starts when a decision is taken to end active monitoring and admit for
surgery, which allows 18 weeks to organise the operation. Again this is not being fully
exploited by the surgeons.
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Summary of action plan to achieve 18 weeks in spinal surgery
Many of the capacity issues can be addressed by recruiting additional surgeons but this is
taking time. However, until they are in post, the backlog will inevitably increase given
current demand.
Therefore, it is important to try to reduce the admitted backlog first. Reduction of waiting
times earlier in the patient pathway will only add to the pressure on inpatient waiting lists
as more patients convert to surgery.
5.1
Ensure compliance with 18 week guidance
This will be through application of access policy and procedures, and via clinic outcome
forms.
Support will be requested from the Department of Health’s Intensive Support Team (IST)
to work in clinic with spinal surgeons to help them understand how to complete Clinic
Outcome Forms (COFs) to ensure all opportunities for clock stops are used. The IST
have also provided spinal surgeon contacts at other Trusts with a view to facilitating some
of the discussions and providing reassurance that decisions not to treat and pursue active
monitoring will not result in patients being “lost”. This will continue to be actively
progressed in the immediate future.
Preliminary work has started to review scope for further validation of patients and sorting
into correct 18 week status. This will be completed in January and will provide good data
quality on spinal patients and so facilitate planning and implementation process.
5.2
Reduce backlog for surgery to sustainable 18 week position
Newly appointed consultants will be utilised to operate as much as possible. However, in
the meantime additional capacity will be sought from NHS and independent sector. This is
explored in further detail below.
5.3
Reduce the wait for first OP appointment
Again the additional posts will support this in the future, but until then work can continue
on establishing sharing/pooling of appropriate referrals within teams to maintain steady
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flow of new appointments. This is not established practice, although progress has been
made in triaging and allocating ‘dear doctor’ referrals amongst the teams. As well as
continuing to pursue this internally, this is another area where facilitation from spinal
surgeons in other Trusts may provide reassurance to RNOH consultants.
5.4
Reduce time back to follow up appointment
Maximum of 3 weeks or eliminate wait for scan and report by completing on day of first
OP appointment. This is already part of overall plan for sustainable 18 week delivery for
all units. The pressure of spinal work is driving consideration of making scanning slots
available to establish ‘one stop shop’ clinics at first appointment. The feasibility of this
approach is being reviewed to establish an implementation plan if it is agreed as the way
forward. This will be completed in January.
5.5
Complete demand and capacity analysis
This is based on data from 2007-08 to enable workforce planning, requirements for
theatre time etc and will be completed by the end of December 2008.
5.6
Support and multi-disciplinary team
Put adequate support services in place and invest in multi-disciplinary clinical staff.
One of our consultant spinal surgeons, Mr Wilson, has put forward a proposal to establish
a multi-disciplinary team of physiotherapists and clinical nurse specialists to support the 2
low back surgeons. They would assist with triage in outpatient clinics as well as preoperative assessment and post-operative care. Similarly, the spinal deformity team have
requested an additional clinical nurse specialist. These posts should therefore increase
productivity and provide better continuity of care for patients and support for consultants.
The feasibility of this approach is being reviewed to establish an implementation plan if it
is agreed as the way forward. This will be completed in January.
Planning for refurbishment of theatres 1 and 2 has already been established which will
provide one extra theatre to the RNOH. The Trust Board will be reviewing the business
case for the additional theatre in the New Year. The current timetable is to put this in
place for June 2009.
Plans for the extension/refurbishment of the Stanmore Clinical Research centre are
already established to ensure additional outpatient preoperative assessment capacity is in
place by March 2009.
Options for the utilisation of space vacated by limb fitting in August 2009 and the impact
of this on the outpatient refurbishment scheduled to begin December 2009 / January 2010
also need to be established.
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Suggestions from non-executive directors
This section addresses the points recently put forward to address the need to progress
towards the 18 week targets in spinal surgery.
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6.1
Reduce the number of potential patients
The only method endorsed by PCTs, NHS London and the Department of Health
is to adopt agreed criteria for referrals.
Currently, the RNOH has agreed criteria with the host PCT for degenerative back
referrals and for spinal deformity for one of the spinal teams (5 surgeons). The
deformity criteria are already more restrictive than the PCT is entirely happy with
and the clinical director has agreed that it would not be useful to narrow the
criteria further.
The remaining 2 surgeons are not using criteria but the general manager (and
others) continue to advise them that it would be helpful. Their practice is slightly
different from the other team.
The approach taken at some other Trusts to limit criteria to such an extent that
this represents effectively a list closure is not supported by the Department of
Health. Continued provision of patient services at the best access times possible
is the overriding priority for the NHS. It is likely that a similar approach by RNOH
would not be in patients’ interests and, additionally, would be potentially counterproductive as we seek support for improving our Healthcare Commission rating,
Foundation Trust and Redevelopment Plans.
6.2
Reduce the number of patients already in the RNOH system through
treating patients outside of current RNOH capacity or at other hospitals
This has been explored to over the last year, and it will continue to be tested and
reported back to the Trust Board. It is essential that progress is made in this
area as reducing the backlog for surgery is a critical step in achieving 18 weeks:
 Enhanced rates for out of job plan working and an accompanying set of
principles have been agreed with all the spinal surgeons, and many of them
have undertaken several Saturdays and overruns on a regular basis. Payment
levels are already at some of the most lucrative levels available in the NHS for
this out of job-plan work. This has enabled the Trust to maintain the 26 weeks
standard. However, although the agreement was based upon planning to
reduce the waiting times further, this reduction has not ensued, partially due to
increased referral rates.
 Capacity has not been available at other NHS institutions in the past, but we
have recently picked up the possibility of sourcing some degenerative spinal
work at the Nuffield in Oxford and also in the independent sector at Spire. The
general manager is engaged in this initiative.
 The general manager is also investigating facilities abroad. The medical and
clinical directors’ opinion is that the latter is unlikely to prove a possibility and
poses significant risks to appropriate patient care.
 The general manager is also researching the possibility of using the private
sector for spinal deformity work. However, all previous attempts at this have
indicated such an arrangement is extremely punitive financially.
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 It is extremely unlikely that spinal surgeons available as locums or on
temporary contracts would have the degree of experience and competence to
carry out the work currently on the waiting list. However, if there are any
suitable candidates, it is likely that this would arise during the recruitment
process for permanent staff.
 In the past, patients have refused offers of transfer to other institutions and are
often unwilling to consider another RNOH surgeon than the one to whom they
have been referred.
 As described above, the timetable for the recruitment of 2 additional spinal
deformity surgeons has been set, the recruitment processes have been
established, clinical leads and directors together with spinal surgeons are
engaged in the process.
6.3
Increase capacity of existing theatres
 The theatre staffing group frequently revisits the issue of pay and incentives.
Currently it is felt that staffing numbers are rather low and increasing working
hours may increase sickness or pose clinical risks. However incentives
remain on the agenda and the possibility of increased pay or recruitment and
retention premia will again be reviewed by the Theatre Staffing group by
January.
 Overall, the theatre staffing position is better than earlier in the year, and there
have been more overruns and Saturday working than previously. Recruitment
in Portugal was recently undertaken to increase numbers further with an
additional 8 staff successfully recruited.
 If other units’ need for additional time diminishes, more time will become
available for spinal work. However, this places particular demands on other
services especially ITU/HDU beds.
6.4
Working with Department of Health Intensive Support Team
The executive team welcomes the help offered by the Intensive Support Team
(IST) and members of the team have been working with the 18 week staff for a
number of months. Russell Emeny is now the IST link for RNOH. He has
reinforced that many aspects of the 18 week programme are strong and well
managed, but also made suggestions for improvement. Feedback and
recommendations have been adopted and are being implemented. Examples
include:
 Suggestions for ensuring Clinic Outcome Forms (COFs) are collected from
patients
 Redesign of the COF to remove some ambiguities and thus secure good data
quality for patient 18 week status.
 Ensure breach sharing data is submitted and relevant referrers notified in
advance to minimise disputes and arbitration.
 Produce weekly COF compliance reports
 Ensure intermediate clock starts and stops are identified and captured along
spinal clinical pathways to ensure true length of pathways is reported. This is
likely to make an improvement in the reported 18 week performance, but to
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date the spinal surgeons are unconvinced of the value of this. However, this
action will be implemented as the new policies and procedures to support 18
weeks are introduced – see above.
7 Conclusions and next steps monitoring
Given the scale of real backlog work facing the Trust, current projections are that
18 week access in Spinal Surgery will not be delivered this financial year. Whilst
some progress may be possible through some of the initiatives outlined in this
report it, current indications are that it is unlikely that there will be a significant
performance improvement until new surgeons are in post. However, all of the
additional suggestions and proposals in this report are being taken forward as a
matter of urgency by the Executive Team including the relevant Clinical Director.
A presentation will be made to Trust Board as to the current estimated impact of
these measures and therefore the current assessment as to when sufficient
progress will have been made in spinal surgery to allow the Trust to be delivering
sustainable 18 weeks access overall.
The actions outlined in this plan will be monitored through 18 week committee
and performance committee. Trust Board will be updated through the monthly
performance report.
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