Examination of Witnesses (Questions 400
- 419)
THURSDAY 23 MARCH 2006
MS JANE
HANNA AND
MR ROBIN
SMITH
Q400 Dr Taylor: If he specifies the
specific orthopaedic surgeon you would not argue with that?
Mr Smith: Absolutely. I will not
say it has always been that way, we have made one or two mistakes
but that is generally the principle.
Q401 Dr Taylor: That is very reassuring
to hear and I hope that is nationwide. The other thing, waiting
list transfer from another hospital, where you always guarantee
to inform the consultant on whose waiting list that patient was
that you were transferring them.
Mr Smith: We have done waiting
list initiatives from several hospitals and the process operates
very much within the hospital. We ask the hospital itself to identify
the patients that we would want to transfer and then they would
make the notes available to us and communicate with their staff.
Again where time has been the essence sometimes the patient has
been taken off a waiting list and transferred because we want
the patient to be treated quickly and the surgeons heard retrospectively
but generally we want the surgeon to be aware and advised of the
change.
Q402 Dr Taylor: Please explain the
"orthopaedic interface clinic", what is that?
Mr Smith: One of the criteria
we set for the treatment centre is that you do not want surgeons
seeing patients they do not need to treat.
Q403 Dr Taylor: Right.
Mr Smith: Conversion rates are
an interesting concept. If you imagine every patient you send
to a surgeon would not necessarily be treated. The NHS conversion
rate is about one in four, so one of every four patients will
go on to further treatment. They will get an opinion or be told
"You do not need further treatment". In orthopaedic
care it was slightly worse than that. We introduced specialist
physiotherapists and general practitioners to advise patients
on the level of morbidity that they were presenting with at that
time. We have been able, through the interface service for orthopaedic
care, to reduce the number of people going to see a surgeon for
treatment to a visit immediately. So out of every four that go
three get treated now, so 75% conversion rate to treatment. If
you look at a lot of the presenting symptoms there are several
factors, such as back pain. A lot of people get referred to an
orthopaedic surgeon for back pain and there are many other systems
that you can introduce such as an interface service that would
manage that much more effectively. What we have provided for the
patient is a pathway from the point at the GP surgery's through
to the surgeon's knife, if you like, and we properly assess their
needs all the way along that pathway.
Q404 Dr Naysmith: Does that include
physiotherapy?
Mr Smith: It does, and they are
specialist physios, specially trained to work with orthopaedic
patients.
Q405 Dr Naysmith: In the literature
there is quite a lot of evidence to suggest that if you let a
patient who is on the orthopaedic surgeon's list see a physiotherapist
lots of them come off the list.
Mr Smith: Absolutely.
Q406 Dr Naysmith: You are putting
that into practice?
Mr Smith: Yes. About 55-60% come
off the list as a result of that intervention.
Q407 Dr Taylor: I had the impression
that treatment centres were literally just factories for doing
operations. Now you are saying that a GP could refer a patient
to one of your orthopaedic people for an orthopaedic opinion?
Mr Smith: If they chose. We would
not normally do that because the interface service is run by the
PCT and we pride ourselves on only sending people to them that
they need to work on.
Q408 Dr Taylor: These local resident
surgeons, what follow-up do they have of the people they have
operated on?
Mr Smith: They have a follow-up
after six weeks post-operatively and then if further follow-ups
are required they would follow them up again. It is usually just
one.
Q409 Dr Taylor: A late complication
would be referred back to the surgeon who did it?
Mr Smith: Yes.
Q410 Dr Taylor: Finally, how much
of your time is involved? I think you are just a representative
of the PCT, are you?
Mr Smith: I am the chair of what
they call the contract management board so I do get quite closely
involved in the treatment centre on behalf of five other PCTs.
I do monitor daily the performance of the treatment centre because
clearly it is a very new initiative and I want to be assured that
things are going as well as we would hope in the centre. I do
take a lot of time and effort to look at it.
Q411 Dr Taylor: What do you monitor
daily?
Mr Smith: I monitor post-operative
complications and patient complaints, concerns arising from the
GPs, concerns arising from the local doctors, consultants and
so on.
Q412 Dr Taylor: How do you report
this to your board on the level of activity and the costs?
Mr Smith: Each PCT board has a
monthly report on the activity of the treatment centre and the
likely implications of it. That will cover activity levels vis-a"-vis
contract and it will cover the risks associated with the centre
and, if necessary, if there are questions being asked, there will
be the intelligence going on in the community at any one time.
Q413 Dr Taylor: Those monthly reports
go to the board. Do they go beyond that to the SHA, to the Department
of Health automatically?
Mr Smith: Yes.
Q414 Dr Taylor: Do you find time
to do anything else, your other responsibilities?
Mr Smith: All the time.
Q415 Chairman: Mr Smith, you said
that one of the areas you look at on a monthly basis is complications.
Have you measured any adverse complications in treatment centres
as opposed to the same level of intense clinical work in the NHS?
Mr Smith: We had the first six
months' review of clinical outcomes. There are 26 performance
indicators that we measure. I passed that to one of our directors
of public health to try and draw a comparison between the NHS
and the treatment centre. Based on the information we were able
to test it against, the treatment centre was doing significantly
better in most areas. The area that we have modified is the time
the patient is in hospital and what we are monitoring at the moment
is the out of hospital experience of the patient. There is an
audit going on at the moment. A patient having a hip replacement
will probably be walking later that day, or the very next day,
and they will be discharged home without follow-up requirements
within an average of four or four and a half days. What we are
able to monitor very carefully is the patient experience in the
hospital, the physical capabilities of the patient in the hospital;
what we are not able to monitor is how the patient felt six weeks
later. I have not received many complaints from patients and the
patient satisfaction survey shows 95 to 98% very satisfied or
satisfied with the service. However, we want to know more about
that experience. Normally the NHS would keep you in hospital for
up to 10 days and the process is very different and of course
patient experience needs to be properly assessed and that is what
we are doing at the moment.
Q416 Chairman: You mentioned your
Icelandic and Swedish surgeons who are additional to your health
community.
Mr Smith: Yes.
Q417 Chairman: What do you think
of this additionality rule that there was on Phase 1 and do you
think there should be any changes on Phase 2?
Mr Smith: We should always try
and engage the whole community in the developments of services
and I am keen to work with NHS colleagues through the treatment
centre programme. I would not personally move back to a contract
which was wholly ran by NHS staff and NHS doctors. I would always
want to introduce new staff, new skills and new techniques to
the centres. We were very fortunate that the New York Presbyterian
Hospital Group were underwriting the competency and the quality
of the doctors in this centre. If you contrast the New York Presbyterian
Hospital's approach to care with our approach to care there is
learning on both sides. It brings a bit of colour and challenge
to the way we take things forward. The question I have in mind
is would we had the change in ophthalmology had we used our own
ophthalmologists? I do not know, but it is a question that I ask
myself when I think should it be fully integrated within the NHS
or should it remain slightly separate.
Q418 Chairman: Do you think if it
was to be in part integrated in Phase 2 that the local NHS health
community would have problems with going in and working in a treatment
centre for one or two mornings a week?
Mr Smith: No, I do not think the
NHS consultants would have a problem at all.
Q419 Mr Campbell: I would like your
opinion on what you see as the future for IST centres within the
health service. Do you see it as a small part or do you see their
future as a bigger part of a mixed economy in the health service?
Mr Smith: I see them as a tool
to delivering fast and appropriate patient care when we need to
and at the time we need it. Cataracts in our area are no longer
a problem. You were waiting 15 months two years ago. I am reducing
the contract for cataracts and increasing the contract for plastic
surgery.
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