Improving planned orthopaedic surgery for adults in north central London
Changes to how adults have surgery for bones, joints and muscles (planned orthopaedic surgery) were proposed in January 2020, which were subject to public consultation.
The proposals affect adults in Barnet, Camden, Enfield, Haringey and Islington (north central London) and some neighbouring areas and included hip and knee replacements; and other surgery to hips, knees, shoulders, elbows, feet, ankles and hands.
The consultation has now closed and you can read the outcome and background to the consultation on these pages.
Background to the consultation: A summary of our proposals
Orthopaedic surgery treats damage to bones, joints, ligaments, tendons, muscles and nerves (the musculoskeletal system). Patients may be referred to an orthopaedic surgeon for a long-term condition that has developed over many years, such as osteoarthritis or other non-emergency damage.
Hip and knee replacements are the best-known kind of orthopaedic surgery offered in the NHS, followed by other surgery of hips, knees, shoulders, elbows, feet, ankles and hands.
Planned surgery is when patients have an appointment booked in advance. It is planned treatment, following a referral to hospital by a GP and an assessment by specialists. It is sometimes called ‘elective’ or ‘non-emergency’ care.
Over 1.5 million people live in north central London and this number is expected to rise. The demand for healthcare is increasing and this will impact particularly on planned orthopaedic surgery. While many of these services are of good quality we know that patients’ experiences vary and could be better and that demand is forecast to increase.
Waiting lists are too long
- In January 2019, over 10,500 residents in north central London were waiting for planned orthopaedic surgery.
- Between January 2018 and January 2019 only 79% of patients referred for orthopaedic surgery in north central London started treatment within 18 weeks; in some of our hospitals, this fell as low as 65% in the winter months
Too many operations are cancelled
- In 2018/19 across north central London, 530 orthopaedic operations were cancelled – 96% of these operations were cancelled on the day of surgery. This equates to 10 cancellations a week. This was due to the demands of emergency services, lack of available beds or staff
Demand for planned orthopaedic surgery is increasing
- The demand for planned orthopaedic surgery is expected to increase by around 9.5% by 2029.
Without change, it is unlikely that local hospitals would be able to reduce waiting lists; the number of cancellations would continue to grow; and we would not be well-prepared to deal with the expected increase in demand for services. If our proposals were approved, the NHS would continue to spend the same amount of money (around £37 million) on orthopaedic services, however we could make much better use of this money and improve care. Over time, this new way of working is expected to save money.
All the NHS hospital trusts who would deliver planned orthopaedic care under these proposals have been part of developing them.
We are proposing a new way to organise planned orthopaedic surgery for adults in north central London
Two partnerships for planned orthopaedic care have been formed by local NHS hospital trusts – with University College London Hospitals (UCLH) and Whittington Health working together, and The Royal Free London Group (Royal Free, Barnet Hospital, Chase Farm Hospital) working with North Middlesex University Hospital (North Mid).
If the proposal is agreed, these partnerships could deliver real improvements in how we provide this care.
- Two NHS hospitals with dedicated operating theatres and beds, for patients who need to stay overnight after their operation – Chase Farm Hospital and University College London Hospital
- A choice of NHS hospitals for those needing day surgery
- A choice of NHS hospitals for outpatient appointments
- Improved education classes for patients to help them understand their operation and what to do to support their recovery
- Appointments with a named surgeon and their surgical team, who would stay with patients throughout their care, regardless of where it takes place
- Rehabilitation support for patients after their surgery
- Access to high dependency or intensive care units for patients needing additional care after their surgery
- Care coordinators to support patients with conditions such as dementia or a learning disability to understand their care and where it might take place
- More complex surgery would continue at the Royal National Orthopaedic Hospital, a super-specialist centre
- Patients with other complex medical conditions, such as haemophilia, will have their surgery at the hospital which specialises in their condition
- Emergency orthopaedic care would continue at all local hospitals with an accident and emergency department.
There are a number of benefits of organising care differently:
- Access to consistently high-quality care for all patients across north central London
- Being able to meet current and future demand for services
- Physically separating emergency and planned surgery, to avoid last-minute cancellations
- Highly-specialist staff who focus on high-volume orthopaedic surgery, and become increasingly skilled at carrying it out
In the future we want to ensure that patients can access high-quality planned orthopaedic surgery without the risk of cancellation, in a timely manner.
We know that with any change there may be disadvantages for some people:
- Some patients may have to travel further on the day of their operation
- Visitors may have to travel further
- Some staff may have to work in a different hospital to where they usually work, on some days of the week
- People with additional needs (such as those with a learning disability, or dementia) could find it confusing to go to a hospital they are not familiar with.
A list of benefits and challenges can be found in our consultation document.
The proposed change could affect anyone living in our five boroughs, and a small number in neighbouring areas, who might need a planned orthopaedic operation in the future. To help us in our decision-making, we’d like feedback from anyone with experience of, or an interest in, these services.
Under our proposals all patients could experience a significant improvement in their care, To achieve this, some patients would have surgery in a different hospital in future, when compared with current arrangements. Around 11,000 patients currently have planned orthopaedic surgery each year across 10 NHS and private hospitals.
Under our proposals, 1460 patients would have their day surgery at a different hospital when compared to current arrangements and around 1360 patients who need an overnight stay for their surgery (such as hip and knee surgery) would have their surgery at a different hospital when compared to current arrangements.*
With the help of their GP or physiotherapist, patients would choose one of the two partnerships for their planned orthopaedic care. The choice of partnership would determine their choice of hospital for outpatient care and where they would have their surgery.
(*This includes patients who currently have NHS care in a private hospital)
|OUTPATIENT||DAY SURGERY||OVERNIGHT STAY|
|Barnet Hospital||Chase Farm||Chase Farm|
|Royal Free Hospital||Chase Farm||Chase Farm|
|Chase Farm Hospital||Chase Farm||Chase Farm|
|North Mid||North Mid||North Mid|
|Whittington Health||Whittington Health||Whittington Health|
|Private hospitals||Private hospitals||Private hospitals|
In the future
In the future, patients will have a choice of the two partnerships for their care. The following table shows where patients could go for different elements of their care.
The table below shows the difference between the orthopaedic care available in north central London today, next to how it would look if these proposals were implemented.
|Not available||Available in some hospitals||Available in the new arrangements|
|Today||In the proposal|
|Hospitals caring our larger numbers of orthopaedic operations provide higher quality care for patients.|
|Ring-fenced operating theatres, wards and specialist staff, separate from A&E departments, minimises cancellations and leads to better care.|
|Teams that carry out surgery six or seven days a week reduces waiting lists and makes maximum use of facilities|
|High dependency or intensive care units and overnight senior medical cover provides support for patients who have complications.|
|Care coordinators to offer support to patients with conditions such as learning disabilities and dementia.|
|Consistent education classes before surgery and high-quality rehabilitation ensures the same high-quality care, in all hospitals.|
Our proposals were developed in an innovative, collaborative way between the providers of health services in north central London, drawing on the feedback from clinicians, NHS Trusts, local patients, stakeholders, and a number of workshops with all of these groups participating.
Our proposals were also reviewed by the London Clinical Senate, a panel of NHS professionals, patients and other groups. They agreed that there was a “clear case for change, based on national best practice and consideration of the local issues”.
Some of the things that patients said were important were included in the proposals:
- Care coordinators to support patients with conditions such as dementia and learning disabilities
- Joining up their digital patient records securely so that information can be shared more easily
- A full travel and transport analysis to help us understand the impact of our proposals and develop ways to minimise any down-sides.
- Patients would always have choice of where they have their care; this is part of the NHS constitution.
- We asked specialists in emergency care to look carefully at our plans and confirm that our plans would not undermine emergency care
We invited views of as many patients, public, staff and partners as possible to inform our plans during our public consultation. This included residents of Barnet, Camden, Enfield, Haringey, Islington and neighbouring areas who might use hospital services in north central London. We were particularly interested in hearing from anyone who is currently having or has had experience of planned orthopaedic surgery, anyone who might need these services in future and their families and carers.
By inviting people to take part in the consultation we wanted to understand whether we have developed the best possible solution to the current challenges, how proposals could be further improved and if there are alternative proposals we hadn't considered. All feedback will be evaluated by an independent company, Participate Ltd.
All feedback was evaluated by an independent company, Participate Ltd.
A full consultation document is available on our website.
Responses to the consultation were independently evaluated by Participate, who shared their report with decision-makers.
- In May 2020, stakeholders had the opportunity to comment on the draft evaluation together with the review of the equalities impact assessment
- In June 2020 the evaluation of responses, feedback from stakeholders and impact assessments was shared with the Joint Health Overview and Scrutiny Committee (JHOSC). A decision-making business case (DMBC) will then be developed outlining the recommended decision
- In June/July 2020 patients and NCL CCG had the opportunity to review the evaluation together and discuss any implications. The final DMBC was presented to NCL CCG for decision
We will monitor waiting times, cancellations, readmission rates, how long patients spend in hospital, Friends and Family test results and other measures to ensure that any changes implemented have been effective.