Orthopaedic summit: 9 December 2024

In 2021, the Welsh Government commissioned the National Clinical Strategy for Orthopaedic Services to develop a road map for orthopaedic services in Wales and the Welsh Orthopaedic Board published its long term strategy for orthopaedic surgery in March 2022.

It set out some real levers for change and a compelling vision for the future, including: 

• transformations in the pathways to support sub-speciality areas,
• supporting people to stay well
• the importance of clinical networks

There have been 3 orthopaedic summits, taking place in:

• August 2022
• February 2023
• December 2024

Progress has been seen since the February 2023 summit, including:

• the development of Neath Port Talbot hospital as a regional orthopaedic surgery centre
• orthopaedic long waits over 104 weeks have more than halved and were the lowest since June 2021
• the Getting it Right First Time (GiRFT) team have worked with each health board and produced action plans for improvements in efficiency and productivity

The ministerial orthopaedic summit held on 9 December 2024 brought together executive officers, operational managers, clinical leads, senior clinicians and the third sector from across Wales to discuss and agree actions to improve outcomes and performance.

The focus of the summit was on pathway improvements, efficiencies, maximising the available workforce and implementing best practice models across Wales.

The NHS Wales Executive’s National Director for Planned Care gave a presentation on the current position of orthopaedic services across Wales, highlighting the variation between health boards. Between February 2023 and November 2024:

• The total waiting list grew by 5.6%.
• 52 week outpatient waits increased by 11.9%
• 104 week total waits have reduced by 54.6% and were at their lowest since June 2021.
• Growth in terms of waiting list volume in some health boards with Aneurin Bevan University Health Board (UHB) seeing a 20% increase in the list size, a 7% increase at Cardiff and Vale and Swansea Bay UHBs Betsi Cadwaladr and Cwm Taf Morgannwg had seen a 7% and 4% reduction respectively.
• 3 health boards had seen an increase in the number of outpatients waiting over 52 weeks for a first outpatient appointment, with a 73% at Betsi Cadwaladr UHB, a 50% at Aneurin Bevan UHB had seen a 56% increase and a 41% increase at Cwm Taf Morgannwg UHB. Swansea Bay, Hywel Dda and Powys had no patients waiting over 52 weeks for their first outpatient appointment.
• Outpatient referrals are increasing, but are still lower than pre-COVID, with the exception of Cwm Taf Morgannwg UHB.
• Outpatient activity is generally below the pre-COVID levels.
• Inpatient and daycase activity is below pre-COVID levels with the exception of Swansea Bay UHB.
• Sub-speciality position shows a split across all areas, but the greatest number waiting for an outpatient appointment was in spines, accounting for 20% of outpatient waits, followed by hand and wrist, with many waiting over 52 weeks.
• One third of those waiting for a new outpatient appointment are waiting at Aneurin Bevan UHB.
• At the end of November 2024, there were 43,700 pathways waiting for inpatient and daycase treatment, with 34% waiting for knee surgery, 17% waiting for hip and 17% waiting for hand and wrist. The majority are waiting in Aneurin Bevan, Betsi Cadwaladr and Swansea Bay UHBs.

The Cabinet Secretary for Health and Social Care acknowledged the challenges orthopaedic services across Wales are facing and the impact these are having on waiting times, recognising that too many people are waiting too long for appointments and treatment.

He was clear that we need to support the NHS to make changes to pathways, theatres, and outpatients, which will help to make the system more efficient and sustainable in the longer term and that we need to make sustainable changes to the way we deliver services. He highlighted that work that the NHS Executive has undertaken with the Getting it Right First Time team. Each health board now has a plan to improve the efficiency and productivity of its pathways and health boards need to act upon these to reduce the variation between health boards and the variation within health boards. Health board must address inefficiencies within their system linked to late starts and early finishes combined with last minute cancellations. The NHS Executive has been asked to focus on this variation.

The Cabinet Secretary stressed the importance of working at a regional level to address fragility, particularly so for high volume areas, and routine procedures. He also called for digital transformation, a review of the way outpatient departments work and to continue the programme of reforms to move care into local communities, closer to people’s homes.

Finally, he extended his thanks to all the staff who work in the service and highlighted his intention to listen to new ideas, to frontline experience and to help the NHS adapt for the future.

The following expectations for health boards were set out:

• the need to work on a regional basis across a range of sub-specialities
• to maximise productivity and minimise variation by implementing the clinical and management best practice including the GiRFT and the National Clinical Strategy for Orthopaedic Services (NCSOS) recommendations and pathways
• ensure new ways of working and sustainable changes are made to the way services are delivered
• to implement efficiency and productivity measures in the workforce to improve capacity to provide services
• to develop the clinical and regional networks to support each other and to learn from each other
• transform the way services are delivered, including increased use of digital techniques, and moving services closer to the patient

Patient experience

Mary Cowern from Cymru Versus Arthritis reflected on the patient experience of waiting in pain for orthopaedic treatment and the impact it has on day to day lives.

She highlighted the effect that long waits have on patients and how this affects their working lives, personal lives, and their mental health. Having their operation can give patients their lives and their independence back.

She highlighted the good progress made by health boards in implementing services to support patients whilst they are waiting for treatment as there are a number of waiting well services that have been introduced in health boards across Wales, including the national 3Ps policy. She felt that health boards need to learn from each other and recognise where good practice is taking place, such as in Hywel Dda University Health Board with the virtual orthopaedic prehabilitation.

Clinical safety

The Honorary Secretary of the British Orthopaedic Association highlighted clinical standards and quality risks, which are essential for the basis of orthopaedic interventions. These are aligned to the 6 quality of care domains:

• effective
• safe
• efficiency
• timeliness
• equity
• patient centred

He challenged the service to understand why agreed pathways and service improvements that had been achieved from previous strategies had not been sustained going forward. How could learning from previous work on reducing orthopaedic waiting times support the implementation of sustainable solutions moving forward.

It was suggested that the prioritisation approach implemented during the COVID-19 pandemic is no longer appropriate, as that only looks at date of addition to the waiting list and does not take into account pain and disability. A new stakeholder lead prioritisation tool is being developed in conjunction with Aberdeen University that is more reflective of the clinical needs of the patient. A survey carried out in Scotland found that of 2,000 patients waiting, 19% of those waiting for a hip replacement and 12% of those waiting for a knee replacement had a negative EQ5D score.

He highlighted that positive improvements are being seen in relation to length of stay, an improvement not matched by any other surgical speciality. However, there are too many sites that still report the annual loss of ring-fenced capacity throughout the year, not just during winter. The BOA is of the view that this is not appropriate and has a working group reviewing this practice.

It was suggested there is more that health boards could do in Wales to implement policies for pre-operative BMI and smoking.

The summit was reminded that in England, the Orthopaedics Outcome Registries Programme was established and mandated by the Secretary of State in 2023 as part of the national patient safety commitment following the Cumberland report. This is a super registry of all implant procedures and is similar to the National Joint Registry. This will have a significant impact on IG and IT infrastructure when it goes live.

The BOA is focused upon implementing technological advancements that will have an impact on productivity, patient outcomes and financial sustainability - these include the use of artificial intelligence, robotic surgery, and biological injectable treatments.

The BOA is committed to developing professional guidance across the whole spectrum of orthopaedic practice.

In summary, BOA are committed to supporting health boards to develop a sustainable orthopaedic service through collaboration, innovation, use of best practice between Welsh Government, NCSOS, GiRFT, BOA and patient advocates.

The summit received an update on the clinical strategy work from the NCSOS. 8 reports have been published:

• report 1: orthopaedic recovery, urgent (for immediate action)
• report 2a: general pathway (guidelines and recommendations)
• report 2b: shoulder and elbow surgery pathway (guidelines and recommendations)
• report 2c: hand and wrist surgery pathway (guidelines and recommendations)
• report 2d: hip surgery pathway (guidelines and recommendations)
• report 2e: knee surgery pathway (guidelines and recommendations)
• report 2f: foot and ankle surgery pathway (guidelines and recommendations)
• report 3: The National Blueprint for Orthopaedic Surgical Delivery in Wales

Report 3 was completed in 2022 and sets out the national blueprint for orthopaedic services in Wales. There were 3 underpinning recommendations:

• establish a Welsh orthopaedic network
• empower clinicians, and
• develop three regional stand-alone orthopaedic hubs.

The orthopaedic strategy is based on 4 pillars:

• organisational reform
• clinical networks
• pathway transformation and
• establishment of surgical hubs

Organisational reform

In line with the recommendations of the orthopaedic blueprint, the following have been established:

• the Wales Orthopaedic Network
• national sub-speciality clinical reference groups, including the addition of trauma and paediatrics
• the NHS Executive Clinical Implementation Network (CIN)

There are a number of actions related to organisational reform included within the main strategy document.

Pathway transformation

There is a programme of work reviewing the existing pathways to determine common themes that could be addressed to improve efficiency and effectiveness such as if there is an issue with radiology on both a spinal and hip pathway, work can be undertaken with radiology and relevant stakeholders to look at the issue and provide revised clinical guidelines to improve the pathway.

Clinical networks 

The clinical network has been established and has reviewed all subspecialities, except paediatrics and trauma. Using the NHS specification document, all procedures were grouped into 2 categories. Firstly, those all surgeons should be performing locally, and that patients should be able to access locally. Secondly, the more complex procedures that should be done on a regional basis and will need to be delivered through regional networks at sub-speciality level. This will involve looking how consultants can work across health board boundaries.

Surgical hubs 

The delivery and performance of orthopaedics is poor, and this has the potential to cause quality and safety issues as some patients are waiting too long and coming to harm. It is important to use the resources effectively across all sub-speciality areas. Action 9 is for all health boards and regional programmes to review all hub assets and use pathway to accreditation to enhance development of hubs. The Wales Orthopaedic Network has developed theatre requirement guidelines to ensure the same procedures are treated the same wherever possible.

Clinical pathways

The summit received an update on the development and implementation of clinical pathways, focussing on the southwest Wales arthroplasty pathway. Some good examples of pathways are the foot and ankle pathways that have been coproduced by multi-professional teams within the CRG and using the community health pathways.

This approach required the health boards to review the existing waiting list which highlighted that 70% of those waiting could be treated at Neath Port Talbot, 30% at Prince Philip and only a small number had to be treated at Morriston. 

This work has resulted in the development of an integrated multi-site hub with high volume, low complexity cases going to Neath Port Talbot on a regional basis. The medium volume, medium complexity cases going to Prince Philip and Morriston being utilised only for those patients that had those interdependency requirements. This approach has resulted in improved waiting times across the region.

There was initially some clinical resistance to regional working, related to clinical practice and unfamiliarity with theatres in different health boards. This has been resolved by the development of regional pathways and processes.

Despite the improved waiting times, there are still improvements to be made related to:

• referral management
• full utilisation of resources
• clinical job plans
• waiting list data
• effective use of the evidence base

To improve waiting times, the NHS Executive and Welsh Government should:

• develop guidelines around BMI and HB1C
• support health boards to develop regional treatment lists
• look at the use of AI tools to support health boards
• develop a national patient information letter that can be shared with health boards and regions and can be sent out to patients waiting and advise them to get back in contact through a single point of contact

To improve waiting times, health boards should:

• look at validating follow-up lists to see what patients could go on a PIFU list and to create additional capacity
• utilise fallow lists
• re-instate funded core sessions that were in place pre-pandemic

The Welsh Orthopaedic Network has supported the provision of wrist arthroplasty in North Wales. It is a low volume high complexity service and aligns with patients being treated closer to home as per ‘A Healthier Wales’ principles. There has been positive patient feedback on the service and will enhance the orthopaedic service in North Wales to attract and retain consultants.

Key points from the group discussion were:

• how can the service be sustainable and reduced reliance on waiting list initiatives
• various approaches to support regional working
• whether the adoption of a single national tariff would reduce inequalities in the system
• could recovery funding be aligned to the actions that need to be implemented via GiRFT and NCSOS?
• workforce flexibility is essential, workforce planning must be wider than anaesthetists and surgeons and include other support staff such as theatre nurses and physiotherapists
• how cultural and organisational development can be implemented to support implementation of regional pathways
• how best to embed PROMS and PREMs to properly support the work and ensure the quality of clinical coding

Barriers to achievement

• time pressures around managing demand and ensuring patients are treated in turn
• digital solutions are not fully developed
• the operational model required to enable regional working may differ for each organisation

The following commitments and actions were agreed and progress against these will be monitored:

• commit to implement the strategy and the agreed clinical pathways to these and highlight barriers to this so we can help unblock
• undertake an analysis of current orthopaedic activity, setting out how and when this will increase to pre-covid activity
• to maximise productivity and minimise variation by implementing the clinical and management best practice, including the GiRFT and the national clinical strategy recommendations and pathways
• to implement efficiency and productivity measures in the workforce to improve capacity to provide services
• to develop the clinical and regional networks to support each other
• to work regionally across a range of sub-specialities, implementing regional PTL reports to ensure the longest waiting patients across the region are seen
• maximise orthopaedic capacity and productivity and minimise variation
• improve the use of PROMS, PREMS and improve clinical coding