Recovery of Orthopaedics: Challenges and Opportunities Webinar Q&A's

Do we have data on >104 week waiters nationally?

At present, the NHS England data does not provide any detail beyond 52 weeks. However, this is due to change. From April, Trusts will be required to submit details beyond 52 weeks, and our expectation is that these details will feed through to the published data in the coming months. We will keep members informed.

For Scotland and Northern Ireland, 52 weeks is currently used as the cut-off for publicly reported data. In Wales, the published data cut off is 36 weeks.

There appears to be a blanket ban on publicity relating to non urgent medical treatments which emanates from NHS England. Can anything be done about this?

Access to the figures and the way they are presented and how often varies from one UK nation to another but we are doing our best to gather the data and ensure it is signposted, via our membership mails and also on our social media 'feed'.

If I did prioritisation 3 monthly there would be no time to operate

The BOA agrees that surgeon review of every patient on their waiting list every 3months is not feasible; however, we are working on some guidance on this. We do feel that the surgeon/surgical team has a responsibility to those on their waiting lists, and a duty of care to review this list in a fair and transparent manner.  We accept that the process of reviewing those on the waiting list must be job planned appropriately and should not be at the expense of existing clinical commitments although it may form part of DCC commitments now and in the foreseeable future.

‘We need a more comprehensive prioritisation scale that can reflect clinical need in light of available local resources.’ And ‘How do we prioritise inside P groups?’ And ‘There is poor consensus on how prioritisation is best achieved and most effective in reducing lists.’

The BOA is working on a position document regarding prioritisation of waiting lists and related issues, and we hope to publish this soon. Regarding prioritisation within P groups, there is a document available from the FSSA (Federation of Surgical Specialty Associations) called ‘Recovery Prioritisation Matrix’, which is intended for weighting cases of the same priority category, see: https://fssa.org.uk/_userfiles/pages/files/covid19/recovery_prioritisation_matrix_rpm_v_260221.pdf.

Can we use PROMS to help prioritisation rather than the loudest voice gets the early surgery? Any confidence is using PROMS?

The BOA supports the use of PROMS as a measure of outcome. We accept that some scores can be used pre-operatively and certainly some QoL scores document change well even if the cause of the change may be multifactorial.  BODS are involved in a pilot study to look at the change in scores over time with respect to patients on the waiting list.

In Scotland-are the more productive sites green sites?

In England they are.  We have good evidence that ring-fenced "green" sites have been able to restart much more effectively and should avoid further shut down in case of further waves or winter pressures.

Do we have to look at the way we utilise theatres including out of hours time?

The BOA believes that theatre utilisation and efficiency must form part of the overall revision of the delivery of T&O services. Clinical need should be considered in relation to local resources and there is some sense behind the idea of local /regional networks  to help equalise access to theatre resources /clinic space/ orthotic and therapy provision etc. The effective use of theatre time is only one part of the solution and we are well aware that staff resources and bed stock are also significant inhibitors of increased throughput.

Given theatre staffing is a rate limiting step, do we need to explore bringing in recently retired anaesthetists and other theatre staff in-especially if we can guarantee green site working only?

The BOA supports innovative ways of working and appreciates that many recently retired colleagues have expressed an interest in supporting their colleagues. We understand that theatre staff are still in short supply. We suspect that local initiatives may work well in this respect and we would be interested to hear of any success stories.

How have other centres managed the deployment of staffing and has the loss of ward staff affected the start up of elective surgery.

The BOA is aware that staff deployment has been a major issue affecting the restart process. Deployment is ongoing in many Trusts; in others, there is a backlog of leave etc that needs to be accounted for too.

Let’s stop mandatory self isolation periods before elective surgery. Older and high risk patients (and all staff) are now vaccinated.

The BOA is in support of reducing or removing the self isolation period prior to surgery when it is proven to be safe to do so. We note that during January and February many places increased to two weeks self-isolation for all, but now that there are fewer infections most sites have reverted to prior arrangements (see question below).

At present, more evidence is needed about whether vaccination has a major impact on the likelihood of asymptomatic carriers being unable to pass on virus if they are admitted to the "green" areas. We also know that vaccination is never 100% effective, and because patients may be at particularly high risk of a serious outcome from Covid infection around the time of surgery, there may need to be a judgement about whether a short isolation period that reduces the risk is still appropriate.

NICE guidance still says isolate for 14 days pre-op in patients with comorbidities (most of our joints) does the BOA have a position on this?

NICE guidance (https://www.nice.org.uk/news/article/nice-publishes-new-covid-19-rapid-guideline-on-arranging-planned-care-in-hospitals-and-diagnostic-services) reads:

• “comprehensive social-distancing and hand-hygiene measures for 14 days before admission”
• “test for SARS‑CoV‑2 within 3 days before admission and self-isolate from the day of the test until the day of admission.”
• “For people who are at greater risk of getting COVID‑19, or having a poorer outcome from it, the guideline says they should be advised that some types of surgery, for example cardiac, carry additional risks for people with COVID-19, and that they should consider self-isolating for 14 days before a planned procedure.” (Emphasis our own here.)

“COVID-19: Guidance for maintaining services within health and care settings”[1] has very similar messaging, including: “Clinicians should advise people who are at greater risk of getting COVID-19, or having a poorer outcome from it, that they may want to self-isolate for 14 days before a planned procedure. The decision to self-isolate will depend on their individual risk factors and requires individualised care and shared decision making.”

Our interpretation is that it is not compulsory that patients with comorbidities MUST self-isolate for 14 days, and that 3 days can be sufficient, as long as this has been carefully discussed and agreed with them. We believe that this is how the guidance is usually applied.

Many patients are telling that it is difficult to see their GP. Many referrals are coming after a telephone chat with GP, physio or a nurse practitioner. No one seems to have seen the patient before a referral, sometimes an inappropriate referral and there by delaying review of appropriate referrals. Can BOA develop guidance for primary care?

We are very aware of issues such as these. The BOA is involved in national guidance for primary care, in conjunction with other major stakeholders for MSK health. We hope this will be published soon.

Who is responsible for joint replacement follow up? And has this changed over the last year?

The BOA believes that the responsibility for safe follow-up of patients who have had joint replacement remains with the surgeon but this may be (and increasingly is) delegated to ESPs and done remotely.

In some of the European countries, the role of orthopaedic medicine speciality in the community is seen as a way of managing demand?

The BOA supports innovative thinking to develop ideas on who we develop and how we improve our services: the use of First Contact Practitioners, AHPs, PAs, CNS and non-operating orthopaedic surgeons (orthopaedic physicians) and sports medicine specialists should all be considered.

Need to push for Independent Sector contracts to have training provision

The BOA and the SAC believe that every surgical procedure should be a training opportunity irrespective of the hospital in which it takes place.