01 Mar 2019

By Phil Turner

Many of us will have been involved with changing our service configuration in order to improve our outcomes, make best use of resources and improve efficiency. At the same time, we are trying to ensure that patient experience is improved and the workforce remains engaged. 

We are still going through the process in Greater Manchester, but I thought the time was right to share some of the lessons and experiences from the project. I have sought to put them into 10 key points though I cannot guarantee that they are in the right order!

1. Demonstrate the need for change

Most transformation projects affect large conurbations where several hospitals or Trusts are providing similar services or two hospitals are close together and could be separated so that there is one ‘hot site’ and one for elective work. To make the case for change you will need a lot of data on activity and variation. I have found that the GIRFT reports are invaluable, but you have to be able to share that data by obtaining written agreement from all parties.

2. Develop a network

Transformation cannot be achieved by an individual. A network of like-minded clinicians from across the region that will be affected is a good way to engage them and delegate the tasks that arise once the project takes off. Successful service change needs to be led by clinicians, but you need the support of management and data analysts. Regular meetings and e-mail exchanges are inevitable.

3. Develop a programme

Hopefully your plans will have caught the attention of the STP or Regional leadership and you will then get the support of project managers. They will develop a programme and support the arrangement of meetings and consultations. They will also hold you to defined timescales which makes sure the project moves on ‘at pace’.

4. Decide on the limits

Ours is a very broad specialty and some of the sub-specialties may already be delivered on a regional or even national basis so they become ‘out of scope’. Typically, this is likely to include spinal services and children’s orthopaedic services. A particularly difficult area is whether to include trauma. The development of Major Trauma Centres and Trauma Networks is now fully established across most of the UK, but the regular day to day trauma and particularly hip fracture management cannot be separated from the provision of elective services.

5. What are the co-dependencies?

You will need to ensure you have considered what other resources you need to provide a safe and efficient service. This will vary from area to area, and they do not necessarily need to be co-located. However, you will have to have a plan as to how you are going to access radiology, pathology, care of the elderly and so on. The list will be long. Other services are also reliant on timely access to trauma and orthopaedics, so these also need to be included.

6. Know your activity

The project managers and STP leadership will want to know that there is a defined benefit from the investment they are making. I am sure most of the readership will have been subjected to external consultancies observing how we work and delivering what seem to be to totally unrealistic opportunity calculations for improved efficiency. Nevertheless, for transformation to be viable, there will need to be a realistic appraisal of how much more activity can be delivered. We discovered remarkable variation in theatre throughput across the city and raising it to the level of the best would allow a minimum 15% improvement even without any other change.

7. What facilities do you have?

It proved remarkably difficult to establish just how many laminar flow theatres there were, let alone access to day-care and short stay wards. There was also marked variation in access to beds dedicated to elective in-patient care which were protected and had appropriate ‘ring-fence’ policies for their use. You may have to visit each site to truly understand what facilities you have at your disposal.

8. What financial savings are there?

The aim of transformation should be better patient care. You have the opportunity to build networks, concentrate complex procedures in fewer sites, improve patient safety and rationalise equipment. You will also have the attention of industry as more sophisticated value-based procurement across a large population becomes very attractive to them. We calculated that by combining procurement practice across the city we hold more than 5% of the national trauma and orthopaedic spend.

9. What about the workforce?

Changing the delivery of our service into ‘hot’ and ‘cold’ sites is attractive as we can maintain elective services throughout the year in a predictable and planned way. However, an inevitable consequence will be split-site working for the clinical staff. It is important to consider the impact on trainees, but we consider that it will be far better as modules can be delivered and the full breadth of the specialty will be experienced at appropriate stages of a progressive career pathway. It is all well and good for clinicians, but many otherstaff will be affected, and they may not want to relocate or work across more than one site.

10. Think of the patient journey

This is probably the most important aspect of transformation. You will need to consider how patients will enter the system and how they will return home. Referral pathways need to be consistent across the whole service and ongoing rehabilitation and follow-up will have to be provided closer to where the patient lives. Our research suggests that patients will travel to have their surgery performed in the best facility by experienced and well supported staff, but they want the rest of the episode to be easily accessible.

Finally, you may have a very clear idea of how you and your colleagues could work together to make a significant improvement for everyone involved, but not all will agree. Difficult decisions and awkward conversations are inevitable. The project will also stand or fall by how it integrates with all the other clinical services that are also included in the transformation themes and this will not be in your control.