The North Wales Planning Forum Requested NPHS to Provide an Analysis Outlining the Potential

National Public Health Service for Wales North Wales Planning Forum Projected Need

Future Projected Need for Healthcare – North Wales Planning Forum

Authors: Jo Charles, Robert Atensteadt Date: June 2008 Version: 1 Status: Final Classification: Public (Internet) / NHS Wales (Intranet) / NPHS (Intranet)

Purpose and Summary of Document:

This document summarises the context and background of work undertaken for the North Wales Planning Forum (NWPF) on the potential consequences of the changing demographic profile on the need for healthcare services. It highlights the main issues, and provides an overview of the contents of the series of linked documents which constitute the response to the NWPF request. These are: Health Needs Assessment Summary : North Wales LHBs/LAs 2007 Key Influences on future trends in healthcare North Wales Planning Forum Analyses.

Publication/Distribution:  Publication in NPHS Document Database

Author: Jo Charles, Robert Atensteadt Date: 3/6/08 Status: Final Version: 0a Page 1 of 16 National Public Health Service for Wales North Wales Planning Forum Projected Need

The North Wales Planning Forum requested NPHS to provide an analysis outlining the potential consequences of the changing demographic profile for North Wales on the need for healthcare services. The analysis was required to take account of, and quantify where possible, the interaction between the need stimulated by the changing demography, and other developments affecting the provision of healthcare.

This document summarises the context in which this work sits, highlights the main issues, and provides an overview of the contents of the series of documents which constitute the response to the NWPF request.

Broad Context

The challenges of 21st Century healthcare are well-known and neatly summarised by Muir Gray 1

Need and demand are increasing faster than the resources available to meet them.

The 3 main causes of these increases are the ageing population, the emergence of new diseases and the proliferation of new interventions and technologies – health and otherwise.

The needs of the Ageing Population

In the main the increasing numbers of the oldest older people (those over 80) are due to the spectacular decline in childhood mortality during the early years of the twentieth century. There is also good evidence that older people are fitter than their counterparts would have been 20 or 30 years ago and that this has contributed to a decrease in mortality at relatively later ages. However, the prevalence of chronic conditions in the population is, and is likely to remain higher – often as a result of the lifestyle factors which are now impacting upon the whole population – i.e. greater availability and reliance upon food high in fat, salt and sugar; decline in energy expenditure in every day life due to changes in the way we live our lives; relative increases in disposable income and increasing affluence of society overall. The prevalence of these risk factors among those now in middle age suggests that the burden of chronic conditions is likely to increase as this group ages, and, for some factors, such as obesity and smoking, the prevalence in younger people suggests even worse outcomes. There is, however, no inevitability about this should we choose to imagine, and invest in creating, a scenario for the future in which health improvement is central.

Need from new diseases

The impact of the emergence of new diseases, such as AIDS, SARS and Avian Flu, is difficult to predict for our local populations, as the burden with all communicable disease is likely to be heavier on the developing world. However, the evolution of some “epidemics” such as eating disorders, ME and obesity will

largely be felt in the developed societies which are, ironically, heavily implicated in their emergence.

Need driven by new interventions and technologies

Healthcare needs can be defined as problems for which there is an effective intervention. As both drug and non-drug interventions are developed new needs will thus emerge – sometimes with substantial implications such as that seen recently with the emergence of new treatments for Age Related Macular Degeneration.

On the whole, there is relatively little that can be done to slow the increase in need, other than to do whatever is possible to prevent or reduce the consequences of the current epidemics fuelling the need. However, responding to need by addressing demand for services and designing appropriate responses is possible.

Demand for Services

Increasing demand for services is inevitable given the increasing consumerism of modern life – fuelled by the rapid changes in accessibility and availability of information typified by, but not exclusively related to, the growth of the Internet.

The response to increasing demand will have to include explicit agreement about what will or will not be treated from publicly funded health services. Although this will relate in part to specific conditions (e.g. cosmetic surgery or gender reassignment) and “low value” services (e.g. Bariatric surgery), it will also increasingly relate to interventions which, although potentially effective, we will simply not be able to afford to provide for everyone who wants them.

Demand within healthcare services can often be fuelled by clinicians as much as by patients and is driven by the essential desire to do the best for their patients. Muir Gray 1 cites the US work of Eddy which demonstrates that the ‘volume and intensity’ of clinical practice is one of the few areas in which managers or commissioners could hope to control increasing costs. As demonstrated earlier, the consequences of the ageing population are generally out of our sphere of control, as, by and large, is inflation – the other main driver of increasing costs.

Managing innovation is thus crucial – whether that innovation relates to high cost interventions, or to the introduction of a relatively small innovation which relates to a common disease or condition. “Managing” here is not synonymous with “stifling”, but refers to the need to have clear and transparent procedures in place for introducing new treatments or services. Such procedures must include information about  the relative value of the innovation;  a systematic review of the evidence;  the numbers of people who would be helped and harmed by the new treatment;

 comparison of the efficacy and effectiveness of the new treatment compared to the highest quality obtainable from the existing service;  comparison of the value of adding the new approach with other aspects of the same service area;  explicit consideration of the need to cut another, lower value service in order to fund the new one.

The key concepts of Effectiveness and Efficiency have now become embedded within our approach to healthcare delivery (even if not always realised as yet), with efficiency represented either through productivity or through cost- effectiveness. However, they are both increasingly limited as, on the whole, we now have far more options which are efficient and effective than can be afforded.

The work of Donabedian – well known to many in healthcare for his development of ideas around structure, process and outcome – also developed the concept of optimality 2. This relates to the balancing of improvements in health against the cost of such improvements, and relies on the 2 laws of Diminishing Returns and Undiminishing Harm.

The Law of Diminishing Returns describes how, as resources are increased benefit increases, but only to a point after which additional benefits are only possible at costs too large relative to the benefits. The Law of Undiminishing Harm recognises that all interventions gave the potential to cause harm ( e.g. through side effects in the case of drugs, or complications arising from surgery) and thus, the more resources are invested and the more people access it, the more likely harm is to occur. This is especially true as the threshold for treatment is widened to include patients less fit and potentially more at risk of harm.

Local Context

The North Wales Planning Forum (NWPF) is well established as the key strategic body for NHS planning in North Wales, with Chief Executive representation from each Local Health Board and Trust, including Welsh Ambulance Service Trust, the Regional Director of Public Health and senior officers from the WAG Regional Office. The NWPF led the development, consultation and implementation of the first stages of the review of secondary care services, culminating in the publication of Designed for North Wales (D4NW) in April 2006. To inform the review, the Forum commissioned Teamwork Management Services to model the activity and financial implications of modernising secondary care services over a ten year period (to 2015) and to provide an overview of activity up to 2020. The modelling required identification of opportunities for clinical efficiency and improvements through best practice, whilst simultaneously considering the impact of population change on the demand for services.

Following a period of public consultation and adoption of the preferred response by Local Health Boards and Trust Boards, the selected option was a move towards the provision of secondary care services on 3 main sites in N Wales. Further refinement of the implications of the selected option was made through four Clinical Redesign Groups addressing Chronic Conditions, Diagnostics,

Children and Family services, and Surgical Services. Each of the groups highlighted possible response options to the changes which would be required to deliver the vision proposed in D4NW. Central to these options are a greater focus on clinical networks to support specialist hospital services, and continued closer integration of community based health and social care services to support out of hospital care.

A number of pieces of work were undertaken by NPHS in support of the development of Designed for North Wales and these provide a sound basis from which the current work can develop further. Appendix 1 highlights key aspects of these publications.

Complexity and limitations of prediction - general

There are considerable risks attached to any exercise in future prediction, and limited opportunities for safe prediction of what the future holds – and many such predictions have been spectacularly wrong – “Heavier than air flying machines are impossible” (Lord Kelvin, President of the Royal Society 1890 – 95). Common errors include  simply extrapolating current trends  believing there is only a single future  underestimating the effect of long term change, and  overestimating the effect of short term change.

It is emphasised that predicting the pace of many changes remains highly subjective, and, that the further into the future the predictions go, the higher the likelihood of error. A Report commissioned by health and social care agencies in the Milton Keynes South Midlands (MKSM) growth area effectively summarised this 3

Planning has to use the best currently available projections, and to expect that these will need to be revised throughout the next 25 years. People recognize the risk that changes made now may have to be undone later. This could be because the future develops in unexpected ways, or it may be anticipated…… But whatever is planned now should strike a balance between current commitment and future flexibility i.e. it should be “futureproof”, as far as possible.

Complexity and limitations of prediction in healthcare

Although the provision of healthcare services is driven by, and influenced by, many factors, the underlying need for healthcare is essentially related to the presence of illness – morbidity – for which an individual seeks attention.

There is particular difficulty attached to the prediction of future morbidity, which in large part relates to the relative paucity of sufficiently accurate and detailed data regarding current levels of morbidity. The implementation of the new GMS

contract, and particularly the Quality and Outcomes Framework, with its focus on systematic identification of those with key conditions, and the application of standardised quality treatment packages, will in the future guarantee a robust and reliable source of data on levels of morbidity within the population, but as yet, data quality and completeness limit the use of QOF data. Mortality data is, on the whole more accurate and reliable, but for many conditions mortality is a poor proxy for assessing morbidity, and is also heavily influenced by the provision and accessibility of services, the socioeconomic status of the individual and the point at which they present with symptoms of illness. Key trends in mortality do give an overall picture of the health status of a population, and a brief analysis of these is included in an accompanying document which reports on current Needs Assessments for N Wales.

Current sources of morbidity data include:

• Patient Episode Database for Wales (PEDW)

• General Household Survey

• Welsh Health Survey

• PACT (Prescription Analysis and Costing) data

• General practice

• Infectious diseases

• Notification of episodes of STDs

• Notification of industrial diseases/accidents

• Notification of congenital malformations

• Disease registers e.g. Cancer registration

PEDW is managed by Health Solutions Wales (HSW) and provides an electronic record of all inpatient and day case activity for Welsh residents in NHS hospitals in England and Wales and for patients treated in Welsh Trusts. Measurement is by ‘Finished Consultant Episodes’, the length of time spent under the care of one consultant rather than the length of admission.. The range of data recorded includes: hospital of treatment, area of residence, patient administrative details, admission details, consultant episode details and clinical details. The system uses diagnosis and operative procedures: OPCS4 and ICD10 systems, and up to 14 diagnoses and 12 procedures can be coded for Although PEDW provides a good source of information about illnesses treated in hospital, its use is limited by the quality of clinical information recorded, as well as the completeness of returns made by some hospitals (although this is improving).

The General Household Survey The General Household Survey (GHS) is a multi-purpose continuous survey carried out by the Social Survey Division of the Office for National Statistics (ONS) which collects information on a range Author: Jo Charles, Robert Atensteadt Date: 3/6/08 Status: Final Version: 0a Page 6 of 16 National Public Health Service for Wales North Wales Planning Forum Projected Need

of topics from people living in private households in Great Britain. The survey started in 1971 and has been carried out continuously since then, except for breaks in 1997/98 (when the survey was reviewed) and 1999/2000 when the survey was re-developed. Data related to population, employment, housing, education, income and family structure and details on many health-related items such as prevalence of disability, utilisation of general practitioners services, dietary habits, alcohol and tobacco consumption, can be obtained from this. There is also scope to insert questions related to current issues of significant national concern. The General Household Survey allows major and minor illnesses to be described in the population as a whole, and can count illnesses that do not normally present to the health services. The main limitation of the general household survey is that since it relies on an individual’s interpretation of their own health and not on professional diagnoses.

The Welsh Health Survey (WHS) is a largely self-completion survey of health in Wales. The survey includes questions about people's use of health services, illnesses, general health and well-being, smoking, alcohol, fruit and vegetables, exercise, carers and questions about themselves (age, sex, weight, height, etc).There were 2 postal surveys in1995 and 1998, each with an achieved sample size of around 30,000 adults. A new continuous survey started in autumn 2003 and is aiming for an achieved sample size of around 30,000 adults and 7,500 children over a two year period. The survey covers Wales, with some results also available for health and unitary authority areas. Results for the 1995 and 1998 surveys were published in reports of each survey, with results from the 2003-05 survey being published on an on-going basis. Summary information is also included in other NAW publications. The information may also be used in briefing or answering ad-hoc requests. Like the General Household Survey, the WHS allows major and minor illnesses to be described in the population as a whole, and can count illnesses that do not normally present to the health services. However, the results are derived from self-completion questionnaires and therefore reflect what people report their health to be i.e. responders have not necessarily received any clinical assessment to diagnose the condition(s) they are reporting. In addition, the data collected between October 2003 and September 2006 are not comparable with the previous surveys of 1998 and 1995, because some of the questions were changed.

This work will not consider in any detail issues concerning where healthcare may be delivered in the future, although this is of considerable importance as a key strategic driver is the move towards delivering care closer to people’s homes. In Our NHS our future Prof Sir Ara Darzi4 summarises this as “localise where possible; centralise where necessary.” It is assumed that this aspect will be covered in the benchmarking work, and that, at least in the short term, the underlying need for healthcare services will not change – although the way in which those needs are met will almost certainly change.

Current Health Status of N Wales Population

Although there is acknowledged risk in simple extrapolation from current trends, it is nonetheless crucial to acknowledge and reflect on factors which have contributed to the current state. Needs Assessments have recently been completed to inform the next round of HSC+WB Strategies for all LHB / LA areas in Wales. The accompanying document Health Needs Assessment Summary : North Wales LHBs/LAs 2007 presents a summary of the key issues identified in each of the 6 N Wales areas, and highlights the main trends which have influenced the current situation in each area.

Key Influences on future healthcare trends

An accompanying document, Key Influences on future trends in healthcare, summarises relevant UK findings on the key influences on future healthcare trends.

Key influences on future healthcare need - rationale for possible indicators

It is widely agreed that 21st Century healthcare, in both the developed world, and increasingly in the developing world also, will be characterised by a relentless increase in the burden of chronic conditions. Whilst much of this will be driven by the increasing age of the population, there is debate about whether it is increasing age per se which will drive the increasing burden.

In conjunction with WAG, NPHS published “A Profile of long-term and chronic conditions” in 2005 5. This described chronic conditions as

those which in most cases can not be cured, only controlled. Such conditions are often life-long and limiting in terms of quality of life.

The table below, taken from this publication, illustrates the differences between acute and chronic conditions and helps to clarify what can be regarded as a chronic condition in contrast to acute conditions.

Acute Condition Chronic Condition

Onset Abrupt Generally gradual and often insidious

Duration Limited Lengthy and indefinite

Cause Usually single Usually multiple and changes over time

Diagnosis and Usually accurate Often uncertain prognosis

Technological Usually effective Often indecisive; adverse intervention effects common

Outcome Cure possible No cure

Uncertainty Minimal Pervasive

Knowledge Professionals knowledgeable Professionals and patients patients inexperienced have complementary knowledge and experiences

Key chronic conditions include Coronary Heart Disease, Cerebrovascular Disease, Diabetes, Respiratory and Musculoskeletal conditions, and neurological conditions, including dementias. Although an important driver of need for acute healthcare response, Cancer will also increasingly become a chronic condition.

In the light of this, the NPHS Health Information Analysis Team (HIAT) prepared a set of analyses to inform the work of the North Wales Planning Forum by applying the regional population projections to a specified set of current hospital admission rates. These included Coronary Heart Disease, Respiratory Disease, Stroke, Cancer and Hip Fracture. The analyses, supported by a full explanation of the methods used, are presented in an accompanying document North Wales Planning Forum Analyses. The document stresses, as referenced above, that extreme caution must be used if any of the results, especially those for the later years, are to be used to inform future planning.

APPENDIX 1

Summary of key findings from previous NPHS reports

Aspects of acute services redesign – key messages from the literature 6

Drivers for change:  The issue of acute service redesign is pertinent to health economies across the UK, and many are reviewing their acute services with a view to improving sustainability  There are a number of common drivers for acute service redesign; changing disease patterns – increasing numbers with chronic conditions, rising emergency admissions, outdated current configurations, implementation of European Working Time Directive and consideration of the evidence base in relation to volume and outcomes.

General points on service redesign:  There should be a focus on locally provided core services, with not all services available on all sites. It is anticipated that this is achieved through some of the following:  Strengthening chronic disease management programmes in the community, primary care, intermediate setting  Managed Clinical Networks – joint working between hospitals, well developed transfer arrangements  Innovative approach to workforce redesign and extension of staff roles  Separation of elective and emergency cases  Development of ICT – use of telemedicine, electronic patient record and digital imaging transfer  There is a decline in access to services with increasing distance from medical care. Rural patients in the UK are more likely to have advanced diabetic retinopathy, higher mortality from asthma, higher death rates from trauma and lower rates of access for angiography and revascularisation  NHS Scotland proposes a model based on networks of rural community hospitals and Rural General Hospitals.

Emergency/Acute Care:  Innovative approaches to service design in relation to Emergency Care include; use of ambulatory care models, Emergency Care Networks, ‘See and Treat’ model and the use of medical assessment units alongside emergency departments  Providing care through Clinical Networks as described in much of the literature will inevitably require the transfer of acutely ill patients at times. This should always be done following the Intensive Care Society Guidelines for the Transportation of the Critically Ill Adult  Workforce redesign and the extension of staff roles will be an essential part of any acute service redesign.

 Information and Communication Technology is a key aspect of service redesign. Telemedicine, the Electronic Patient Record and the digital transfer of images will be a vital part of working in an integrated way across community, intermediate and acute care, and in working as part of Clinical Networks  Access to services, particularly in relation to public transport and NHS transport systems is key when any service redesign is considered

Management of chronic/long term conditions:  To date there has been limited systematic use by the NHS in Wales of GP based information on chronic diseases for planning purposes. Data collection as part of the Quality and Outcomes Framework could improve this.  There is a move towards a more generic approach to management of long term conditions i.e. basic principles of management are the same regardless of the specific condition  Key elements of an effective chronic disease management programme include; broad managed care programmes, targeting high risk people, sharing skills and knowledge, patient involvement in decision making, self management education, self monitoring, telemedicine and use of disease registers.  Effective programmes can improve clinical outcomes and quality of care for people with chronic diseases, and ensure they are managed predominantly in the community setting, therefore reducing hospital admissions and attendances.

Impact of Medical Technological Advances 7

IT & Telecommunications:  Significant capacity shortcomings in ICT in Wales have been identified.  Technological developments are likely to be one of the most important drivers of medical spending.  ICT will improve links between healthcare providers.  The focus of care will shift from secondary services.  Patients will have greater control over their care.  Telemedicine could improve links between patients and expert opinion.  Telemedicine can enable self-diagnosis and self-care at home.

Genetics:  Genetic screening could identify people at risk of a particular disease and allow appropriate interventions to be introduced before the disease develops.  The earliest gains are predicted in pharmacogenetics.  Ethical and financial issues could slow advances.

Minimally invasive surgery:

 Minimally invasive surgery will reduce hospital stay and promote outpatient operations.

Miniaturisation:  Care could be moved from secondary to primary services. Miniaturisation could potentially enable people with chronic diseases to remain out of hospital.

Drivers to Services 8

There are 6 main categories of ‘drivers’ to be considered, when ‘horizon scanning’ the future of health care services:

Rising public expectations:  Expectations are rising, the patient of the future will be better informed and less deferential than previously; public involvement in decisions is on the increase, and the medicalisation of normal life events continues.

Demographics and epidemiology:  The population structure of Wales is changing, with an ageing population, a declining birth rate, and changing family structures where carers are often older persons themselves.

New technologies:  Technological advances include molecular genetics, robotics, nanotechnology, biotechnology and the use of robotics. These may increasingly facilitate changes in health care provision, however future projections about their use may be unrealistic and over optimistic.

Information and communications technology and technology management:  There is greater access to health information for health care staff and patient alike, however the ability and readiness to embrace and use the information varies with factors such as age and circumstance.

Workforce capacity, education and training:  The ability to recruit and retain a skilled and qualified workforce is vital. However the working population is ageing, flexible career pathways are required, while suitable education and training will be needed to support the changing roles.

System performance, quality and political factors:  Integration is required between and across organisations to meet needs of local communities. The current ‘unbalanced’ health care cycle is unsustainable, and consideration must be given to all health and social care sectors when redesigning services

Dependencies & Expectations 9

Dependencies:  Dependency has been described as the need for human help (or care) beyond that customarily required by a healthy adult  North Wales’s ageing population could increase dependency on health and health care services over the next 20-30 years. Demographic, family and social changes may lead to a reduction in informal care provision, leading to increased dependency on formal health and health care services. The decline in the occurrence of CHD in younger people is offset by an increase in the occurrence in an ageing population. The incidence of diabetes is increasing in all age groups.  The prevalence of diabetes increases with age. People with diabetes are more likely to be admitted to hospital. An ageing population could result in more people being dependant on services for respiratory conditions which older people are at greater risk of, including, COPD, influenza & pneumonia. Musculoskeletal conditions impair greatly on quality of life.  Musculoskeletal conditions are one of the most common reasons for referral to secondary care. Musculoskeletal disorders increase with age.  Fracture incidence and costs are predicted to rise by over 1% per annum as a result of the ageing population in Wales.

Expectations:  It is difficult to predict exactly what people’s expectations of health care services will be in the future. While it is likely patients’ expectations for choice and involvement will increase, different patients will want different things from the NHS.  Wanless identifies several trends that are contributing to the rising expectations placed on the NHS:  Globally, there is widespread evidence of a greater desire for choice as well as increased tailoring of services;  People in the UK have higher disposable income and the expansion in higher education has fuelled rising expectations;  The continually growing emphasis on high skill, knowledge focused, flexible career paths will impact on health and social services; both in terms of adapting to accommodate these changing lifestyles and meeting the needs these pressures generate, such as increased expectation of increased information and involvement around decision making;  Changing patterns of work will continue to affect the family, especially the position of women as carers;  As more people are working and working for longer has meant that people are demanding more accessible and convenient, available 24 hours and day, seven days a week;  There has been a reduction in deferential attitudes and people are increasingly likely to use their ‘voice’ to complain if they receive poor services.  Medical trends also raise expectations:  Medical advances increase the range of treatments that available.

 Increasing success rates have increased people’s expectation of being in good health as they get older.  The number of conditions being officially classified is continuing to grow, for example, post traumatic stress disorder and myalgic encephalomyelitis.  People are taking more active interest in their own health. There has been a rapid extension health clubs in the UK.  Patients are taking more responsibility for their own health and this is likely to increase in the future as the population ages and acute diseases are transformed into chronic conditions;  Patients increasingly want access to a wide range of treatments and services beyond the traditional boundaries of the NHS. Spending on alternative treatments such as herbal and homeopathic medicines is increasing.  In the future, the public will expect the NHS to provide:  A universal and fair service that contributes to social solidarity.  Safe, high quality treatment: patients will want the best treatment outcomes, with minimum variability of success; rapid uptake of new technologies; greater emphasis on pro-activity by GPs, with focus on lifestyle, prevention and screening; effective clinicians and other staff; and accurate and helpful information on service performance.  Fast access, ‘waiting, but only within reason’.  An integrated, joined up system: innovations such as the electronic health record will fuel expectations; patients are likely to be less accepting of requests for repetitive information or communication breakdowns.  Comfortable accommodation services: patients will expect healthy food in a comfortable environment; a single or double room; and accessible healthcare settings.  Services that are designed around patient’s individual needs.

Predicted Future Changes in Orthopaedics in Wales: A Horizon Scanning Exercise 10 Future challenges in orthopaedics include the following:

The scale of the problem: 1 Orthopaedic problems impose a vast social and economic burden on society. 2 It is estimated that 50%of the UK population will require surgery at some time during their lifetime. 3 Injury remains a ‘neglected epidemic’. 4 The validity of routine data in orthopaedics is questionable 5 Consultant activity trends are influenced not only by individual work rates, but also by management and clinical systems in place.

Demographic and epidemiological changes: 6 The population of Wales is projected to increase by more than 1% over the next ten years, but with wide variation by age group. Most orthopaedic diseases/conditions are more common in the elderly, and

therefore the demand for orthopaedic conditions will probably rise, however, the impact of an ageing society is difficult to predict. 7 Lifestyle issues affect bone health, and the role of prevention is key as individuals can do much to improve their own bone health. The projected increases in activity being forecast within this report highlight the need to concentrate on preventative activities, and to decrease fracture rates in the older population.

Advances in science and technology: 8 Enormous advances have been made in the fields of biology, science, physics and engineering, all of which have rewarded the orthopaedic speciality. Such advances cannot be ignored and will impact on service delivery and numerous ways. 9 Economic evaluations in orthopaedics are less common than in other areas of medicine.

Changing expectations: 10 People’s expectations of the NHS have risen dramatically and unmet need clearly exists in orthopaedics. However, orthopaedic problems are not the sole problem of the health service. Social care and the health service need to work together on appropriate integrated care pathways to reduce inappropriate referrals and direct patients to the correct specialities and expertise at an earlier stage.

Workforce issues: 11 There is no single blueprint for orthopaedic services. 12 Concern surrounds new training routes and working time regulations, and these need to be monitored closely. 13 New ways of working have been shown to be effective. Orthopaedic activity is multi-disciplinary in nature and the roles and abilities within teams should be recognized and used to the fullest, in order to benefit the patient and service.

References

1. Muir Gray J A 2007 How to get better value healthcare Offox Press

2. Donabedian A 2002 An Introduction to Quality Assurance in Health Care Oxford University Press

3. Milton Keynes and South Midlands Health and Social Care Subgroup Supporting the development of a Health and Social Care Strategy Framework for the MKSM Sub-Region

Accessed on line November 2007 at http://www.mksm.nhs.uk/FileAccess.aspx? id=144

4. Darzi A 2007 Our NHS Our future. NHS Next Stage Review Interim Report: Summary

Accessed on line November 2007 at http://www.ournhs.nhs.uk/fromtypepad/283411_ourNHS_summary_v2acc.pdf

5. NPHS 2005 A Profile of long-term and chronic conditions in Wales

6. Jones S 2006 Aspects of acute services redesign – key messages from the literature NPHS

7. Designed for Life Project Team 2005 Impact of Medical Technological Advances NPHS

8. Owen T A 2005 Drivers to Services, NPHS 2005

9. Designed for Life Project Team 2005 Dependencies and Expectations NPHS

10.Owen T A 2006 Predicted Future Changes in Orthopaedics in Wales: A Horizon Scanning Exercise NPHS

Author: Jo Charles, Robert Atensteadt Date: 3/6/08 Status: Final Version: 0a Page 16 of 16