A Comparative Picture of Orthopaedic Services Betsi Cadwaladr University Health Board Date: June 2015 Reference number: 705A2014 This report has been prepared on the basis of work done under the Government of Wales Act 1998 and the Public Audit (Wales) Act 2004. The Wales Audit Office study team consisted of Anne Beegan, Sian Davies, Andrew Doughton, Kate Febry, Delyth Lewis and Stephen Lisle under the direction of David Thomas. Huw Vaughan Thomas Auditor General for Wales Wales Audit Office 24 Cathedral Road Cardiff CF11 9LJ The Auditor General is independent of the National Assembly and government. He examines and certifies the accounts of the Welsh Government and its sponsored and related public bodies, including NHS bodies. He also has the power to report to the National Assembly on the economy, efficiency and effectiveness with which those organisations have used, and may improve the use of, their resources in discharging their functions. 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Contents Summary report 4 1 Primary and community based services 12 Primary care provision 12 GP referrals 15 Community musculoskeletal assessment and treatment services 17 2 Outpatients and diagnostic services 20 Outpatient services 20 Physiotherapy services 24 Radiology services 26 3 Inpatient services 28 Waits and preparation for admission 28 Admission 32 During admission 33 Discharge 34 4 Follow-up and outcomes 38 Follow-up arrangements 38 Patient outcomes and experience 39 Appendices Appendix 1 – Sources of data 43 Page 3 of 44 - A Comparative Picture of Orthopaedic Services - Betsi Cadwaladr University Health Board Summary report 1 In 2013, the Auditor General undertook a local mandated review of orthopaedic services across Wales. The review sought to answer the following question: ‘Are orthopaedic services efficient, effective and economical and are they being designed and delivered in a sustainable manner?’ The findings of that work are set out in the national report A Review of Orthopaedic Services. 2 As part of the methodology underpinning the review, we collected a range of data to understand the performance of current orthopaedic services within each health board. This report sets out our view of orthopaedic services in Betsi Cadwaladr University Health Board (the Health Board) and our view of how the service compares to the rest of Wales. 3 We have based our view on the efficiency, effectiveness and economy of orthopaedic services provided by the Health Board using the patient pathway. Collection of the data has been from a range of sources, which are set out in Appendix 1, and the data used is the most available data at the point of reporting. The findings from the data analysis are set out in the main body of this report but the high-level messages are set out in Exhibit 1. Exhibit 2 is a summary assessment that uses a traffic light rating to show how the Health Board compares with the rest of Wales on each indicator and, where applicable, Welsh Government targets. Exhibit 1: High-level messages An increasing demand and partially ineffective orthopaedic outpatient services are resulting in long waits for outpatient, diagnostic and inpatient treatment. Once patients are admitted, they generally have a short hospital stay, although inpatient resources could be better utilised and some outcomes following surgery need to improve: investment in primary care is reducing at a time when GP referral rates are increasing and although there are well-established Clinical Musculoskeletal Assessment and Treatment Services (CMATS) in place, they are struggling to meet the increasing demand; although physiotherapy services are able to meet demand, some aspects of outpatient services are inefficient and waits for radiology tests can be long, particularly in relation to MRI scans; pre-operative assessment arrangements are in place and hospital stay is generally shorter than the rest of Wales but more could be done to reduce waits for admission, increase day-case rates and bed occupancy, and improve theatre utilisation across the Health Board; and follow-up arrangements generally work well although outcomes from surgical intervention are mixed both across the Health Board and in comparison with the rest of Wales. Page 4 of 44 - A Comparative Picture of Orthopaedic Services - Betsi Cadwaladr University Health Board Exhibit 2: Summary assessment Primary and community based services Indicator Health board performance Performance rating Has the Health Board invested in primary care provision? Increased investment in Spend on primary care provision for primary care musculoskeletal problems reduced musculoskeletal by four per cent between 2010 and provision 2013. Total spend on primary Average spend per head of care provision population on primary care is just below the all-Wales average at £11.60. Proportion of total The proportion of total spend on musculoskeletal spend primary care is the second lowest in allocated to primary care Wales at 9.9 per cent. Range of community The range of community based based services available services available to GPs is less to GPs positive than other health boards. Receipt of alternative The extent to which patients intervention prior to receive alternative intervention prior surgery to surgery is variable, with a higher proportion of patients receiving physiotherapy advice and exercise programmes than the all-Wales average. Is demand for secondary care services managed? GP referral rate The rate of GP referrals per 100,000 head of population has increased to just below the all-Wales average. Trend in referrals The trend in GP referrals increased in March 2013 although the number of referrals is now around 1,300 per month. Is the CMATS operating effectively? CMATS in place The Health Board has introduced CMATS in each of the localities. CMATS operational CMATS comply with the key Welsh arrangements Government principles across the three localities. CMATS staffing levels The level of staff per 1,000 GP referrals is lower than the majority of teams across Wales. Page 5 of 44 - A Comparative Picture of Orthopaedic Services - Betsi Cadwaladr University Health Board Primary and community based services Indicator Health board performance Performance rating Patients treated by 12.6 per cent of patients referred CMATS received a face-to-face assessment Descriptive indicator by CMATs. Waiting times for The average wait from referral to face-to-face assessment face-to-face assessment by by CMATS CMATS is outside the Welsh Government target of eight weeks, with a wait of 12 weeks in east and west, and 14 weeks in central. Outpatient and diagnostic services Indicator Health board performance Performance rating Are outpatient services effective? Waits for first outpatient The percentage of patients waiting appointment more than 26 weeks for their first outpatient appointment has fluctuated over the past three years, with performance since August 2013 above the all-Wales position. Consultant outpatient The number of consultant sessions outpatient sessions per 1,000 GP Descriptive indicator referrals is around the average for Wales. Cancelled outpatient The proportion of outpatient clinics clinics cancelled for 2012-13 ranged between 2.8 and 8.8 per cent. Follow-up to new ratios The ratio of follow-up to new appointments is 1.94 follow-ups to every new, which is above the Welsh Government target of 1.9 but below the all-Wales average. Did Not Attend (DNA) The DNA rate for new rates appointments is within the all-Wales average at 7.2 per cent but the DNA rate for follow-up appointments is the second highest in Wales at 9.4 per cent. Both DNA rates are higher than Welsh Government targets. Patient cancellations The Health Board was unable to report the proportion of patient - cancellations. Page 6 of 44 - A Comparative Picture of Orthopaedic Services - Betsi Cadwaladr University Health Board Outpatient and diagnostic services Indicator Health board performance Performance rating Co-ordination of visits Ninety-two per cent of patients felt that the Health Board tried to co-ordinate the number of visits that they needed to make. This is the second highest in Wales. Cost per outpatient The cost of an orthopaedic attendance outpatient attendance is higher than the all-Wales average at £142.15 and the second highest across Wales. Are physiotherapy services able to meet demand? Waits for physiotherapy The percentage of patients waiting services less than eight weeks is higher than the all-Wales average at 86 per cent, with very few patients waiting more than 14 weeks. Range of settings Physiotherapy services are provided in a range of primary, community and acute settings. Ease of access Patients are able to self-refer directly to the physiotherapy service.