Public consultation

Find out about the proposal

Please download and read our consultation booklet that sets out why and how we want to change the way we organise planned orthopaedic inpatient surgery and what it might mean for you. The booklet explains how we asked for views to be given and how we are using them to guide our decision making. 

Please note, the consultation is now closed. 

Full pre-consultation business case
Executive summary of the pre-consultation business case - this  sets out the detail of our proposal
Summary of consultation proposal
Easy Read version of summary of consultation proposal 

Or you can read the plain text version of the consultation booklet below. This is accessible for screen readers and can be translated into other languages using the button at the top right of this page.

Plain text version contents:

• Overview
• What is planned orthopaedic inpatient surgery?
• About this consultation
• Our proposal
• Why are we suggesting changes to orthopaedic surgery?
• How would services change?
• How would it work for patients in practice?
• How was Central Middlesex Hospital selected as the proposed location and what would it mean for patients?
• Benefits and challenges
• How the proposals could affect different communities in north west London
• Evidence used in developing our proposal
• How to give your views
• Ways to take part in the consultation
• Getting more involved

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Overview

"Our response to the Covid-19 pandemic has shown just what can be achieved when we work more collaboratively, joining up our care and making the best possible use of our combined expertise and resources.

One of the ways we were able to maintain more planned care during the later phases of the pandemic was by establishing ‘fast track surgical hubs’. These were facilities within our hospitals that focused on specific, routine operations, separated as far as possible from urgent and emergency care. This meant that operations were less likely to be put on hold when there was pressure on our emergency services.

As we come out of the pandemic with long waiting lists and many other challenges, we want to draw on best practice and go further with our improvements. We want to bring together much of the routine, inpatient orthopaedic surgery for the population of north west London in a purpose-designed centre of excellence, completely separated from emergency care. Evidence built over many years shows that when this type of surgery is done frequently, in a systematic way, there is an improvement in both quality and efficiency.

Clinicians and managers from across the four acute trusts have worked with GPs and other colleagues, as well as with patients and lay partners, to develop a detailed proposal for an ‘elective orthopaedic centre’ – orthopaedic services have some of the longest waiting times in north west London. We now want to share this proposal with as many patients, local residents and staff as possible, to hear your views and ideas so that we can continue to improve health and healthcare with – and for – our local communities."

 What is planned orthopaedic inpatient surgery?

Orthopaedic surgery treats damage to bones, joints, ligaments, tendons, muscles and nerves (the musculoskeletal system). Patients may be referred to an orthopaedic surgeon for a long-term condition that has developed over many years, such as osteoarthritis.

Hip and knee replacements are the most common type of orthopaedic surgery offered in the NHS. However, other types of surgery of the hips, knees, shoulders, elbows, feet, ankles and hands are also types of orthopaedic surgery.

Planned surgery is when patients have their operation booked in advance. It is generally arranged after a referral to hospital by a GP or community service followed by an assessment by hospital specialists in an outpatient clinic. It is sometimes called ‘elective’ or ‘non-emergency’ care.

Inpatient care describes when a patient stays in hospital while receiving medical care or treatment.

About this consultation

We are holding a public consultation between Wednesday 19 October 2022 and Friday 20 January 2023 to get feedback on our proposal. We want to connect with as many people as possible across north west London, ensuring everyone has the chance to find out more, share their views and possibly get involved in the project.

The proposed change could affect anyone who needs inpatient orthopaedic surgery in the future, who lives in one of the eight boroughs of north west London or in a neighbouring area and who might be a patient in one of the hospitals involved in our proposal. If the proposal goes ahead, there would be a change to where and/or how surgery would take place for around 4,000 adults per year.

To inform our decision-making, we would welcome feedback from anyone with an interest in these services, including: 

• Anyone who is currently having or has had planned orthopaedic surgery
• Anyone currently on our waiting lists for orthopaedic surgery or who might need these services in future
• Families and carers of people who use, have used or might use these services
• Residents of Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Kensington and Chelsea, Westminster and neighbouring areas who might use hospital services in north west London
• Staff and professional representative bodies such as trade unions, local medical committees and Royal Colleges
• Community representatives, including the voluntary sector
• Staff and partners in health and social care
• Local authorities.

By inviting people to take part in the consultation we want to understand whether:

• We have developed the best possible solution to the current challenges in providing planned orthopaedic surgery in north west London
• We are doing all we can to ensure that services are of the best quality
• We are doing the right things to ensure everyone who needs care can access it in a timely way
• There are more things we could do to make services responsive and tailor them for those with specific needs
• You have any alternative proposals, and what they are

Responsibility for this consultation

The Integrated Care Board in North West London is called NHS North West London. It is the statutory NHS organisation responsible for developing a plan that meets the health needs of the local population, managing the NHS budget and arranging for the provision of health services in north west London.

They – and NHS England London – have given the go ahead for this consultation following a review of a ’pre-consultation business case’ developed by the North West London Acute Provider Collaborative.

You can download a copy of the pre-consultation business case which provides much more detail on the elective orthopaedic centre proposal. You can also read the pre-consultation business case executive summary.

The North West London Acute Provider Collaborative is made up of the four acute NHS trusts in north west London – Chelsea and Westminster NHS Foundation Trust, The Hillingdon Hospitals NHS Foundation Trust, Imperial College Healthcare NHS Trust and London North West University Healthcare NHS Trust. They are independent organisations but make strategic decisions together to help share best practice, use resources in the best way for all patients, and develop consistently high quality services. In total, they manage 12 acute and specialist hospitals as well as some community-based and online services.

The North West London Integrated Care System brings together all health and care organisations in north west London. It covers the eight boroughs of north west London .

Next steps after the consultation

After the North West London Acute Provider Collaborative has considered everyone’s views on the proposal, they will produce a consultation outcome report. This will be used to develop a ‘decision- making business case’. NHS North West London will then consider the decision-making business case and its recommendations in order to decide whether to implement the proposal, update the proposal or find an alternative solution.

See current provision of planned orthopaedic surgical care in north west London illustrated below:

Our ambition

We want to bring together much of the routine, inpatient orthopaedic surgery for the population of north west London in a purpose-designed centre of excellence at Central Middlesex Hospital, completely separated from emergency care services.
 
This means that:

• Patients will have faster and fairer access to surgery and would be much less likely to have their operation postponed due to emergency
  care pressures.
• Care would be of a consistently high quality, benefitting from latest best practice and research, provided by clinical teams that are highly skilled in their procedures.
• The centre would be extremely efficient, enabling more patients to be treated at a lower cost per operation.
• Patients will have better outcomes, experience and follow-up.

In addition, capacity created in other north west London hospitals by bringing together routine surgery in the elective orthopaedic centre would be able to be used for surgical patients who have more complex needs and for other specialties.

Why are we suggesting changes to orthopaedic surgery?

We need to reduce our waiting times

The Covid-19 pandemic has had a big impact on waiting times for planned care across the entire NHS, particularly for orthopaedic care, which accounts for more than a quarter of all surgery nationally.

In August 2022, more than 15,000 people were waiting for orthopaedic care in north-west London hospitals. Just under 3,700 of these people had had their initial assessment and were waiting for an operation. The proportion of people waiting more than 52 weeks for orthopaedic care has increased by more than a quarter during the pandemic. Even though procedures like hip or knee replacements are not usually considered to be time critical, waiting for treatment can badly affect your quality of life and many conditions can worsen over time, making treatment and recovery harder.

We need all our care to be consistently of the highest quality

Performance against national indicators for clinical outcomes and patient experience in northwest London is amongst the best, for some measures in some trusts. But there is much room for improvement in all trusts and a lot of unnecessary variance between trusts. But there is much room for improvement in all trusts and a lot of unnecessary variance between trusts. North west London hospitals are in the bottom half for many quality measures when ranked against all NHS trusts in England. 

Hospitals in north west London also perform relatively poorly in terms of cancellation rates for orthopaedic operations. This is related to the impact of urgent and emergency care pressure at hospitals that provide planned, urgent, and emergency care. And there is also wide variation across our trusts in terms of how well our operating theatres are used, including how much unnecessary ‘down time’ there is between operations.

We need to make our care more patient focused

Though we generally get positive feedback from patients that our staff are caring, kind and helpful, they are much less positive about their experience of navigating the healthcare system. Patients have reported frustration with long waiting times between their initial assessment and surgery or while attending their appointments, having to chase up their follow-up appointments or feeling worried due to re-scheduling or cancellations.

Elderly or disabled patients often say travel to appointments is a problem. Patients also highlight communication problems, such as lack of coordination between GPs and hospital services or confusing information. Patients say they want more control over their care and they want us to organise our care system so that it is as clear, consistent and straight forward as possible.

We need to help improve health and reduce health inequalities

Musculoskeletal (MSK) disorders are the third leading contributor to the burden of disease in Greater London. MSK conditions are one of the most common long-term health conditions for the most deprived 20 per cent of the population. While many of the ways to prevent and limit the impact of MSK disorders sit outside the control of acute hospitals and even the wider NHS, improving orthopaedic surgery would particularly help older patients and patients from more deprived backgrounds.

We need to be prepared for the future

If we do nothing, our waiting lists will continue to grow faster than our capacity to provide care. By 2030 we expect the number of people waiting for orthopaedic surgery in north west London will increase by almost a fifth if we continue as we are now.

We also want to make sure we make the most of digital and other technological advances, without leaving anyone behind.

All or some elements of planned orthopaedic surgical care are currently provided in nine hospitals in north west London. There are many differences between the hospitals. Some have A&E departments and intensive care units and special types of operating theatres and so are suitable for more complex types of surgery and for operations on patients with more complex needs. These hospitals are also more affected by urgent and emergency care pressures. Other hospitals have more dedicated day-case surgery facilities, suitable for less complex surgery.

Currently, where you go if you need orthopaedic surgery depends to a large degree on where you live and whether you have any preferences. But the complexity of your needs and the surgery you require also have an impact. For example, if you have a number of other health problems which means you are at more risk from surgery, you will need to have your operation at a hospital with more intensive after-care services. 

See proposed provision of planned orthopaedic surgical care in north west London map illustration below:

Our proposal

The proposed elective orthopaedic centre would bring together most ‘routine’ orthopaedic inpatient surgery for patients who are otherwise generally well – an example of what is known as ‘low complexity, high volume’ surgery. There are around 4,000 operations of this type in north west London each year. Evidence built over many years shows that when this type of surgery is done frequently, in a systematic way, there is an improvement in both quality and efficiency.

Outpatient care (including pre-operative assessment and post-operative rehabilitation and follow up) would continue to be provided as and where it is now. And day case and complex surgery would continue in the hospitals where they are provided currently.

If a patient can have their operation at the elective orthopaedic centre, their end-to-end care would remain under the surgical team based at their ‘home’ orthopaedic hospital. Their ‘home’ surgical team would travel with them to undertake the surgery, supported by the centre’s permanent clinical support team and an electronic patient record system that is shared by all the hospitals in north west London. This would help provide joined up care and make sure that expertise continues to be developed across the surgical teams in north west London.

How would it work for patients in practice?

This is an example of how the pathway would work in practice. After having had hip pain for a few months and with a family history of arthritis, Samira, aged 70, makes an appointment with her GP.

1. After a discussion, Samira and her local GP decide to ask for advice from a hospital specialist, booking her in for an x-ray at a local community diagnostic centre to help inform that review. Her GP also puts her in touch with the local community musculoskeletal service to consider any immediate help, such as physiotherapy or ‘social prescribing’, for example to exercise classes.

2. Samira is able to keep track of her appointments and consultations via a secure app on her phone. She also uses the app to access exercise videos and record her symptoms. She gets a message to book an online appointment to speak with her GP and a surgical specialist from a local hospital – they are all able to see her x-ray – and they decide she doesn’t yet need a hip replacement but that she should be closely monitored.

3. After two years, Samira’s GP and hospital surgeon let her know that her latest x-ray and online symptom tracker show that she should now consider a hip replacement. It is a routine replacement and she is in good health. So, she is able to book in her surgery at the elective orthopaedic centre for 12 weeks later. While she waits, she is asked to take part in ‘joint school’ – a mix of advice and support online and in-face at her local hospital – to help ensure she has the best possible outcome from her surgery.

4. Samira has her hip replacement under the care of the surgeon from her local hospital and goes home after a short stay. She is booked in for an immediate programme of physiotherapy and rehabilitation – a mix of online and in face support at her local hospital.

5. Samira is able to ask for further review and advice from her local hospital specialist if and when she feels she needs it. Longer term, she continues to take part in an online programme of exercise and advice and benefits from periodic physiotherapy support.

How was Central Middlesex Hospital selected as the proposed location and what would it mean for patients?

We assessed all of the NHS acute hospital sites in north west London (excluding the specialist Western Eye and Queen Charlotte’s and Chelsea hospitals), as well as the possibility of using non-NHS sites.

A single elective orthopaedic centre at  Central Middlesex Hospital was found to be the best option as:

• It is a modern and high-quality estate which, with some limited expansion and remodelling, could offer a 41-bed facility tailored to systematised surgery
• It is one of only two hospitals in north west London that does not provide urgent and emergency care, so is much less impacted by urgent and emergency care pressures
• None of the existing services would need to be moved as there is plenty of room for expansion.

Accessibility

We undertook detailed analysis of the average time to travel to each of our hospitals from all parts of north west London.

We found that Central Middlesex Hospital has:

• The shortest median (midpoint) travel time by car at 22 minutes
• The second shortest median (midpoint) travel time by public transport at 45 minutes.

We calculate around 4,000 inpatient operations per year could be provided at an elective orthopaedic centre at Central Middlesex Hospital following a systematised ‘high volume, low complexity’ approach. This would enable the centre to provide routine surgery for all patients with low complexity needs who currently have these operations in north west London hospitals (see table).

Low complexity inpatient orthopaedic operations in north west London hospitals by borough of patients (2019).

More detailed information on the selection of Central Middlesex Hospital can be found in the pre-consultation business case.

More practicalities

What services would be included in the elective orthopaedic centre?

The elective orthopaedic centre would offer only low complexity, planned inpatient surgery. Complex inpatient surgery would be out of scope, as would joint revisions (for when a hip or knee replacement needs to be repaired or replaced again) and spinal surgery. Spinal surgery in north west London is provided through a separate centralised service run by Imperial College Healthcare’s neurosurgical service made up of neurosurgeons as well as orthopaedic surgeons. Children’s orthopaedic surgery is also out of scope.

Day case surgery has been excluded currently on the basis that there is greater benefit from shorter travel distances on the day of surgery. Day case surgery and some complex surgery provided by London North West University Healthcare would continue at Central Middlesex Hospital as that is also one of their ‘home’ orthopaedic hospitals.

What are the timescales?

We have prioritised the development of this proposal in order to tackle the backlog in our waiting lists and improve the quality of orthopaedic care as quickly as possible.

After consulting with a wide range of people likely to be affected by the proposed changes, we would like to take a decision on whether or not to proceed to implementation by early 2023. If the decision is to proceed, a period for contracting and construction would follow, with the elective orthopaedic centre able to open by autumn 2023.

What works would be involved and how much would it cost?

We estimate it would cost around £9.4 million to expand capacity and make the building changes at Central Middlesex Hospital.

This includes the cost of building two additional laminar flow operating theatres, creating a larger recovery unit and remodelling some parts of the existing estate.

The development of an elective orthopaedic centre for north west London would help clinical teams to provide orthopaedic surgical care:

• that consistently meets national best practice standards by having greater specialisation in specific operations
• that is more efficient by taking a more systematised approach, drawing on national best practice
• that separates planned orthopaedic surgery from urgent and emergency services, in line with guidance and policy from NHS England, Royal College of Surgeons and the National Clinical Advisory Team
• that makes best use of the facilities and skills of the four acute trusts that supports surgical skills training and new role development as well as better and more flexible ways of working
• that supports continuous improvement and innovation.

Patient experience benefits

As well as improved quality of care, the proposed changes in planned orthopaedic inpatient surgery would:

• support faster and fairer access for patients who need orthopaedic surgery across northwest London
• prevent conditions from getting worse when waiting a long time for surgery
• mean fewer postponed operations due to urgent and emergency care pressures
• help care to be more joined up across the whole of the musculoskeletal care pathway
• support more focus on care before and after surgery to help reduce the risks of surgery and enable faster recovery.

Staff benefits

While the development of an elective orthopaedic centre would require change for many staff working in this specialty, it would:

• support the development of both planned and urgent and emergency surgical skills across all the north west London teams
• allow greater specialisation in skills for staff based permanently in the centre
• support more focus on research, education and innovation
• facilitate the development of new roles and ways of working.

Challenges

We know that with any change there may be some disadvantages for some people. We think the key challenges for this proposal would be:

• some patients would have to travel further to get to and from Central Middlesex Hospital to have their operation
• some visitors would also have to travel further
• some staff would have to work in a different hospital to the one they work in now and may need to work on different sites on different days
• people with additional needs (such as those with a learning disability or dementia) could find it confusing to have their inpatient surgery in a different, possibly unfamiliar, hospital.

We are developing plans to minimise these challenges, looking at how other centres have developed solutions. For example, the South West London Elective Orthopaedic Centre, established in 2004, has a contract in place with a local taxi firm to provide transport for patients who would otherwise struggle to get there and back home. We are also very keen to get your ideas through the consultation events and survey.

We also heard concerns in our earlier discussions with patients and local communities that a greater use of digital services and apps could leave some patients behind. We are exploring potential dedicated roles for digital coaches and care co-ordinators as part of the further detailed planning for the proposed elective orthopaedic centre.

Again, we are very keen to hear more views and ideas.

How the proposals could affect different communities in north west London

When the NHS proposes changes to services, we need to make sure we take into account the needs of everyone who uses or will use these services in future.

As part of our work in developing the proposal we have carried out an equalities and health impact assessment (EHIA) and a travel analysis and we have compiled feedback to date from patients and local communities. This includes the outcome of conversations with just over 70 people this summer about bone and joint care in north west London and some early feedback on the possibility of a dedicated centre for planned orthopaedic surgery.

What some community members told us so far

People understand the need to reduce waiting times and support work to enable this to happen as quickly as possible, even if it means travelling further to be seen faster.

• A dedicated centre for routine orthopaedic surgery was seen as a good idea, particularly as a way of maximising staff time and developing clinical expertise.
• Our patients generally praised acute care and most of the concerns raised were in relation to pathways into hospital care. We have shared these insights widely with lead clinicians and partners within the north west London healthcare system to inform how the implementation of issues, as well as informing improvement and transformation projects, such as a project to improve and standardise the provision of community musculoskeletal services.
• Some concerns were raised about ease of travel into Central Middlesex Hospital, particularly for those with further to travel. We are exploring how we can improve accessibility to the site.

We now want to have conversations with as many people as possible who may be affected by the proposed change. We would like to hear from a diverse mix of the population who would be served by the proposed elective orthopaedic centre, particularly those identified as being most at risk of barriers to access or poorer health outcomes,and including those belonging to disadvantaged groups or sharing one or more protected characteristic.

• People in the 45+ age group who are already on our waiting lists and their families/carers – this group makes up most of the target population for the elective orthopaedic centre. Our involvement activities indicate that we need to focus on increasing participation from people most likely to be suitable for routine surgery.
• People with more complex health care needs - who may face specific challenges in accessing orthopaedic services and navigating the healthcare system, such as:
  • people who are disabled or who have hearing impairments, learning disabilities or autism
  • people with a mix of health needs, such as hypertension and diabetes
  • people with mental health related issues.

• Black, Asian and other minoritised groups – people from minoritised ethnic groups (particularly those for whom English is their
  second language) are more likely to report poorer outcomes. The Covid-19 pandemic has further highlighted structural disadvantages faced by these groups. We need to make sure our plans for the elective orthopaedic centre do not deepen these inequalities.
• LGBTQIA+ groups – high incidences of prejudice experienced by people identifying as LGBTQIA+, including negative attitudes from healthcare professionals, may prevent individuals from accessing treatment.
• Groups likely to incur longer travel times – while Central Middlesex Hospital site has the shortest average travel time by car and the second shortest average travel time by public transport, there is variation in travel times for residents across the boroughs. We need to ensure we understand views on accessibility from across
  the sector.
• Residents living in the most deprived areas – deprivation can be a barrier in access to healthcare and our EHIA indicates that over a half of the north west London population are more deprived than the national average, with a particular concentration of high deprivation in the middle of the geographical region.

How would our staff be affected by this proposal?

As we move forward with public consultation, we will also be stepping up engagement with staff and partners to develop the detail of care pathways, staffing models and training and support plans for the proposed elective orthopaedic centre.

Based on what we know works well in other centres, we envision a staffing model where some staff – such as ward, theatre and administrative staff – would be based permanently at Central Middlesex Hospital. Then other staff – primarily surgeons – would move with ‘their’ patients from their ‘home’ orthopaedic care to the elective orthopaedic centre to undertake the surgery.

If the proposal is taken forward, we would undertake a formal consultation with the staff who are affected. Other types of planned orthopaedic care will continue at all hospitals that currently provide planned orthopaedic care and so we would continue to need orthopaedic staff in these hospitals.

Evidence used in developing our proposal

Evidence in the UK and around the world shows that undertaking ‘high volume, low complexity’ surgery in dedicated centres, in a systematised way with specialist staff, is likely to result in better quality of care for patients.

Further information on the evidence behind our proposals can be found in our pre-consultation business case. This includes:

• A national review of adult elective orthopaedic services in England Getting It Right First Time (GIRFT) (2015)
• High volume low complexity (HVLC) programme GIRFT
• Separating emergency and surgical care: recommendations for practice Royal College of Surgeons (2007)
• The case for surgical hubs Royal College of Surgeons (2022)
• Reconfiguration of clinical services: what is the evidence? The King’s Fund (2014)
• Examining new options and opportunities for providers of NHS care. The Dalton Review (2014)
• International Society of Orthopaedic Centres

The main data sources used include:

• Hospital Episode Statistics (HES) digital.nhs.uk
• Dr Foster (TelestraHealth.co.uk)
• Model Hospital
• GLA Housing Led Population Projections
• Office for National Statistics
• Google MapS

We also reviewed the trusts’ own databases on complaints, theatre usage etc.

Key case study

South west London elective orthopaedic centre

Since 2004, planned orthopaedic surgery across south west London has been consolidated at SWLEOC (South West Elective Orthopaedic Centre), a centre of excellence for orthopaedic surgery. SWLEOC is a partnership between four acute trusts and is the largest hip and knee replacement centre in the UK, providing elective orthopaedic surgery services for 1.5 million people across the region with around 5,200 procedures a year. The facility is located on the Epsom Hospital site but is self-contained with 71 beds and a high dependency unit. The Care Quality Commission has rated the service as outstanding – its highest rating. Read more at eoc.nhs.uk.