The Chairman of the Committee has asked Shropshire CCG to share its thoughts and proposals for orthopaedic surgery in Shropshire and the suggested engagement activity with the public around these proposals.  A report is attached and Dr Julie Davies, Director of Strategy and Service Redesign, Shropshire CCG will give a presentation at the meeting. 

 Dr Julie Davies, Director Strategy and Service Redesign, Shropshire Clinical Commissioning Group, introduced the paper before members and gave a presentation on the CCG’s proposals to change the pathway for patient referrals for hip and knee replacement surgery. (a copy of the report and presentation are attached to the signed minutes) She explained:

·       the context for the proposals;

·       benchmarking information – which showed the CCG was an outliner in spend compared to other similar CCGs;

·       The case for change and reducing the variation in procedure rates;

·       The details of the proposal;

      and

·       plans for further patient and public engagement.

In considering the information presented to them, the Committee commented, asked questions and raised issues relating to:

·     The availability of alternative options, such as physiotherapy, as it was understood there was a shortage of physiotherapists in Shropshire;

·     The need to recognise that Shropshire had more agricultural and forestry workers and therefore the figure for hip and knee replacements should be expected to be higher;

·     Whether cancellations of scheduled operations, including at hospitals outside of the county, contributed to pressure at Shropshire’s hospitals;

·       Whether putting an operation off until later might increase the clinical risks, as a patient would have aged in that time;

·       Whether peer CCGs used a similar cut off score

·       Information about the review carried out in 2014

·       Whether hip and knee surgery being seen as routine was an issue

·       The potential impact of the move in Worcestershire to carry out all orthopaedic surgery at the Royal Alexandra Hospital in Redditch

In response, Dr Davies reassured Members that comparisons had been made with comparative CCGs in terms of work and ethnic mix, age, deprivation and rurality. 

She acknowledged the challenge around provision of physiotherapists which would need to be factored into any decision made.  A complete physiotherapy review was planned to help balance and ensure resources were in the right place.

She reported that some peer CCGs had adopted similar scores although others did not use the same scale.  If the CCG did decide to change the threshold, it would be kept under review on an annual basis. Members noted that there would always be clinical exceptions to the scoring procedure. 

In terms of cancellations of scheduled surgery, this was constantly under consideration and a booking and scheduling review under way.    However, this was not a particular issue at Robert Jones and Agnes Hunt hospital as it did not deal with emergency cases.

Dr Davies confirmed that hip and knee surgery was viewed as being fairly routine. However, it did involve risks and she acknowledged that these risks could increase as patients got older.  The Director of Public Health reported that in general, the less surgery people had, the better they were.  He also highlighted that delaying initial surgery meant less chance of replaced joints wearing out.  Research conducted by the University of Birmingham on ageing in conjunction with clinicians had demonstrated the disadvantages of surgical intervention unless it was really needed. 

Dr Davies also emphasised that proposals were not just about saving money but about best use of resources to ensure the best care overall for Shropshire patients.  The proposals needed consideration as part of efforts to ensure the whole health care system of patient care would be sustainable for the future.

Members commented on the good quality of the analysis within the paper and the work undertaken on maximising use of alternative action against surgery, such as the pilot work on osteoarthritis delivered by the University of Keele and Arthritis Research UK in the south of the county.  The Committee felt that taking a position to wait until the optimum point for getting the best outcomes from surgery was the right thing to do.    It was hoped that if the right balance was achieved through conservative management that the need for a scoring threshold may no longer be needed.

The Committee went on to ask about plans for public engagement and stressed the need for the public to be helped to understand the potential change. 

Mathew James, Head of Governance and Involvement, explained plans for advertising the proposals which would involve utilising the Association of Local Councils, Healthwatch, local Patient Groups, the Voluntary and Community Sector and local newspaper.  He welcomed any further suggestions for accessing networks and the Committee suggested that Mrs Cosh, Senior Citizens Forum, be asked to help this.  A series of listening workshops was also planned across the county, to allow discussion of the proposals and gain people’s views.

The Healthwatch representative confirmed that Healthwatch was happy to be involved with targeted engagement activity, and if the change did take place could also monitor activity and responses to it.  She also welcomed plans for better primary care management which fit in well with the Community Fit part of Future Fit.

In conclusion, the Committee agreed that the proposal for a more conservative management pathway for patients accessing hip and knee replacement surgery in Shropshire was an appropriate way forward, and emphasised the need for any changes to be kept under careful review.