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SPINE MATTERS

UKSSB Quarterly eBulletin
September 2015

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Charles Greenough (National Clinical Director for Spinal Disorders)

·      Spinal Transformation Project including GIRFT 
I am delighted to be able to inform you that the Pathfinder Pathway for Low Back Pain and Radicular Pain has been taken up in the new Spinal Transformation Project which is being funded by NHS England.  As some will be aware there has been a very disappointing delay between the completion of this work by the clinical group (which included representatives from all spinal societies) and any movement on implementation.

 

The Spinal Transformation Project encompasses three separate pieces of work, which in actual fact have very great synergies and interactions. In addition to the Pathway, the second piece of work is on Spinal Networks (see Ashley Cole’s article below). This is another recommendation of the Spinal Taskforce report in 2013; and under Sir Bruce Keogh pilot spinal networks have been running in four Centres in England.  The spinal networks will be based on a spinal hub, where the majority of specialised spinal surgery is undertaken.  Spinal hubs will often be co-located with major trauma centres or with neurosurgical centres, or will be in other major spinal surgical centres such as the Royal Orthopaedic Hospital, Birmingham or the Royal National Orthopaedic Hospital.  Each of these hubs will have a geographical network of partner hospitals which will be district general hospitals.

 

The network is designed to provide audit, governance and support for surgeons in partner hospitals via implementation of regional multi-disciplinary meetings of the surgeons in the network.  This will provide increased quality of care as the networks develop.  The Pathfinder Project will essentially provide each surgical centre with its own network within primary care to manage back pain and radicular pain.  The Pathfinder Pathway will also have the function of expediting appropriate referrals and reducing inappropriate referrals for low back pain to the spinal surgeons by implementing a coherent and comprehensive management pathway within primary care.

 

The third element is the result of a task and finish group of NHS England which produced a spinal tool kit.  This is designed to address the significant 18 week backlog in spinal surgery in collaboration between commissioners and provider trusts. Alison Tonge, Regional Director, North made several proposals to NHS England and this has resulted in the appointment of a senior manager and a project manager to implement the Spinal Transformation Project. (The text of this paper is on the UKSSB website). The appointments are due to be made over the course of the summer and implementation plans will be drawn up in early autumn.  This will be undertaken through a collaborative commissioning route.

 

In addition, the “Get It Right First Time” (GIRFT) initiative, headed by Tim Briggs at the BOA, will be a partner in the Spinal Transformation Project.  The GIRFT team will provide some funded sessions for the appointed clinical champions to aid implementation.  Spinal GIRFT will produce a detailed analysis of all hospital based spinal activity throughout England and enable comparison of rates and costs of interventions. With progressive adoption of the BSR, it is anticipated outcomes will rapidly become an intrinsic part of what will become an annual report.

 

The methods of implementation are necessarily undecided at this point, but one plank of the implementation will probably be a number of “roadshows” around the country, addressing both CCG commissioners and the local commissioners from NHS England in the regions.

 

I am delighted that finally we have got some progress towards an actual implementation of all the hard work that the pathfinder and related groups have put in.  This will transform management in primary care and, in my belief, will transform the prognosis for patients presenting with simple low back pain.  The construction of an implementation vehicle will also allow the management of low back pain and radicular pain to remain up-to-date in the future, as when new evidence becomes available, changes may be made to the pathway which will then have a direct route of implementation.  I will keep you informed and up-to-date as to developments over the next few months.  If you have any suggestions or comments, I would be very pleased to hear them.

 

Letter to Trust CEOs

Letter of 22nd July 2015 to Trust Chief Executives requesting support for the British Spinal Registry (including administrative support) which should now have been received by all relevant Trusts.

 


 

Regional Spinal Networks (RSN) Proposal

Ashley Cole (Complex Spinal Surgery Clinical Reference Group Chair)

Introduction

Over the last 2 years there have been dramatic changes in the way Spinal Services are commissioned with the formation of CCGs commissioning ‘non-specialised’ spinal procedures and NHS England (through Local Area Teams) commissioning ‘specialised’ procedures. A group of clinicians including representation from all the Spinal Societies were asked to defined which spinal procedures are non-specialised’ and which are ‘specialised’. Initially, providers of specialised services were supposed to provide services for 1 million population. This largely guided the split between specialised and non-specialised with a maximum of 50-60 providers of specialised services. The initial consensus was to make as much specialised as possible within the rules as it was perceived that one commissioning body would be easier to deal with than the 210 CCGs. Over time, there has been a proposal to reduce the number of centres providing specialised services to 15-20. Despite efforts to date, spinal services continue to cause problems both as a high cost specialised service and achieving the 18 week target.

There remain concerns that many centres currently providing specialised services might be de-commissioned and services centralised. The Regional Networks Proposal was initially recommended in the Spinal Task Force Report of 2013 and is the number one recommendation:

‘NETWORKS: All commissioners of spinal services should ensure that comprehensive spinal networks are established to facilitate integrated care pathways. Clinical commissioning groups and specialist commissioning must interface along these pathways. The networks for general spinal work (including primary care) must be co-ordinated with the individual and sometimes differing networks for trauma and cancer.‘

These networks were to establish safe, efficient and effective pathways for both elective spinal services and emergency care.

The intention is that Regions will propose their own Network Structure based on a ‘flexible template’. This proposal will be reviewed to ensure it meets the core objectives and then commissioned. This proposal has obtained support from NHS England which is keen to support spinal services and to allow clinicians to shape the way we deliver care to our patients. During a time where doctors seem to have reducing influence on their working environment, this is a unique opportunity for spinal surgery to shape its own future. The Regional Networks will collaborate to define and achieve shared goals in areas such as education and research. The proposed ‘Core Principles’ for each Regional Network are:

1.     Excellent care for patients
2.     Supported audit and research
3.     Sustainable and motivated working practice for all staff
4.     Education for all staff
5.     Future workforce provision

Sir Bruce Keogh authorised implementation of the networks and four pilot sites were established in November 2014. The pilots were Bristol, Liverpool, Middlesbrough and Sheffield. This document is based on the combined experience of these pilots.

A.    Regional Spinal Network (RSN) – Initial Planning

1.     Define the Spinal Hub(s): The Hospital Network comprises a spinal hub(s) and a number of partner hospitals. The Spinal Hub is where the 24/7 emergency spinal service is located but not necessarily where all the emergency work is done. The spinal hub of the pilot networks was a major spinal centre: The Bristol Royal Infirmary, The Walton Centre, The James Cook University Hospital and The Northern General Hospital. These centres undertook specialised surgery with 24/7 availability of spinal surgeons and appropriate investigations. Three of these spinal centres had a neurosurgical presence and all were co-located with major trauma centres. Appropriate paediatric support was available to Centres undertaking paediatric deformity surgery. It is anticipated that a region may have more than one Spinal Hub.

2.     Spinal Hubs will have integrated relationships with a number of partner hospitals which will in general be Trauma Units and District General Hospitals. Within the pilots were three types of partner hospitals:
a.     Hospitals where there is a group of three or more spinal surgeons undertaking a varied caseload which might include some specialised spinal surgery, commissioned by the relevant area team or by the CCG. Some had their own internal MDT meetings. These were orthopaedic surgeons by back ground.
b.     Hospitals where one or two surgeons were involved in spinal surgery on a part time or special interest basis undertaking non-specialised spine surgery commissioned by local CCGs. These were orthopaedic surgeons by back ground.
c.     Hospitals with an emergency department but without any surgeons undertaking spinal surgery on site.

The configuration of networks will be locally determined. In some areas Partner hospitals will potentially have a choice between two hubs, and this will be a local decision. The MDT is a professional body, and local considerations will determine the configuration anticipated to achieve the most effective function.

3.     Once the Regional Network has been defined, activity needs to be defined:
a.     Number of Spinal Consultants and WTE in each hospital
b.     Services provided in each hospital: Emergency on-call, Emergency surgery, Specialised surgery, non-specialised surgery, paediatric surgery
c.     Current MRI availability in each hospital with an Emergency Department
d.     Current and future operational relationships between the component units.

B.    Emergency Care

The Spinal Hub(s) will provide 24/7 Consultant Spinal on-call for emergencies. Partner Hospitals may provide partial on-call services (eg, 8-8 weekdays) or may provide a service for some or all spinal emergencies where urgent but not emergency surgery is required. Consideration must be given to local resources especially where more complex surgery is required.

Spinal pathways and management protocols need to be agreed between the spinal hub and the partner hospitals for the assessment, triage and appropriate management of spinal emergencies. All acute primary care referrals should be assessed and admitted (if necessary) by the orthopaedic team at the patient’s nearest acute unit, and that all ED referrals in partner hospitals should also first be assessed and admitted (if necessary) by the local orthopaedic team. If specialist spinal input is deemed necessary this should be initiated and referrals received by at least SpR grade clinicians.

The precise arrangement will depend on the experience and capacity of the spinal surgeons available in the partner hospital together with supporting infrastructure. Written protocols were agreed in Sheffield for the management of common presentations (Appendix 1).

For hospitals with no spinal presence, the objective is to provide a system of advice and support to allow patients to be safely treated as close as possible to their own homes and to support orthopaedic teams in achieving this objective. Continued advice as management progresses was an integral part of this protocol.

For the effective management of emergency care an electronic referral and response system is essential. This is because:
·       Response to telephone referrals are often subject to delays if staff are unavailable immediately (eg, in theatre)
·       Discontinuity if staff change over during the referral process
·       Degradation of information if the receiving surgeon needs to seek further opinion and provides no written record of the information received or advice given
·       If further advice is required there may be no written notes to refer to and then the process may have to start from scratch

There are three such systems available at present: Refer-a-patient, Orion and NORSE. The purpose of the system is to facilitate communication between the hub and the partner hospital, to provide on-going communication where patient management is continued in the partner hospital and to provide a permanent record of the information contained within the referral and responses. The system must fulfil some basic requirements:
·       The referring clinician must provide a written synopsis of the clinical situation, which may be proforma driven or in free text.
·       Provide a list of imaging sent with the referral through Image Exchange Portal (IEP)
·       Allow clarification of any points of the presentation
·       Allow updates in the light of further investigations or change in clinical condition
·       Allow written advice to be received and up-dated in the light of further information, or consultation with senior opinion.
·       Record the identity of staff involved and their seniority.
·       Provide an audit trail.
·       Allow analysis of referrals patterns and workload.
·       If possible linkage to the British Spine Registry (BSR) for admitted patients would be desirable
·       It should also have the facility to generate a summary letter to the referring agency to be sent the day following referral irrespective of whether the patient attended for assessment.

This is a potential QIPP as recent litigation has included cases in which although a patient never attended for assessment advice was given but no record or inadequate record of advice given was kept and subsequently disputed.

Imaging in the Partner Hospitals requires careful planning. The first principle of care is that it should normally be provided in the facility closest to the patient’s home. It is unacceptable for a patient who arrived at a partner hospital during hours when the imaging service was running to be subsequently transferred simply to obtain imaging. Elective imaging lists must have protocols to allow interruption or extension for emergency referrals. This must apply to weekend sessions as well as weekday sessions. NICE guidance for metastatic spinal cord compression (CG75) indicates that emergency scanning in partner hospitals is most cost effective if scanning is available from 8 until 8 on weekdays and from 9 until 3 at weekends.

Partner Hospitals should provide prompt and uncomplicated repatriation of patients requiring rehabilitation (with the exception of spinal cord injury) or when surgery is not required. In addition to being better for patients and their relatives, this often allows easier access to any required local services. There should be an escalation policy for occasions where this system fails to work.

C.    Elective Care

1.    Regional MDT

The regional MDT will be established for all surgeons undertaking spinal surgery both in the hub and in partner hospitals. Core membership will be every surgeon undertaking spinal surgery together with a musculo-skeletal or neuroradiologist to provide advice on imaging. Other members to be locally agreed and who may attend less frequently might include an oncologist, infection control, consultant in linked spinal cord injury centre, representatives from community services for back pain and radicular pain. Core membership should attend (75 percent) of meetings.
The centre of the clinical functioning of the Spinal Network is the Regional multi-disciplinary meeting. This will be a meeting involving surgeons from all of the hospitals in the network to be held on a regular basis. The location and frequency of these meetings will be determined by the particular needs of each individual network, but it is envisaged that meetings might be held on a monthly basis or possibly every fortnight. Meetings may be face to face, or in networks with a large geographical spread might alternate with virtual meetings.

The way the Regional MDT operates will be determined by the experience and capacity of the partner hospital involved but would form an overarching governance structure and should be considered a partnership between hospitals in the Network. The primary function would be to provide a larger critical mass of surgical opinion and expertise to improve audit governance and quality control. Prospective data collection would be mandatory (see below). Necessary prerequisites for Hospitals to be commissioned to undertake specialised spinal surgery are satisfactory audit and governance including attendance at the regional MDT, proven quality control and appropriate facilities, rehabilitation support and integrated discharge arrangements with local services.

For the Spinal Hub and partner hospitals where specialised surgery is undertaken, the purpose of the MDT will be to provide audit and governance for more complex cases and to allow surgeons undertaking specialised spinal surgery to join in larger groups for peer review, clinical advice and quality assurance. In these circumstances the MDT may comprise of a discussion of individual cases for specialised spinal surgical procedures and presentation of audit of practice[1] and of particular procedures. It would not be anticipated that all cases be discussed. The data from the referral system will be a part of the information reviewed. Complications must be recorded with formal internal review at least on a monthly basis. Specialised spinal surgery will be given some priority but the function of the MDT is to provide audit and governance for both specialised and non-specialised surgery (Appendix 2 shows suggested cases for MDT discussion).

For centres undertaking only non-specialised spinal surgery, most value may be obtained by considering the results of audits of practice over the previous year, to include audits of specific surgical procedures together with outcome measures and discussion of individual cases of a more complex nature. The benefits of the MDT will in this case be to provide support to surgeons who may be single handed or working as a pair from a larger group through discussion and for governance.

For hospitals with no spinal presence, audit of referrals and of management pathways might form a significant component.

Pilot sites have identified that support of each Trust in job planning, administrative support and travel time is essential. The biggest barrier to establishment is lack of this support.

The MDT is not a disciplinary venue. If commissioners have substantial concerns about the practice of an individual surgeon or Trust then commissioners must initiate an investigation out-with the MDT structure. Clinicians will naturally try to assist with provision of advice, but in some cases it is recognised that advice from outside the Network may be required to allow maintenance of the normal Network functioning.

Further work is required to provide a working template for these Regional Networks in the different Regions.

2.    Local MDT

The Spinal Hub and Partner Hospitals will still continue to have their regular local MDT meeting when the Regional MDT is not scheduled. This could include discussion of emergency cases, routine elective cases, complex cases, complications, audits and other educational activities. The frequency of these, who attends and documentation should be discussed by the local team and agreed with the Regional Spinal Network. It would be expected that Spinal Hubs and Partner Hospitals performing specialised surgery will have weekly MDT meetings.

3.    Inter Hospital Co-operation

In elective practice the network may also make provision in appropriate circumstances for surgeons from partner hospitals to undertake specialised procedures in the hub to take advantage of facilities or surgical support. This has a number of associated financial and capacity issues which would need to be resolved.

Consideration should be given to mechanisms to ensure that all hospitals within the RSN have approximately equal waiting times.

None of the pilots have as yet addressed this network functionality in practice.

4.    Back Pain and Referrals from Primary Care

All the hospitals in the network will have a role in the management of referrals from primary care and the audit and governance of these referrals. Effective and timely primary care pathways will reduce disability, reduce inappropriate referrals and expedite referral of patients with surgically remediable conditions. Implementation of the Pathfinder Project will involve co-operation of CCGs, all regional hospitals, spinal Consultants and established triage and treat services.

5.    Other Providers

In some networks active NHS Elective Centres may exist which will provide an effective platform for non-specialist surgery. Independent providers who undertake Any Qualified Provider (AQP) work will be integrated into this hospital network to provide more transparent audit and governance and provide professional support. Surgeons in these independent hospitals, who may not have formal NHS appointment, will be brought into the network to ensure a more robust local delivery and quality assurance.

D.    British Spine Registry (BSR)

For those Centres undertaking specialised spine surgery the use of the BSR is mandatory[2]. It is strongly recommended that the BSR is also used for non-specialised spinal surgery to provide the audit and outcome data which is essential for a quality control and effective governance.

The registry may be used by the network to monitor the number and location procedures and ensure that patient outcomes and experience (PROMs and PREMs) are recorded.

E.    CQUIN

The Trauma Programme of Care has supported a CQUIN for the Regional MDT for 2015/2016, which is now available. Uptake has been variable in the pilot sites, in one case due to reluctance by the Trust, and in another by difficulties establishing the regional MDT. There has been some confusion within Trusts as to how this CQUIN will function.

To maximise uptake with the new implementation it is suggested that the CQUIN be rolled over to 16/17.

F.     Research/Audit

The RSN must establish a plan for spinal research and audit. Time must be considered in job planning to allow this.

G.    Training

Spinal networks will also improve spinal training by providing postings for trainees at a level appropriate to their experience. In the future it is anticipated that all trainee spinal surgeons will spend time within the spinal hub(s) in both neurosurgery and orthopaedic surgery whilst spinal surgery evolves to its own speciality.

H.    Resources

·       When established the Networks will require some overall funding, which may come from Participating Trusts and Commissioners.
·       Participating surgeons and other professionals will need PA allowance in their job plan to attend required MDTs. On call PAs may need adjusting for increased referrals and record keeping. Referrals may be complex, eg, spinal oncology and a time allowance with administrative support is required.
·       Funding for Network Management
·       Virtual Clinics: These are volume reviews of patient records acquired from initial assessment in triage clinics and imaging by senior clinicians with the assessing AHP. This determines the next step in patient management and provides excellent support and tuition to the triage profession(s). It is an efficient use of Consultant time but needs a mechanism for remuneration.
·       Administrative support will be required for the MDT, and for surgeons attending from partner hospitals.
·       Data manager for BSR.
·       Arrangements for commissioning of any cross working arrangements between hospitals.

I.      Frequency Asked Questions

Attendance at the Regional MDT will involve travel time and time from what is already a busy clinical practice. How will this be funded?
The CQUIN for 2015/16 for spinal networks will provide funding for the attendance at the Regional MDT.

The Regional MDT will take time and in some areas travel time may be significant. In some Centres multi-disciplinary meetings between sites are already undertaken by video linkage using a twin screen approach with image on one screen and participants on the other. In the future this might save considerable travelling.

Does every case for specialised spinal surgery need to be discussed?
This is a decision for each individual network and will depend on the surgical expertise and the capacity of the partner hospitals. In some circumstances a mixture of case discussions and review of indications and audit of complications and measured outcomes may be employed. The intention is to provide quality assurance of practice within the network.

Some of our specialised cases, for example intradural surgery or cord vascular problems, have already been discussed in a specialised MDT. Do these need to be presented again at the Regional MDT?
If cases have been discussed in an appropriate MDT setting then the network may decide that presentation at the Regional MDT would be unnecessary. Policy decisions of this sort should be recorded by the Regional network.

 

Our centre undertakes some specialised spinal surgery commissioned by CCGs. Will this continue?
In the new arrangements for NHS England, it is intended that all specialised services should be commissioned by NHS England Specialised Commissioning. However, there is a considerable legacy of CCG commissioned specialised services and undoubtedly it will take some time to work through this.

Do the Spinal Networks have any role in where spinal services are commissioned?
It is wholly the responsibility of the Regional Teams for specialised surgery and the CCGs for non-specialised surgery to determine where and under what circumstances services are commissioned. The spinal networks have no role in this decision. The Regional MDT is a clinical structure based on a collaboration, co-operation and clinical support. Commissioners may request the support of the Regional MDT to provide evidence of appropriate quality assurance, audit and governance for the procedures that they are commissioning and providers may similarly use the MDT to assure themselves of the quality and governance of their practice.

J.    Members of the Spinal Network Working Party

Prof

Charles

Greenough

Chair

Chair

Mr

David

Stockdale

Commissioner

Trauma Programme of Care

Mr

Paul

May

Consultant Neurosurgeon

Trauma Programme of Care

Mr

Ashley

Cole

Consultant Orthopaedic Spinal Surgeon

Chair of Specialised Spinal Surgery CRG

Mr

Stephen

Morris

Consultant Orthopaedic Spinal Surgeon

Lead – Bristol Pilot Site

Mr

Martin

Wilby

Consultant Neurosurgeon

Lead – Liverpool Pilot Site

Mr

Simon

Tizzard

Consultant Neurosurgeon

Lead – Middlesbrough Pilot Site

Mr

Neil

Chiverton

Consultant Orthopaedic Spinal Surgeon

Lead – Sheffield Pilot Site

Mrs

Glynis

Peat

Centre Manager

Representative Spinal Hub

Mr

Vivek

Panikkar

Consultant Orthopaedic Surgeon

Representative Partner Hospital

Mr

Alistair

Stirling

Consultant Orthopaedic Spinal Surgeon

Chair United Kingdom Spine Societies Board (UKSSB)




[1] Audit would include indications for surgery, complications and surgical outcomes including PROMs and PREMs.

[2] Spine Tango is a suitable alternative for existing users of this system. Data will be transferred into the BSR.

 

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