Community Hernia Repair Service

Transcription

1 Community Hernia Repair Service January 5, 2018

2 1.0 Background information 1.1 Project team Project sponsor (SRO) Sarah Walker Project lead (PM) Samson Agboola Contract lead Robert McGowan Provider lead Dr. Ram Dhillon Clinical lead (CRO) Dr. Angela Joseph Finance lead Chris Perera Quality & patient engagement lead Claire Lambe 1.2 Version control Date Author Summary of changes Samson Agboola Business case formation Samson Agboola Changes from CP and SW Samson Agboola Comments from CM, JT, and PMO 1.3 For PMO use Approved by Date of approval Location of file Finance lead Budget allocated Budget code Budget holder Delivery plan due Page 2 of 14

3 2.0 Table of contents PILOT - COMMUNITY HERNIA REPAIR SERVICE Page 1.0 Background information 1.1 Project team 1.2 Version control 1.3 PMO use 2.0 Table of contents 3.0 Introduction 4.0 Purpose 5.0 Objectives 6.0 Options 6.1 Option 1: No change 6.2 Option 2: Pilot 6.3 Preferred option 7.0 Benefits 8.0 Dis-benefits 9.0 Timescales 10.0 Finance 11.0 Risks, issues and dependencies 12.0 Governance 13.0 References/Appendices A B Equality impact assessment Page 3 of 14

4 3.0 Executive summary It is estimated that over 70,000 inguinal hernia repairs are performed annually in the NHS with most being done under general or regional anaesthetic (e.g. injection into spinal canal) with some level of sedation in a secondary care setting. The procedure can be performed as laparoscopic (keyhole) surgery or as open surgery. 409 of these procedures were carried out for Hillingdon patients in 2016/17, though a breakdown of exactly what type of anaesthetic and which method of surgery was used is not available. Of the 409 procedures: 275 were day cases (67%) 111 were elective inpatients (indicating a possible inpatient overnight stay) (27%) 3 elective patients with excess bed days (1%) 20 non-elective admission (5%) Probus Health & Surgical Centre conducted a study i over a 46-month period, from 1st March 2005 to 31 December 2008, to determine if hernia repairs could be delivered in the community. During this time, 1164 hernia repairs (25 per month, 303 per year) were undertaken under local anaesthesia in the community. Sutton CCG commissioned a similar community service that has been running since February For this service from February December 2016, 88 patients underwent an inguinal hernia repair procedure and have had 2 follow up appointments; monitored at 7 days and 40 days post-surgery. Of these 88 patients 85 could be contacted and: 83 of these (98%) reported no issues outside of the standard healing process (e.g. twinges, mild discomfort around the wound, bruising etc) after 7 days 1 reported some wound discharge 1 reported a haematoma and scrotal swelling Both issues were settled and resolved resulting in all 85 contactable patients reporting no issues of note after 40 days A friends and family audit on these 88 patients showed that 87 / 88 (99%) patients would recommend this course of treatment Studies have shown both cost and clinical benefits in providing hernia repairs in a community care setting ii, whilst NICE guidance states, and the Sutton community service example shows, that this method is clinically safe to use iii. 4.0 Purpose In the UK, inguinal hernia repairs are carried out under general, regional or local anaesthetic with varying levels of sedation, if any, depending on clinical criteria. Many of these cases can be carried out under local anaesthetic without any sedation, and performed in a setting outside of hospital iv. Inguinal hernia repairs are amongst the most frequently postponed elective procedures in secondary care, mostly due to bed unavailability. This, in addition to a 7-week average waiting time for general surgery procedures, presents an opportunity to develop alternate pathways for hernia repair to take place in a community setting, thus reducing pressures on secondary care. This paper proposes the piloting of a one stop shop walk in walk out clinic in an out-of-hospital setting exclusively for inguinal hernia repair. The procedure will be performed under local anaesthetic, without sedation for 18 months with a view to formally procure dependent on the pilot review. Page 4 of 14

5 Strict exclusion criteria within the referral form would ensure that only patients appropriate for treatment under local anaesthetic would be referred and accepted. Assuming a minimum uptake of 28% of 2016/17 activity (based on Sutton CCG procedures), the community service would see 100 procedures carried out through the new service. Funding for the service will come from the subsequent reductions in secondary care activity and will produce a cost saving of 33k, or 119k if all activity is moved into the community. The service will also see improvements in patient experience and service quality. Following approval of the pilot, the service requires 4 months before go-live, to develop the fullservice specification, agree terms with a provider and mobilise the new service. This will see 2/18 of the savings realised in 2017/18, 12/18 s realised in 2018/19, and 4/18 s in 2019/ Objectives The proposed change to the pathway aims to: 1. Establish a pilot walk in walk out service to carry out inguinal hernia repair procedures under local anaesthetic without any sedation, in an out of hospital setting for patients who meet the referral criteria 2. Transfer (=/>)100 cases of inguinal hernia repair activity in secondary care, using 2016/17 as the baseline, to the Community Hernia Repair Service 3. Decrease the average cost of an inguinal hernia repair procedure to Hillingdon CCG through removing avoidable outpatient appointments and bed day stays from the pathway 4. Reduce the waiting times for hernia repair and subsequently general surgery, as well as the number of cancelled procedures 5. Release valuable theatre and bed day capacity in secondary care 6.0 Options considered The paper proposes a piloted community inguinal hernia repair to be performed under local anaesthetic without sedation as a pilot for 18 months with a view to formally procure following evaluation of the pilot, and inform the specification for a Community Hernia Repair service. The Rila Group the same provider used by Sutton CCG has been selected as the pilot provider. The provider will not only provide hernia repairs in the community, but will also act as a triage for all hernia s. This will see all hernia referrals sent to the community service who will treat patients suitable for the community service, and refer all other patients to THH. Page 5 of 14

6 6.1 Option 1: No change PILOT - COMMUNITY HERNIA REPAIR SERVICE Benefits Consistency through maintained current service Greater pool of experienced consultants to carry out surgery General anaesthetic allows for laparoscopic surgery Immediate access to emergency services should severe complications arise Limitations Patients not suitable for general anaesthetic may not receive optimal treatment Surgical resources (theatres, surgeons etc) may be prioritised for more urgent procedures resulting in increased likelihood of cancellations for hernia procedures Wait times for general surgery continue to be an average of at least 10 weeks instead of an estimated 4 weeks for a community service Patients undergoing laparoscopic surgery have greater risks of complications (e.g. bowel perforation) and longer wait times Continue usage of unnecessary levels of sedation and general anaesthetic when not always needed thus increasing cost, clinical risk of complications and patient length of stay 6.2 Option 2: Pilot Community Hernia Repair Service Benefits Releases theatre capacity in secondary care Enables more patients with long term conditions to undergo the procedure Patient experience is improved by reducing number of separate visits needed to care provider and reducing the time needed to carry out the procedure Limitations Slower accessibility to emergency services if serious surgical complications occur Any patient anxiety will need to be well managed without sedation or general anaesthetic Patients may opt for laparoscopic surgery which will still need to be treated by the Trust Decreased waiting times to undergo procedure Less risk of complications than if general anaesthetic was used Vastly reduces risk of hospital acquired infections such as MRSA More cost-effective method to carry out hernia repairs Patient avoids the after-effects of sedation / local anaesthetic Lower project resource requirement Page 6 of 14

7 Service can launch sooner (4 months mobilisation period) without a competitive tendering process 6.3 Preferred option The preferred option would be to pilot the Community Hernia Repair Service on an 18-month term so clinical outcome from the service can be fully evaluated, and the service specification can be refined before committing to a longer-term contract and allocating resources into a full competitive tender process. CURRENT PATHWAY PROPOSED PATHWAY Current Service When compared to the, a Community Hernia Repair Service presents the CCG with an opportunity to improve the quality of hernia repairs for its patients. Under the current model of care, all patients undergoing a hernia repair procedure require an initial outpatient appointment with a general surgeon. An estimated 1/8 of these patients will have a long-term condition (Diabetes, Heart Disease, COPD, etc) which will require further outpatient appointments with relevant specialist(s) to assess their suitability for general anaesthetic. Due to increasing demand, these visits usually occur on separate days adding unnecessary delays and inconvenience to the patient s care pathway. If a patient is not approved for general anaesthetic, additional time is added to patient waiting time. Page 7 of 14

8 Once a patient is approved for surgery, they are admitted to the hospital to undergo the procedure and would then require a bed following surgery to recover from the anaesthetic. Whilst most patients go home on the same day, in 2016/17, ~28% of patients stayed in a bed overnight, with 1% staying even longer. Evidence has shown that 2% of patients undergoing hernia repair in secondary care will have a minor complication (most likely arising from the general anaesthetic), and 1% having a major complication v. This requires patients to occupy an ITU / ICU bed for 1 or 2 nights; if a bed is not confirmed as being available at the start of surgery, then the procedure also has the potential to be cancelled. Proposed Service: A case study of a community hernia repair service vi documented over 1164 hernia repairs, under non-monitored local anaesthetic, in a primary care setting. The results were positive and patient satisfaction extremely high. There were 12 (1%) patients who experienced complications of a minor nature. This service also enabled patients with significant co-morbidities, making them unsuitable for general anaesthetic, to have the benefits of a repair. The proposed walk in walk out service in a community clinic setting will offer inguinal hernia repair procedures under local anaesthetic. The procedure will be carried out by a skilled and experienced surgeon with an anaesthetist present throughout the procedure. The anaesthetist will carry out infiltration prior to surgery with the surgeon topping up the anaesthetic as required. By using stringent referral criteria and carrying out the procedure under local anaesthetic, the initial outpatient appointment with the surgeon will be carried out in the same visit just before surgery so patients do not have to make separate visits. This will result in increased cost effectiveness, greater accessibility for patients (especially for those unable to have a regional or general anaesthetic), and better patient experience with most patients being able to arrive, have the procedure and leave the clinic, within 2-3 hours, providing further efficiency and patient experience benefits. 7.0 Benefits The tangible benefits of delivering this project are: Description Measure Reduced waiting times for patients undergoing an inguinal hernia repair procedure Secondary care waiting lists Reduced risk of procedure being cancelled Number of secondary care cancellations Patient has a lower length of stay Number of overnight hospital stays for hernia repair patients Releases already stretched secondary care theatre and bed day capacity Reduction in number of secondary care hernia repairs Page 8 of 14

9 Reduced cost to CCG of carrying out procedure Decreased spend on hernia repairs Better patient experience Patient friends and family test 8.0 Dis-benefits Dis-benefits include: Ensure the clinicians are enabled to recognise if serious surgical complications occur Any patient anxiety will need to be well managed without sedation or general anaesthetic Patients may opt for laparoscopic surgery which will still need to be treated by the Trust 9.0 Timescales Action Date Engagement and drafting of business case August 2017 Business case approval and pilot provider selected November 2017 Develop service spec, confirm provider and begin patient engagement December 2017 Begin mobilisation of service and GP engagement January 2018 Service commencement February 2018 Mobilisation of this service would be expected to take ~4 months once a provider has been instructed to proceed Finance The Community Hernia Repair Service will provide treatment for the following HRG s: FZ18A: Inguinal Umbilical or Femoral Hernia Repairs 19years and over with Major CC FZ18B: Inguinal Umbilical or Femoral Hernia Repairs 19years and over with Intermediate CC FZ18C: Inguinal Umbilical or Femoral Hernia Repairs 19years and over without CC Implementation Costs: 17.5k (Full cost = 32k: 50:50 split with provider) in pump priming for equipment and service establishment Rent/space utilisation price included in agreed tariff = Commercially sensitive Page 9 of 14

10 Cost Savings (based on 2016/17 average cost and volume): Worst Case Scenario (based on Sutton CCG uptake): Hernia Repair ( ) Comm Hernia Repair ( ) Cost Diff ( ) Activity Shift Total Saving , Best Case Scenario: Hernia Repair ( ) Comm Hernia Repair ( ) Cost Diff ( ) Activity Shift Total Saving , Current Service (based on 2016/17 activity): Value HRG DC EL NELEM Total FZ18A Activity FZ18B FZ18C FZ18A Cost FZ18B 65, , , , FZ18C 341, , , Total Activity Total Cost 412, , , , *activity rounded to nearest whole number 83% of this activity relates to The Hillingdon Hospital Average cost of inguinal hernia repair in secondary care = Proposed Service (based on 2016/17 activity): Worst Case Scenario: First Outpatient Appointment Avoided ,278 * As per the current pathway, every patient undergoing procedure must have a first outpatient appointment. The proposed service will take this step away Value HRG DC EL NELEM Community Hernia Repair Service* Total FZ18A Activity FZ18B FZ18C FZ18A , Cost FZ18B , FZ18C Total Activity Page 10 of 14

11 Total Cost 289, , , , , Average cost of inguinal hernia repair for CCG = Assumes 28% reduction in acute hernia repair activity Cost Saving: 596, ,416 (+ 17,278) = 53,000 Best Case Scenario: First Outpatient Appointment Avoided ,376 * As per the current pathway, every patient undergoing procedure must have a first outpatient appointment. The proposed service will take this step away Value HRG DC EL NELEM Community Hernia Repair Service Total FZ18A Activity FZ18B FZ18C FZ18A , , Cost FZ18B , , FZ18C , , Total Activity Total Cost , , Average cost of inguinal hernia repair for CCG = All hernia repair activity is shifted into the community Cost Saving: 596, ,950 (+ 57,376) = 176, Risks, issues and dependencies 11.1 Risks Risks Likelihood Impact Total Mitigation Patients may still choose to have their surgery in hospital under general anaesthetic GPs may not refer patients to community service The community service may be delayed in mobilisation GPs will receive guidance on how to discuss options with patients, explain the advantages and disadvantages and reduce patient anxiety In addition to engagement activities, a GP awareness scheme is under development Consider adding service to e-referral system Mobilisation plan will be closely monitored by the CCG and support provided to minimise slippage Page 11 of 14

12 There may be challenge around the decision not to have a competitive tender that prevents the service from commencing Pilot may negatively impact relationship with Trust if not selected provider The CCG will inform Trust of pilot in advance 12.0 Governance Project Board Membership Role Name Organisation Clinical Sponsor Dr. Angela Joseph Hillingdon CCG Management Sponsor Sarah Walker Hillingdon CCG Project Manager Sam Agboola Hillingdon CCG 13.0 References Page 12 of 14

13 PROPOSAL SCREENING SECTION REFER TO SUPPORTING NOTES TO COMPLETE NEXT SECTION EQUALITY IMPACT ANALYSIS POPULATIONS (Protected Characteristics) (N6) State Any Sub- Group/s Eg. Age: Sex: Female Race: Sri Lankan Age Disability All 5 Impact 1-9 where: 1 = Highly ve 5 = Neutral 9 = Highly +ve Please describe reason for Impact Score The HRGs included in the proposed service does not apply to children and young people. This is due to the risk involved with providing paediatric surgery. For 18+ patients there is high positive impact which includes: Care closer to home Reduced hospital stays Fewer side effects due to anaesthesia used Less waiting time for procedure Similarly, to the current service, provider appointments will need to be planned flexibly to respond to diverse disabled people s different needs arising. This might include: Gender Reassignment All 5 Advocates Transport and physical access Providing interpreters (BSL) Marriage & Civil Partnership Pregnancy & Maternity All 5 All 5 Race All 5 Religion & Belief All 5 Sex All 5 Sexual Orientation All 5 Page 13 of 14

14 EO.5 BME Children Under 5 EO.6 BME Young People / Adults and Mental Health PILOT - COMMUNITY HERNIA REPAIR SERVICE N/A N/A N/A EO.7 Carers All 5 The service provides care for young people/adults with mental health issues, and will provide equal access for all age groups (18+) as well as support patients with mental health needs. With the proposed service being community based it will be closer to community services, and able to provide a robust signposting service i Over a thousand ambulatory hernia repairs in a primary care setting ii Over a thousand ambulatory hernia repairs in a primary care setting iii R Dhumale et al: Groin Hernia; Ann R Coli Surg Engl: 2010:92: iv Evidence-based management of groin hernia in primary care--a systematic review v Safety: Minor complications and Major complications vi R Dhumale et al: Groin Hernia; Ann R Coli Surg Engl: 2010:92: Page 14 of 14