Irish Institute of Trauma & Orthopaedic Surgery

Irish Institute of Trauma & Orthopaedic Surgery

Council Meeting

5th February 2011

The Irish Institute of Trauma & Orthopaedic Surgery Council Committee meeting was held in the Old Presidents Room of the Royal College of Surgeons in Ireland on Saturday 5th February 2011.

In Attendance

Mr David Moore President

Mr Paddy Kenny Secretary

Mr Keith Synnott Director of Training

Prof John O’Byrne

Mr Bill Curtin Mr Eamonn Kelly

Mr John Quinlan Mr Nasir Awan

Mr Seamus Morris

Mr James Harty

Mr Denis Collins

1.0  Apologies

Mr Mark Dolan

Mr Ashley Poynton

2.0  Minutes of the previous meeting

The minutes of the previous meeting held on 11th September 2010 were circulated and signed as an accurate record.

3.0  Matters arising

There were no matters arising out of the minutes.

4.0  Specialist Division of the Register applications

The Chair suggested that a subcommittee of three or four people should be formed to review the applications for the specialist division of the register. It was felt that the process would be more objective if the president and the secretary of the Institute were not involved. Professor O’Byrne, Mr Awan, Mr Kelly and Mr Condon nominated themselves. The Director of Training would remain on the review panel. Mr Synnott advised that it takes a few hours to go through the applications, and he suggested that the sub committee should review the applications together. It was agreed that the committee would meet on a Friday in Cappagh. Currently there are three applications to be reviewed.

It was agreed that Niamh would forward the applications to Professor O’Byrne. Mr Kenny suggested writing to ISPTC requesting a fee for reviewing applications.

5.0  National Joint Register update

The Chair advised that the Institute was in the process of setting up a national register through the college but run by the Institute and funded by the HSE. A meeting had taken place with Mr White two weeks ago and he would like the Institute to engage with HIQA (Health Information & Quality Authority) and the ESRI. Mr Seamus Butler and Mr Ritchie Dooley from the HSE are still involved but the Institute is driving it. The Chair advised that every joint in the country that is done has to go on the register. The private hospitals need to be engaged also. There are issues with regard to getting people involved with the register and how it will be run from a governance and confidentiality point of view. When the document is finished hopefully all those bases will be covered. The Chair said that he had spoken to Mr John Matheson in New Zealand and that he appears to have already addressed all the issues that could be faced here, including colleagues that may need to be advised that their outcomes are less than favourable.

The Chair advised that HIQA’s role is primarily based around the public sector. They can also make recommendations that apply to the private sector. They can advise an institution that they won’t get accreditation, and that joint surgery cannot be performed unless every joint is on the register. HIQA will help to drive the register as they are involved with quality assurance. They do not have a role in licensing at the moment. The college are getting involved in clinical audit and governance. Mr Green has costed the project and savings have been deliberately underestimated.

6.0  Orthopaedics/Rheumatology Triage system/Outpatient waiting list initiative

The Chair advised that the HSE has a big drive on the acute emergency medicine programme and a musculoskeletal programme. Mr Kenny reported that according to the latest HSE figures there are 32,000 people on an outpatient waiting list to see an orthopaedic surgeon and 7500 people waiting on an outpatient waiting list to see a rheumatologist. In an effort to address this, one of the things that they have come up with which runs very successfully in the UK and in some hospitals in Ireland is a physio triage system. The best example of this is the back clinic in Tallaght. Only 15% of these patients need to see a surgeon and only a small percentage of those will end up having an operation. In conjunction with Rheumatology, two senior physiotherapists have been to the UK to see how the system works there, and in Cappagh the physio dept are running 10 day courses for senior physios on triage. Dr Barry White’s office and the HSE are going to allocate 24 new physiotherapy posts specifically for triage for musculoskeletal outpatients. Senior physios will be taken out of their old posts and put in these jobs and there will be a backfill to fill those 24 jobs. The allocation has not been completely approved yet. A meeting took place with the rheumatologists and the physios and they have put forward a provisional allocation of the physios. There will be six physios distributed throughout the four HSE regions, to reflect orthopaedics and rheumatology services.

·  3 physios will be allocated to Tallaght (with a possibility of doing clinics in Naas)

·  2 physios will be allocated to St Vincent’s

·  2 physios will be allocated to Beaumont (with one of those doing clinics in Drogheda, with the possibility of Monaghan and Cavan)

·  One physio in the Mater

·  2 in Cappagh

·  1 in Connolly

In the HSE South

·  3 physios will be allocated to Waterford and Kilreene

·  3 physios will be allocated to Cork (St Mary’s, Mercy and they may also to outreach clinics in Kerry)

In the HSE West

·  2 physios will be allocated to Limerick/Croom

·  3 physios will be allocated to Galway(one of the Galway physios may also work in Castlebar)

·  1 physio will be allocated to Sligo/Manorhamilton.

Mr Kenny advised that the allocations are mostly based on numbers but also on efficiency. The RDO’s will make the final decision. The hospitals that are seeing the most patients and putting through the most patients are the ones that are being supported. GP’s will refer patients in, obviously there is backlog but this will become more streamlined. The Chair added that this will only work if the resources are there to deal with the surgery as it comes through. The physios will hopefully be put in place in the summer and there will be a strict audit for the first six months of where it is working and not working and if it’s not working the physios will be taken out and placed elsewhere.

It is estimated that each physio will see approximately thirty five new patients a week. There are some cases that won’t be suitable for physios. The rheumatologists have some concerns that the physios will refer patients to them for more non surgical procedures like knees for injection, routine shoulders for injection. Most of these clinics will run with an orthopaedic registrar in the clinic. Mr Synnott advised that in back pain there are clear guidelines as to who does/doesn’t needs x-rays; in other specialities it is much more difficult.

The physio will be running the clinic under the consultant’s name and letters will be co-signed. For the first 6 months every patient that comes through a clinic will be under a named consultant. Mr Curtin advised that this was discussed in Galway and that a national undergraduate musculoskeletal curriculum needs to be set up so that GP’s are better trained in musculoskeletal. The Chair asked everyone to inform their units.

7.0  AVLOS project /Cost Saving/implant costs

The Chair spoke about Prof Frank Keane’s and Dr Barry White’s presentations at the AGM last November which concerned average length of stay and how this could be reduced. Dr White had mentioned that there was a suggestion from the HSE that there may be protected funding for some aspects of medical treatment. The first pilot will be hip and knee surgery. Two weeks ago Mr Moore and Mr Kenny had met with someone from HSE finance and he had brought a document which showed the cost of every elective and trauma & orthopaedic procedures in 2009, a ball park figure of 350 million euro’s spent on orthopaedic surgical care in the country with every case listed. The figures are however a little bit unreliable, as they were all based on hipe. They are trying to get an average cost for joint replacements for example over the last year. They would argue that there is no reason why it should be cheaper to do a joint in Cork, Leitrim, and Galway etc. The HSE will then do a pilot study for 9 months on the cost of 1000 joint replacements to see if the length of stay is reduced and reduce the cost of prosthesis then can 1000 joint replacements be done more cheaply. From the start the Institute officers have said they need to be reassured that money will be saved so that another 100 joint replacements can be done, than this would happen rather than all the money going back into the central fund.

At the moment all the HSE are doing is costing hips and knees and seeing how they can manage that better. In the past it has been suggested that if the HSE have physios working at weekends, this would reduce the Wednesday, Thursday, Friday replacements and would get people out of hospital faster. The Chai said that they asked the HSE finance person to check with Hipe to find out the AVLOS for every joint done in the country for 2009/2010. This will allow us to see if there is a direct correlation between the day of the week and the surgery done.

Immediately we can say it will save us going through the 9 month trial. Unless it’s proven that it saves money it is going to be hard to get the system in place. They will then have a model, to show that if you give the doctors control, they will get the NTPF involved (expertise in negotiating costs) who will negotiate with the hospitals. It can then be shown that it is cheaper to do a hip in Cappagh than the mater private then the NTPF, all money that we have will buy services in Cappagh. Ultimately the idea is that the money will follow the patient. They will roll this out into all the other areas, not just orthopaedics but elective care.

The Chair informed the committee that the cost saving on implants is devolving onto Kevin Mulhall’s lower limb arthroplasty group. Mr Kenny advised that Mr Mulhall had met with the procurement people from the HSE finance. It had been a brief meeting, nothing has come of it yet, but they want the prices to come down and they want us to buy nationally rather than regionally. Mr Kenny said that we want their agreement to standardise some care pathways or some treatments, for example hemiarthroplasties. This is all being investigated, and figures are being gathered from around the country as to what implants are being used for what. It is at the early stages but the arthroplasty group are trying to fix prices with the help of the HSE. This will evolve into the antibiotic prophylaxis and the DVT prophylaxis. This will be forced on us for cost reasons so therefore it is very important that the Institute have a view. The lower limb committee are collecting figures. Mr Harty advised that in Cork they costed every implant locally and they have dropped their costing by 15% for every company. Mr Awan advised that he had spoken to Professor Mulhall and that in Navan/Drogheda they were getting all the numbers for all the implants used and how the costs for the last two years, but that this has to involve the whole country as this is the only way savings can be made. The Chair advised that there are 10,000 joint replacements done a year in the country and just about half are done in the public service. There are huge savings to be made on implant costs and there is a huge variation in the price of implants alone. The Chair advised that if people are written to and asked for information they should write back with their figures.

8.0  ASR Update

Mr Curtin advised that he has involved since last October, and that there were regular meetings up to November. There seemed to be a big communication gap between DePuy and the HSE and the hospitals in terms of obtaining consent. It had been very frustrating to sit at these meetings as the whole focus seemed to be on the legal teams of the HSE and DePuy rather than focused on the problems of doctors dealing with patients. Many of the problems encountered could have been helped by having a national joint register. Last November Mr Curtin said that he had rung Mr Ian Kelly, and Mr David Bell and told them that they was no progress being made. From the consent issue as a doctor talking to a patient it would be possible to talk a patient into allowing DePuy have a copy of the original operation note which would let DePuy see that on a certain day in this hospital that this particular patient had an ASR implant and that the implant was appropriate. There was a copy of one of the documents that DePuy had forwarded. It was a form that the surgeon who is proposing doing revision surgery would have to complete. This would be a reiteration that this patient has been through the ASR voluntary recall process phases 1 & 2 because there are problems with the implant, I am suggesting a revision for this that and the other and the surgeon signs it. Mr Curtin felt that this information together with a copy of the implant should be sufficient for DePuy to fund the procedure. Mr Curtin went beyond DePuy to vice president of European operations, Mr Andrew Berkell who agreed. Mr Curtin advised Mr Tony Keily and Mr Ian Kelly last week and said that he was going to this meeting but that he had no mandate from DePuy as to what they were going to do. Mr Berkell had contacted Mr Curtin and told him that DePuy were looking for the patient to sign a waiver giving DePuy access to the implants. Mr Curtin rang back and said this wouldn’t work. Mr Curtin said that he had had five phone conversations this morning and he said that unless DePuy can give a statement that they would be happy with a copy of the operation note and the DePuy 57 document he isn’t taking it any further. They said they would do this and this would essentially mean that there will be a page the patient will sign, ‘I consent that a copy of my operation note goes to DePuy’.