SURVIVE AND PROSPER: The Orthopaedic Triage and Podiatric Foot Surgery Experience David A. Wylie Head of Podiatric Services, Acute Services Division 9 th March 2011 Podiatry Managers’ Training Event Northampton Park Inn

Podiatric Surgery in UK  Late 1970’s early 1980’s (Podiatry and LA) The History  King’s Fund Audit 1997  Day Surgery theatres in Primary Care  150 podiatrists involved in podiatric surgery 42 consultants in podiatric surgery (1550+ orthopaedic surgeons – 60+ foot surgery as main sub-specialty)

1999Appointment of Head of Podiatry  Key Result Area “Get theatre working!” “The day I support podiatric surgery will be the day my Royal College supports podiatric surgery!” Surgical Director The story so far….

2002 Memorandum of Agreement  Collaboration between RCS Edinburgh RCPS Glasgow Society of Chiropodists & Podiatrists Glasgow Caledonian University & Queen Margaret University The story so far….

 providing a Scottish Podiatric Surgery service fully integrated with Orthopaedic surgery PODIATRIC SURGERY SERVICES  delivering joint clinical training to Podiatric & Orthopaedic surgery trainees in Scotland  offering a whole system solution to national Orthopaedic redesign projects The story so far….

2003:1 st BUSINESS CASE PRODUCED “Ye cannae dae that!” The story so far…. No recovery area No evidence that podiatry contributes positively to Orthopaedics Podiatric Surgery can’t work in partnership with Orthopaedic Surgery

The Funding Challenges  £400k from CCI in 2005 to re-develop day theatre in department of podiatry, Southern General Hospital, South Glasgow 2005 Business Case to redevelop theatre

2006Business Case to establish Orthopaedic Triage “Ye cannae dae that!” The story so far…. No evidence that podiatry keeps patients off Orthopaedic waiting lists

The Funding Challenges  £76k from CCI in 2006 to develop primary care foot and ankle triage posts IN PARTNERSHIP WITH ORTHOPAEDICS 2006 Business Case to establish triage

2006Business Case to establish Podiatric Surgery “Ye cannae dae that!” The story so far…. No evidence that podiatric surgery will work in Scotland (since we are different from England!)

The Funding Challenges 2009 Business Case to establish pilot Podiatric Surgery service  £110k from Scottish Government in 2009 to establish pilot Podiatric surgery service for 39½ weeks

The Service Model (A) 0.4 wte AFC Band 9 AHP Consultant in Podiatric Surgery (B) 0.3 wte 1 AFC Band 8a Extended Scope Practitioner (C) 0.2 wte AFC Band 7 Extended Scope Practitioner (E) 0.2 wte Honorary AHP Consultant in Podiatric Surgery (Glasgow Caledonian University) (D) 0.2 wte Rotational ESP Primary / Secondary Care

The Service Model  Triage by Orthopaedic Triage Podiatrist  Listing by Orthopaedic Triage Podiatrist  Pre-op assessment by AHP Consultant in Podiatric Surgery  Day Case surgery  Local Anaesthetic  1 week dressing  2 week follow up  12 week follow up

The Team  William Money Allied Health Consultant in Podiatric Surgery  Primary & Secondary Care Podiatrist  University links  Direct links with orthopaedics

The Outcomes 1.Capacity & Productivity 2.Activity & Casemix 3.Referral Sources 4.Clinical Effectiveness 5.Sequellae

1 Capacity & Productivity  2 new day case theatre sessions established in the redeveloped department of Podiatry theatre  No planned theatre sessions were cancelled during the pilot.  Conversion rate for patients referred for surgery of 98%.

Mar – Nov 2010 Pod Surgery SGH As a % of Total Procedures (135)Example of level of surgery Orthopaedics GGH As a % of total procedures (390) COMPLEXNAComplex hindfoot / ankle184.6% MAJOR +NAAnkle / hindfoot6015.4% MAJOR3626.5%Forefoot / midfoot % INTER9570.5% Usually soft tissue or small bone % MINOR43.0% Wound debridement, injections, etc.328.2% TOTAL135100%390100% 2Activity & Casemix

3Referral Sources Referral SourceTOTAL% PRIMARY CARE PODIATRY ORTHOPAEDIC TRIAGE ORTHOPAEDICS SGH Mr R Carter ORTHOPAEDICS GGH Mr S Moir PODIATRY SGH TOTAL113100

3aOrthopaedic Triage Model Minor / Intermediate / Major / Day Case / LA 20% 80% 70% Podiatry 30% Surgery 70% 30% Orthopaedics / Orthotics Complex / In Patient / GA

3aOrthopaedic Triage Model Minor / Intermediate / Major / Day Case / LA PODIATRIC / ORTHOPAEDIC SURGEON 20% 80% 70% Podiatry (56% Total) 30% Surgery (24% Total) 70% (17% Total) 30% (7.2% Total) Orthopaedics / Orthotics Complex / In Patient / GA ORTHOPAEDIC / PODIATRIC SURGEON Out Patient ORTHOPAEDIC PODIATRIST

3aOrthopaedic Triage Model

4Clinical Effectiveness Manchester Oxford Foot Questionnaire (MOXFQ) (n = 117) DIMENSIONPre-operative Score Post-operative Score Significance Walking & Standing 5414p < Foot Pain5418p < Social Interaction 4710p < PRE AND POST OPERATIVE FOOT FUNCTION SCORES (Quantitative)

4Clinical Effectiveness PATIENT SATISFACTION (Qualitative) How satisfied are you with your surgery? PASCOM-10 (n = 117) 90% How likely would you be to recommend your surgical experience to someone else? PASCOM-10 (n = 117) 93%

5Sequellae

The creation of Podiatric Surgery posts deliver the most advanced clinical roles available to AHPs in line with the National AHP Strategy “Building on Success” (2002) Podiatric Surgery has been shown to deliver excellent outcomes in terms of patient satisfaction, post-surgical complications and clinical outcomes AHP Consultants in Podiatric Surgery enable established surgical specialists to utilise their skills more appropriately whilst also delivering cost effective and clinically effective outcomes Summary

1999 Appointment of new Podiatry Manager 2002 Creation of SAB in Scotland 2003 Validation of MSc in Podiatric Surgery First Business Case produced 2005 £400k to redevelop Podiatry Day Theatre 2006 £75k to establish Orthopaedic Podiatric Triage in 1 o care 2007 Lobbying of MSP’s 2009 £110k to establish Podiatric Surgery 2010 Pilot Podiatric Surgery Pilot report produced 2011 Latest Business Case produced (14 th !!) “Ye cannae dae that!” The story so far……..

Dermatology: Harvesting of plantar keratoderma biopsies Botox injections Diabetes Supplementary prescribing Patient admission Vascular Triage of PVD patients Rheumatology Triage of foot referrals to orthopaedics Other things “Ye cannae dae!” The story so far……..

Overview of Structure Business Case Executive Summary Benefits of Podiatric Surgery Increased activity Increased capacity Increased productivity Increased effectiveness Costs of Podiatric Surgery

Overview of Structure Business Case 1 Introduction 2 Description of Service Capacity (How many sessions?) Locus of delivery (Where and when in the system?) Volume and casemix (with justification) Staffing & skill mix (with justification/ evidence of safety etc.)

Overview of Structure Business Case 3 Costing options Consultant and registrar staff costs only Support staff from existing nursing or podiatry service pool c. £160k Consultant & registrar staff costs plus consumables Support staff from existing nursing or podiatry service pool c. £240k Full marginal costings c. £350k (Cost per case no more than £750 for anything up to Major)

Overview of Structure Business Case 4 Job Plan 5 Links with other services (inc. referral management) 6 Anticipated outcomes (inc. Key Performance Measures) 7 Appendices (inc. surgical pathways showing governance arrangements etc)

Podiatry on the brink… of what? Thank You