WEBVTT 00:00:00.000 --> 00:00:01.740 Welcome to the deep dive. Today we're getting 00:00:01.740 --> 00:00:05.179 into something really fundamental, how high quality 00:00:05.179 --> 00:00:08.199 trauma in orthopedic care is actually delivered 00:00:08.199 --> 00:00:11.380 or should be delivered within the NHS. And we're 00:00:11.380 --> 00:00:13.400 using a fascinating source for this, aren't we? 00:00:13.660 --> 00:00:15.759 The British Orthopedic Association's advisory 00:00:15.759 --> 00:00:18.679 book for consultants. It's not exactly bedside 00:00:18.679 --> 00:00:21.100 reading, but it's critical stuff. Exactly. It's 00:00:21.100 --> 00:00:23.600 aimed squarely at senior doctors, consultants 00:00:23.600 --> 00:00:25.980 who are navigating what the book itself calls 00:00:25.980 --> 00:00:29.320 unprecedented change. That's right. More demand. 00:00:29.440 --> 00:00:32.399 resources stretched thin, constant pressure on 00:00:32.399 --> 00:00:34.840 targets. That 18 -week wait time, for instance. 00:00:35.399 --> 00:00:37.479 It's a tough environment. So our mission today, 00:00:37.659 --> 00:00:40.240 using this BOA book, is to really unpack what 00:00:40.240 --> 00:00:43.799 it takes. What are the standards, the challenges, 00:00:44.000 --> 00:00:46.700 the absolute must -haves for leading an orthopedic 00:00:46.700 --> 00:00:49.159 service safely and effectively? Well, it kicks 00:00:49.159 --> 00:00:51.700 off by highlighting quite a big shift in what's 00:00:51.700 --> 00:00:54.359 expected of a consultant. Oh, how so? He talks 00:00:54.359 --> 00:00:56.700 about moving away from just being consultant 00:00:56.700 --> 00:00:58.939 -led sort of overseeing things towards being 00:00:58.939 --> 00:01:01.179 consultant delivered. Meaning much more hands 00:01:01.179 --> 00:01:03.679 -on involvement right through the patient's journey. 00:01:04.120 --> 00:01:06.599 Precisely. Direct involvement. And it's not just 00:01:06.599 --> 00:01:08.859 about the surgery itself. It's leadership, it's 00:01:08.859 --> 00:01:11.180 engaging with commissioning, shaping how care 00:01:11.180 --> 00:01:13.200 pathways work. Yeah. You know, the whole system. 00:01:13.359 --> 00:01:15.879 And showing that the care is high quality. How 00:01:15.879 --> 00:01:19.120 does the book advise on that? Ah, well, outcomes 00:01:19.120 --> 00:01:21.379 measurement is central. And orthopedics actually 00:01:21.379 --> 00:01:23.680 has a bit of history here. The book mentions 00:01:23.680 --> 00:01:27.430 EA Codman way back. pushing this idea of the 00:01:27.430 --> 00:01:30.329 end result concept, basically tracking what actually 00:01:30.329 --> 00:01:32.769 happens to patients. That's quite forward thinking 00:01:32.769 --> 00:01:35.709 for the early 20th century. And today, that means 00:01:35.709 --> 00:01:38.569 things like PROMs, patient reported outcome measures. 00:01:38.810 --> 00:01:41.629 Exactly. PROMs, patient reported experience, 00:01:41.909 --> 00:01:44.230 measures PREMS, the friends and family test. 00:01:44.890 --> 00:01:47.670 So it's not just did the operation fix the problem, 00:01:47.730 --> 00:01:49.750 but what was the patient's actual experience 00:01:49.750 --> 00:01:52.129 like? Which feels much more holistic. It is. 00:01:52.269 --> 00:01:54.750 And it's not just optional data collection. For 00:01:54.750 --> 00:01:57.310 GMC revalidation, the process all doctors go 00:01:57.310 --> 00:01:58.829 through every five years to prove they're fit 00:01:58.829 --> 00:02:01.609 to practice. There's a clear expectation to measure 00:02:01.609 --> 00:02:04.290 your own patient's experience. It's about accountability, 00:02:04.450 --> 00:02:07.989 really. And speaking of patients, the book tackles 00:02:07.989 --> 00:02:10.870 something quite specific, doesn't it? About patients 00:02:10.870 --> 00:02:13.650 wanting to see the same surgeon. Yes. This is 00:02:13.650 --> 00:02:17.509 a really key point for the BOA. They're, well, 00:02:17.689 --> 00:02:20.009 they're quite wary of pooled waiting lists if 00:02:20.009 --> 00:02:22.229 they aren't managed very carefully. Because of 00:02:22.229 --> 00:02:24.469 the risk of feeling like just a number? Partly, 00:02:24.650 --> 00:02:28.069 yes. Depersonalization. Not knowing who's actually 00:02:28.069 --> 00:02:31.050 going to do your operation, but also lack of 00:02:31.050 --> 00:02:34.150 clarity on who's responsible. The BOA insists 00:02:34.150 --> 00:02:36.969 on proper patient consent for that model, and 00:02:36.969 --> 00:02:39.449 that should only happen after a full pre -assessment, 00:02:39.669 --> 00:02:41.469 ideally where the patient meets the operating 00:02:41.469 --> 00:02:42.969 surgeon. You shouldn't be meeting them for the 00:02:42.969 --> 00:02:45.430 first time just before you go under. Definitely 00:02:45.430 --> 00:02:47.789 not. It undermines that trust, doesn't it? Absolutely. 00:02:48.110 --> 00:02:50.610 Okay, let's shift focus slightly to the consultant's 00:02:50.610 --> 00:02:53.189 professional life. Revalidation is obviously 00:02:53.189 --> 00:02:56.069 huge. It is. Fundamentally, it's there to assure 00:02:56.069 --> 00:02:59.189 everyone, patients, the public, employers, that 00:02:59.189 --> 00:03:01.770 doctors are up -to -date, competent, and safe. 00:03:02.000 --> 00:03:05.060 It's a five -year cycle linked to a responsible 00:03:05.060 --> 00:03:07.680 officer in their organization who then recommends 00:03:07.680 --> 00:03:10.379 to the GMC. And staying up to date involves continuing 00:03:10.379 --> 00:03:13.500 professional development, CPD. Essential. And 00:03:13.500 --> 00:03:15.900 it's a statutory requirement for revalidation. 00:03:16.180 --> 00:03:18.199 It can't just be narrow clinical stuff either. 00:03:18.300 --> 00:03:20.500 It needs to cover everything, clinical practice, 00:03:20.879 --> 00:03:23.219 academic work, management, leadership. The book 00:03:23.219 --> 00:03:26.680 suggests about 50 hours or points a year. And 00:03:26.680 --> 00:03:28.500 reflective practice is important there too. Very 00:03:28.500 --> 00:03:31.259 much so. Not just attending a course, but reflecting 00:03:31.259 --> 00:03:33.520 on what you learned and how it changes your practice. 00:03:34.379 --> 00:03:36.780 And study leave, maybe 10 days a year with pay 00:03:36.780 --> 00:03:39.280 and expenses, is needed to make this happen. 00:03:39.580 --> 00:03:42.759 But how does that fit into a packed consultant 00:03:42.759 --> 00:03:45.620 schedule? That's where SBA time comes in. Exactly. 00:03:46.080 --> 00:03:48.680 Supporting professional activity time. The BOA 00:03:48.680 --> 00:03:51.219 book is really clear. This isn't downtime or 00:03:51.219 --> 00:03:54.240 an optional extra It's essential for professional 00:03:54.240 --> 00:03:56.379 development for quality improvement for patient 00:03:56.379 --> 00:03:58.800 safety. It has to be part of the job plan So 00:03:58.800 --> 00:04:01.580 it's protected time for things other than direct 00:04:01.580 --> 00:04:03.740 patient contact. That's it and the book splits 00:04:03.740 --> 00:04:06.039 it a bit There's core SPA things like your CPD 00:04:06.039 --> 00:04:08.319 keeping up with journals appraisal prep mandatory 00:04:08.319 --> 00:04:11.139 training and then employer directed SPA that 00:04:11.139 --> 00:04:14.460 could be audit research governance meetings managing 00:04:14.460 --> 00:04:17.149 roles teaching And external duties, too, like 00:04:17.149 --> 00:04:19.470 working with the royal colleges. Yes, that counts, 00:04:19.689 --> 00:04:21.889 too. And the evidence, particularly thinking 00:04:21.889 --> 00:04:24.209 back to reports like the Francis Inquiry, just 00:04:24.209 --> 00:04:27.569 underlines how vital protected SBA time is for 00:04:27.569 --> 00:04:30.129 maintaining quality and safety. You can't do 00:04:30.129 --> 00:04:33.050 it on the fly. OK, that makes sense. So moving 00:04:33.050 --> 00:04:35.589 from the individual consultant to the service 00:04:35.589 --> 00:04:38.470 itself, what are the building blocks? What does 00:04:38.470 --> 00:04:42.069 the book say is required for a good TNO service? 00:04:42.410 --> 00:04:44.970 Right. The nuts and bolts. It talks about beds 00:04:44.970 --> 00:04:47.689 and facilities, no magic number, but guiding 00:04:47.689 --> 00:04:49.610 principles. Things like efficient pre -assessment 00:04:49.610 --> 00:04:51.610 clinics are highlighted. They're key for sorting 00:04:51.610 --> 00:04:54.069 patient fitness, reducing cancellations, getting 00:04:54.069 --> 00:04:55.930 discharge planning started early. And things 00:04:55.930 --> 00:04:59.129 like day surgery. Yes, ambulatory care. It can 00:04:59.129 --> 00:05:01.689 work well, help manage bed pressures, but only 00:05:01.689 --> 00:05:04.730 with really careful patient selection and good 00:05:04.730 --> 00:05:07.170 post -op support, like follow -up calls. And 00:05:07.170 --> 00:05:09.689 infection control must be huge in orthopedics. 00:05:09.870 --> 00:05:12.629 Absolutely massive. You cannot overseed it. Think 00:05:12.629 --> 00:05:14.910 MRSA screening and treatment, how you manage 00:05:14.910 --> 00:05:17.430 patients who do have infections, the devastating 00:05:17.430 --> 00:05:20.430 cost, human and financial, of infected joint 00:05:20.430 --> 00:05:22.730 replacements. It's critical. And that relies 00:05:22.730 --> 00:05:25.970 on staff as well as processes. Totally. You need 00:05:25.970 --> 00:05:28.730 enough properly trained staff, orthopedic nurses 00:05:28.730 --> 00:05:32.029 who know the procedures, physios, OTs. And the 00:05:32.029 --> 00:05:34.269 book flags the need for seven -day working to 00:05:34.269 --> 00:05:36.430 maintain standards across the week, not just 00:05:36.430 --> 00:05:38.589 Monday to Friday. It also mentions the debate 00:05:38.589 --> 00:05:41.170 about where services are located, combining trauma 00:05:41.170 --> 00:05:43.649 and elective or keeping them separate. Yeah, 00:05:43.649 --> 00:05:46.889 pros and cons. Combined sites can seem efficient, 00:05:47.029 --> 00:05:49.629 but elective lists often get canceled for trauma 00:05:49.629 --> 00:05:52.480 emergencies. That's huge. disruptive. I can imagine. 00:05:52.839 --> 00:05:55.000 Separate sites protect the planned work, but 00:05:55.000 --> 00:05:57.100 then you have potential issues with staff traveling, 00:05:57.519 --> 00:05:59.600 duplicating kit, maybe losing that cross -cover. 00:05:59.959 --> 00:06:02.639 There's no single perfect model. It depends on 00:06:02.639 --> 00:06:04.920 local circumstances. And the book is emphatic 00:06:04.920 --> 00:06:07.660 about needing the right staff beyond just doctors. 00:06:07.839 --> 00:06:10.420 Oh absolutely. High quality nursing is vital. 00:06:10.579 --> 00:06:13.420 Ideally, nurses with specific orthopedic qualifications 00:06:13.420 --> 00:06:16.139 or experience. Staffing numbers need to reflect 00:06:16.139 --> 00:06:18.759 the workload and patient dependency with the 00:06:18.759 --> 00:06:21.160 right skill mix. What about advanced practitioners, 00:06:21.519 --> 00:06:23.279 nurse practitioners, physio practitioners? They 00:06:23.279 --> 00:06:25.560 have an important role, definitely. Extended 00:06:25.560 --> 00:06:27.939 scope practitioners, advanced nurse practitioners. 00:06:28.980 --> 00:06:32.620 But the book is clear. The consultant keeps overall 00:06:32.620 --> 00:06:35.920 clinical responsibility, and patients must know 00:06:35.920 --> 00:06:38.139 who they're seeing and what their qualifications 00:06:38.139 --> 00:06:41.829 are. Transparency is key. And physio and OT. 00:06:42.189 --> 00:06:45.329 Obviously crucial for recovery. Fundamental for 00:06:45.329 --> 00:06:47.629 getting people moving, getting them home safely, 00:06:47.990 --> 00:06:50.750 helping them regain independence. For inpatients, 00:06:50.829 --> 00:06:53.149 the book recommends a specialist ortho -physio 00:06:53.149 --> 00:06:55.889 lead. Staffing needs to match the case complexity. 00:06:56.110 --> 00:06:58.829 Major trauma or big revision surgeries need more 00:06:58.829 --> 00:07:00.790 input. And 7 -Day Physio helps with that, getting 00:07:00.790 --> 00:07:02.750 people home sooner. It does, helps reduce length 00:07:02.750 --> 00:07:05.009 of stay. And occupational therapists are vital 00:07:05.009 --> 00:07:08.189 to assessing home environments, organizing equipment, 00:07:08.250 --> 00:07:10.569 splints, helping with the return to work. They're 00:07:10.569 --> 00:07:13.259 key for timely discharge. Consultant support 00:07:13.259 --> 00:07:15.339 is often needed to make sure these therapy services 00:07:15.339 --> 00:07:17.699 get the resources they need. Hand therapy even 00:07:17.699 --> 00:07:20.040 gets its own section. It does because it's so 00:07:20.040 --> 00:07:22.279 specialized and makes such a difference to outcomes 00:07:22.279 --> 00:07:25.439 after hand injuries or surgery. Needs dedicated 00:07:25.439 --> 00:07:28.600 therapists, physios, or OTs, ideally working 00:07:28.600 --> 00:07:31.199 towards accreditation. The book even suggests 00:07:31.199 --> 00:07:33.860 a staffing ratio roughly one senior therapist 00:07:33.860 --> 00:07:36.800 plus support per hand consultant. Okay, let's 00:07:36.800 --> 00:07:39.160 step inside the operating theater. What are the 00:07:39.160 --> 00:07:41.720 essentials there, according to the BOA? Dedicated 00:07:41.720 --> 00:07:44.420 theater time is non -negotiable. Not enough allocated 00:07:44.420 --> 00:07:47.100 time just leads to cancellations. Simple as that. 00:07:47.220 --> 00:07:49.639 Which impacts waiting lists and patient stress. 00:07:50.019 --> 00:07:52.600 Hugely. So you need regular scheduled trauma 00:07:52.600 --> 00:07:56.819 lists every day, plus 247 emergency cover with 00:07:56.819 --> 00:07:59.589 senior surgeons and anesthetists available. Clean 00:07:59.589 --> 00:08:01.850 elective cases need to be separated from trauma 00:08:01.850 --> 00:08:04.930 or potentially infected cases. And timing is 00:08:04.930 --> 00:08:07.850 critical for emergencies. Yes. Immediate access 00:08:07.850 --> 00:08:09.889 for some things dislocated hips, compartment 00:08:09.889 --> 00:08:12.730 syndrome, and for most long bone fractures, access 00:08:12.730 --> 00:08:15.449 within 24 hours is the standard. Open fractures 00:08:15.449 --> 00:08:17.910 need timely debridement too, although the old 00:08:17.910 --> 00:08:20.350 strict six -hour rule is less rigid now unless 00:08:20.350 --> 00:08:23.050 it's heavily contaminated. Access to good imaging 00:08:23.050 --> 00:08:25.220 and theater is also vital. What about the air 00:08:25.220 --> 00:08:27.160 in the theater? I know that's a big focus for 00:08:27.160 --> 00:08:29.839 joint replacements. It is. Ultra -clean air ventilation 00:08:29.839 --> 00:08:32.700 systems, UCA, are mandatory for joint replacements 00:08:32.700 --> 00:08:35.360 and major implant surgery. It's a key part of 00:08:35.360 --> 00:08:37.059 preventing infection. Does it make a difference? 00:08:37.279 --> 00:08:39.279 The evidence suggests it does, significantly. 00:08:39.840 --> 00:08:42.200 The book cites data showing that UCA, combined 00:08:42.200 --> 00:08:45.399 with prophylactic antibiotics, slashed deep infection 00:08:45.399 --> 00:08:48.299 rates historically, from maybe 11 % right down 00:08:48.299 --> 00:08:51.799 to nearer 0 .3%. Patient factors like diabetes 00:08:51.799 --> 00:08:54.259 or smoking matter, too. Of course, they need 00:08:54.259 --> 00:08:57.379 optimizing. But the environment is critical. 00:08:57.740 --> 00:09:00.120 And the BOA has strong views on general theater 00:09:00.120 --> 00:09:03.440 practice. Very strong. Orthopedic implant surgery 00:09:03.440 --> 00:09:05.919 demands, they argue, higher sterile precautions 00:09:05.919 --> 00:09:08.519 than many other types of surgery. Strict control 00:09:08.519 --> 00:09:11.139 of who's in theater, how they move, impermeable 00:09:11.139 --> 00:09:14.259 gowns, drapes, hoods, masks, the whole setup. 00:09:14.379 --> 00:09:16.940 And they back surgeons who refuse to operate 00:09:16.940 --> 00:09:19.460 if standards aren't met. Yes. The book explicitly 00:09:19.460 --> 00:09:21.639 states they support members who feel patient 00:09:21.639 --> 00:09:24.320 safety is compromised by substandard conditions. 00:09:24.740 --> 00:09:26.679 That's quite a statement. Instrument cleaning, 00:09:26.980 --> 00:09:29.360 decontamination, another vital step. Absolutely 00:09:29.360 --> 00:09:31.679 vital. Whether it's done onsite or centrally, 00:09:31.940 --> 00:09:34.940 the process has to be robust. A crucial point 00:09:34.940 --> 00:09:37.639 the book makes. If you don't have an immediate 00:09:37.639 --> 00:09:40.340 way to re -sterilize a dropped instrument onsite, 00:09:40.679 --> 00:09:42.940 you really need two sets available before you 00:09:42.940 --> 00:09:45.419 start. And teamwork between the theater team 00:09:45.419 --> 00:09:48.220 and decontamination staff is essential. What 00:09:48.220 --> 00:09:51.559 about small things like screws? Should they be 00:09:51.559 --> 00:09:54.320 in individual packets? Interestingly, the BOA 00:09:54.320 --> 00:09:57.279 view is... No, probably not. They argue it's 00:09:57.279 --> 00:09:59.440 actually more expensive, takes longer during 00:09:59.440 --> 00:10:01.879 the operation, and might even increase infection 00:10:01.879 --> 00:10:04.059 risk because of all the extra handling movement 00:10:04.059 --> 00:10:06.700 opening packets. So better to have them sterilized 00:10:06.700 --> 00:10:09.200 on a rack with the main instruments? That's their 00:10:09.200 --> 00:10:11.639 preference, yes. Seems counterintuitive, perhaps, 00:10:12.000 --> 00:10:14.259 but their reasoning is about minimizing operating 00:10:14.259 --> 00:10:17.320 time and movement. What else? Blood banks? Tissue 00:10:17.320 --> 00:10:19.559 banks? Need access to both, and they must be 00:10:19.559 --> 00:10:22.539 properly accredited by the MHRA. Hospitals need 00:10:22.539 --> 00:10:25.039 clear protocols for blood use, transfusion triggers, 00:10:25.500 --> 00:10:27.600 maybe using cell salvage techniques to conserve 00:10:27.600 --> 00:10:30.480 blood. And risks to staff. Bloodborne viruses. 00:10:31.159 --> 00:10:33.779 Yes. Orthopedics is higher risk because of power 00:10:33.779 --> 00:10:36.639 tools, sharp bone fragments, irrigation fluid, 00:10:37.259 --> 00:10:40.159 hep B immunization is recommended, assume every 00:10:40.159 --> 00:10:42.740 patient is potentially infectious, use proper 00:10:42.740 --> 00:10:45.879 PPE like splash card masks, and have clear procedures 00:10:45.879 --> 00:10:48.320 if someone does get an exposure. Okay. Outside 00:10:48.320 --> 00:10:50.559 of theaters clinics, outpatient and fracture 00:10:50.559 --> 00:10:53.940 clinics need specific things too. They do. Ideally, 00:10:53.960 --> 00:10:56.019 purpose designed, near x -ray in the plaster 00:10:56.019 --> 00:10:58.759 room. Enough rooms, big enough for teaching. 00:10:59.159 --> 00:11:01.179 Proper walls for privacy, not just curtains. 00:11:01.980 --> 00:11:05.000 Separate areas for clean dressings and potentially 00:11:05.000 --> 00:11:07.740 contaminated ones. Enough staff for smooth flow, 00:11:07.960 --> 00:11:09.919 chaperones available. Fracture clinics should 00:11:09.919 --> 00:11:12.539 also check for falls risk, bone health. And getting 00:11:12.539 --> 00:11:15.500 information, write notes, letters. Crucial. Medical 00:11:15.500 --> 00:11:17.529 records need to be easily available. Letters 00:11:17.529 --> 00:11:19.450 to GPs should be out within three working days, 00:11:19.769 --> 00:11:22.350 accurate, saying what the plan is, risks, benefits. 00:11:22.830 --> 00:11:24.850 Same for discharge summaries. Operation notes 00:11:24.850 --> 00:11:27.129 need to be detailed, legible or typed, listing 00:11:27.129 --> 00:11:29.950 everyone involved, the implants used, any issues, 00:11:30.250 --> 00:11:32.330 clear post -op instructions. Sounds like a lot 00:11:32.330 --> 00:11:34.230 of admin. Where does the consultant do all this? 00:11:34.409 --> 00:11:37.429 Good point. The book stresses that proper office 00:11:37.429 --> 00:11:40.350 accommodation isn't a luxury. Each consultant 00:11:40.350 --> 00:11:43.429 needs their own office, ideally equipped with 00:11:43.429 --> 00:11:46.860 IT access. It's needed for that admin time, for 00:11:46.860 --> 00:11:50.019 SPA activities, leadership tasks, hot desking, 00:11:50.480 --> 00:11:52.980 strongly discouraged, inefficient, insecure. 00:11:53.399 --> 00:11:56.720 Juniors need decent space, too. And medical secretaries 00:11:56.720 --> 00:11:59.700 are key to managing that admin load. Absolutely 00:11:59.700 --> 00:12:02.240 essential. The book is very firm. At least one 00:12:02.240 --> 00:12:04.500 full -time trained medical secretary per consultant 00:12:04.500 --> 00:12:07.700 is needed for a safe, effective service. They're 00:12:07.700 --> 00:12:10.740 the link with GPs. patience, coordinating everything. 00:12:11.220 --> 00:12:13.299 A name secretary helps the consultant work efficiently 00:12:13.299 --> 00:12:15.779 and safely. And you need cover for when they're 00:12:15.779 --> 00:12:18.159 on leave. Teaching facilities also get a mention. 00:12:18.259 --> 00:12:21.120 Yes, a dedicated room for teaching, for multidisciplinary 00:12:21.120 --> 00:12:23.940 meetings, trauma handovers. Access to simulation 00:12:23.940 --> 00:12:25.840 facilities is increasingly important for training 00:12:25.840 --> 00:12:28.580 safely. And good IT for accessing online journals 00:12:28.580 --> 00:12:30.940 and resources. Let's just quickly revisit SBA 00:12:30.940 --> 00:12:32.759 Times supporting professional activity. You said 00:12:32.759 --> 00:12:35.500 it was crucial. Yes, the book really hammers 00:12:35.500 --> 00:12:37.580 this home. It's fundamental for keeping skills 00:12:37.580 --> 00:12:40.200 up, improving the service, patient safety, innovation. 00:12:40.679 --> 00:12:43.080 It cites the Francis Report. It lists those core 00:12:43.080 --> 00:12:46.120 things like CPD and appraisal and the employer 00:12:46.120 --> 00:12:48.340 -directed stuff like audit, research management, 00:12:48.759 --> 00:12:51.059 plus time for external roles. It's not optional. 00:12:51.340 --> 00:12:53.960 Okay. Now, what about patients with particularly 00:12:53.960 --> 00:12:57.159 complex needs? How should services cater for 00:12:57.159 --> 00:12:59.919 them? This requires access to a whole range of 00:12:59.919 --> 00:13:02.120 support services, and the book notes that provision 00:13:02.120 --> 00:13:04.340 varies across the country. Things like rehab, 00:13:04.460 --> 00:13:07.919 physio, OT, hand therapy, but also special support 00:13:07.919 --> 00:13:10.440 like care of the elderly teams, especially for 00:13:10.440 --> 00:13:13.179 hip fractures, social services input for discharge. 00:13:13.919 --> 00:13:15.940 Seven -day trauma management is vital here too. 00:13:16.090 --> 00:13:18.970 And often, it means linking with regional specialized 00:13:18.970 --> 00:13:21.490 services in other hospitals. Clear pathways, 00:13:21.730 --> 00:13:23.950 named contacts are needed. Things like image 00:13:23.950 --> 00:13:26.769 exchange portals, IDPs are essential for sharing 00:13:26.769 --> 00:13:28.909 scans for discussion. What sort of specialized 00:13:28.909 --> 00:13:32.529 services? Major trauma networks, obviously. Specialist 00:13:32.529 --> 00:13:35.789 spinal injury services. Plastic surgery for complex 00:13:35.789 --> 00:13:39.070 limb reconstruction. Vascular surgery for injuries 00:13:39.070 --> 00:13:41.889 involving blood vessels. Neurosurgery. The list 00:13:41.889 --> 00:13:44.970 goes on. Smooth pathways and communication between 00:13:44.970 --> 00:13:47.980 centers are key. And specialist orthopedic hospitals, 00:13:47.980 --> 00:13:50.419 they have a particular role? They do. Centers 00:13:50.419 --> 00:13:52.960 of Excellence, Homes for Networks, dealing with 00:13:52.960 --> 00:13:55.559 the most complex cases, leading on training and 00:13:55.559 --> 00:13:58.299 research. They face funding challenges, as the 00:13:58.299 --> 00:14:00.500 national tariff doesn't always reflect that complexity, 00:14:00.799 --> 00:14:03.139 but they're vital. They need top -notch facilities 00:14:03.139 --> 00:14:05.480 themselves, of course. The book also talks about 00:14:05.480 --> 00:14:08.620 treatment centers, ISTCs, or NHSTCs. What was 00:14:08.620 --> 00:14:11.019 the take on those? Well, it outlines their development 00:14:11.019 --> 00:14:13.500 set up to boost capacity, sometimes using non 00:14:13.500 --> 00:14:16.620 -UK staff initially. They often focused on straightforward 00:14:16.620 --> 00:14:19.259 elective cases, which could concentrate the complex 00:14:19.120 --> 00:14:22.840 back in NHS hospitals. Were there concerns? Yes. 00:14:23.279 --> 00:14:25.820 The BOA flagged concerns about quality assurance, 00:14:26.259 --> 00:14:29.120 short contracts, lack of mandatory audit, into 00:14:29.120 --> 00:14:32.240 complications. And a big one was the risk of 00:14:32.240 --> 00:14:34.759 separating elective and trauma work, potentially 00:14:34.759 --> 00:14:37.340 descaling surgeons in acute hospitals and harming 00:14:37.340 --> 00:14:39.899 training. The hope or expectation was they'd 00:14:39.899 --> 00:14:42.519 become better integrated, staffed by UK -trained 00:14:42.519 --> 00:14:45.000 surgeons. And the major trauma networks themselves, 00:14:45.320 --> 00:14:48.539 set up from 2012 in England? A big shift. Getting 00:14:48.539 --> 00:14:51.240 patients to the right place fast. Major trauma 00:14:51.240 --> 00:14:54.039 centers or trauma units. Orthopedic surgeons 00:14:54.039 --> 00:14:56.460 are key members of the MTC teams, needing to 00:14:56.460 --> 00:14:59.360 be readily available. Surgeons in the TU's manage 00:14:59.360 --> 00:15:01.759 a range of trauma, but need to be expert in that 00:15:01.759 --> 00:15:04.299 initial stabilization phase. Good communication 00:15:04.299 --> 00:15:06.799 for repatriation is crucial. Underpinning all 00:15:06.799 --> 00:15:08.960 of this, though, is the workforce itself. The 00:15:08.960 --> 00:15:10.659 book seems quite concerned here. Definitely. 00:15:10.840 --> 00:15:13.320 It's a major theme. Trying to pin down exact 00:15:13.320 --> 00:15:15.779 numbers needed is hard because care is spread 00:15:15.779 --> 00:15:18.179 across NHS, private sector, treatment centers. 00:15:18.860 --> 00:15:21.620 But the trend is undeniable. Demand is soaring. 00:15:21.879 --> 00:15:24.620 Aging population, more active population, rising 00:15:24.620 --> 00:15:26.759 joint replacements. And trauma isn't going away. 00:15:27.059 --> 00:15:29.240 No, hip fractures particularly. The book estimates 00:15:29.240 --> 00:15:31.639 a capacity gap may be 15 % shortfall currently. 00:15:31.919 --> 00:15:34.159 And the workforce is changing more women, people 00:15:34.159 --> 00:15:36.759 working longer. But the absolute key message 00:15:36.759 --> 00:15:39.379 is, consultants cannot work effectively or safely 00:15:39.379 --> 00:15:41.600 without enough support staff. Junior doctors, 00:15:41.700 --> 00:15:44.600 nurses, therapists, admin staff. There's often 00:15:44.600 --> 00:15:47.059 a mismatch between the need and the actual posts 00:15:47.059 --> 00:15:49.559 available. Right. Let's touch on how the book 00:15:49.559 --> 00:15:52.480 advises assessing consultant workload. Section 00:15:52.480 --> 00:15:55.240 two, I think. Yes. It starts by stating the obvious, 00:15:55.360 --> 00:15:57.899 perhaps, but it's crucial. Workload capacity 00:15:57.899 --> 00:16:01.129 depends hugely on facilities and support. Deficiencies 00:16:01.129 --> 00:16:03.750 hold consultants back. It also acknowledges consultants 00:16:03.750 --> 00:16:06.470 often work well beyond their contracts. The 2003 00:16:06.470 --> 00:16:09.149 contract introduced programmed activities, PAs. 00:16:09.409 --> 00:16:11.049 That's right in England, Scotland, and Northern 00:16:11.049 --> 00:16:13.950 Ireland. Replacing the old notional half days. 00:16:14.370 --> 00:16:16.529 A PA is roughly four hours. Standard week is 00:16:16.529 --> 00:16:19.090 10 PAs. Wales had a slightly different system. 00:16:19.690 --> 00:16:21.889 The idea through job planning was to make the 00:16:21.889 --> 00:16:24.129 whole workload transparent and ensure extra work 00:16:24.129 --> 00:16:27.350 was recognized. So the job plan is key. It's 00:16:27.350 --> 00:16:29.909 an agreement. reviewed annually, detailing all 00:16:29.909 --> 00:16:33.350 the duties. Direct clinical care, DCC, supporting 00:16:33.350 --> 00:16:36.129 professional activities, SPA, any extra roles 00:16:36.129 --> 00:16:39.029 like clinical director, on -call work, emergency 00:16:39.029 --> 00:16:41.549 visits, travel times, it's all part of it and 00:16:41.549 --> 00:16:45.009 should be factored in. The 2003 -04 contract 00:16:45.009 --> 00:16:47.629 specifically allocated PAs for being on -call. 00:16:48.009 --> 00:16:50.570 What about how often consultants should be on 00:16:50.570 --> 00:16:52.950 -call? Ideally, the book suggests no more frequent 00:16:52.950 --> 00:16:55.230 than a one in six rota. though small units might 00:16:55.230 --> 00:16:57.309 struggle with that. The intensity, how busy it 00:16:57.309 --> 00:16:59.429 actually is, whether there's good junior support 00:16:59.429 --> 00:17:02.470 needs to be reflected in the PA allocation. The 00:17:02.470 --> 00:17:05.089 aim is to plan activity rather than rely on excessive 00:17:05.089 --> 00:17:08.069 unplanned extra hours. Up to 12 PAs total can 00:17:08.069 --> 00:17:10.150 be paid. Beyond that might be time off in lieu. 00:17:10.950 --> 00:17:13.289 Resident on call isn't standard unless specifically 00:17:13.289 --> 00:17:16.170 agreed. And specific tasks. How do they fit in 00:17:16.170 --> 00:17:19.369 the workload? Fracture clinics can be unpredictable 00:17:19.369 --> 00:17:22.210 with new patients but need proper staffing under 00:17:22.210 --> 00:17:25.609 consultant direction. Trained orthopedic practitioners 00:17:25.609 --> 00:17:28.529 can see some patients. Ward rounds are a central 00:17:28.529 --> 00:17:32.289 clinical time, part of DCC. Need to maximize 00:17:32.289 --> 00:17:34.890 theater use. Trend towards more complex cases 00:17:34.890 --> 00:17:37.710 on inpatient lists. Need enough time between 00:17:37.710 --> 00:17:40.150 cases orthopedics often needs longer turnover. 00:17:40.769 --> 00:17:42.869 And crucially, time for supervising trainees 00:17:42.869 --> 00:17:45.509 must be built in. It's a balancing act between 00:17:45.509 --> 00:17:47.589 theater and clinic time to manage waiting lists. 00:17:48.230 --> 00:17:50.690 Ardent is non -negotiable too. Part of governance. 00:17:51.289 --> 00:17:53.769 Regular sessions needed. Contributing data to 00:17:53.769 --> 00:17:56.029 national registries like the NJR is standard, 00:17:56.349 --> 00:17:58.849 but needs admin support. Consultant involvement 00:17:58.849 --> 00:18:00.890 and management, clinical directorates is also 00:18:00.890 --> 00:18:03.509 important. Orthopedics is expensive, needs clinical 00:18:03.509 --> 00:18:05.809 input on spending. And emergency surgery. We 00:18:05.809 --> 00:18:08.250 touched on theater access. Yes, resources need 00:18:08.250 --> 00:18:10.630 to be there when needed. Dedicated emergency 00:18:10.630 --> 00:18:13.289 theater. And training means supervision. Complex 00:18:13.289 --> 00:18:15.250 emergencies need direct consultant supervision, 00:18:15.630 --> 00:18:17.509 or at least the consultant needs to be informed, 00:18:17.849 --> 00:18:20.619 even for minor cases done by trainees. Rotas 00:18:20.619 --> 00:18:22.559 should allow the on -call consultant to be free 00:18:22.559 --> 00:18:24.940 to supervise. Finally, what about part -time 00:18:24.940 --> 00:18:27.680 consultants? Generally, duties are pro rata. 00:18:28.380 --> 00:18:30.559 But the book rightly points out that things like 00:18:30.559 --> 00:18:33.059 committee work or departmental roles might need 00:18:33.059 --> 00:18:35.900 specific allocation, irrespective of their part 00:18:35.900 --> 00:18:38.200 -time hours, to ensure their contribution isn't 00:18:38.200 --> 00:18:41.619 lost. The standard DCC to SPA ratio under the 00:18:41.619 --> 00:18:46.000 2003 contract is roughly 2 .1. So, reading through 00:18:46.000 --> 00:18:48.160 this book, it paints an incredibly detailed picture 00:18:48.160 --> 00:18:51.640 of just how vast the consultant orthopedic surgeon's 00:18:51.640 --> 00:18:53.960 role is now. It's far beyond just operating. 00:18:54.140 --> 00:18:56.930 It really is. Clinical expertise, yes, but also 00:18:56.930 --> 00:18:59.430 leadership, team coordination, upholding really 00:18:59.430 --> 00:19:01.990 strict safety standards, theater protocols, infection 00:19:01.990 --> 00:19:05.230 control, record keeping, plus that constant need 00:19:05.230 --> 00:19:08.190 for professional development, revalidation, CPD, 00:19:08.349 --> 00:19:10.630 that vital SPA time. And doing all that while 00:19:10.630 --> 00:19:12.750 navigating the complexities of the NHS structure, 00:19:13.190 --> 00:19:15.230 the workforce shortages we talked about, the 00:19:15.230 --> 00:19:17.210 different ways services are provided, it's a 00:19:17.210 --> 00:19:19.569 huge undertaking. The book really does feel like 00:19:19.569 --> 00:19:22.069 that essential guide, trying to help consultants, 00:19:22.069 --> 00:19:24.569 as it says, get things right against a backdrop 00:19:24.569 --> 00:19:28.069 of huge demand and constant change. It highlights 00:19:28.069 --> 00:19:30.509 how much relies on having the right infrastructure, 00:19:30.789 --> 00:19:33.289 the right staffing, and that protected time. 00:19:33.990 --> 00:19:36.009 Absolutely. And understanding these pressures, 00:19:36.329 --> 00:19:38.349 these standards, these requirements outlined 00:19:38.349 --> 00:19:40.930 here, it's valuable insight for anyone involved 00:19:40.930 --> 00:19:42.849 in health care and the NHS, whatever their role. 00:19:43.130 --> 00:19:45.450 If you found this deep dive helpful, we'd really 00:19:45.450 --> 00:19:47.230 appreciate it if you could take a moment to rate 00:19:47.230 --> 00:19:49.230 and share this show. So here's a final thought. 00:19:50.130 --> 00:19:52.170 Given the increasing demand we know is coming, 00:19:52.490 --> 00:19:54.869 the aging population, people staying active longer, 00:19:55.289 --> 00:19:57.849 and that acknowledged capacity gap in orthopedics, 00:19:58.690 --> 00:20:01.250 how can innovation in service delivery genuinely 00:20:01.250 --> 00:20:03.349 ensure that quality and safety are protected 00:20:03.349 --> 00:20:06.029 for every patient needing musculoskeletal pair 00:20:06.029 --> 00:20:06.569 in the future?