Welcome to the deep dive. Today we're getting
into something really fundamental, how high quality
trauma in orthopedic care is actually delivered
or should be delivered within the NHS. And we're
using a fascinating source for this, aren't we?
The British Orthopedic Association's advisory
book for consultants. It's not exactly bedside
reading, but it's critical stuff. Exactly. It's
aimed squarely at senior doctors, consultants
who are navigating what the book itself calls
unprecedented change. That's right. More demand.
resources stretched thin, constant pressure on
targets. That 18 -week wait time, for instance.
It's a tough environment. So our mission today,
using this BOA book, is to really unpack what
it takes. What are the standards, the challenges,
the absolute must -haves for leading an orthopedic
service safely and effectively? Well, it kicks
off by highlighting quite a big shift in what's
expected of a consultant. Oh, how so? He talks
about moving away from just being consultant
-led sort of overseeing things towards being
consultant delivered. Meaning much more hands
-on involvement right through the patient's journey.
Precisely. Direct involvement. And it's not just
about the surgery itself. It's leadership, it's
engaging with commissioning, shaping how care
pathways work. Yeah. You know, the whole system.
And showing that the care is high quality. How
does the book advise on that? Ah, well, outcomes
measurement is central. And orthopedics actually
has a bit of history here. The book mentions
EA Codman way back. pushing this idea of the
end result concept, basically tracking what actually
happens to patients. That's quite forward thinking
for the early 20th century. And today, that means
things like PROMs, patient reported outcome measures.
Exactly. PROMs, patient reported experience,
measures PREMS, the friends and family test.
So it's not just did the operation fix the problem,
but what was the patient's actual experience
like? Which feels much more holistic. It is.
And it's not just optional data collection. For
GMC revalidation, the process all doctors go
through every five years to prove they're fit
to practice. There's a clear expectation to measure
your own patient's experience. It's about accountability,
really. And speaking of patients, the book tackles
something quite specific, doesn't it? About patients
wanting to see the same surgeon. Yes. This is
a really key point for the BOA. They're, well,
they're quite wary of pooled waiting lists if
they aren't managed very carefully. Because of
the risk of feeling like just a number? Partly,
yes. Depersonalization. Not knowing who's actually
going to do your operation, but also lack of
clarity on who's responsible. The BOA insists
on proper patient consent for that model, and
that should only happen after a full pre -assessment,
ideally where the patient meets the operating
surgeon. You shouldn't be meeting them for the
first time just before you go under. Definitely
not. It undermines that trust, doesn't it? Absolutely.
Okay, let's shift focus slightly to the consultant's
professional life. Revalidation is obviously
huge. It is. Fundamentally, it's there to assure
everyone, patients, the public, employers, that
doctors are up -to -date, competent, and safe.
It's a five -year cycle linked to a responsible
officer in their organization who then recommends
to the GMC. And staying up to date involves continuing
professional development, CPD. Essential. And
it's a statutory requirement for revalidation.
It can't just be narrow clinical stuff either.
It needs to cover everything, clinical practice,
academic work, management, leadership. The book
suggests about 50 hours or points a year. And
reflective practice is important there too. Very
much so. Not just attending a course, but reflecting
on what you learned and how it changes your practice.
And study leave, maybe 10 days a year with pay
and expenses, is needed to make this happen.
But how does that fit into a packed consultant
schedule? That's where SBA time comes in. Exactly.
Supporting professional activity time. The BOA
book is really clear. This isn't downtime or
an optional extra It's essential for professional
development for quality improvement for patient
safety. It has to be part of the job plan So
it's protected time for things other than direct
patient contact. That's it and the book splits
it a bit There's core SPA things like your CPD
keeping up with journals appraisal prep mandatory
training and then employer directed SPA that
could be audit research governance meetings managing
roles teaching And external duties, too, like
working with the royal colleges. Yes, that counts,
too. And the evidence, particularly thinking
back to reports like the Francis Inquiry, just
underlines how vital protected SBA time is for
maintaining quality and safety. You can't do
it on the fly. OK, that makes sense. So moving
from the individual consultant to the service
itself, what are the building blocks? What does
the book say is required for a good TNO service?
Right. The nuts and bolts. It talks about beds
and facilities, no magic number, but guiding
principles. Things like efficient pre -assessment
clinics are highlighted. They're key for sorting
patient fitness, reducing cancellations, getting
discharge planning started early. And things
like day surgery. Yes, ambulatory care. It can
work well, help manage bed pressures, but only
with really careful patient selection and good
post -op support, like follow -up calls. And
infection control must be huge in orthopedics.
Absolutely massive. You cannot overseed it. Think
MRSA screening and treatment, how you manage
patients who do have infections, the devastating
cost, human and financial, of infected joint
replacements. It's critical. And that relies
on staff as well as processes. Totally. You need
enough properly trained staff, orthopedic nurses
who know the procedures, physios, OTs. And the
book flags the need for seven -day working to
maintain standards across the week, not just
Monday to Friday. It also mentions the debate
about where services are located, combining trauma
and elective or keeping them separate. Yeah,
pros and cons. Combined sites can seem efficient,
but elective lists often get canceled for trauma
emergencies. That's huge. disruptive. I can imagine.
Separate sites protect the planned work, but
then you have potential issues with staff traveling,
duplicating kit, maybe losing that cross -cover.
There's no single perfect model. It depends on
local circumstances. And the book is emphatic
about needing the right staff beyond just doctors.
Oh absolutely. High quality nursing is vital.
Ideally, nurses with specific orthopedic qualifications
or experience. Staffing numbers need to reflect
the workload and patient dependency with the
right skill mix. What about advanced practitioners,
nurse practitioners, physio practitioners? They
have an important role, definitely. Extended
scope practitioners, advanced nurse practitioners.
But the book is clear. The consultant keeps overall
clinical responsibility, and patients must know
who they're seeing and what their qualifications
are. Transparency is key. And physio and OT.
Obviously crucial for recovery. Fundamental for
getting people moving, getting them home safely,
helping them regain independence. For inpatients,
the book recommends a specialist ortho -physio
lead. Staffing needs to match the case complexity.
Major trauma or big revision surgeries need more
input. And 7 -Day Physio helps with that, getting
people home sooner. It does, helps reduce length
of stay. And occupational therapists are vital
to assessing home environments, organizing equipment,
splints, helping with the return to work. They're
key for timely discharge. Consultant support
is often needed to make sure these therapy services
get the resources they need. Hand therapy even
gets its own section. It does because it's so
specialized and makes such a difference to outcomes
after hand injuries or surgery. Needs dedicated
therapists, physios, or OTs, ideally working
towards accreditation. The book even suggests
a staffing ratio roughly one senior therapist
plus support per hand consultant. Okay, let's
step inside the operating theater. What are the
essentials there, according to the BOA? Dedicated
theater time is non -negotiable. Not enough allocated
time just leads to cancellations. Simple as that.
Which impacts waiting lists and patient stress.
Hugely. So you need regular scheduled trauma
lists every day, plus 247 emergency cover with
senior surgeons and anesthetists available. Clean
elective cases need to be separated from trauma
or potentially infected cases. And timing is
critical for emergencies. Yes. Immediate access
for some things dislocated hips, compartment
syndrome, and for most long bone fractures, access
within 24 hours is the standard. Open fractures
need timely debridement too, although the old
strict six -hour rule is less rigid now unless
it's heavily contaminated. Access to good imaging
and theater is also vital. What about the air
in the theater? I know that's a big focus for
joint replacements. It is. Ultra -clean air ventilation
systems, UCA, are mandatory for joint replacements
and major implant surgery. It's a key part of
preventing infection. Does it make a difference?
The evidence suggests it does, significantly.
The book cites data showing that UCA, combined
with prophylactic antibiotics, slashed deep infection
rates historically, from maybe 11 % right down
to nearer 0 .3%. Patient factors like diabetes
or smoking matter, too. Of course, they need
optimizing. But the environment is critical.
And the BOA has strong views on general theater
practice. Very strong. Orthopedic implant surgery
demands, they argue, higher sterile precautions
than many other types of surgery. Strict control
of who's in theater, how they move, impermeable
gowns, drapes, hoods, masks, the whole setup.
And they back surgeons who refuse to operate
if standards aren't met. Yes. The book explicitly
states they support members who feel patient
safety is compromised by substandard conditions.
That's quite a statement. Instrument cleaning,
decontamination, another vital step. Absolutely
vital. Whether it's done onsite or centrally,
the process has to be robust. A crucial point
the book makes. If you don't have an immediate
way to re -sterilize a dropped instrument onsite,
you really need two sets available before you
start. And teamwork between the theater team
and decontamination staff is essential. What
about small things like screws? Should they be
in individual packets? Interestingly, the BOA
view is... No, probably not. They argue it's
actually more expensive, takes longer during
the operation, and might even increase infection
risk because of all the extra handling movement
opening packets. So better to have them sterilized
on a rack with the main instruments? That's their
preference, yes. Seems counterintuitive, perhaps,
but their reasoning is about minimizing operating
time and movement. What else? Blood banks? Tissue
banks? Need access to both, and they must be
properly accredited by the MHRA. Hospitals need
clear protocols for blood use, transfusion triggers,
maybe using cell salvage techniques to conserve
blood. And risks to staff. Bloodborne viruses.
Yes. Orthopedics is higher risk because of power
tools, sharp bone fragments, irrigation fluid,
hep B immunization is recommended, assume every
patient is potentially infectious, use proper
PPE like splash card masks, and have clear procedures
if someone does get an exposure. Okay. Outside
of theaters clinics, outpatient and fracture
clinics need specific things too. They do. Ideally,
purpose designed, near x -ray in the plaster
room. Enough rooms, big enough for teaching.
Proper walls for privacy, not just curtains.
Separate areas for clean dressings and potentially
contaminated ones. Enough staff for smooth flow,
chaperones available. Fracture clinics should
also check for falls risk, bone health. And getting
information, write notes, letters. Crucial. Medical
records need to be easily available. Letters
to GPs should be out within three working days,
accurate, saying what the plan is, risks, benefits.
Same for discharge summaries. Operation notes
need to be detailed, legible or typed, listing
everyone involved, the implants used, any issues,
clear post -op instructions. Sounds like a lot
of admin. Where does the consultant do all this?
Good point. The book stresses that proper office
accommodation isn't a luxury. Each consultant
needs their own office, ideally equipped with
IT access. It's needed for that admin time, for
SPA activities, leadership tasks, hot desking,
strongly discouraged, inefficient, insecure.
Juniors need decent space, too. And medical secretaries
are key to managing that admin load. Absolutely
essential. The book is very firm. At least one
full -time trained medical secretary per consultant
is needed for a safe, effective service. They're
the link with GPs. patience, coordinating everything.
A name secretary helps the consultant work efficiently
and safely. And you need cover for when they're
on leave. Teaching facilities also get a mention.
Yes, a dedicated room for teaching, for multidisciplinary
meetings, trauma handovers. Access to simulation
facilities is increasingly important for training
safely. And good IT for accessing online journals
and resources. Let's just quickly revisit SBA
Times supporting professional activity. You said
it was crucial. Yes, the book really hammers
this home. It's fundamental for keeping skills
up, improving the service, patient safety, innovation.
It cites the Francis Report. It lists those core
things like CPD and appraisal and the employer
-directed stuff like audit, research management,
plus time for external roles. It's not optional.
Okay. Now, what about patients with particularly
complex needs? How should services cater for
them? This requires access to a whole range of
support services, and the book notes that provision
varies across the country. Things like rehab,
physio, OT, hand therapy, but also special support
like care of the elderly teams, especially for
hip fractures, social services input for discharge.
Seven -day trauma management is vital here too.
And often, it means linking with regional specialized
services in other hospitals. Clear pathways,
named contacts are needed. Things like image
exchange portals, IDPs are essential for sharing
scans for discussion. What sort of specialized
services? Major trauma networks, obviously. Specialist
spinal injury services. Plastic surgery for complex
limb reconstruction. Vascular surgery for injuries
involving blood vessels. Neurosurgery. The list
goes on. Smooth pathways and communication between
centers are key. And specialist orthopedic hospitals,
they have a particular role? They do. Centers
of Excellence, Homes for Networks, dealing with
the most complex cases, leading on training and
research. They face funding challenges, as the
national tariff doesn't always reflect that complexity,
but they're vital. They need top -notch facilities
themselves, of course. The book also talks about
treatment centers, ISTCs, or NHSTCs. What was
the take on those? Well, it outlines their development
set up to boost capacity, sometimes using non
-UK staff initially. They often focused on straightforward
elective cases, which could concentrate the complex
back in NHS hospitals. Were there concerns? Yes.
The BOA flagged concerns about quality assurance,
short contracts, lack of mandatory audit, into
complications. And a big one was the risk of
separating elective and trauma work, potentially
descaling surgeons in acute hospitals and harming
training. The hope or expectation was they'd
become better integrated, staffed by UK -trained
surgeons. And the major trauma networks themselves,
set up from 2012 in England? A big shift. Getting
patients to the right place fast. Major trauma
centers or trauma units. Orthopedic surgeons
are key members of the MTC teams, needing to
be readily available. Surgeons in the TU's manage
a range of trauma, but need to be expert in that
initial stabilization phase. Good communication
for repatriation is crucial. Underpinning all
of this, though, is the workforce itself. The
book seems quite concerned here. Definitely.
It's a major theme. Trying to pin down exact
numbers needed is hard because care is spread
across NHS, private sector, treatment centers.
But the trend is undeniable. Demand is soaring.
Aging population, more active population, rising
joint replacements. And trauma isn't going away.
No, hip fractures particularly. The book estimates
a capacity gap may be 15 % shortfall currently.
And the workforce is changing more women, people
working longer. But the absolute key message
is, consultants cannot work effectively or safely
without enough support staff. Junior doctors,
nurses, therapists, admin staff. There's often
a mismatch between the need and the actual posts
available. Right. Let's touch on how the book
advises assessing consultant workload. Section
two, I think. Yes. It starts by stating the obvious,
perhaps, but it's crucial. Workload capacity
depends hugely on facilities and support. Deficiencies
hold consultants back. It also acknowledges consultants
often work well beyond their contracts. The 2003
contract introduced programmed activities, PAs.
That's right in England, Scotland, and Northern
Ireland. Replacing the old notional half days.
A PA is roughly four hours. Standard week is
10 PAs. Wales had a slightly different system.
The idea through job planning was to make the
whole workload transparent and ensure extra work
was recognized. So the job plan is key. It's
an agreement. reviewed annually, detailing all
the duties. Direct clinical care, DCC, supporting
professional activities, SPA, any extra roles
like clinical director, on -call work, emergency
visits, travel times, it's all part of it and
should be factored in. The 2003 -04 contract
specifically allocated PAs for being on -call.
What about how often consultants should be on
-call? Ideally, the book suggests no more frequent
than a one in six rota. though small units might
struggle with that. The intensity, how busy it
actually is, whether there's good junior support
needs to be reflected in the PA allocation. The
aim is to plan activity rather than rely on excessive
unplanned extra hours. Up to 12 PAs total can
be paid. Beyond that might be time off in lieu.
Resident on call isn't standard unless specifically
agreed. And specific tasks. How do they fit in
the workload? Fracture clinics can be unpredictable
with new patients but need proper staffing under
consultant direction. Trained orthopedic practitioners
can see some patients. Ward rounds are a central
clinical time, part of DCC. Need to maximize
theater use. Trend towards more complex cases
on inpatient lists. Need enough time between
cases orthopedics often needs longer turnover.
And crucially, time for supervising trainees
must be built in. It's a balancing act between
theater and clinic time to manage waiting lists.
Ardent is non -negotiable too. Part of governance.
Regular sessions needed. Contributing data to
national registries like the NJR is standard,
but needs admin support. Consultant involvement
and management, clinical directorates is also
important. Orthopedics is expensive, needs clinical
input on spending. And emergency surgery. We
touched on theater access. Yes, resources need
to be there when needed. Dedicated emergency
theater. And training means supervision. Complex
emergencies need direct consultant supervision,
or at least the consultant needs to be informed,
even for minor cases done by trainees. Rotas
should allow the on -call consultant to be free
to supervise. Finally, what about part -time
consultants? Generally, duties are pro rata.
But the book rightly points out that things like
committee work or departmental roles might need
specific allocation, irrespective of their part
-time hours, to ensure their contribution isn't
lost. The standard DCC to SPA ratio under the
2003 contract is roughly 2 .1. So, reading through
this book, it paints an incredibly detailed picture
of just how vast the consultant orthopedic surgeon's
role is now. It's far beyond just operating.
It really is. Clinical expertise, yes, but also
leadership, team coordination, upholding really
strict safety standards, theater protocols, infection
control, record keeping, plus that constant need
for professional development, revalidation, CPD,
that vital SPA time. And doing all that while
navigating the complexities of the NHS structure,
the workforce shortages we talked about, the
different ways services are provided, it's a
huge undertaking. The book really does feel like
that essential guide, trying to help consultants,
as it says, get things right against a backdrop
of huge demand and constant change. It highlights
how much relies on having the right infrastructure,
the right staffing, and that protected time.
Absolutely. And understanding these pressures,
these standards, these requirements outlined
here, it's valuable insight for anyone involved
in health care and the NHS, whatever their role.
If you found this deep dive helpful, we'd really
appreciate it if you could take a moment to rate
and share this show. So here's a final thought.
Given the increasing demand we know is coming,
the aging population, people staying active longer,
and that acknowledged capacity gap in orthopedics,
how can innovation in service delivery genuinely
ensure that quality and safety are protected
for every patient needing musculoskeletal pair
in the future?