The North West London elective orthopaedic centre (NWL EOC), based at Central Middlesex Hospital, first opened to patients in December 2023. It has been developed in partnership between the four acute trusts in North West London which make up the North West London acute provider collaborative (NWL APC) [1].
The NWL APC formally came together as a board in common, with a single chair across the four trusts, in July 2022. From the outset the collaborative aimed to strengthen shared decision-making and support effective use of resources to "provide better care for more people, more fairly". Given the timing of the establishment of the APC and the development of the EOC, it has proved to be an effective testing ground for the aims of the partnership.
The initial concept and plans for the EOC pre-dated the collaborative, but it is notable that progress on the EOC was accelerated after the collaborative became formally established and its governance arrangements were put in place. The governance structures of the NWL APC supported the decision-making process, providing a forum for decisions to be made across the four trusts, and a stronger grounding for implementing shared processes needed to make the hub as effective as possible. It also supported the trusts in securing £9.4m of capital funding through the TIF to develop the operating theatres for the EOC.
The initial strategic case for the development of the centre was driven by increasing waiting lists for orthopaedic procedures, and an inequitable geographical distribution of service provision across North West London. The disruption in elective care during the pandemic caused the waiting list for orthopaedic surgery to increase by 30% by January 2023 (based on 2019 levels). In addition, analysis of future trends, such as the projected population growth in the system, and growing burden of musculoskeletal (MSK) disorders (the third biggest contributor to the total burden of disease in Greater London) supported the case to increase orthopaedic capacity.
The EOC was therefore established to deliver HVLC procedures on behalf of the collaborative. The Central Middlesex Hospital, part of London North West NHS University Healthcare NHS Trust (LNWH) was chosen as the site for the centre, due to the availability of suitable space, away from emergency services, allowing the EOC to operate as a 'cold site', and having the shortest median travel time for the North West London population.
The centre has been designed around a system-wide model of care – ensuring that wherever a patient lives in North West London, their operation can take place at the new centre. Care is overseen by the consultant from their local hospital, who travels to the EOC to perform the operation, while the rest of their care – before and after the operation – takes place at their local hospital, in the community, or online at home. Considerable effort was focused on working alongside local residents to develop the EOC transport solution. This ensures that patients travelling to Central Middlesex Hospital from across North West London can access comprehensive, tailored travel advice, and are specifically supported when a complex, costly or lengthy journey is involved.
The day-to-day operational and financial management of the centre is led by LNWH, which runs the EOC as a standalone business unit. This enables the hub to have a distinct budget as well as transparency across all trusts which share in the costs. It also avoids additional cost pressures being absorbed solely by LNWH, and allows for a 'risk share/gain share' approach, with the partnership agreement underpinned by a service-level agreement between all partners.
In addition to the establishment of the NWL APC, three additional enabling factors supported the success of the EOC's development:
- All four NWL acute trusts moved to a shared electronic patient record (EPR) system in 2022, allowing the trusts to safely and seamlessly share health records. This is a key benefit for the running of the centre, supporting referrals across the whole system and helping to create a more joined-up pathway for patients.
- Clinical leads from across the four trusts collaborated to develop a joint clinical strategy for elective orthopaedic surgery, which set the ambition to have a single centre of excellence. The strategy sets out the clinical model to support elective orthopaedic services and the crucial role of the EOC in delivering this model.
- In keeping with the aim of joined-up, seamless care for patients, the ICB procured a new community MSK service for North West London, in parallel with the development of the EOC. The service which will be delivered through a lead provider model, created the opportunity to develop a full MSK pathway, supporting patients into and out of MSK community services as well as within and between hospital services. The joined-up approach enables patients to be referred to the most appropriate community-based treatment, and specialist advice or care when needed. And post-surgery, the EOC's discharge hub acts as a single point of referral for patients who need social care, community rehabilitation, or bedded rehabilitation. Patients with low complexity needs who are eligible for the EOC remain under the care of their 'home' surgical team at all stages in their hospital journey, accessing their pre and post-operative care locally and travelling with their surgeon to the EOC only for their procedure.
In addition to the benefit that will be gained from a seamless, system-wide approach, and the ambition to be a centre of excellence, the EOC aims to deliver specific benefits such as a reduction in surgical complications and length of stay, and efficiencies by enabling more patients to be treated at a lower cost per operation. The collaborative has also placed a strong focus on ensuring equity of access and is undertaking detailed waiting list monitoring and work to improve communications, engagement and support, as well as providing faster and fairer access to orthopaedic surgery across the system.
With the NWL APC as a catalyst, implementation has been delivered at pace. The EOC opened its doors in December 2023, just seven months after full business case approval. It then moved to full capacity, with five operating theatres, in April 2024.
[1] Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College Healthcare NHS Trust, London North West University Healthcare NHS Trust, and The Hillingdon Hospitals NHS Foundation Trust.