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Review Groups' Conclusions on Anaesthetic Services, Unscheduled Medical Care and Rehabilitation Services at The Vale of Leven Hospital

May 18, 2007 2:27 PM

NHS Greater Glasgow took over responsibility for health services in Clyde in April 2006.  We were committed to fully implementing the Lomond Integrated Care Pilot at the Vale of Leven Hospital. This would have resulted in the withdrawal of on-site anaesthetic cover with GPs receiving additional training to take on responsibility for out-of-hours emergency care.

However anaesthetists and physicians raised concerns about the withdrawal of anaesthetic cover and did not believe it was safe to proceed with the pilot.

We therefore reported these concerns in September last year and announced that we would need to plan for the transfer of emergency care services to other hospitals in Greater Glasgow and Clyde.

While we were taking forward these plans, the then Health Minister and community representatives asked the Health Board to re-examine the work undertaken by Argyll and Clyde in relation to the sustainability of anaesthetic cover at the Vale of Leven together with a wider health needs assessment for the total population of West Dunbartonshire.

Therefore three groups of experts were established to look at anaesthetics, unscheduled medical care and rehabilitation services. These groups were made up of senior clinical and managerial staff.

From the outset, the expert reviews have been subject to close scrutiny by community stakeholders and other interested parties. A Community Engagement Group was established to review the work of these groups and ensure community interests were represented.

The reviewers have also taken account of work undertaken previously by staff of the former NHS Argyll & Clyde and have considered the implications of new working arrangements under NHS Greater Glasgow and Clyde. The current service model for A&E in north Clyde which has seen all A&E services centralised at the RAH since 2004 was also factored into the reviews.

This decision would then be put to the Health Minister in the Scottish Executive for consideration and ministerial approval.

Following consultation, the NHS Board would review the outcome and then determine its final decision.

Consultation would take place over three months and would give all members of the public an opportunity to put forward their views.

The Board does not meet again until 26th June 2007, at which point it will decide whether to proceed to full public consultation on these recommendations.

A report will be made to the Board of NHS Greater Glasgow and Clyde.

The recommendations are subject to community comment at meetings on 18th and 21st May.

What Happens Next?

If they do not want to do this, NHSGGC operates on a 'no redundancy' basis and every effort will be made to find staff posts at the Vale or other sites they would prefer.

If the NHS Board decides to accept the recommendations of the expert group and they come to pass as a result of full public consultation, staff would be offered the opportunity to move with their services to the Royal Alexandra.

What will happen to the staff who provide unscheduled care at the Vale?

The process to date had been monitored by the Scottish Health Council, a component of NHS QIS charged with ensuring that NHS Boards meet their responsibilities to involve patients and the public in decision-making.  At a meeting held on 17th April 2007, the Council expressed that it was 'satisfied' with the engagement work NHSGGC had undertaken to that point.

What have you done to ensure community interests are taken into account throughout this process?

This capacity and the established working arrangements between the sites will allow the additional 5,500 patients per year to be cared for.

Will the RAH have enough beds to cope with the extra patients?
Yes - the RAH has built up a decade's worth of experience and capacity to deal with the 8,000 plus patients from the Vale catchment area it already treats.

The current service model for A&E in north Clyde has already seen all A&E services centralised at the RAH since 2004.

In fact, this approach will be better for many patients as they will not face two journeys if they are taken to the Vale, assessed and found to require more specialised care at the Royal Alexandra.

The Scottish Ambulance Service have indicated that they can safely support the proposals to transport 5,500 such patients from the Vale catchment to Paisley.

The key issue for any emergency patient is that their condition is stabilised so they can then receive treatment. Ambulance paramedic crews are trained to do this.

Will the extra time taken to transport someone from the Vale catchment to the RAH mean patients will die?

At the end of the day the proposals have been based on the best possible assessment of what is safest for patients and this includes consideration of travel times and distances.

The pressures for change described affect hospitals in both urban and rural setting equally and the reality is that similar proposals have come forward right across the UK.

A great deal of time was invested in ensuring the viewpoints of NHS staff and residents from the NHS Highland area were fed into the review process.

Has the expert group taken into account the needs and difficulties of a rural population?

Discussions are underway with the Scottish Ambulance Service and the exact impact of the recommendations are being finalised. The Service has indicated that it would be able to provide appropriate capacity to support the implementation of the proposals to take emergency medical admissions from the vale catchment to the Royal Alexandra in Paisley.

Will there be enough ambulances to cope with the extra demand your changes will cause?


QUESTIONS AND ANSWERS

When NHS Greater Glasgow and Clyde took responsibility for the Vale of Leven Hospital in April 2006, there was an early commitment to review services and to carry out an examination of patient flow and future needs.  NHSGGC stated that its core responsibility was to ensure safe, sustainable, affordable and effective delivery of patient care.

The Lomond Integrated Care Pilot was based on provision of 'upskilled' GPs to provide the bulk of out-of-hours inpatient care on the Vale site, later to be replaced by specifically trained Primary Care physicians.  Phase One implementation of the pilot began in January 2006.

The lack of available staff was a consistent factor, with locums required to maintain anaesthetic care.  The group's innovative proposal was designed to find a way of avoiding the loss of unscheduled inpatient care as a direct consequence to the loss of anaesthetics.

The pilot programme had emerged from a clinical group set up in October 2004 to respond to issues emerging from the acute services strategy consulted upon by NHS Argyll and Clyde.  Following the move of A & E services to Paisley, ongoing staffing problems had led the former Board to conclude that out-of-hours anaesthetic cover at the Vale was not sustainable - this meant that unscheduled inpatient could not be sustained locally. 

Given that the pressures for change remained, NHS Argyll and Clyde managers approved interim arrangements proposed to them by Vale of Leven and local Primary Care clinicians - the 'Lomond Integrated Care Pilot'.

The former Board's response was to propose concentration of all specialist inpatient care on the Royal Alexandra site.  The remaining options for the Vale site were for the hospital to become either an Ambulatory Care Hospital or a so-called 'Intermediate Site'.  These options were taken out to public consultation in 2004 and generated a high level of controversy.  However, the strategy was never formally concluded before the dissolution of NHS Argyll and Clyde was announced in May 2005.

Additionally, the former Board also wrestled with a considerable recurrent overspend on its budget (£30 million per year) and geographical factors - in that the location, size and scale of the Vale of Leven Hospital in particular was proving unattractive to potential clinical recruits.

* Significant specialist workforce shortages
* The impact of the European Working Time Directive and new
* Consultant and Junior Doctor contracts
* Pay modernisation

The former NHS Argyll and Clyde, like all local health systems in the UK, had responded to overwhelming pressure for service reconfiguration arising from a number of familiar sources:

The Vale of Leven Hospital in Alexandria currently provides a Medical Assessment Unit, unscheduled medical admissions, a Minor Injuries Unit, rehabilitation services, a Community Midwifery Unit and a range of day case and short-stay surgical services.  A & E services are provided at the Royal Alexandra Hospital in Paisley.

Background

Notes for Information

Ends

No decisions have been made at this stage and if the recommendations are approved by the NHS Board they would then be subject to formal public consultation.

Next Steps
These recommendations will be presented to the community and staff representatives already engaged in this process at a meeting later today and to a wider group of community interests at a meeting on Monday.
 
At this stage these conclusions have yet to be taken to the NHS Board.  A report is to be drawn up following feedback from community representatives and this will be presented to the Board at its next meeting in June.

Rehabilitation services
In relation to Rehabilitation Services, this review group has concluded that if unscheduled medical care transfers to the Royal Alexandra, approximately the same number of rehabilitation beds could be maintained as are currently on the Vale site.

"As the anaesthetic group has concluded that anaesthetics are not sustainable at the hospital, the group has told us it has no option but to conclude that unscheduled medical admissions cannot be safely provided at the hospital and should be transferred to the Royal Alexandra Hospital."

Liz Jordan, Associate Medical Director for Clyde services, explained: "Anaesthetic cover is an essential component in the treatment of unscheduled medical admissions.  The Integrated Care Pilot at the Vale, which sought to address the long-standing problems with anaesthetic cover at the hospital, cannot be implemented in full due to clinical concerns. 

There is  also insufficient physical A & E capacity at the Western Infirmary to deal with the additional patient numbers and the infirmary could not easily expand physical facilities in order to provide appropriate critical care resources.  The other factor is that any solution based on the Western Infirmary could only be short-term; the Infirmary will be closed as part of modernisation plans in Glasgow and the A&E component of its services will be located in the new South Glasgow Hospital by 2012

However it was concluded this was not possible as the Royal Alexandra has already developed emergency theatre, High Dependency Unit and Intensive Care Unit capacity to cope with demand emanating from the Vale.  This capacity has been developed over the past decade since the most acutely unwell patients from the Vale catchment began to be taken to Paisley

They have recommended that unscheduled medical patients should be admitted to the Royal Alexandra Hospital in Paisley.  This recommendation was reached after the group looked at a number of alternative options including the possibility of transferring patients to the Western Infirmary. 

They have stated that as anaesthetic cover cannot be sustained, it is not possible for unscheduled medical admissions to continue on the Vale site.

Review staff have recommended that it is not clinically safe to provide unscheduled medical care without anaesthetics.

Unscheduled Medical Care
The experts examining the future of Unscheduled Medical Care at the Vale also left no stone unturned in their review. However the conclusion of the anaesthetics group have been critical to the recommendations on Unscheduled Medical Care.


Continued/

"Taking all these factors together, the review staff have concluded that anaesthetics are not sustainable on the site."

"However, no permanent solutions to providing anaesthetic cover have been identified.  In addition to the lack of capacity to deliver a cross-site rota we have also explored the possibility of a stand-alone anaesthetic rota. However the Regional Education Advisor has confirmed that the workload at the hospital is not sufficient to meet the training needs of trainees
or maintaining consultants' skills, meaning a stand-alone rota cannot be developed at the hospital.

John Dickson, Clinical Director for Anaesthetics in Clyde, was one of the clinicians on the group. He explained: "There are various reasons why anaesthetics are not considered to be sustainable by the anaesthetic experts.  The current position of using locum staff to maintain anaesthetic services at the Vale is untenable.

The recommendation of the anaesthetics review staff is that anaesthetics is not sustainable at the Vale of Leven site.

The community wanted the expert reviewers to look at different staffing models including the possibility of introducing a Clyde-wide rota for anaesthetics. This was explored however cross-site cover, with anaesthetists rotating to the Vale to provide cover, cannot be delivered either from within the Clyde anaesthetics staffing or from other sites in Glasgow as there is no additional capacity to provide the cover required.

In the 15 months from February 2006 to April 2007, anaesthetics staff were called to deal with, on average, approximately one patient per week out of hours between 6 pm and 8 am and just over one patient a week in normal hours between 8 am and 6 pm. 

As part of their considerations the review staff looked at a number of other national models of anaesthetic provision, including those at Kendal, Elgin and Hexham Hospitals.  However none offered a viable model for the Vale.  Kendal Hospital, which at one point functioned without anaesthetic support out of hours, has since reviewed this position due to clinical safety concerns.

Anaesthetics
The anaesthetics experts were tasked with exploring all possible options for the future provision of anaesthetic on the hospital site.


Clinicians from the three expert groups set up to review the sustainability of anaesthetic services, unscheduled medical care and rehabilitation services at the Vale of Leven Hospital, have now concluded their works and will today give their recommendations to local staff and community groups.

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