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What is ‘unscheduled’ medical care?

This is assessment, observation and treatment of patients who have taken ill and need swift attention but do not need emergency or intensive care. Although not the most seriously ill, the patients’ conditions are serious enough that they are unable to wait for a scheduled GP or hospital appointment.

What is ‘planned’ care?

‘Planned’ care is by far the most commonly used type of service at the Vale of Leven or any other hospital – this means that the treatment is organised in advance following referral from a GP or as a follow-up to previous hospital care.

Why is anaesthetics cover at the Vale of Leven unsustainable?

For the past two and a half years we have been considering the issues related to the provision of unscheduled medical care at the Vale of Leven. This area has also been subject to review by two different groups of independent experts. Currently, unscheduled medical care is provided to 6,300 patients each year at the Vale of Leven and is supported by access to anaesthetic cover. Including the two independent reviews, there have been four reviews of anaesthetic services at the Vale of Leven, all of these have concluded that anaesthetic services are not sustainable 24 hours every day. This means that we need to change the way in which unscheduled medical care is provided at the Hospital.

The reviewers have confirmed that it is not possible to continue with current ‘out of hours’ (evening, overnight and weekend) anaesthetics cover. Arrangements put in place by the former NHS Argyll in Clyde depend on locum (temporary contract) consultants – efforts to recruit full-time consultants have been unsuccessful, mainly because the numbers of patients requiring anaesthetic care are low and the posts would not be able to meet their training and accreditation requirements. It is also not possible to rotate anaesthetists from other hospitals to provide cove, as this could not be justified by the low patient numbers at the Vale, and as this would also adversely impact services at those sites.

How were these proposals developed?

NHS Greater Glasgow and Clyde took responsibility for the Vale of Leven Hospital in April 2006. At that point we committed ourselves to a full review of all services provided at the hospital.

Reviews and engagement with staff, patient and community representatives were carried out over 2007, leading to public consultation on Mental Health Services and Maternity Services across the whole of Clyde in 2008.

The Cabinet Secretary for Health and wellbeing sought an independent viewpoint about the potential future of services at the Vale of Leven Hospital. She initiated an Independent Scrutiny Panel, chaired by Professor Angus MacKay, with a remit to review NHS Greater Glasgow and Clyde’s findings on the main service strands and to confirm proposed options for the future or suggest alternatives. The panel reported its findings in December 2007 having reviewed proposals for unscheduled medical care, Rehabilitation Services, Mental Health Services and Maternity Services at the Vale in 2007.

A further review of services at the Vale of Leven Hospital was commissioned by the Cabinet Secretary. This concentrated directly on the issue of the sustainability of anaesthetic cover at the hospital and was chaired by Professor Chris Dodds. The review was commissioned on 12th June 2008 and findings reported on 15th August.

The Board of NHS Greater Glasgow and Clyde considered the cumulative outcomes of the Mental Health and Maternity Consultations in addition to the findings of the Independent Scrutiny Panel and Independent External Clinical Review at its August 2008 meeting.

The Board agreed to develop a long-term, sustainable plan for the future of the Vale of Leven Hospital and instructed officers to begin engagement with stakeholders in order to work up proposals to be brought together into a single, comprehensive vision for the future of the Vale of Leven site.

Over the past two months NHS staff have met with a wide range of patient, voluntary and community interests in West Dunbartonshire, Argyll and the Lochside. The proposals now out to consultation have been influenced by the feedback received.

Who will manage critical risk patients under the proposed arrangements?

Since 2004, all patients from the area requiring Accident and Emergency Care have been taken to the Royal Alexandra Hospital in Paisley. Well-established protocols are in place to ensure that ambulance crews and GPs are able to assess each patient and ensure that those who are most ill are stabilised and moved to the care of the most appropriate professionals.

This means that no-one who needs emergency care, or has a high chance of needing emergency care, should be admitted to the Vale of Leven Hospital in the first place.

Under the proposed new service arrangements at the Vale, the basic principles of this arrangement are not going to change.

Currently, those ‘unscheduled’ patients not found to need attention at an A & E unit or intensive care, but still needing swift assessment and possible admission, are taken to the Medical Assessment Unit at the Vale of Leven Hospital. Currently the unit receives cover from anaesthetists because of a proportion of existing patients who may present a higher risk of becoming more unwell..

As the 2008 independent review found, it is not possible to maintain the arrangements left in place at the Vale by NHS Argyll and Clyde to ensure anaesthetists are available ‘out of hours’ overnight and at weekends.

The proposed new model for unscheduled care at the Vale will not have on-site anaesthetic cover for this service, so there will need to be changes to the categories of patients who will be accepted, to ensure the chances of anyone being inappropriately brought to the Vale or suffering complications whilst there are reduced even further.

By doing this we can confidently say that the numbers of patients becoming critically ill whilst at the Vale will be very low indeed. But where a patient does deteriorate in future, as now, our staff are prepared to take action. There are long-established arrangements in place to stabilise patients and use ambulances to take them to the A & E or to the most appropriate specialist service at another site.

What model of care can be offered at the Vale’s Medical Assessment Unit without anaesthetic cover?

Initial assessment of patients will be carried out by ambulance crews or GPs and by staff at the Vale using a clinical scoring system and protocols. Those patients who are most seriously injured or ill, or at high risk of their condition worsening, and perhaps needing anaesthetics care, will be taken to the Royal Alexandra Hospital and not the Vale of Leven.

Those patients who are taken to the Vale will placed under the care of a consultant supported GP-led acute unit. This means that General Practitioner doctors, who are skilled and trained to deliver appropriate acute care to the types of patients who will be cared for in the Vale, will have responsibility for unscheduled medical patient care at the Vale of Leven Hospital.

There will be Doctors on-site 24 hours each day, 7 days each week in the Hospital and during busy times there will be more Doctors available. There will be 24 hour hospital consultant support to provide telephone or telemedicine advice to the GPs when it is required. There will also be scheduled daily on-site hospital consultant support to provide the GPs with advice on patients when this is required. This arrangement will ensure that patients admitted to the Vale of Leven Hospital under the care of GPs have access to consultant advice and expert opinion if needed.

What education and training will be given to staff providing the new model of unscheduled medical care?

GPs and the nursing team supporting them, will undergo an intensive training course which ensure they have the sills to deal with the types of patients who will be using unscheduled medical care services.

How will staff decide which patients are taken to the Royal Alexandra Hospital or to the Vale?

There are currently protocols and clinical assessment scoring systems in place which ensure that the most acutely unwell medical patients bypass the Vale of Leven Hospital. By refining these protocols, lowering their threshold and bypassing all patients with some types of medical complaints we can safely bring forward a model of care which will allow between 70% and 80% of the 6,300 patient episodes to continue to be provided at the Vale.

The introduction of a scoring system which identifies those patients that should not attend the Vale is important as it allows us to assess patients’ physiological condition to determine those that may potentially require higher dependency or more specialist care.

This scoring system will be used by GPs, the Scottish Ambulance Service and in the Medical Assessment Unit at the Vale to identify those patients who should go to the RAH regardless of their medical condition or symptom. The physiological criteria that will be included in the scoring system include heart rate, blood pressure and level of consciousness amongst other things. This will be a more refined version of the scoring system that is currently widely used in the Vale of Leven area. This scoring system will identify those patients most at risk of requiring higher dependency care.

In addition to the further development of the scoring system it has also been agreed that patients with the following conditions will not be treated at the Vale of Leven Hospital:

- Patients who have suffered from a stroke or a suspected stroke

- Patients who have taken a drug overdose

- Haematemesis patients requiring hospital care (patients with gastro-intestinal bleeding)

- Patients requiring inpatient haematology (blood-related conditions) care

- Patients with neutropenic sepsis (fever and infection due to low white blood cell counts, which can occur with patient undergoing chemotherapy)

- Patients requiring hospital care due to epileptic seizures

From 1st November 2008, patients from across the West of Scotland who experience a certain type of heart attack (STEMI – blocked arteries) will be taken directly to the Golden Jubilee National Hospital by the ambulance service. We estimate that this will be the case for approximately 50 patients from the area served by the Vale of Leven.

How many more people will be taken to the Royal Alexandra Hospital in Paisley as a result of the new model of unscheduled care?

The changes that we propose for unscheduled medical care would mean that between 1,000 and 1,900 additional patients would have to travel to the Royal Alexandra Hospital each year. Significant numbers of these will travel by ambulance.

Is it proposed to increase the number of ambulances and crews available to cope with the increased numbers of patients who would be taken direct to the Royal Alexandra Hospital (RAH) in Paisley rather than the Vale of Leven Hospital?

The Scottish Ambulance Service has made it clear that the RAH is accessible for emergency ambulances and do not anticipate any significant problems in being able to move patients there rapidly. All patients requiring access to A & E services from the Vale catchment are already taken to the RAH – about 5,000 each year - and the Scottish Ambulance has been experienced in achieving this since 2004.

The Scottish Ambulance Service has not identified any adverse clinical outcomes as a result of transferring these patients. Similarly, an audit that was undertaken after A & E services transferred to the RAH revealed that there was no detrimental clinical impact on patients from the Vale of Leven area as a result of this change.

Our proposals are designed to ensure that as many people as possible should continue to use the Vale of Leven as their local hospital. Based on a very detailed, thorough review of the numbers and types of patients requiring ‘unscheduled’ care at the Vale, we estimate that between 70 and 80% of them would still use Vale services, with the remainder - between 1,000 and 1,900 patients - being taken to Paisley or other sites. Significant numbers of these will travel by ambulance.

The NHS Board are committed to working with the Scottish Ambulance Service to provide the extra funding needed to ensure an increased level of paramedic services including vehicles to enable the rapid transfer of patients around the clock.

A small number of patients taken to the Vale may, following further assessment and observation by the GP-supported unit, be indentified as needing transfer to the RAH. Existing arrangements to allow transfer to other sites are well-established and quite routine in virtually all hospitals. The Scottish Ambulance Service is also clear that these small numbers of transfers can also be organised without difficulty.

Will ambulances only be assigned to cover the Vale of Leven catchment?

One of the issues that will be agreed between NHSGGC and the Ambulance Service before any changes are made is the location where ambulances will be based. In practice, vehicles cannot be assigned to remain in one particular area only – ambulance crews have to take their patients to the most appropriate sites for the treatment they need and this can mean, on occasion, travel to sites outwith the area when specialist care is required. However, the ambulance service operates a ‘dynamic’ service , which means when ambulances from one area are taking patients to Paisley or elsewhere, vehicles from other areas will be able to provide cover if required

What will happen to patients who make their own way to the Vale of Leven Hospital?

In short, the same as at any other hospital. Under the proposals the patient will be assessed by the onsite team – in this case the GP-supported unit responsible for ‘unplanned’ care at the vale of Leven Hospital. If it is clinically safe and appropriate for the patient to receive care at the Vale of Leven, that is what will happen. If the patient needs emergency or specialised care, the team at the Vale will stabilise him or her, make the person comfortable and arrange rapid transfer to the appropriate site by ambulance. This is a standard arrangement at all hospitals and nothing we are proposing will change this.

How much money will be allocated to the Vale of Leven Hospital to make these changes?

We have indicated where we can our estimates of the investment that will be required to take forward elements of the proposals. We have already committed over £1 million to improving the fabric of buildings at the Vale of Leven Hospital. When public consultation is complete, the NHS Board will submit the resulting recommendations to the Cabinet Secretary. If the Cabinet Secretary agrees to the proposals, we will be then able to develop a full business plan and so provide an accurate cost for delivering the ‘Vale Vision’.

What happens if there is an accident or traffic jams, or closure of the Erskine Bridge, preventing access to Paisley?

Accident and Emergency patients have been taken from Helensburgh, the Lochside and West Dunbartonshire to the RAH in Paisley safely since 2004. Blockages on the A814 and A82 would also potentially restrict access to the Vale of Leven Hospital and the Ambulance Service is practised in finding and using alternative routes in these situations.

The Erskine Bridge has been closed to all vehicles twice since October 2007, although it was closed to high-side vehicles more often. Emergency ambulances are not classed as high sided vehicles and so are not affected by these latter restrictions.

Since January 2008, Transport Scotland, and their operating company Amey, have introduced a new system which comprises signs on all approach roads to the Erskine Bridge to warn drivers of wind speeds and restrictions.  This means drivers of vehicles, including ambulances, have earlier warning of the need to use alternative routes and, by following the guidance, this helps alleviate congestion that previous bridge closures caused on the local road network.