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NHS Scotland
Creating a world
class NHS
Evidence Search and Synthesis
Ann Lees & Knowledge Broker Network
01/08/2015 Version Draft 0.4
Contents
The Evidence Search and Synthesis Team: ......................................................................... 3
Version Updates ................................................................................................................ 3
Disclaimer ........................................................................................................................ 4
The Question .................................................................................................................... 5
Key Sources ...................................................................................................................... 6
Summary .......................................................................................................................... 7
Burns care..................................................................................................................... 8
Cancer (larger volume) ................................................................................................ 13
Cancer (smaller volume and related oncology) .............................................................. 16
Cardiac/cardiovascular surgery ..................................................................................... 20
Dermatology ............................................................................................................... 22
Emergency and unscheduled care ................................................................................. 25
ENT ............................................................................................................................ 40
Gynaecology................................................................................................................ 47
Hospital Reduction ....................................................................................................... 49
Intensive care ............................................................................................................. 54
Major trauma .............................................................................................................. 58
Maternity .................................................................................................................... 60
Medical Specialties ....................................................................................................... 63
Neonatal ..................................................................................................................... 66
Neurosurgery .............................................................................................................. 72
Ophthalmology ............................................................................................................ 75
Oral & Maxillofacial Surgery .......................................................................................... 87
Orthopaedics ............................................................................................................... 94
Out of Hours Services .................................................................................................. 97
Paediatric (specialist & regional/local) ......................................................................... 102
Primary Care Services ................................................................................................ 105
Radiology .................................................................................................................. 112
Stroke ....................................................................................................................... 115
Surgical specialties..................................................................................................... 126
Urology ..................................................................................................................... 129
Vascular .................................................................................................................... 132
Appendices ................................................................................................................... 136
Appendix 1: Search protocol for Second Search, instructions for ESS team .................... 136
Appendix 2: Burns staffing ......................................................................................... 138
Appendix 3: Cancer searches further sources .............................................................. 142
Appendix 4: Planning Tools ........................................................................................ 144
2|Page
The Evidence Search and Synthesis Team:
NHS Ayrshire and Arran:
Julie Wands, Library Manager
NHS Fife:
Marie Muszynski, Library Services Co-ordinator
Dorothy Woolley, Librarian
NHS Grampian:
Paul Manson, Clinical Librarian
NHS Greater Glasgow and Clyde:
Michelle Kirkwood, Knowledge Services Manager
Catriona Denoon, Library Services Manager
Ann Lees: Health Economist
Kirsty Coltart, Beatson Librarian
Liz Garrity, Assistant Librarian
Seona Hamilton, Subject Specialist Librarian
Shona MacNeilage, Library Manager
Tracey McKee, Subject Specialist Librarian
John Scott, PHRU Librarian
Chloe Stewart, Subject Specialist Librarian
Health Management Library &
Information Services – NHS
National Services Scotland:
NHS Highland:
Gill Earl, Library Services Manager
Alison Bogle, Librarian
Rob Polson, Subject Librarian
With thanks to: Mark Newman at the EPPI Centre http://eppi.ioe.ac.uk/cms/ for
advice re: framing the question.
Version Updates
Changes and additions made for Draft Version 0.4 are:
NHS Fife Knowledge Services joined the Knowledge Broker Network for
this work.
All specialties re-organised to alphabetical
ENT search added
Cardiac /Cardiology Surgery search added
Medical Specialties search added
Major Trauma updated to second search protocol
Orthopaedics updated to second search protocol
Maternity updated to second search protocol
Neonatol updated to second search protocol
Out of Hours updated to second search protocol
New table added to appendix 4 detailing decision aid tools mapped to
the drivers for change as provided by Imison et al (see key papers)
Key sources expanded
Summary table amended, current level of service delivery has been
deleted, and recommended future service delivery has been updated
Burns search appendices moved to the Appendix of the document (now
Appendix 2
Pg 3
All
Pg
Pg
Pg
Pg
Pg
Pg
Pg
Pg
Pg
40
20
63
58
94
60
66
97
144
Pg 6
Pg 7
Pg 138
3|Page
Cancer searches extra reading moved to the Appendix of the document
(now Appendix 3)
Consistency of referencing system applied across all references
Hyperlinks to abstracts and full text embedded into the titles of the
references, and links checked
Consistency of layout applied to all searches
Pg 142
All
All
All
Disclaimer
The search protocol has been provided in the Appendices of this report. Note that
although the search protocol was expanded from the first search set to the second
search set it still cannot be considered a thorough search of the evidence base, nor
was the quality of any evidence listed assessed.
4|Page
The Question
The current x service (e.g. neurosurgery) is currently provided on a
national/regional/local (delete as required) basis in NHS Scotland.
Key question
For the x service, is there evidence that a. national, b. regional or c. local level
delivery produces the best outcomes?
Include reference to:
1. Optimal population levels for providing the service; e.g. Recommendations
for service or staff inputs per x population.
2. Clinical outcomes ; e.g. quality or health improvement indicators/ measures /
standards for the service
3. Other service attributes:
•
•
•
sustainable clinical workforce planning (including training and education
for clinical specialists)
patient satisfaction
cost, including NHS, social care, wider costs such as transport and costs
to patient/ carer
5|Page
Key Sources
Over the course of searching, four sources surfaced with applicability across a wide
range of topics, and addressing a number of questions. These were:
1. Imison, C., Sonola, L, Honeyman, M., Ross, S. The reconfiguration of clinical
services, what is the evidence. The King’s Fund, November 2014. (Accessed
30/06/2015)
2. Imison, C., Sonola, L., Honeyman, SR., Edwards, N. Insights from the clinical
assurance of service reconfiguration in the NHS: the drivers of reconfiguration
and the evidence that underpins it – a mixed method study. Health Services and
Delivery Research 3: 9 March 2015. Accessed 01/08/2015
3. NHS England, Monitor (Accessed 30/06/2015)
See also: Five Year Forward View – The Success Regime: a whole system
intervention (June 2015) and
Exploring international acute care models (December 2014) (Accessed
30/06/2015)
4. Consultant physician working with patients (2013), Royal College of Physicians –
revised 5th edition. (Accessed 30/06/2015)
6|Page
Summary
Current level of
service delivery
Level of service delivery
suggested by literature
evidence
1. Burns care
Regional
2. Cancer (larger volume)
Regional
3. Cancer (smaller volume and
Specialised centres
related oncology)
(national?)
4. Cardiac/Cardiovascular Surgery
Specialised
Centres/Regional?
5. Dermatology
Local / regional?
6. Emergency and unscheduled
Local/ Referral to specialist
care
centre (eg stroke/cardiac)
7. ENT
Local/Referral to specialist
regional care
8. Gynaecology
Local
9. Hospital reductions
Local / centralisation of
some services &
development of networks
10. Intensive care
Regional / local
11. Major trauma
Complex trauma
centralised into a small
number of trauma centres
12. Maternity
Local
13. Medical Specialties
See summary at search
14. Neonatal
Local/ Referral to specialist
regional care
15. Neurosurgery
Regional or national
16. Ophthalmology
National /regional
17. Oral & maxillofacial surgery
Regional?
18. Orthopaedics
Regional?
19. Out of hours services
Local
20. Paediatrics
Specialist and regional
linked to local
21. Primary care services
Local
22. Radiology
Networks for reporting
(national?)
23. Stroke
Local with concentration of
specialist care
24. Surgical specialities
Regional / local
25. Urology
National / regional / local
26. Vascular
Regional / national
? Where there is a question of what the evidence is saying a question mark is in
place, either further evidence is required or the answer may lay in the analysis of
volume/ distance or another factor.
Data on the current level is pending, and will be added once available.
Specialty
7|Page
Burns care
For burns services, is there evidence that a. national, b. regional or c. local
level delivery produces the best outcomes?
Key points:
The evidence suggests it is best to provide burn care in specialised centres in order
to concentrate clinical expertise and experience and to optimise patient outcomes.
Locating specialised burn services as close to ‘at risk’ populations as possible is
recommended.
Population Required
Butler, 2013(1)
Burn victims represent an extremely challenging patient group with
multiple medical, psychological and social demands that must be met
from the first admission through to late reconstructive surgery and
social re-integration.
With burns contributing a significant proportion of the trauma
workload, the provision of burn care within the UK trauma network
must be carefully considered. Future plans for burn care provision
should consider moving burn care centres to current major trauma
centres.
Holmes,
2011(2)
Collaboration across multiple fronts is required including disaster and
emergency planning research, and burn outreach/education. The
trauma community has unequivocally demonstrated that this is
possible and improves outcomes.2
Stylianou,
2015(8)
The age groups that are more susceptible to burn injury are children
and the elderly. Although referral and admission to burns services is
roughly the same for adults and children, adults have higher mortality
rates indicating that that the severity of the injury is higher in the
adult age group
In terms of workload the burn injury service in England and Wales has
increased from on average 5,500 cases in 2003 to more than 13 000
cases in 2011.
Burns Network,
2011(5)
One of the key messages in the literature is the link between burn
injury prevalence, population density, high levels of social deprivation
and ethnic minority groups.
According to the World Health Organisation, burn injuries occur
disproportionately among racial and ethnic minorities as low
socioeconomic status increases the susceptibility of these groups to
burns
Access to appropriate care as quickly as possible is important when
treating severe burn injuries.
The main issues and gaps in current service provision:
8|Page
Adult services
• Co-location with adult ICU and HDU
• Co-location with the support services of an acute hospital
Paediatric services
• Co-location
• Co-location
• Co-location
• Co-location
with
with
with
with
a burn ward
paediatric intensive care (PICU)
other paediatric services
major trauma centres
To be sustainable for the future, specialised burn services need to be
prepared to manage the increasing admissions of people with more
complex health needs. For example, specialised burn services should
have appropriate care pathways to support and coordinate follow up
care for patients post discharge.
Butler, 2013(1)
; Burns
Network,
2011(5)
The evidence suggests it is best to provide low volume services, such
as burns, in a small number of specialised centres in order to
concentrate clinical expertise and experience and to optimise patient
outcomes. Locating specialised burn services as close to ‘at risk’
populations as possible is recommended. This maximises accessibility
and minimises patient travel, however it must be acknowledged that
some patients will have to travel to receive care for very severe
injuries.
Hop, 2014(3) ;
Stylianou,
2015(8)
Minor burn injuries should be treated within the community, but more
severe burns require hospitalisation in specialised departments with
care provided by a multidisciplinary team. Multidisciplinary care has
been proven to offer the best possible outcome for the patient and has
achieved a significant reduction in mortality for patients with major
burns during the last 50 years.
NHS England,
2013(7)
Appendix 2 illustrates the number of burn centres per population in the
USA, Austria, Germany, Switzerland and the European Union.
In England and Wales burn care is organised using a tiered model of
care. This involves triaging patients according to their clinical
requirements. Non-complex injuries are referred to burn facilities,
more complex burns referred to burn units and the most complex
injuries referred to a small number of designated burn centres.
Burn Centres need to be able to demonstrate ability to respond
effectively to major incidents involving a significant number of burns’
casualties.
NNBC, 2013(6)
The National Burn Care Standards 2013 sets out the recommended
levels of staffing and support services required for: Adult and Paediatric Burn Centres
 Adult and Paediatric Burn Units
 Adult and Paediatric Burn Facilities
See Appendix 2 for required staffing levels and support services.
9|Page
The National Burn Care Standards 2013 lay out clearly that:Burn Care Centres must admit a minimum of 100 acute burns
patients annually averaged over a three year period, at least 30
must require unit level care and at least 10 patients must be
regarded as requiring centre level care.
The same for paediatric Burn Care Centres.
Burn Care Units should admit a minimum of 100 adult acute
burns patients annually averaged over a three year period. At
least 30 must require unit level care.
Burn Care Facilities should manage at least 100 acute burns
patients annually, averaged over a three year period either as inpatients or out-patients. The activity data can be associated with
adults or children or both.
Clinical Outcomes
Holmes,
2011(2)
However, only a limited number of publications have attempted to
analyse modern burn care and outcomes as a function of the
treatment facility, one study found that higher volume centres had
better outcomes than lower volume centres. Data suggests that
verified Burn Centres, despite treating more severely burned patients,
appear to achieve better functional outcomes after burns.
When considering modern burn outcomes, mortality alone is no longer
sufficient. Acute and long-term functioning must be considered in
current outcomes benchmarking and quality of care analyses.2
Holmes,
2011(2) ; Burns
Network, 2011
(5)
There is an absence of clinical outcome measures for specialised burn
care nationally. The lack of clinical outcome data makes assessment
of the quality of care provided by current services difficult, but this is a
common problem for all specialised burn services .
Hranjec,
2012(4)
Data shows that mortality is dependent on the treating facility in
addition to the already known risk factors—%Total Body Surface
Area(TBSA) burned group, the presence of inhalation injury, age
together with % of Full Thickness Burn (FTB) which also is a a
significant predictor of burn outcomes.
Stylianou, 2015
(8)
Mortality during the past four decades has decreased mainly because
of improved medical knowledge on the pathophysiology of burn
injuries, which in turn results in better therapy that increases survival
rates. Since no major advancement has been made in burn treatment
during the past decade, the observed mortality decrease in England
and Wales could be attributed to the reorganisation of burn services
with implementation of the recommendations of the National Burn
Care Review: Strategy for Burn Injury in 2001 and the centralising of
the management of complex burn injuries into a smaller number of
specialised burn centres.
Other Service Attributes
Vogt, 2011(9)
As the organisation of effective burn teams can vary considerably, no
single existing burn care facility can serve as the ideal model to be one
10 | P a g e
hundred percent copied into another community.
Routine training and updating of medical staff on new resources and
treatments will allow for the continued success of burn patients. Burn
treatment, specifically paediatric burn treatment, requires an
interdisciplinary approach for optimal outcome.
Butler, 2013(1)
Evolving clinical practice and technology has resulted in some services
that previously could only be provided in an acute hospital now being
provided in a local setting. The potential to provide a communitybased service will depend on the care element being considered. For
example, reconstructive surgery for a scar contracture must still be
provided at the burn centre by a specialised burn surgeon. However
patient rehabilitation should have the capacity to be delivered near to
the patient’s home.
Telemedicine in burn care has been widely studied for its role in the
acute management of burn patients and the outpatient management
of those not requiring transfer to a burn centre. There is evidence
supporting the conclusion that photographic and video telemedicine
was both effective and feasible in providing acute and outpatient burn
care.1 However, the UK analysis of the cost effectiveness of
telemedicine in acute burn care showed that the financial savings to
the burn centre investing in the technology were minimal, due to the
large start-up costs and relatively low costs of patient transfer in
comparison to other countries, such as Australia and the USA.
Hop, 2014(3)
Burn care is traditionally considered expensive care. Hop etal (2014, p
436) state that the mean annual cost of burn patient treatment in
Spain was $99,773 compared with $13,826 for the mean annual cost
of treatment for stroke survivors during their first year post stroke and
$13,823 for annual care for HIV/AIDS patients. Burn care costs are
high because patients often need specialised burn centre treatment
during a substantial length of stay, including time- and materialintensive surgical and nonsurgical wound care, intensive care, and
long periods of rehabilitation. It was found the the most expensive
burn care component was hospital stay.
Several options for reducing the cost of burn care include the use of
ambulances instead of helicopters, the use of less expensive dressing
materials, and early excision and grafting. However there is a lack of
systematic costs studies and economic evaluations of the extent or
distribution of burn care costs or of the global variation in costs.3
Hop (2013) recommends that future research on cost-effective burn
care focuses on reducing hospital stay length without compromising
the quality of care.
References
1. Butler, DP, 2013. The 21st century burn care team. Burns 39(3):375-379.
(Accessed 01/07/2015)
2. Holmes JH, Carter JE, Neff LP, et al, 2011. The effectiveness of regionalized
burn care: an analysis of 6,873 burn admissions in North Carolina from
11 | P a g e
2000 to 2007. Journal of the American College of Surgeons 212(4):487-
493. (Accessed 01/07/2015)
3. Hop MJ Polinder S, Van Der Vlies CH, et al, 2014. Costs of burn care: a
systematic review. Wound Repair & Regeneration 22(4):436-450.
(Accessed 01/07/2015)
4. Hranjec T, Turrentine FE, Stukenborg G et al, 2012. Burn-center quality
improvement: are burn outcomes dependent on admitting facilities and is
there a volume-outcome "sweet- spot"?. American Surgeon, 78(5):559-566.
5.
6.
7.
8.
(Accessed 01/07/2015)
London and South East of England Burn Network, 2011. Specialised burns
care: case for change. (Accessed 30/06/2015)
National Network for Burn Care, 2013. National burn care standards.
National Network for Burn Care (NNBC) (Accessed 30/06/2015)
NHS England, 2013. NHS standard contract for specialised burns care (all
ages).Schedule 2 – The services. A. Service specifications. D06/S/a. NHS
England. (Accessed 30/06/2015)
Stylianou N, Buchan I, Dunn KW, 2015. A review of the international Burn
Injury Database (iBID) for England and Wales: descriptive analysis of burn
injuries 2003–2011. BMJ Open 2015;5:1-10. (Accessed 1/07/2015)
9. Vogt PM, Busche MN, 2011. Evaluation of infrastructure, equipment and
training of 28 burn units/burn centers in Germany, Austria and Switzerland.
Burns, 37(2), p257-264. (Accessed 01/07/2015)
For further information see Appendix 2
12 | P a g e
Cancer (larger volume)
For larger volume cancer services, is there evidence that a. national, b.
regional or c. local level delivery produces the best outcomes?
Key points:
Evidence suggests that centres treating a large number of patients with a particular
type of cancer produce better patient outcomes than those that see fewer patients.
Population Required
Valdagni, 2011(9)
"Prostate Cancer Units will most often be established in large or
medium-sized hospitals; they should cover a population of at
least 300,000 people. Some highly specialised units will be larger
and considerably engaged in clinical research activity. A Unit
must be of sufficient size to have more than 100 newly
diagnosed cases of prostate cancer coming under its care (for
treatment and observation) each year". (page 3)
RCP, 2013(3)
"The workload of a medical oncologist, measured by the
number of new patients seen annually, should be
approximately 200 (100–150 for academic medical
oncologists)". (page 159)
DOH, 2011(11)
"As some cancers are more common than others, NICE has
defined appropriate population and activity thresholds for
different cancer services in a series of evidence-based cancer
Improving Outcomes Guidance documents (IOGs). In order to
ensure quality care for patients, these IOGs will continue to be a
feature of all commissioned services". (page 72)
RCP, 2013(3)
"The constitution is specific for each tumour type as set out by
improving outcomes guidance (IOG). Until the reorganisation of
the health service in April 2013, cancer units were each part of
one of 34 cancer networks, with each network serving a
population of 1–3 million. Since this date the network functions
are being absorbed into the new strategic clinical networks that
will serve larger populations and cover multiple specialist areas.
Within each network there are tumour site-specific boards to
ensure a coordinated approach for both the organisation of
services and the equity of access for patients. There is an
established national programme of peer review to ensure that
services are appropriate, effective and in line with national
guidance. There is increasing focus on new models of care, eg
centralising wherever necessary to improve outcomes for
complex treatment delivery". (page 154)
DOH, 2011(11)
"A significant amount of cancer care is best commissioned for
populations covering 1½ – 2 million. This includes specialist
surgical services for upper gastrointestinal, urological,
gynaecological, head and neck cancers and chemotherapy and
radiotherapy". (page 71)
Clinical Outcomes
13 | P a g e
HIS, 2013(1)
There are a range of Quality Performance Indicator documents
published from 2013-15. The following tumour sites have their
own QPI; Bladder, Breast, Colorectal, Lung, Melanoma, Prostate.
Kesson, 2012(10)
"the introduction of teams providing multidisciplinary care for the
treatment of breast cancer was associated with 18% lower breast
cancer mortality at five years and 11% lower all cause mortality
at five years, compared with similar patients treated in
neighbouring areas over the same time period." (page 4)
RCP, 2013(3)
"Cancer is increasingly a long-term condition and many
cancer survivors receive complex and toxic ongoing
disease-modifying treatments. It is imperative that reductions in
new:follow-up ratios are not used as a quality indicator in this
setting". (page 156)
BPS, 2015(5)
For psycho-oncology services the British Psychological Society
proposes 6 domains of service quality and outcomes; safe,
equitable, patient centred, responsive, effective, efficient.
Other Service Attributes
Workforce
Planning
RCP, 2013(3)
"The training and supervision of specialty medical oncology
registrars (StRs) is becoming more detailed and time-consuming.
There are currently 248 trainees within 25 training programmes
across the UK. The minimum time for higher specialist training in
oncology is 4 years, but, as it is a research-based specialty, many
undertake extra out-of-programme research". (page 156)
RCR, 2014(8)
Over the next five years "estimated increase in courses of
systemic therapy of 8% and radiotherapy courses of 1% per
annum, leading to a 9% per annum increase in the workload of
clinical oncologists". (page 8)
RCP, 2013 (3)
"The predicted medical oncology workforce requirement in the
UK is a minimum of 550 posts, representing 2.75 whole-time
equivalent (WTE) posts per 200,000–250,000 population". (page
159)
Patient
Satisfaction
Macmillan,
2013(6)
Uses case studies to illustrate its proposed 10 domains to
improve the cancer patient's experience; patient centred care,
timely referral into secondary care, communication, emotional
support, information and support, shared decision making and
care planning, continuity of care, financial and work support,
physical environment, user involvement in service design and
delivery.
HIS, 2013(2)
The 2013 Cancer Patient Experience QPI has indicators for
communication, information and shared decision making.
14 | P a g e
References:
1. Healthcare Improvement Scotland, Scottish Cancer Taskforce, 2013. Cancer
Quality Performance Indicator: Cancer patient experience. Healthcare
Improvement Scotland. (Accessed 30/06/2015)
2. Healthcare Improvement Scotland/Scottish Cancer Taskforce, 2013. Cancer
Quality Performance Indicators page. (Accessed 30/06/2015)
3. Royal College of Physicians, 2013. Consultant Physicians working with
patients: medical oncology chapter (revised 5th edition, 2013). (Accessed
01/07/2015)
4. London Cancer North & East, 2013. London Cancer Specialist Services
Reconfiguration: a case for change in specialist cancer services. London
Cancer North & East. (Accessed 01/07/2015)
5. British Psychological Society, 2015. Demonstrating quality and outcomes in
psycho-oncology. British Psychological Society. (Accessed 01/07/2015)
6. Macmillan Cancer Support, 2013. Improving cancer patient experience: top
tips guide. Macmillan Cancer Support. (Accessed 01/07/2015)
7. Royal College of Radiologists, 2014. Clinical oncology: the future shape of the
specialty. Royal College of Radiologists. (Accessed 01/07/2015)
8. Royal College of Radiologists, 2014. Clinical oncology workforce: the case for
expansion. Royal College of Radiologists. (Accessed 01/07/2015)
9. Valdagni R, Albers P, Bangma C et al, 2011. The requirements of a specialist
Prostate Cancer Unit: a discussion paper from the European School of
Oncology. European Journal of Cancer 47(1):1-7. (Accessed 01/07/2015)
10. Kesson EM, Allardice GM, George WD et al, 2012. Effects of multidisciplinary
team working on breast cancer survival: retrospective, comparative,
interventional cohort study of 13 722 women. BMJ 344:e2718. (Accessed
01/07/2015)
11. Department of Health (2011) Improving outcomes: a strategy for
cancer. Department of Health. (Accessed 01/07/2015)
Further reading available in Appendix 3
15 | P a g e
Cancer (smaller volume and related oncology)
For smaller volume cancer services and related oncology, is there evidence
that a. national, b. regional or c. local level delivery produces the best
outcomes?
Key points:
Evidence suggests that centres treating a large number of patients with a particular
type of cancer produce better patient outcomes than those that see fewer patients.
Reaching the number of patients to achieve these high volume benefits is not
possible for centres treating rarer or complex cancers, unless they each serve a very
large population.
Population Required
RCP, 2013(7)
The British Committee for Standards in Haematology
(BCSH) has defined three major levels of care for patients
with haematological malignancies . NICE recommends that
patients with haematological cancers are managed by
multidisciplinary haemato-oncology teams serving a
population of more than 500,000, with link networks between
hospitals and that the treatment of acute leukaemia be limited
to hospitals that treat at least five patients annually. (page
127)
The Scottish
The NHS Scotland Cancer Plan for Children and Young People
Government, 2012(3) states that services will operate as a single, cohesive and
sustainable service for Scotland with care provided in a variety
of settings but led by the decisions made by the MultiDisciplinary Team (MDT) to promote consistency and equity of
care.
London Cancer,
2013(9)
"specialist services for rare and complex cancers should be
focused in fewer centres that meet international best practice"
(page 8)
Crawford, 2012(1)
"The guidance was service based, requiring a reorganisation
of services, and dealt with moderately rare cancers (ovarian,
uterine, cervical and vulval) with marked survival differences.
Best practice would include multidisciplinary team
management and a concentration of surgical expertise in
one hospital serving a population in excess of one million."
(page 160)
Chan, 2013(2)
"the Association of Upper Gastrointestinal Surgeons (AUGIS)
has recommended that such units should consist of four to six
surgeons, each carrying out a minimum of 15-20
resections per year and serving a population of 1-2 million".
(page 7)
RCP, 2013(8)
"Less common tumour types are centralised within a cancer
centre with a critical volume of patients and staff to deliver
the highest possible standard of care". (page 154)
16 | P a g e
Clinical Outcomes
HIS, 2013(5)
There are a range of Quality Performance Indicator
documents published from 2013-15. The following tumour
sites have their own QPI; Acute Leukaemia, Brain &
CNS, Cervical, Endometrial, HepatoPancreatoBiliary, Head &
Neck, Lymphoma, Ovarian, Renal, Sarcoma, Testicular, Upper
GI.
Woo, 2012(4)
A Cochrane Review found low quality, but consistent evidence
to suggest that women with gynaecological cancer who
received treatment in specialised centres had
longer survival than those managed elsewhere. The evidence
was stronger for ovarian cancer than for other gynaecological
cancers.
London Cancer,
2013(9)
"For complex procedures there is a positive relationship
between the volume of patients that cancer services see and
the outcomes that they achieve. Higher patient volumes also
improve the research environment, particularly for rarer
cancers. There is evidence that cancer patients who
participate in clinical trials can have better outcomes." (page
10)
"The London-wide Case for Change notes that other factors
including training and experience, complementary surgical
teams, hospital resources, organisation and processes of care
can also influence clinical outcomes. It is fundamental that
specialist services have high availability and are delivered by
appropriately qualified teams with sufficient practice to
maintain their skills and sustain expertise. Centralisation of
specialist cancer services would provide a means of
consolidating scarce specialist expertise to improve clinical
quality. Such concentration of care, with larger numbers of
patients, creates centres of excellence that support training
and provide cover to ensure consistently safe staffing levels
that meet working time requirements." (page 11)
"Specialist and rarer cancer services should be linked to high
quality cancer research institutions that can demonstrate and
improve uptake to clinical trials, introduce and access
innovation more rapidly, and promote translational research in
the cancer field including, where appropriate, Academic Health
Science Centres (AHSCs) and specialist cancer organisations".
(page 13)
BPS, 2015(10)
For Psycho-Oncology services the British Psychological Society
proposes 6 domains of service quality and outcomes; safe,
equitable, patient centred, responsive, effective, efficient.
Crawford, 2012(1)
"This centralisation of care resulted in an improvement in 5year survival from 58.6 to 68.6% for all gynaecological
cancers that could be staged and graded. These changes have
17 | P a g e
been most
marked within endometrial and ovarian cancers." (page 164)
Chan, 2013(2)
Analysis of a reconfigured regional UGI cancer service; "The
curative to palliative treatment ratio increased by 71%,
operative morbidity fell 50%, lengths of hospital stay reduced
on average by 3 days, median survival improved by 20% and
overall 1 year survival improved by nearly 20%". (page 723)
Other Service Attributes
Workforce
Planning
RCP, 2013(8)
"The training and supervision of specialty medical oncology
registrars (StRs) is becoming more detailed and timeconsuming. There are currently 248 trainees within 25
training
programmes across the UK. The minimum time for
higher specialist training in oncology is 4 years, but, as it
is a research-based specialty, many undertake extra
out-of-programme research". (page 156)
Over the next five years "estimated increase in courses of
systemic therapy of 8% and radiotherapy courses of 1% per
annum, leading to a 9% per annum increase in the workload
of clinical oncologists". (page 8)
"The predicted medical oncology workforce requirement in the
UK is a minimum of 550 posts, representing 2.75 whole-time
equivalent (WTE) posts per 200,000–250,000 population".
(page 159)
Patient Satisfaction
Macmillan, 2013(11)
Uses case studies to illustrate its proposed 10 domains to
improve the cancer patient's experience; patient centred care,
timely referral into secondary care, communication, emotional
support, information and support, shared decision making and
care planning, continuity of care, financial and work support,
physical environment, user involvement in service design and
delivery.
HIS, 2013(6)
The 2013 Cancer Patient Experience QPI has indicators for
communication, information and shared decision making.
References:
1. Crawford R, Greenberg D, 2012. Improvements in survival of gynaecological
cancer in the Anglia region of England: are these an effect of centralisation of
care and use of multidisciplinary management?. BJOG: An International
Journal of Obstetrics & Gynaecology 119(2):160-5. (Accessed 30/06/2015)
2. Chan DS, Reid TD, Whit C et al, 2013. Influence of a regional centralised
upper gastrointestinal cancer service model on patient safety, quality of care
18 | P a g e
and survival. Clinical Oncology (Royal College of Radiologists) 25(12):719-25.
(Accessed 30/06/2015)
3. Scottish Government, 2012. Cancer plan for children and young people in
Scotland 2012-2015 : managed service network for children and young
people with cancer in Scotland. Scottish Government. (Accessed 30/06/2015)
4. Woo YL, Kyrgiou M, Bryan A et al, 2012. Centralisation of services for
gynaecological cancer. Cochrane Database of Systematic Reviews 2012, Issue
3. Art. No.: CD007945. (Accessed 01/07/2015)
5. Healthcare Improvement Scotland, Scottish Cancer Taskforce, 2013. Cancer
Quality Performance Indicator: Cancer patient experience. Healthcare
Improvement Scotland. (Accessed 30/06/2015)
6. Healthcare Improvement Scotland, Scottish Cancer Taskforce, 2013. Cancer
Quality Performance Indicators page. Healthcare Improvement Scotland.
(Accessed 30/06/2015)
7. Royal College of Physicians, 2013. Consultant Physicians working with
patients: haematology chapter (revised 5th edition). (Accessed 01/07/2015)
8. Royal College of Physicians, 2013. Consultant Physicians working with
patients: medical oncology chapter (revised 5th edition). (Accessed
01/07/2015)
9. London Cancer North & East, 2013. London Cancer Specialist Services
Reconfiguration: a case for change in specialist cancer services. (Accessed
01/07/2015)
10. British Psychological Society, 2015. Demonstrating Quality and outcomes in
Psycho-Oncology. British Psychological Society. (Accessed 01/07/2015)
11. Macmillan Cancer Support, 2013. Improving cancer patient experience: top
tips guide. (Accessed 01/07/2015)
12. Royal College of Radiologists, 2014. Clinical oncology: the future shape of the
specialty. (Accessed 01/07/2015)
13. Royal College of Radiologists, 2014. Clinical oncology workforce: the case for
expansion. (Accessed 01/07/2015)
Further reading available in Appendix 3
19 | P a g e
Cardiac/cardiovascular surgery
For cardiac/cardiovascular surgery, is there evidence that a. national, b.
regional or c. local level delivery produces the best outcomes?
Key Points
• Higher case volume by both individual surgeons and in institutions has some
association with improved outcomes; other factors including the availability
of related services are also important.
Population Required
Turner, 2014 (1)
A recent rapid review found a number of studies indicating
improved outcomes in congenital heart disease with higher
case volumes, but it is unclear how far this is due to volume
alone.
The evidence base consists of US studies and may be of
limited relevance to the UK. Few studies give figures for the
optimal size of congenital heart disease centres.
British Cardiovascular
Intervention Society,
2011 (2)
Hospitals providing a primary percutaneous coronary
intervention service need to serve a population of at least
200,000 in order to achieve a minimum of 100 PCI
procedures per year.
British Cardiovascular
Intervention Society,
2011 (3)
Transcatheter aortic valve implantation should be performed
only by centres which can perform a minimum of 24 cases per
year, and 50 cases per year is optimal.
Clinical Outcomes
London Cardiac and
Stroke Networks,
2011 (4)
To improve outcomes in acute aortic dissection, elective
surgery for this condition should only be performed by cardiac
surgeons who perform more than 10 cases of major thoracic
aortic vascular surgery per year and who attend aortic
vascular multidisciplinary meetings at least twice a month.
It should only be performed at sites with ‘a cohesive thoracic
aortic vascular service and an active multidisciplinary team’,
and where additional related services (including specialist
intensive care and anaesthesia, cardiothoracic specialist
imaging and interventional radiology) are available.
To improve outcomes in mitral valve repair patients should be
assessed only by specialist teams and operated on by cardiac
surgeons who perform at least 25 mitral valve operations per
year, and by teams who perform at least 50 such operations.
References:
1. Turner, J, Preston, L, Booth, A et al., 2014.What evidence is there for a
relationship between organisational features and patient outcomes in congenital
20 | P a g e
heart disease services? A rapid review. Heart Services and Delivery Research.
No.2.43 . Accessed 21/07/2015.
2. Statement on the development and peer review of new PCI services. British
Cardiovascular Intervention Society, 2011. Accessed 03/08/2015
3. Transcatheter aortic valve implantation. British Cardiovascular Intervention
Society, 2011. Accessed 27/07/2015.
4. Cardiac surgery service specification. London Cardiac and Stroke Networks, NHS
England, 2011. Accessed 03/08/2015
21 | P a g e
Dermatology
For dermatology services is there evidence that a. national, b. regional or
c. local level delivery produces the best outcomes?
Key Points:
• There is little evidence to suggest at what level this specialty should be
delivered.
• There is some evidence on the consultant: patient ratio
• There is some indication of providing clear roles for primary and secondary
interfaces to improve care
• Use of technology suggest some improvement could be made (at a regional
level?) allowing for patient access to specialty staff across a wide area
Population Required
British Association of
Dermatologists, 2014(7)
RCP London, 2013(1)
Centre for Workforce
Intelligence, 2010(2)
‘Although the BAD suggests that there is an ongoing
need for a minimum number of designated dermatology
beds (two beds per 152,229 population), the survey
conducted by BAD and The King’s Fund suggested that
dermatology does not need dedicated beds, except
perhaps in the tertiary centres.’ (pg.39)
There is evidence that dermatology training availability
and takeup among community service staff (including
pharmacists) does not reflect the high level of
community demand (pg.30)
A population of 250,000 requires 4 whole-time
equivalent (WTE) consultants (ie one consultant per
62,500 based on DH 2009–10 figures).
This does not allow for specialist clinics, teaching
students, supervising or training any grade of staff,
ward referrals, inpatient care, on-call work, travel or
MDTs.
There is a shortfall of over 250 WTE dermatology
consultants in NHS England (pg.87)
The report outlines the workforce requirements for the
specialty as follows:
‘In 2007, there were 560 (490 WTE) consultant
dermatologists (substantive and locum posts) in the UK
and approximately 210 StRs. For the population of
61,000,000, the workforce requirements for a highquality, consultant-led service are 610 (WTE)
dermatologists.
Dermatology is predominantly an outpatient specialty
and the following calculations are based on the
workload in the outpatient department.
A 250,000 population generates 3,750 new patient
referrals per year. Each new patient on average
generates two follow-up appointments making a total of
11,250 patients each year. In areas where referral
patterns have changed in the light of recent government
initiatives, up to 40% of referrals may be retained in
22 | P a g e
Quality Indicators
Royal Free London(3)
King’s Fund,2010(4)
primary care. As such, a 250,000 population would
continue to generate 2,250 new and 4,500 follow up
patients per year in secondary care.’
Dermatology clinical quality indicators are:
• Eczema
• Psoriasis
• Quality of life in inflammatory skin conditions
In GP Practices “There is scope for quality measurement
in diagnosis and referral, but most indicators will serve
only as ‘tin openers’ (designed to prompt further
investigation) rather than ‘dials’ (unambiguous markers
of performance). Referral rates are an important
example of this, and primary care trusts should be
strongly discouraged from using overall referral rates as
a performance management measure”
Other Service Attributes
British Association of
Models of Integrated Service Delivery in Dermatology
Dermatologists, 2007(5)
Any future model of care should concentrate on service
delivery governed by three broad statements:
• Secondary Care Teams should do those things that
only they can do (see below)
• Care should be delivered in the right place by
individuals with the right skills and at the right time
Bedfordshire, 2014(6)
1.
2.
3.
• Policies should facilitate patient self-management.
New dermatology model - Miss F notices an irritating
rash on her arm and goes to see her GP who examines
her. The GP prescribes a standard treatment, but
unfortunately, this does not resolve the issue. Her GP
then refers Miss F to the new dermatology integrated
service triage team. Within one working day of being
referred to the dermatology triage team, Miss F is
allocated an appointment to see a specialist
dermatology nurse. At the appointment the specialist
nurse uses sophisticated technology to take an image of
the rash. The image is immediately reviewed by a
dermatologist. The dermatologist prescribes the specific
cream necessary to treat Miss F’s rash. Miss F is given
specific instructions for managing her rash. Miss F is
also given contact details should her rash become worse
and be offered an appointment within a week.
References:
Levell NJ, Jones SK, Bunker CB, 2013. Consultant physicans working with patients.
Royal College of Physicians. (Accessed 04/06/2015)
Centre for Workforce Intelligence, 2010. Dermatology: Medical specialty workforce
factsheet. CFWI. (Accessed 04/06/2015)
Royal Free London NHS Foundation Trust (No date provided). Dermatology clinical
quality indicators. (Accessed 04/06/2015)
23 | P a g e
4.
5.
6.
7.
Foot C, Naylor C, Imison C, 2010. The quality of GP diagnosis and referral. The
King’s Fund. (Accessed 04/06/2015)
Dermatology Workforce Group, 2007. Models of integrated service delivery in
dermatology. British Associated of Dermatologists. (Accessed 04/06/2015)
Optum, 2014. New Dermatology Service to Launch August 1 that will improve care
for thousands of people across Bedfordshire. (Accessed 04/06/2015)
British Association of Dermatologists, King’s Fund, 2014. How can dermatology
services meet current and future patient needs while ensuring that quality of care is
not compromised and that access is equitable across the UK? British Association of
Dermatologists. (Accessed 23/06/2015)
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Emergency and unscheduled care
For the emergency and unscheduled care service, is there evidence that a.
national, b. regional or c. local level delivery produces the best outcomes?
Key Points:
• Local access is required for the majority of emergency and unscheduled care.
• Further evidence is required regarding the health and other impacts of
centralising emergency services, particularly in less populated areas.
• A case has been made for centralisation of some aspects of emergency care,
such as stroke and cardiac care, in urban areas.
• There are evidence based models for care within individual emergency care
settings, including 7 day access to the multidisciplinary team. Flow from the
emergency department to other areas of the hospital continues to require
whole system focus.
Population Required
House of Commons “A strong case has been made for centralisation of treatment
Health Committee, for patients with certain conditions such as stroke care, cardiac
2013(1)
care and major trauma. When implemented successfully, the
creation of specialist centres enhances clinical skills and
concentrates resources, with demonstrably improved outcomes
for patients. Centralisation, however, is by no means a universal
remedy for the ills of emergency care. Service redesign must
account for local considerations and be evidence based. Some
rural areas would not realise the benefits from centralising
services that London has, therefore the process must only
proceed on the basis of firm evidence. The goal is to improve
patient outcomes – centralisation should not become the end in
itself. “ (page 6)
NHS England,
2013(2)
All A&E departments should be part of a formal trauma
network. There have been very few studies to assess the
impact of centralising A&E services. The limited evidence
available suggests that if services are centralised, there are
risks to the quality of care where the centralised service does
not have the necessary A&E capacity and acute medical support
for the additional workload. A proportion of A&E attenders can
safely be seen in community settings but there is little evidence
that developing these services in addition to A&E will reduce
demand. Changes to A&E services may not result in savings,
and significantly increased distances to A&E may increase
mortality for the very few patients with the severest illnesses.
This needs to be taken into account when assessing the net
benefit of any proposal to centralise A&E services. There are
opportunities to support local access through networked
arrangements and to provide remote support to A&E through
telemedicine links to smaller units.
There is strong evidence to support a senior doctor presence in
A&E seven days a week. Professional guidance suggests
25 | P a g e
consultants should be available at least 16 hours a day.
Nurse practitioners are a safe alternative to junior doctors.
The evidence also shows that A&E services require:
• 24/7 support from diagnostics, including pathology and
radiology
• rapid access to critical care
• rapid access to specialist medical opinion, including
geriatricians and paediatricians (on-site) and specialist surgical
opinion (senior staff may be remote but part of a network)
• liaison mental health services.
Healthcare for
London, 2010(3)
“Every urgent care centre should be part of a polysystem to
enable wider integration and efficient delivery of care.” (page 3)
“Polysystem – a clinically-led model of care involving all
partners in the network and supported by a primary care-led
polyclinic hub. Polysystems typically provide health and
wellbeing services across populations of 50,000 to 80,000
people.” (page 7)
“Through A Framework for Action, the London
recommendation for this is to establish a primary care-led
urgent care centre at the front of every A&E in London
operating directly in an on site polyclinic or as an integrated
part of a wider polysystem. This will be the first point of contact
for self-referred patients attending hospital with unscheduled
care needs.” (page 5)
Clinical Outcomes
London Quality &
All emergency admissions to be seen and assessed by a
Safety Programme, relevant consultant within 12 hours of the decision to admit or
2013(4)
within 14 hours of the time of arrival at the hospital.
Prompt screening of all complex needs inpatients to take place
by a multi-professional team including physiotherapy,
occupational therapy, nursing, pharmacy and medical staff. A
clear multi-disciplinary assessment to be undertaken within 14
hours and a treatment or management plan to be in place
within 24 hours. An overnight rota for respiratory physiotherapy
must be in place.
Consultant involvement for patients considered ‘high risk’ should
be within one hour.
In order to meet the demands for consultant delivered care,
senior decision making and leadership on the acute medical/
surgical unit to cover extended day working, seven days a
week.
All hospitals admitting medical and surgical emergencies to
have access to all key diagnostic services in a timely manner
24/7 (critical examinations within 1 hour)
All hospitals admitting medical and surgical emergencies to
have access to interventional radiology 24/7 (critical within 1
hour)
All admitted patients to have discharge planning and an
estimated discharge date as part of their management plan as
26 | P a g e
soon as possible and no later than 24 hours post-admission. A
policy is to be in place to access social services seven days per
week.
All hospitals admitting emergency general surgery patients to
have access to a fully staffed emergency theatre immediately
available and a consultant on site within 30 minutes at any time
of the day or night.
All acute medical and surgical units to have provision for
ambulatory emergency care.
Single call access for mental health referrals to be available
24/7 with a maximum response time of 30 minutes.
Hospitals admitting emergency patients have access to
comprehensive 24 hour endoscopy services with formal
consultant rota.
All hospitals dealing with complex acute medicine to have onsite
access to levels 2 and 3 critical care (i.e. intensive care units
with full ventilatory support). All acute medical units to have
access to a monitored and nursed facility.
Emergency
Medicine
Taskforce, 2012(5)
Recommendations:
1. An increase in Emergency Medicine Consultant numbers to
ensure a consultant presence for 16 hours a day, 7 days/week
in all Emergency Departments and 24 hours a day, 7 days/week
in larger departments or Major Trauma Centres.
2. Work with the CfWI to explore workforce modelling in EM.
3. EM trainee numbers should be carefully calibrated to support
continued Consultant expansion.
4. Early exposure to the EM component within ACCS core
training to improve early experience and improve MCEM pass
rates.
5. Develop alternative routes into EM training for trainees
currently in other specialty programmes.
6. Explore the recognition of transferable competences of
trainees currently in other specialities to increase the pool of
trainees eligible to apply for EM training at a level higher than
CT1.
7. Support Associate Specialist and Staff Grade Doctors
(Specialty Doctors) in their roles to ensure retention and
increase work satisfaction. Measures to achieve this should
include:
• Job planning to avoid unsocial hours’ predominance and
enhance support for CPD.
• The College of Emergency Medicine will look to ways of
supporting the development of this group using the
College curriculum and assessment systems.
27 | P a g e
8. GPs could be invited to consider the following options:
• Ensuring prompt access to community Urgent Care for
as much of the 24 hour period each day as possible,
improving access available in the evenings and at
weekends.
• GPs could provide Primary Care expertise in a facility colocated with the ED.
• GPs could work with the ED team to facilitate discharge
of patients back to community facilities.
• Those GPs who wish to develop Emergency Care skills
as a special interest should be encouraged to acquire
skills and competences as agreed by the RCGP and CEM.
9. Expand training of clinical nurse specialists and PAs, and
define their roles. It is clear that the day-to-day delivery of ED
care will require significant expansion of the non-medical clinical
workforce. No formal estimates have been performed but given
current issues re: delivering care, the Taskforce recommends
that there is a need for at least 10 such higher specialty trainee
and SAS rota clinicians per ED. To ensure consistency,
development of the roles of each of these groups should be
underpinned by:
A national curriculum for ED-specific competencies
• National Standards for skills and competencies
• National Assessment framework
And the working group also recommends that the College
supports such developments.
10. There is a real urgency about the ED workforce crisis, and
these recommendations need to be enacted urgently. For PAs,
core generalist training takes two years, and universities need
up to a year to initiate programmes. Thus, a recommendation
to use PAs within ED needs to be made quickly so that new
graduates will be available from summer 2014, and can then
undertake post-graduate training and provide a significant
impact on the ED workforce by say mid-2015. In addition, many
PAs taking a generalist PA course will not enter ED, thus
significant numbers of PA courses need to be instituted as soon
as possible. Lastly, PAs are not statutorily registered and thus
cannot prescribe not order x-rays, both of which are clearly
significant barriers to their effective implementation.
Registration with HPC would solve this problem quickly.
International
Federation for
Emergency
Medicine, 2012(6)
Quality indicators to be used within each ED:
• Facilities
• Numbers and skill mix of staff
• Culture of quality
• Data support
• Key process measures in place
• Access block present
28 | P a g e
•
•
•
British Geriatric
Society, 2012(7)
Evidence based practice
Patient experience measured & acted upon
ED staff experience measured & acted upon
1. All older people accessing urgent care should be routinely
assessed for pain, delirium and dementia, depression, nutrition
and hydration, skin integrity, sensory loss, falls and mobility,
activities of daily living, continence, vital signs, safeguarding
issues, end of life care issues. These assessments will need to
be undertaken by various teams and should be prioritised
according to the needs of the patient.
2. The presence of one or more frailty syndrome (see above)
should trigger a more detailed comprehensive geriatric
assessment, to start within 2 hours (14 hours overnight) either
in the community, person’s own home or as an in-patient,
according to the person’s needs.
3. There must be an initial primary care response to an urgent
request for help from an older person within 30 minutes
4. Ambulatory emergency pathways with access to
multidisciplinary teams should be available with a response time
of less than four hours for older people who do not require
admission but need on-going treatment (e.g. in a Clinical
Decisions Unit).
5. Health and social services should be commissioned such that
they can contribute to early assessment of older people,
including mental health assessments. Mental health services
should be commissioned such that they can contribute to
specialist mental health assessments in older people within 30
minutes if appropriate.
6. A 24/7 single point of access (SPA) including a
multidisciplinary response within two hours (14 hours overnight)
should be commissioned. This should be coupled to a live
directory of services underpinned by consistent clinical content
(NHS pathways). Discharge to an older person’s normal
residence should be possible within 24 hours, seven days a
week – unless continued hospital treatment is necessary.
7. Older people coming into contact with any healthcare
provider or services following a fall with or without a fragility
fracture should be assessed for immediately reversible causes
and subsequently referred for a falls and bone health
assessment using locally agreed pathways.
8. Older people who present with intentional self-harm should
be considered as for failed suicide; along with older people with
unintentional self-harm they should be assessed for on-going
risk of further self-harm in any setting .
29 | P a g e
College of
Emergency
Medicine, 2011(8)
College of
Emergency
Medicine, 2011(9)
Healthcare for
London, 2009(10)
CEM Quality indicators:
• Ambulatory care
• Unplanned re-attendance
• Total time spent in ED
• Left without being seen
• Service experience
• Time to initial assessment
• Time to treatment
• Consultant sign-off
The College of Emergency Medicine recommends that every
Emergency Department should have a minimum of 10 whole
time equivalent Consultants in Emergency Medicine. This
would allow a consultant to be present to supervise care for
a minimum of 14 hours a day.
Key aspects of modern emergency medicine practice:
• Early involvement of senior Emergency Medicine
clinicians
•
Rapid expert early assessment
•
Prompt commencement of time critical interventions
•
Unrestricted access to imaging (CT, Ultrasound, Plain
radiography) by Emergency Medicine doctors to allow
immediate diagnosis of life threatening conditions
•
Expertise in relevant critical care skills in collaboration
with colleagues from anaesthesia and intensive care
•
The extended presence of Emergency Medicine
consultants providing leadership and supervision
•
Development of Clinical Decision Units (CDUs)as a core
component of Emergency Department activity providing
protocol-driven periods of investigation, observation and
review for patients who would otherwise be admitted to
scarce and expensive hospital beds or discharged,
potentially unsafely.
“Proposed indicators for unscheduled care:
• Improvement in patient experience of the unscheduled care
system
• Effective management of acute asthma
• Effective management of fractured neck of femur
• Effective management of pain
• Effectiveness of falls assessment and prevention
• Participation in audit (e.g. by professional bodies College of
Emergency Medicine, RCGP clinical audit toolkit for OOH
services and local audit processes)
• Time to clinical assessment by an appropriately skilled
professional in an urgent care setting.
• How promptly definitive care (patient assessed, treated and
discharged) is received in an urgent care setting.
• Time taken to transfer patients from an Urgent Care Centre to
an adjoining ED when treatment in the ED is assessed to be
30 | P a g e
required.
• Time taken for a patient with an acute mental health problem
attending an UCC/ED to be seen by a psychiatric liaison team/
CRHT.
• The extent to which relevant information is shared and how
quickly this occurs.
• 999 callers conveyed to alternative (than ED) pathways (i.e.
treated at scene, conveyed to community settings)
• Emergency admissions for ambulatory care sensitive
conditions (ASCs)
• Patients re-admitted as emergencies within a short period
following discharge.” (14 days / 28 days mental health) (pages
11-14)
Other Service Attributes
Scottish
Government,
2015(11)
Themes:
New models of care required, not stretching existing resources.
Care in the most appropriate location (25% of acute hospital
patients do not need acute hospital care).
Palliative and end of life care in appropriate setting.
Anticipatory care planning for control and choice.
Integrated partnerships role in preventing admissions and
supporting discharge.
Acute care models; e.g. acute general surgery follow vascular
model with majority of care local and fewer specialist sites with
ICU and interventional radiology access.
Primary care working across the interface. Model to include
hubs and community hospitals.
Sustainable workforce includes greater range of nursing roles
and AHP input.
Local emergency care plans.
Scottish
Government,
2013(12)
Year 1 focus on increasing capacity in the acute sector
(inconsistent results).
Year 2 focus on integrated approach, including improving day of
care audit results, meeting targets and fit for purpose –
including patient journey/ flow, management of older people &
delayed discharge, place of care, front door and senior decision
making, 7 day working.
The King’s Fund,
2015(13)
“Although the impact could be highly positive, redesigning the
urgent and emergency care system is likely to be highly
challenging. Specific actions for commissioners could include:
•
providing effective signposting to help patients choose
the right service
•
ensuring that hospital and community services can
adjust service levels in response to changes in demand,
so that need and provision are kept in balance
•
ensuring that A&E departments adopt best practice for
handling ‘majors’ including early senior review
31 | P a g e
RCEM, 2015(14)
•
ensuring that hospitals and local authority social service
and housing departments work effectively together to
reduce delayed discharges and shorten lengths of stay
•
mapping and analysing patient flows around the system
to identify bottlenecks and the scope for changing
pathways to reduce the use of hospitals and to ensure
that there is sufficient capacity across the health and
social care system. “ (page 11)
In Scotland, to rebuild the Emergency Medicine service the
College is calling for the following four steps to be taken:
STEP 1: Safe and sustainable staffing levels must be achieved
STEP 2: Terms, working conditions, and funding, must be fair
and effective
STEP 3: Exit block and overcrowding must be tackled
STEP 4: Primary care facilities must be co-located with
Emergency Department services
The College urges The Scottish Government, politicians and
NHS leaders to work together to take the four steps needed to
rebuild emergency care.
RCPE, 2015(15)
“The RCEM rightly highlights safe and sustainable staffing as a
key issue in Emergency Medicine.. Ensuring we have
collaborative working throughout hospitals will help to address
the problem of “exit block” identified by RCEM, where patients
cannot progress through the hospital from Emergency
Departments to the appropriate ward, usually because the
inpatient beds are full. Improving “patient flow” throughout the
hospital is vital and many of the issues highlighted in the RCPE
statement on this issue are still outstanding.”
NHS England,
2014(16)
“Across the NHS, urgent and emergency care services will be
redesigned to integrate between A&E departments, GP out-ofhours services, urgent care centres, NHS 111, and ambulance
services.” (page 4)
New care model - urgent and emergency care networks
More and more people are using A&E – with 22 million visits a
year. [overall] the NHS responds to more than 100 million
urgent calls or visits every year.
Proposed changes:
“Making more appropriate use of primary care, community
mental health teams, ambulance services and community
pharmacies, as well as the 379 urgent care centres throughout
the country. This will partly be achieved by evening and
weekend access to GPs or nurses working from community
bases equipped to provide a much
greater range of tests and treatments; ambulance services
32 | P a g e
empowered to make more decisions, treating patients and
making referrals in a more flexible way; and far greater use of
pharmacists.
* Developing networks of linked hospitals that ensure patients
with the most serious needs get to specialist emergency centres
• Ensuring that hospital patients have access to seven day
services where this makes a clinical difference to outcomes.
• Proper funding and integration of mental health crisis
services, including liaison psychiatry
• A strengthened clinical triage and advice service that links the
system together and helps patients navigate it successfully
• New ways of measuring the quality of the urgent and
emergency services; new funding arrangements; and new
responses to the workforce requirements that will make these
new networks possible.” (page 21-22)
RCPE 2013(17)
“It is important to set standards and agree targets that reflect
whole systems to avoid unforeseen consequences through the
knock-on effects of focusing on specific targets.. Improving
patient flow and thus quality is a multi-professional, multi-sector
responsibility.. Front-door demand, particularly after hours,
must be addressed through targets for community-based
emergency services and residential and nursing homes, and by
lifting patient confidence to reduce self-referrals to A&E.
Similarly, discharge delays must be minimised with target
response times once a patient is clinically ready to go home..
Boarding levels are a symptom of a hospital in crisis and as
such should be monitored closely.”
RCGP, 2013(18)
“No one part of the system - hospital departments, GPs or
ambulance services - is to blame but the overall fragmentation
of the system is not serving the best interests of patients.. the
RCGP is committed to working with NHS England and other
partners to help develop, as the Committee recommends,
innovative proposals for community-based urgent care
services.”
NHS
Confederation,
2013(19)
Health and social care demand has radically changed and the
NHS needs a workforce ready to meet patient and public needs
in the
21st century.
• Urgent and emergency care would particularly benefit from
workforce transformation, ensuring the right type of care at the
most appropriate time and place.
• Staff roles, training and deployment will need to change to
enable more care to be delivered by teams outside of hospital.
• Urgent and emergency care would particularly benefit from
workforce transformation, ensuring the right type of
care at the most appropriate time and place.
• Staff roles, training and deployment will need to change to
enable more care to be delivered by teams outside of hospital.
33 | P a g e
Royal College of
Physicians,
2013(20)
Ten priorities for action:
• develop effective and simplified alternatives to hospital
admission across seven days
• adjust the financial incentives across the system, so that
they support effective management of demand for
unscheduled care
• focus on supporting patients to leave hospital seven
days a week
• organise high-quality consultant-led hospital services
across seven days
• promote greater collaboration within the hospital and
beyond to manage emergency patients
• We must ensure that there is sufficient capacity within
the hospital, and the wider system, to meet changing
demand
• focus on ambulatory (‘day case’) emergency care where
appropriate
• develop a sustainable workforce, fit for the future
• We must show leadership
• focus on public health and preventive health strategies
NHS South West
London, 2012(21)
Recommendation 1: The Urgent Care CWG recommends all
A&E departments have an integrated Urgent Care Centre/
primary care stream to deal with undifferentiated primary care
and urgent care caseload alongside A&E departments in
hospitals.
Recommendation 2: Stand alone services that offer urgent
appointments must define their services carefully and in
language that a lay person will understand to avoid confusion.
The group also noted that stand alone urgent services must
absorb current activity and neither duplicate nor increase
demand and be able to demonstrate this.
Recommendation 3: The group also determined that all A&Es
should treat children and that adult only services are not a
suitable option.
Recommendation 4: There should EITHER be a drive to
recruit fully to the recommendations set out on the College of
Emergency Medicine standards for traditional A&E units OR with
the developments of UCCs at the front end of an A&E the
implementation of a suitable workforce model composed of
Consultants and GPs to reflect the needs of the population
served.
Recommendation 5: An A&E department needs access to
emergency surgery, senior clinical decision makers and
competent clinical staff to carry out the most appropriate
intervention in and out-of-hours.
Recommendation 6: Acute Assessment Unit‟s (AAU‟s) should
be delivering emergency ambulatory care to ensure swift and
effective decision making preventing prolonged length of stay.
This should be consultant led and be open 24/7.
Recommendation 7: Urgent and emergency services need to
34 | P a g e
be more joined-up to provide efficient and effective care.
Community services need to respond to urgent needs and be
commissioned to do so.
Recommendation 8: Simplified and up to date information
about services needs to be improved and communicated with
the public.
Recommendation 9: Consistent electronic clinical data
recording and more integrated IT systems and reporting in
different urgent and emergency care services is essential to
avoid patients repeatedly being asked for the same information,
to support decision making for patients and for the delivery of
services.
Recommendation 10: The standards and recommendations
of the NHS London and London Health Programmes adult
emergency services review should be implemented.
King’s Fund,
2012(22)
Ambulatory care-sensitive conditions (ACSCs) account for one in
every six emergency hospital admissions in England.
• The proportion of emergency admissions for ACSCs is
larger in under-5s and over-75s. Children are predominantly
admitted for acute conditions, older people for chronic
conditions, and both groups for vaccine-preventable conditions.
e.g. Influenza, pneumonia, chronic obstructive pulmonary
disease (COPD), congestive heart failure, dehydration and
gastroenteritis.
• The rate of emergency admissions for ACSCs varies among
local authorities from 9 to 22 per 1,000 population.
• The rate in the most deprived areas is more than twice the
rate in the least deprived areas in England.
King’s Fund,
2012(23)
The potential reductions in bed use by patients over 65 are
considerable.. Areas that have well developed, integrated
services for older people have lower rates of bed use and also
deliver a good patient experience and have lower admission
rates.
RCGPs, 2011(24)
The vision for Commissioners of a 24/7 urgent care service will
be markedly different from what we have been accustomed to.
Patients do not have problems that fit neatly into time periods
and if we are to be truly patient-centred then only a 24/7
approach is appropriate.
The “whole system” is considerably bigger than most
professionals may have imagined and the relationships and
interdependencies
can be better managed by developing the helicopter view over
the wider system of urgent care provision so that it can become
more joined-up.
Commissioners are faced with many challenges which can begin
to be addressed as urgent care services and professionals work
towards common goals leading to greater consistency in
accessing individual services; quality and safety embedded in a
culture of improvement and focused on the clinical needs of the
35 | P a g e
patient; better patient experience; greater integration between
services; and value for money within the confines of the NHS
budget.
Primary Care
Foundation / NHS
Alliance, 2011(25)
Decisions about the location, remit, scope and need for
specific services should take into account:
• the availability of, and impact on, other services across the
local health community
• the actual or projected demand for the service accessibility,
particularly for ‘hard to reach’ patient groups, and the need
to provide an equitable service across the area, while
recognising individual solutions may differ depending on the
locality’s needs
• the availability of back-up and support services,
especiallyfor patients whose condition is more acute
• the need for individual services to be of a sufficient size –
this allows good governance, enables good use of services’
skill mix and for staff to experience a sufficiently diverse
range of cases to provide good quality care.
Emergency Care
Intensive Support
Team, 2011(26)
Highlights areas of good practice proven to reduce bed
occupancy, cost and harm events, while increasing the
satisfaction of the clinical team.
King’s Fund,
2010(27)
Identifies interventions which do and do not contribute to
avoiding hospital admissions in different care settings.
National Institute,
2010(28)
The need for person centred services that are responsive and
which can safely and effectively differentiate potentially life
threatening problems from those that are less urgent have
been longstanding priorities in UK urgent care policy.. A new
contract that allowed GPs to opt out of their 24 hour
responsibility for patients accelerated local initiatives to develop
skill mix in urgent care. Our task was to understand ‘who cares
for patients’ and the impact of changing workforce patterns and
skill mix at different levels. We found a multidisciplinary
approach to delivering urgent care in each case study in which
nonmedical professionals were frequently substituting for
general practitioners, though GPs remained a vital part of the
service. There were many examples of bespoke roles which
responded to the needs of local services. (page 252)
Designing integrated and effective systems
there was evidence that where there had been work at the local
system level to deliberately redesign urgent care services
around the needs of patients and effective patient pathways,
this had generated less complex pathways and processes (page
243).
Workforce planning
In urgent out-of-hours care, the balance appears to have
moved towards a surplus of GPs and a shortage of nurse
practitioners and ECPs. (page 244)
The effectiveness of first point of contact assessment
36 | P a g e
This research has shown the important interface between the
structure of urgent care systems and the prevailing skill mix. An
effective and safe first point of assessment, triage and referral
is important in order that the patient is referred to the most
appropriate person to meet their needs. (page 244)
Education and training
in urgent health care GPs are an important resource in the
training and support of registrars, nurses and allied health
professionals.
Healthcare for
London, 2010(3)
“Four key recommendations were made for improving acute
care:
• Access should be significantly improved through urgent care
centres with doctors on site. Urgent care centres in hospitals
should be open 24 hours a day, seven days a week (the
focus of this document), the hours of those in the
community settings will depend on local need.
• There should be a single point of contact (by telephone) for
urgent care.
• There should be centralisation and networks for major
trauma, heart attack and stroke.
• Dispatch and retrieval protocols for London Ambulance
Service need to be aligned with centralisation.” (page 5)
“Urgent care centres at the front of emergency departments will
be staffed by multidisciplinary teams that include GPs and nurse
practitioners (including emergency nurse practitioners) who are
able to access support and advice, when necessary, from
consultants in emergency medicine.” (page 7)
“We expect mental health assessments to be conducted at the
urgent care centre by local mental health service providers.”
(page 27)
“Ideally, urgent care centres should be able to refer patients for
rapid delivery of an enhanced package of community support
24 hours a day, seven days a week, where this may avoid an
admission to hospital.” (page 28)
“We expect a clinical assessment by an appropriately trained
clinician to occur within 20 minutes (15 minutes for children) of
the patient arriving... Within 60 minutes of the patient arriving
at the urgent care centre, a clinical decision needs to be made
as to whether the patient will be treated in the urgent care
centre and discharged, or whether they need to be transferred
to the emergency department. ..” (page 31)
References:
1. House of Commons Health Committee, 2013. Urgent and emergency services.
(Accessed 22/07/2015)
37 | P a g e
2. The King’s Fund, 2014. The reconfiguration of clinical services. What is the
evidence? (Accessed 14/07/2015)
3. Healthcare for London, 2010. A service delivery model for urgent care centres :
commissioning advice for PCTs. (Accessed 04/06/2015)
4. London Quality and Safety Programme, 2013. London Quality Standards. Acute
medicine and emergency general surgery. (Accessed 13/07/2015)
5. Emergency Medicine Taskforce, 2012. Interim Report. (Accessed 09/07/2015)
6. International Federation of Emergency Medicine, 2012. Framework for quality
and safety in ED. (Accessed 13/07/2015)
7. British Geriatric Society, 2012. Silver book : quality care for older people with
urgent and emergency care needs. (Accessed 13/07/2015)
8. College of Emergency Medicine, 2011. Emergency department clinical quality
indicators : a CEM guide to implementation. (Accessed 13/07/2015)
9. The College of Emergency Medicine, 2011. The emergency medicine operational
handbook : the way ahead. (Accessed 09/07/2015)
10. Healthcare for London, 2009. Quality indicators to support commissioning of
unscheduled care. (Accessed 04/06/2015)
11. Scottish Government, 2015. Sustainability and seven day task force interim
report. (Accessed 14/07/2015)
12. Scottish Government, 2013. National unscheduled care action plan 2013-16. Year
2 action plan : 2014/2015. (Accessed 14/07/2015)
13. The King’s Fund, 2015. Transforming our health care system : ten priorities for
commissioners. Chapter 10: Managing urgent and emergency activity. (Accessed
09/07/2015)
14. Royal College of Emergency Medicine, 2015. STEP Campaign. Available at
(Accessed 14/07/2015)
15. Royal College of Physicians Edinburgh, 2015. RCPE comment on Royal College of
Emergency Medicine STEP campaign. (Accessed 14/07/2015)
16. NHS England, 2014. New care model - urgent and emergency care networks.
(Accessed 04/06/2015)
17. Royal College of Physicians Edinburgh, 2013. Developing Health Board LDPs to
support delivery of the 2020 vision for health and social care. (Accessed
14/07/2015)
18. Royal College of General Practitioners, 2013. RCGP response to Health Select
Committee report on urgent and emergency care. (Accessed 14/07/2015)
19. NHS Confederation, 2014. Urgent and emergency care forum. A workforce fit for
the future Working together to improve the delivery of urgent and emergency
care. (Accessed 09/07/2015)
20. Royal College of Physicians, 2013. Urgent and emergency care: a prescription for
the future. (Accessed 09/07/2015)
21. NHS South West London, 2012. Urgent and emergency care clinical working
group: final clinical report. (Accessed 09/07/2015)
22. The King’s Fund, 2012. Emergency hospital admissions for ambulatory care
sensitive conditions – identifying the potential reductions. (Accessed 13/06/2015)
23. The King’s Fund, 2012. Older people and emergency bed use. (Accessed
13/06/2015)
24. Royal College of General Practitioners, 2011. Guidance for commissioning
integrated urgent and emergency care – a whole system approach. (Accessed
09/07/2015)
25. Primary Care Foundation, NHS Alliance, 2011. Breaking the mould without
breaking the system – new ideas and resources for clinical commissioners on the
journey towards entegrated 24/7 urgent care. (Accessed 13/07/2015)
38 | P a g e
26. Emergency Care Intensive Support Team (ECIST), 2011. Effective approaches in
urgent and emergency care. 1. Priorities in acute hospital. (Accessed
13/07/2015)
27. King’s Fund, 2010. Avoiding hospital admissions – what does the research
evidence say? (Accessed 13/07/2015)
28. National Institute for Health Research, 2010. The impact of changing workforce
patterns in emergency and urgent out of hours care on patient experience, staff
practice and health system performance. (Accessed 13/07/2015)
29. NHS England, 2013. High quality care for all, now and for future generations.
Transforming urgent and emergency care services in England : urgent and
emergency care review. End of phase 1. Report, appendix 1 – revised evidence
base from the urgent and emergency care. (Accessed 09/07/2015)
30. NHS London Health Programmes, 2013. Quality and safety programmes:
emergency departments – a case for change. (Accessed 09/7/15)
39 | P a g e
ENT
For the ENT service, is there evidence that a. national, b. regional or c.
local level delivery produces the best outcomes?
Key Points:
•
•
•
•
There is no clear evidence for local, regional, or national service provision.
However access to outpatients/day surgery should be maintained for the
majority of cases, with referral to specialist services for the rest. The
minimum number of operations required to maintain expertise of highly
specialised surgeons may be used to determine whether these ‘more’
specialist ENT is delivered at either a regional or national level, whilst the
majority ‘minor’ ENT services delivered via outpatients and day surgery at the
local level.
o Access to services could be further enhanced for rural communities
through telemedicine
There is no clear evidence provided of optimum numbers for the workforce,
although comparisons could be made to other countries. Cognisance should
also be given to the changing population (growth in elderly) and
determinants (e.g. decline of smoking) and how these will determine the
need for ENT services.
Evidence does indicate that the ENT workforce is multi-disciplinary and
improvement to clinics could be made (e.g. same day assessment) to make
the most of nurse specialist and ENT consultant time.
Further improvements could be made by spreading current good practice and
working on improved referral pathways.
Population Required
CfWI,
2010(11)
NHS England – Otolaryngology consultants forecast to increase to 649
WTE by 2018.
Luxenberger Pg600, Figure 2 lists ENT doctors per 100 000 inhabitants across
, 2014(1)
European countries and year data taken from , data taken from
Eurostat:
Bulgaria
370
2009
Denmark
341.6
2008
Germany
364.1
209
Estonia
326.7
2009
Finland
272.7
2008
Island [Ireland?] 360.8
2010
Italy
336.2
2009
Croatia
266.9
2009
Latvia
300.4
2009
Malta
309.7
2010
Norway
399.9
2009
Austria
477.9
2010
Poland
217
2009
Rumania
225.9
2009
Switzerland
381.2
2009
40 | P a g e
Slovenia
Spain
Check Republik
Hungary
United Kingdom
Cyprus
240.1
378.6
355.5
302.3
267.7
285.6
2009
2010
2009
2009
2010
2008
This data does not take in to account the range of services provided by
ENT doctors, and how they differ across the EU, or how patients
access these services (direct primary care, or via referral)
“A possible explanation for these big differences in the supply of ENT
manpower between the United Kingdom, Ireland and continental
Europe may be the answer to the question whether or not ENT is seen
as a prevailing surgical specialty” pg 602
There is a significant correlation between physician/population ratio
and waiting times across acute and (most) chronic conditions.
ENT UK,
2015(13)
Recommended numbers for ENT Clinics
RECOMMENDED
SAFE NUMBERS
SEEN IN ENT
CLINICS
GENERAL
CLINICS
Maximum in
One
session/PA
Maximum in
One
session/PA
Maximum
in One
session/PA
Without Patent
Administration
(i.e. separate
PA’s for clinic
administration)
With
Imbedded
Administration
(i.e. all admin
done within
clinic session
time)
Reduced by
25% when
teaching or
Supervising
To see the
cases and
teach
10
9 or 7
Consultant or
Associate
Specialist
20
minutes
per
patient
12
Higher Surgical
Trainee (ST3+)
(Must be
supervised)
ENT Specialty
Doctor (Must be
supervised)
20
minutes
per
patient
20
minutes
per
patient
12
12
N/A
Trust Doctor or
equivalent
(Must be
supervised)
20
minutes
per
patient
12
N/A
N/A
N/A
If reached
top of scale
will be
working as
“associate
specialist
equivalent”
see above
N/A
41 | P a g e
Supervised refers to the requirement for a consultant or associate specialist
(pre 2008) to be timetabled to be in every session undertaken by a junior
doctor (leave excepted). Speciality Surgeons (SDs) must be fully
supervised until the top of the scale has been reached.
Core Trainee
GP trainee
ST 1 and 2
“SHO”
No
Patients
Booked
There to be
taught and can
have 3-6
patients
booked
N/A
N/A
Sub Specialist
Clinics
Head and Neck
Skull Base
Advanced
Rhinology etc
30
Minutes
per
patient
8
N/A
6
CfWI,
2010(11)
Children and the elderly population are most reliant on otolaryngology
and will drive the requirement for those services. Over 60s are
increasing at the rate of 2% per year and under 19s at a rate of
0.5%).
Smoking is seen as a factor in prevalence of head and neck cancers.
Second hand smoke has links to laryngitis.
Research suggests a link between smoking and hearing loss.
ASH
Scotland,
2014(6)
Smoking across Scotland has declined, as well as adult second hand
smoke exposure, however more works need to be done to meet the
5% reduction target for 2034.
Clinical Outcomes
NHS
England,
2015(4)
Action plan objectives
1. To improve the hearing health of all communities, improve
equalities and reduce inequalities through prevention of hearing
loss; to ensure that diverse communities are aware of the
importance of good hearing and communication; and that
effective and up to date communication support is provided
promptly for those living with hearing loss to ensure they
realise their aspirations.
2. To improve the hearing health of all communities, improve
equalities and reduce inequalities through prevention of hearing
loss; to ensure that diverse communities are aware of the
importance of good hearing and communication; and that
effective and up to date communication support is provided
promptly for those living with hearing loss to ensure they
realise their aspirations.
3. To have services which are integrated, work collaboratively,
and focus upon the individual needs of the person with hearing
loss, inclusive of any other co-existing physical and mental
health conditions and pathologies, to provide a patient centred
management and decision making partnership.
4. To ensure that people with hearing loss, in all communities, are
supported to stay as well as possible and are included in all
42 | P a g e
approaches to reducing the incidence of other conditions and to
reduce the need for unscheduled healthcare and mitigate the
risk of isolation.
5. To ensure that people of all ages with hearing loss of all
severities are actively supported to participate fully in society,
and are not limited in their potential to succeed in education,
employment, family and community life, all facets of individual
living, and in the pursuit of sport, leisure and other activities.
Van de
Heyning,
2013(14)
British Cochlear Implant Group (BCIG) standards considered to be the
best practice. These standards have the same basic structure with the
two subdivisions – 1. Resource and 2. Processes
1. The resources are:
a. Team structure, accommodation, and clinical facilities
2. Processes can be split into 13 steps:
a. Referral and Selection
b. Assessment process
c. Cooperation with other services
d. Pre-op information and counselling
e. The device
f. Surgery and in-patient care
g. Fitting and tuning
h. Post op rehab and assessment
i. Follow up and long term maintenance
j. Device failure
k. Clinical management
l. Transfer of care
m. Patient feedback
NICE,
2015(5)
Current pathways and guidance for ENTare available in the following
categories:
• Ear and hearing conditions
• Ear nose and throadt conditions: general and other
• Nasal conditions
• Sleep apnoea and snoring
• Tonsil conditions
Gander,
2011(8)
The most common referral pathway for tinnitus was from general
practice to hospital based ENT and from there to hospital based
audiology department. This was generally effective but there was
room for improvement in GP referral and patients access to services.
CfWI,
2010(11)
Changes in practice driven by technology and greater use of day
surgery.
Other Service Attributes
Barnes,
2011(2)
Dundee model of Emergency ENT service involves consultants taking a
week at a time away from their elective surgical commitments in order
to directly participate in emergency care with the following results:
• Enhances outpatient services
• Beneficial effect on elective referral targets
• Valued by local GPs
43 | P a g e
•
•
ENT
Services
2008(12)
More efficient emergency service
Provides important educational opportunities
85% of ORL-HNS activity can be delivered in ambulatory care ie
outpatients and day surgery
A&E doctors with basic ENT training may deal with more minor ORLHNS emergencies at local hospitals. More serious conditions and those
requiring intervention can be stabilised and transferred to a main
centre with a 24 hour a day, 7 day a week ORL-HNS inpatient and
emergency service available.
Harris,
2013(9)
Providing an intensive same day assessment for Cochlear Implants
provides the following benefits:
• More efficient use of time
• Patient participation and satisfaction
• Efficiency savings (primarily in the time of the ENT consultant
and Specialist Nurse)
• Led by audiological/rehabilitation clinicians rather than the ENT
Consultant whose time is better used working only with those
patients going forward to surgery
• Same day discharge for patients who do not meet the criteria
Hagan,
2013(7)
Team structure for EAS (Electric Acoustic Stimulation) similar to that
for CI (Cochlear Implant) with some additional knowledge and skills:
a) Otologists (20 CI operations per year to maintain expertise)
b) Audiologists, clinical scientists, physiologists, speech and
language therapists, clinical physiologists, engineer, coordinator
c) Administrator/secretary
d) EAS implant head of service
For EAS implant team there should also be an experienced acoustician/
audiologists with specific experience of providing hearing aids to
profoundly deaf people. The EAS team should also have, or have close
clinical contact with: Hearing and acoustician services, Tinnitus,
Balance, Radiology, Medical Physics, Genetic Counselling, Psychology,
Psychiatry, Interpreter Services, Social Services for the deaf and deaf
advocacy.
ENT should also have appropriate accommodation with appropriate
technology/ and multi-modal telecoms access for hearing impaired
patients.
Van der Pol, Reporting on a comparison of costs of patients in Shetland using tele2010(3)
endoscopy vrs attending a clinic on the mainland the following bottom
line is provided in table 2 (pg 91):
Av cost
per
patient
Teleendoscopy
Mainland
Staff
Equipment
Disposables
Travel
Total
72.11
278.08
3.24
0
353.43
17.73
12.37
1.62
349
380.52
44 | P a g e
These costs are based on the costs of both the NHS and patients, and
on a minimum of 27 patients a year.
This model could be used for other mainland communities.
Kokesh,
2011(10)
Where there is a lack of access to medical specialty care, coupled with
a high prevalence of ear disease is important to develop innovative
ways to extend reach.
Store and forward telemedicine uses an asynchronous approach that
allows the sender to gather the data from the patient and then forward
to a consultant to review and reply at a later time. The form of
telemedicine provides for:
• Increased access
• Saved travel costs
• Improved quality
Eley,
2010(3)
In England and Wales direct GP referral to audiology clinics for hearing
aids were introduced (amongst other things) to reduce outpatients
waiting times and demand on ENT appointments. These direct referral
audiology clinics continues to provide a cost-benefit to the NHS and
reducing demand.
References:
1. Luxenbergerm W, Lahousen T, Mollenhauer H et al, 2014. Manpower and
portfolio of European ENT. European Archives of Otorhinolaryngology
271:599-606. (Accessed 29/07/2015)
2. Barnes ML, Hussain SSM, 2011. Consultant based otolaryngology emergency
service: a five-year experience. Journal of Laryngology & Otology 125:12251231. (Accessed 29/07/2015)
3. Eley KA, FitzGerald JE, 2010. Direct general practitioner referrals to audiology
for the provision of hearing aids : a single centre review. Quality in Primary
Care 18:201-6. (Accessed 29/07/2015)
4. NHS England, 2015. Action plan on hearing loss. Department of Health.
(Accessed 27/07/2015)
5. NICE, 2015. Ear, nose and throat conditions. (Accessed 27/07/2015)
6. ASH Scotland, 2014. Smoking in Scotland where are we now? ASH Scotland.
(Accessed 27/07/2015)
7. Hagan, R, 2013. Quality standards for combined electric and acoustic
stimulation. Cochlear Implant International 14:S2:S27-S33. (Accessed
27/07/2015)
8. Gander PE, Hoarre DJ, Collins L, et al, 2011. Tinnitus referral pathways within
the National Health Service in England : a survey of their perceived
effectiveness among audiology staff. BMC Health Services Research 11:62.
(Accessed 27/07/2015)
9. Harris F, 2013. Same day assessment for adult cochlear implant candidates.
Cochlear Implants International 14:S4:S52-S55. (Accessed 27/07/2015)
10. Kokesh J, Ferguson AS, Patricoski C, 2011. The Alaska experience using
store-and-forward telemedicine for ENT care in Alaska. Otolaryngology Clinics
of North America 44:1359-1374. (Accessed 27/07/2015)
11. Centre for Workforce Intelligence, 2010. Medical Specialty Workforce
factsheet : Otolaryngology. (Accessed 27/07/2015)
45 | P a g e
12. British Association of Otorhinolaryngologists - Head and Neck Surgeons,
2008. The provision of otorhinolaryngology and head and neck surgery
services in England. (Accessed 27/07/2015)
13. ENT UK. ENT Consultants and SAS Surgeons: recommended numbers for ENT
Clinics. ENT UK Website. (Accessed 27/07/2015)
14. Ven de Heyning P, Adunka O, Arauz SL, et al, 2013. Standards for practice in
the field of hearing implants. Cochlear Implants International 14: S2:S1-S5.
(Accessed 27/07/2015)
46 | P a g e
Gynaecology
For gynaecology services is there evidence that a. national, b. regional or
c. local level delivery produces the best outcomes?
Key points:
• Evidence located so far indicates that this service should be delivered at a
local level where possible for the best patient outcomes
Population Required
RCOG, 2012(1)
This RCOG report outlines the College’s position on the
future of the delivery of women’s healthcare. The central
message, for this piece of work, is summed up by the
following recommendation:
“Women need a specialist workforce that is able to work in
integrated clinical teams, providing care locally where
possible. Tomorrow’s specialists will work differently: in
teams with peers, providing on-site care 24 hours a day, 7
days a week, in non-hospital settings, as ‘localised where
possible, centralised where necessary’ becomes the norm.”
Clinical Outcomes
Choo , 2014(2)
This twelve month before and after study reports on the
reconfiguration of gynaecology services in Nottingham
University Hospital NHS Trust, which serves approximately
2.5 million individuals.
The centralisation of services at one hospital site and
emergency gynaecology at another was assessed based on
clinical outcomes, patient experience, staff satisfaction,
teaching / training / R&D, and value for money.
Main findings:
• 6% reduction in admissions
• 14% increase in free theatre sessions
• 84% increase in cancelled elective theatre procedures
• However, mean number of elective procedures
remained similar
• Reduction in patient length of stay on emergency
wards and reduction in waiting list time
• Significant increase in device related incidents (clinical
incidents)
• Consultants significantly more dissatisfied with
caseload and standard of care, also dissatisfied with
time / funding / opportunity for R&D
• No impact on trainee teaching
• Financial impact not reported
47 | P a g e
Other Service Attributes
FSRH, 2011(3)
Service standard document produced by the Faculty of
Sexual and Reproductive Healthcare which includes a total
of 11 different standards; including nurse lead care and
access to services.
References:
1. Royal College of Obstetricians and Gynaecologists, 2012. Tomorrow’s specialist.
RCOG. (Accessed 23/06/2015)
2. Choo T, Deb S, Wilkins J, Atiomo W, 2014. Evaluating the impact of the
reconfiguration of gynaecology services at a University Hospital NHS trust in the
United Kingdom. BMC Health Services Research 14:428. (Accessed 22/06/2015)
3. Faculty of Sexual and Reproductive Healthcare. Service standards for sexual and
reproductive healthcare. November 2011. (Accessed 22/06/2015)
48 | P a g e
Hospital Reduction
What evidence is there that whole hospital reduction produces improved
outcomes?
Key Points in response to the key question:
• There is little evidence around whole hospital reconfiguration, and much of
the evidence that does exist is out of date. In particular, there is a lack of
evidence that service reconfiguration can deliver significant savings and little
evidence regarding safe staffing models.
• Recent reviews suggest that smaller hospitals are not inherently less safe or
less efficient but that centralisation of some local hospital services and
development of supporting clinical networks can improve quality.
• New models of care for creating viable smaller hospitals are proposed in NHS
England, based on models in place in a few locations in Europe.
Population Required
The King’s Fund, Volume and outcomes
2014(1)
“The limited evidence on hospital size and quality shows no clear
link between size and outcomes ...
•There is no clear evidence that smaller hospitals (turnover of
less than £300 million) consistently perform worse on indicators
of quality (Monitor 2014)
• There is some evidence that greater volumes of care are
associated with better outcomes. But for most procedures, the
volume at which optimal results are achieved is generally below
that at which most hospitals operate (Posnett 2002). (page 21)
Imison, 2015(2)
Beds per population and hospital size international
comparisons
“Between 1998 and 2008, the number of acute care hospital beds
per 100,000 populations in Europe registered an average
reduction of 18%. However, the UK has one of the lowest
numbers of acute hospital beds per 100,000 in Europe: 239 beds
per 100,000 versus a European Union average of 361 beds and a
European Region average of 461 beds. The UK also has much
larger hospitals. The average hospital in England serves a
population of around 300,000, based on 172 hospitals with A&Es
and supporting inpatient services. This compares with an average
‘general hospital’ in the European Union that in 2011 served a
population of 54,000. (page 29)
Clinical Outcomes
The King’s Fund,
2014(1)
“The link between volumes of care and outcomes does not
necessarily demonstrate a causal relationship – there are small
units with good outcomes and vice versa. Volumes should not be
used in isolation as a justification for centralising care (Harrison
2012).
• ‘The existing research provides little support for concentrating
care in very large hospitals… This leads to a more complex
49 | P a g e
pattern of care with concentration of some functions but possible
dispersion of others’ (European Observatory on Health Care
Systems 2002).
• The precise relationship between inter-specialty links and
patient outcomes is poorly understood. In most countries,
guidelines are based on the opinions of the medical profession
rather than research evidence. Better research evidence is
needed in this area (Posnett 2002).
Large studies from the United States show that ‘critical access
hospitals’ serving rural populations, with an average of 18 beds,
had slightly higher mortality rates for acute myocardial infarction
(7.3 per cent), congestive heart failure (2.5 per cent) and
pneumonia (2 per cent) compared with other hospitals with an
average of 82 beds (Joynt et al 2011). Key factors were lack of
access to critical care and poor clinical processes rather than
volumes of care. Another study of surgical care showed that for
low-risk procedures, the outcomes at critical access hospitals
were the same as for other hospitals (Gadzinski et al 2013).”
(page 22)
Imison, 2015(2)
“The relationship between volume/size and efficiency is not clear,
though there is little current evidence to draw on. The most
significant work, by Posnett, is now over 10 years old. This
concluded that ‘On the basis of available research evidence,
bigger is not better: at present there is no reason to believe that
further concentration in the provision of hospitals will lead to
automatic gains in efficiency or patient outcomes’ (Posnett 2002,
page 1065).”
“The JCC argued that the ideal hospital would serve a population
of 450,000 to 500,000. At the time only 10% of hospitals were
this size. At this size, the JCC said, a hospital would have
sufficient staffing to provide the full range of acute specialties,
including acute medicine, acute surgery, trauma and
orthopaedics, obstetrics and gynaecology, paediatrics and a full
anaesthetic service including critical care. However, as Edwards
suggests, these assertions were based primarily on professional
judgement rather than research-based evidence. There has been
no significant attempt since to try to define an ‘ideal’ catchment
population for a hospital.” (page 28)
Other Service Attributes
The King’s Fund,
2014(1)
Workforce (including the impact on quality)
• “Acute providers are finding it difficult to recruit to a range of
consultant roles. Meeting guidelines on consultant-delivered care
would be near impossible with the current numbers of
consultants. Providers are increasingly working in
partnerships/networks with other providers to address workforce
shortages (Monitor 2014).” (page 22)
Finance
• There is no clear correlation between hospital size and financial
50 | P a g e
performance. While size of hospital may be an increasingly
important factor in explaining financial performance, several
other factors are likely to be influential (Monitor 2014) ...
The main financial benefit of seven-day services for hospital
trusts is reducing length of stay. But in our sample of trusts, the
savings did not cover the extra costs involved. Costs are usually
highest in smaller or more rural trusts (Healthcare Financial
Management Association and NHS England 2013).” (page 23)
Access
“A few studies suggest that greater distance to hospital is
associated with an increased risk of mortality once illness severity
has been taken into account. Nicholl et al (2007) found a 1 per
cent increase in mortality risk for each 10km increase in distance,
an effect that was amplified in people with respiratory distress.
• Some authors have described a ‘distance decay’ effect under
which distance from hospital services reduces patients’ utilisation
of them (services are taken less often or later). This impact is
disproportionately felt by those with low incomes, poor access to
transport, and by elderly people and people with disabilities
(Mungall 2005).” (page 24)
Technology
• “Telehealth can offer a number of potential benefits such as
reducing the need to travel to outpatient clinics, providing quicker
diagnosis, and avoiding referrals to hospital for diagnosis or
treatment. It also has the potential to deliver clinical services
more efficiently (Audit Scotland 2011).” (page 24)
The role of clinical networks
• “Networks offer a way of making the best use of scarce
specialist expertise, standardising care, improving access, and
reducing any ‘distance decay’ effects that can result from the
concentration of specialist services in large centres (Edwards
2002). ‘In successful networks of care built around specialist
children’s hospitals, children will receive the best quality of care
as close to where they live as possible’ (Kennedy 2010).
• There are examples from stroke, trauma, and neonatal services
of clinical networks improving outcomes and quality of care
(Morris et al 2014; Cameron et al 2008; Gale et al 2012).
• Clinical networks can take a long time to establish, can present
governance challenges, and require effective leadership and
shared processes in order to succeed (Ferlie et al 2011).” (page
24)
Key clinical and service interdependencies
“There have been various attempts to define the core set of
acute services required of a hospital, particularly to support local
A&E services (Darzi 2007; Royal College of Physicians 2007). In
both instances, the model covered A&E, acute medical care,
critical care and diagnostics (including computerised tomography
(CT) scanning).
The Healthcare for London model (Darzi 2007) also included
paediatric assessment. However, this model faces workforce and
financial sustainability challenges...” (page 25)
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Relevant college guidance
“Big is not necessarily better. Outcome measures for acute care
are being developed but, with the possible exception of major
trauma, we are not at the stage of providing robust evidence”.
(Academy of Medical Royal Colleges 2007)” (page 25)
Imison, 2015(2)
Workforce
There is a significant gap in the evidence about safe staffing
models and the appropriate balance of junior and senior medical
as well as other clinical staff. (page 105)
Finance
Finance is a primary driver of reconfiguration but there is very
limited evidence to suggest that reconfiguration will deliver
significant savings. .. (page 105)
Quality
Quality drivers have been subsidiary and often linked to
workforce numbers. It is the limits to medical workforce numbers
and financial considerations, not quality or access, that have set
the reconfiguration agenda. The patient voice, rather than
advocating and driving change, has been a major obstacle to the
changes proposed. (page 105)
Clinical co-dependency
“A key factor in determining the configuration of hospital services
is the clinical co-dependency between different services. This can
result in a domino effect whereby the loss of one service can go
on to destabilise the whole acute service provision in a hospital. A
key question is what is the ‘de minimis’ set of acute services in a
hospital, particularly to support local A&E services. There have
been a number of attempts to describe this. In both instances the
model included A&E, acute medical care, critical care and
diagnostics including computerised tomography (CT) scanning.
The Healthcare for London model also included paediatric
assessment..” (page 29)
Models of care
NHS England
2015(3)
“NHS England and Monitor will work together to consider whether
any adjustments are needed to the NHS payment regime to
reflect the costs of delivering safe and efficient services for
smaller providers relative to larger ones … building on the earlier
work of Monitor looking at the costs of running smaller hospitals,
and on the Royal College of Physicians Future Hospitals initiative,
we will work with those hospitals to examine new models of
medical staffing and other ways of achieving sustainable cost
structures … we will create new specialized models for smaller
acute hospitals that enable them to gain the benefits of scale
without necessarily having to specialize services. Building on the
recommendations of the forthcoming Dalton Review, we intend
to promote at least three new models:
In one model, a local acute hospital might share management
either of the whole institution or of their ‘back office’ with other
52 | P a g e
similar hospitals not necessarily located in their immediate
vicinity. These type of ‘hospital chains’ already operate in places
such as Germany and Scandinavia.
In another new model, a smaller local hospital might have some
of its services on a site provided by another specialized provider –
for example Moorfields eye hospital operates in 23 locations in
London and the South East. Several cancer specialist providers
are also considering providing services on satellite sites.
And as indicated in the PACS model [see below under Primary
Care], a further new option is that a local acute hospital and its
local primary and community services could form an integrated
provider. (Website section “new care models – viable smaller
hospitals”).
References:
1. King’s Fund, 2014. The reconfiguration of clinical services: what is the evidence?
King’s Fund. (Accessed 24/06/2015)
2. Imison C, Sonola L, Honeyman M et al, 2015. Insights from the clinical assurance
of service reconfiguration in the NHS: the drivers of reconfiguration and the
evidence that underpins it – a mixed study. Health Services and Delivery
Research 3(9). (Accessed 23/06/2015)
3. NHS England, 2015. New care model: viable smaller hospitals. High quality care
for all, now and for future generations. Chapter 3. (Accessed 29/06/2015)
53 | P a g e
Intensive care
For intensive care is there evidence that a. national, b. regional or c. local
level delivery produces the best outcomes?
Key points:
• The evidence located this far seems to indicate there would be some benefit
to delivering intensive care on a regional basis, with central co-ordination,
and use of tele-ICU, without detriment to patient outcomes.
• There does appear to be some consensus on the number of units per head of
population and consultant:patient and nurse:patient ratios.
• Further improvement and standardization of care could be delivered through
Clinical Decision Support Systems, enabling better adherence to guidelines
and improved patient discharge.
Population Required
Cronin, 2007(4)
Royal College of
Physicians, 2011(10)
Faculty of Intensive
Care Medicine ;
Intensive Care Society,
2013(3)
Monitor, 2014(2)
.... “to meet the needs of a population of 500 000 on 95% of
occasions would require 30 intensive care beds and 55 highdependency care beds if these were provided in a single unit;
and if they were provided in three separate units, the number
of beds would increase by 10%.” [No citation given in
text] (page 4)
The RCP recommends the population served by each WTE
consultant is 1:500,000 approx. In the Census of 2010 it was
estimated that Scotland had 1:600,000-1, 000,000.
“In general, the Consultant/Patient ratio should not exceed a
range between 1:8 – 1:15 and the ICU resident/patient ratio
should not exceed 1:8.” (page 4)
The Nurse /patient ration should not exceed 1:1, or 1:2
(dependent on level of care) (page 7)
“A Consultant in Intensive Care Medicine must be immediately
available 24/7, be able to attend within 30 minutes and must
undertake twice daily ward rounds”. (page 5)
▪ The provision of critical care is fairly similar across the regions
considered.
– In England as well as internationally, critical care is provided
through intensive care units (ICUs) that specialise in treating
critical cases.
– Many countries have defined 3 different levels of intensive
care units.
– Like in England, in the Netherlands and Sweden almost all
acute hospitals have ICU beds regardless of size
▪ The types of standards for ICUs in England are fairly similar to
other countries. While the exact targets may differ, most
countries have minimum nurse ratios, consultant availability
targets, pharmacy and network requirements. The one
exception is Arkansas, where there are only very basic
requirements for ICUs
▪ The different levels of ICUs allows in for standards and
recommendations to be set according to these levels, and many
54 | P a g e
Reed, 2014(8)
countries have done this.
– Victoria, Ontario, the Netherlands, and Sweden all set
different staffing and size requirements for the three ICU levels
– In England only the nurse ratios are dependent on patient
acuity.
▪ Where internationally comparable standards exist, England
generally has more lenient requirements
– England requires only 1 consultant per 15 patients, while
Germany, the Netherlands and Sweden have set stricter
standards.
– Similarly, the minimum requirement for the availability of
pharmacy services in England is Monday through Friday, while
other countries require 24/7 access.
▪ This is partly driven by the use of the acuity levels for ICU
standards in other countries. As standards in England are set
once for all level 2/3 ICUs, they need to be achievable for both
levels of care, thus generally lowering requirements. However,
even the international standards for lower levels of ICU are
similar or even stricter that in the NHS
▪ Critical care networks exist in England and abroad, but their
degree of implementation varies.
– In England, geographically remote ICUs should have an
established review/referral relationship with a larger centre.
– In Victoria and Ontario, the requirements for referral
agreements only hold for lower level care units.
– Critical care networks are mandatory in The Netherlands,
however implementation varies and agreements can be
unclear. To enable the delivery of a critical network,
transportation agreement and resources are vital. In the
Netherlands, six specialized mobile ICUs cover the transport of
critically ill patients across the country.
▪ Central coordination to optimise capacity utilisation is seen in
some countries.
– Victoria has a central coordinating body working with all
public and private hospitals in the state to coordinate critical
care capacity.
– In Ontario a real-time information system monitors all critical
care admissions in the province
▪ Like in the NHS, other countries are considering or have
implemented centralisation of critical care
– In the Netherlands, insurers are looking to centralise critical
care services and reduce the number of hospitals with ICUs
from 91 to 50
– In Toronto critical care services are centrally organised and
rely on transfers – however the facilities operate at ≥95%
occupancy and repatriation of patients is a major challenge
(Executive summary, page 1)
Reduced staffing by surgical intensivists may result in longer
mechanical ventilation and increased risk of venous
thromboembolism but no overall increase in morbidity and
mortality.
Clinical Outcomes
55 | P a g e
Welsh Government,
2013(13)
This Delivery Plan sets out initial national outcome indicators
and NHS assurance measures, which will indicate whether
progress is being made.
Percentage of general surgical patients with a predicted
mortality score of greater than 10% cared for outside critical
care. (page 14)
Deaths whilst awaiting critical care admission. (page 16)
Percentage of critical care discharges within 4 hours ready for
discharge time (page 20)
Publish data on outcome indicators and assurance measures on
websites (page 23)
Martinez, 2014(6)
A consensus approach was used to define 5 outcome measures
for broad use to evaluate quality of ICU care, and inform
quality improvement:
CLABSI: Central line associated bloodstream infection
MRSA: Methicillin-resistant Staphylococcus Aureus
PE: Pulmonary Embolism
PU: Pressure Ulcer
GIB: Gastrointestinal Beed
Stelfox, HT, 2015(11)
Clinical decision support for the discharge process, including
assessing patient readiness for discharge, will improve
outcomes for the patient, and standardize care across a system
Noguiera do Santos,
Clinical decision support may increase adherence to guidelines
2014(7)
(measured through quality indicators) and may improve
standardization of care.
Other Service Attributes
Fortis, 2014(5)
Tele-ICU offers a financial benefit and provides an opportunity
for 24/7 ‘intensivist’ standardized care across the system.
Abraham, 2012(1)
Patient safety could be improved at consultant handovers
though use of a communication framework.
Wallace, 2015(12)
“given the increasing role that interhospital transfer plays in
critical care, more efficient use of ICU beds may be obtainable
through regional planning, building off regional estimate” .
(Note regions in the US defined by the Dartmouth Atlas of
Healthcare www.dartmouthatlas.org)
Wunsch, 2011(14)
States that a comparison of UK and US ICU outcomes is not
advisable, as the criteria for entry to ICUs vastly different
between UK and US
Reriani, 2012(9)
24 hour care as opposed to on demand care “offers improved
processes of care and staff satisfaction and decreased ICU
complication rate… and hospital costs, but no change in ICU or
hospital mortality”
References:
1. Abraham J, Kannampallil TG, Parel VL, 2012. Bridging gaps in handoffs: a
continuity of care based approach. Journal of Biomedical Informatics 45:240254. (Accessed 30/06/2015)
2. Monitor, 2014. International comparisons of selected service lines in seven
health systems. Annex 3 – review of service lines: critical care. UK
Government (Accessed 28/06/2015)
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3. Faculty of Intensive Care Medicine, Intensive Care Society, 2013. Core
standards for intensive care units. (Accessed 30/06/2015)
4. Cronin E, Nielsen M, Spollen S, et al, 2007. Adult critical care. Health Care
Needs Assessment (HCNA). 3rd series. University of Birmingham.
(Accessed 04/06/2015)
5. Fortis S, Weinert C, Bushinski R et al, 2014. A health system-based critical
care program with a novel tele-ICU: implementation, cost, and structure
details. Journal of the American College of Surgeons 291:4:676-683.
(Accessed 30/06/2015)
6. Martinez EA, Donelan KM Henneman JP et al, 2014. Identifying meaningful
outcome measures for the Intensive Care Unit. American Journal of Medical
Quality 9:2:144-152. (Accessed 30/06/2015)
7. Nogueira dos Santos MAFR, Tygeson H, Eriksson JH, et al, 2014. Clinical
decision support system (CDSS) effects on care quality. International Journal
of Health Care Quality Assurance 27:8:707-718. (Accessed 30/06/2015)
8. Reed CR, Fogel SL, Collier BR, et al, 2014. Higher surgical critical care staffing
levels are associated with improved National Surgical Quality Improvement
Program quality measures. Journal of Trauma and Acute Care Surgery
77:1:83-88. (Accessed 30/06/2015)
9. Reriani M, Biehl M, Sloan JA, et al, 2012. Effects of 24-hour mandatory vs on
demand critical care specialist presence on long-term survival and quality of
life of critically ill patient in the intensive care unit of a teaching hospital.
Journal of Critical Care 27:421.e1-421.e7. (Accessed 30/06/2015)
10. Royal College of Physicians, 2011. Census 2010 Specialty Report.
(Accessed 30/06/2015)
11. Stelfox HT, Lane D, Boyd J, et al. 2015. Scoping review of patient discharge
from Intensive Care. Chest 142:2:317-327. (Accessed 30/06/2015)
12. Wallace DJ, Angus DC, Seymour CJ, et al, 2015. Critical care bed growth in
the US. A comparison of regional and national trends. American Journal of
Respiratory and Critical Care Medicine 191:4:410-416. (Accessed 30/06/2015)
13. Welsh Government, 2013. Together for health : a delivery plan for the
critically ill. A delivery plan up to 2016 for NHS. (Accessed 04/06/2015)
14. Wunsch H, Angus DC, Harrison DA, et al., 2011. Comparison of medical
admissions to intensive care units in the US and UK. American Journal of
Respiratory and Critical Care Medicine 183:1666-1573 (Accessed 30/06/2015)
57 | P a g e
Major trauma
For major trauma services, is there evidence that a. national, b. regional or
c. local level delivery produces the best outcomes?
Key Points:
• ‘Formalised systems of trauma care, in which care for the most complex
patients is centralised into a small number of trauma centres, improve patient
outcomes.’ King’s Fund (1) pg.60
Population Required
National Audit Office,
2010(2)
“International research shows that for a hospital to develop
and maintain optimal skills in major trauma it would need to
see 650 cases per year.” (page 30)
Royal College of
Surgeons of England,
2009(3)
“It is clearly recognised that there is a volume and outcome
relationship in major trauma care and it is recommended that
the MTC should see at least 400 major trauma patients each
year. Major trauma centres with a sufficient volume of work
to gain experience in managing these patients have a 15–
20% improvement in outcomes (at 600+ patients per year).
Conversely, low-volume MTCs have little impact on patient
outcomes. Each MTC should therefore serve a minimum
population of approximately 2–3 million people.” (page 11)
Clinical Outcomes
National Audit Office,
2010(2)
“The published literature suggests that where trauma systems
have been introduced, in-hospital mortality reduces by 15 to
20 per cent. On the basis of our estimate of 3,000 deaths in
hospital from major trauma each year, this suggests an
additional 450 to 600 lives could be saved each year across
England.” (page 8)
NHS England, 2013(4) Data from the 2013 Trauma Audit and Research Network
(TARN) national audit indicated that there was a 20%
reduction in mortality among severely injured patients since
the introduction of major trauma centres in England in 2012.
Other Service Attributes
Workforce
Centre for Workforce
Intelligence, 2011(5)
Staffing risks anticipated with the establishment of major
trauma centres have been identified for nurses, interventional
radiologists, emergency medicine doctors, and all
rehabilitation staff. (page 6-13)
Costs
National Audit Office,
2010(2)
“We estimate that major trauma costs the NHS between £0.3
and £0.4 billion a year in immediate treatment. The cost of
any subsequent hospital treatments, rehabilitation, home care
58 | P a g e
support, or informal carer costs are unknown. We estimate
that the annual lost economic output as a result of major
trauma is between £3.3 billion and £3.7 billion.” (page 4)
King’s Fund, 2014(1)
No evidence on the financial impact of moving to regional
trauma networks has been found (page 61)
Healthcare
Improvement
Scotland, 2013(6)
No evidence on the cost-effectiveness of major trauma
centres generalisable to the UK has been found.
References:
1. King’s Fund, 2014. The reconfiguration of clinical services: what is the evidence?
(Accessed 23/06/2015)
2. National Audit Office, 2010. Major trauma care in England. (Accessed
22/06/2015)
3. Royal College of Surgeons of England, 2009. Regional trauma systems: interim
guidance for commissioners. (Accessed 23/06/2015)
4. NHS England, 2013. Independent review of major trauma networks reveals
increase in patient survival rates. (Accessed 23/06/2015)
5. Centre for Workforce Intelligence Regional Trauma network Team, 2011.
Regional trauma networks. (Accessed 23/06/2015)
6. Healthcare Improvement Scotland, 2013. Major trauma centres as the core
component of a trauma service: technologies scoping report 17. (Accessed
23/06/2015)
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Maternity
For the maternity service, is there evidence that a. national, b. regional or
c. local level delivery produces the best outcomes?
Key Points:
•
•
•
•
•
RCOG recommend that maternity services should be locally delivered
RCOG and the RCM recommend a specific number of consultants and midwives,
respectively, based on the number of births/deliveries
Consultants (obstetricians) had the best outcomes for high risk/more complex
births and midwives for lower risk births
Economically midwives may be better employed in co-ordination with other
doctors or obstetricians
It has been suggested that task sharing among health professionals can result in
some cost savings in maternity units
Population Required
NICE, 2015(1)
Undertake a systematic process to calculate the midwifery
staffing establishment. The process (or parts of the
process) could be supported by a NICE endorsed toolkit (if
available). The process should contain the following
components:
• Use historical data about the number and care
needs of women who have accessed maternity
services over a sample period
• Estimate the total maternity care hours needed over
the sample period based on a risk categorisation of
women and babies in the service.
• Divide the total number of maternity care hours by
the number of women in the time period to
determine the historical average maternity care
hours needed per woman.
• Use data on the number of women who are
currently accessing the maternity service and the
trend in new bookings to predict the number of
women in the service in the next 6 months.
• Multiply the predicted number of women in the
service over the next 6 months by the historical
average maternity care hours needed per woman to
determine the predicted total maternity care hours
needed over the next 6 months.
• From the total predicted maternity care hours,
identify the hours of midwife time and skill mix to
deliver the maternity care activities that are
required.
NICE, 2015(1)
These recommendations are for registered midwives in
charge of assessing the number of midwives needed on a
day-to-day basis. As a minimum, assess the differences
between the number of midwives needed and the number
60 | P a g e
of midwives available for each maternity service in all
settings:
once before the start of the service (for example, in
antenatal or postnatal clinics) or
the start of the day (for example, for community visits), or
once before the start of each shift (for example, in hospital
wards).
This assessment could be facilitated by using a toolkit
endorsed by NICE.
During the service period or shift reassess differences
between the midwifery staff needed and the number
available when:
• there is unexpected variation in demand for
maternity services or midwifery care
• there is unplanned staff absence during the shift or
service
• women and babies need extra support or specialist
input
• a midwifery red flag event has occurred (page 24)
RCOG, 2012(2)
This RCOG report outlines the College’s position on the
future of the delivery of women’s healthcare. The central
message, for this piece of work, is summed up by the
following recommendation:
“Women need a specialist workforce that is able to work in
integrated clinical teams, providing care locally where
possible. Tomorrow’s specialists will work differently: in
teams with peers, providing on-site care 24 hours a day, 7
days a week, in non-hospital settings, as ‘localised where
possible, centralised where necessary’ becomes the norm.”
RCOG, 2010(3)
This RCOG document outlines the maternity standards set
out by the College and also by the NHS. It includes a useful
section / table which outline the number of consultants and
appropriate rotas required on labour ward based primarily
in relation to the number of deliveries / births.
Clinical Outcomes
Sandall, 2014(4)
This report published by the NHS National Institute for
Health Research (NIHR) examined the effect of the
maternity workforce in relation to service quality and
outcomes.
The report examined and analysed data from a number of
sources across NHS England and determined a total of ten
indicators, including patient satisfaction, healthy baby, and
healthy mother.
Among the conclusions made by the report were:
• Trust size or status was not significantly associated
61 | P a g e
•
•
•
•
Sandall, 2011(5)
with positive outcomes; although larger trust size
was associated with reduced healthy mother and
health mother /baby dyads and increased the
likelihood of childbirth interventions.
Greater numbers (or increased numbers) of doctors
had the greatest impact in high risk women
Greater numbers (or increased numbers) of
midwifes had the greatest impact in low risk women
The addition of support workers generally had a
negative effect on healthy mother /baby dyads in all
risk categories
Economically, midwives are best employed in
coordination with obstetricians and other doctors.
This report published by the King’s Fund reviews available
evidence on staffing in maternity units in relation to
outcomes. The report highlights that:
* task sharing across health professionals, including
nurses, doctors, midwifes, and support workers can result
in cost savings while maintaining safety
* midwives can be used across maternity services for low
and medium risk women/pregnancies meaning that
obstetricians can focus on more complex or high risk cases
RCM(6)
The BirthRate plus tool is endorsed by the RCM as a means
of assessing appropriate midwife staffing levels, skill mix,
and deployment in the community and acute settings.
Other Service Attributes
References:
1. NICE, 2015. Safe midwifery staffing for maternity settings. NG4. NICE, Feb 2015
(Accessed 04/06/2015)
2. Royal College of Obstetricians and Gynaecologists, 2012. Tomorrow’s specialist.
(Accessed 21/07/15)
3. Royal College of Obstetricians and Gynaecologists, 2010. Labour ward solutions.
(Accessed 21/07/15)
4. Sandall J, Murrells T, Dodwell M, et al, 2014. The efficient use of the maternity
workforce and the implications for safety and quality in maternity care : a
population-based, cross-sectional study. Health Service Delivery Research 2:38.
5. Sandall J, Homer, C, Sadler, E, et al, 2011. Staffing maternity units. Getting the
right people in the right place at the right time. King’s Fund. (Accessed 21/07/15)
6. Royal College of Midwives (No date provided). Birthrate plus: what it is and why
you should be using it. (Accessed: 22/07/15)
62 | P a g e
Medical Specialties
For the medical specialties, is there evidence that a. national, b. regional
or c. local level delivery produces the best outcomes?
Key Points: in response to the key question - from RCP 2013 (Ref 1):
Medical specialty
Acute internal medicine
Future organisation
(dominant in bold)
Local
General internal medicine
Local
Allergy
Local/ regional
Audiovestibular medicine
Regional/ national
Cardiovascular medicine
Local/ regional/
national
Clinical genetics
Regional/ national
Clinical neurophysiology
Clinical pharmacology
Dermatology
Regional/ national
Local/ regional
Local/ regional/
national
Local
Diabetes and endocrinology
Geriatric medicine
Haematology
Immunology
Infectious diseases
Medical oncology
Local/ regional/
national
Local/ regional/
national
Local
Local/ regional
Regional
Regional/ local
Regional/ national
Medical ophthalmology
Metabolic medicine
Neurology
Nuclear medicine
Regional/ local
National/ regional
Local/ regional
Regional/ national
Palliative medicine
Pharmaceutical medicine
Rehabilitation medicine
Renal medicine
Local/ regional
Regional
Regional/ local
Regional/ local/
national
Local/ regional/
Gastroenterology and
hepatology
Genitourinary medicine
Respiratory medicine
Population requirement
At least 3 acute
physicians per acute
hospital
At least 3 acute
physicians per acute
hospital
1 + 1 paediatric WTE per
250000
1 + 1 paediatric WTE per
250000
1:6 on call rota for
250000. 3 paediatric
WTE per million.
Service for population of
1 to 5 million
1 WTE per 300000
1 WTE per 250000
4 WTE per 250000
Specialist diabetic service
in DGHs. Physicians
share general medicine
commitment
6 WTE (with medicine)
per 250000
2 WTE per 250000
5 WTE per 250000
3 WTE per 250000
10 WTE per 5 million
1 WTE per 250000
2.75 WTE per 200250000
1 WTE per 250000
New specialty (TBC)
3.6 WTE per 250000
30-35 WTE per 5 million
(hub & spoke)
2 WTE per 250000
No specification
1.5 WTE per 250000
50 WTE for 5 million
7 WTE per 250000
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Rheumatology
Sport & exercise medicine
Stroke medicine
national
Local/ regional
Regional
Local/ regional/
national
3 WTE per 250000
2 WTE per 300000
35 WTE stroke
specialists for 5 million
Population Required
RCP 2013 (1)
As above
Clinical Outcomes
Future Hospital
Commission
2013 (2)
“Patients who do not fit clinical criteria for a specific specialist
medical admission pathway should benefit from receiving
continuing, coordinated care delivered by a trained generalist
(acute or (general) internal medicine or geriatric medicine
physician) with in many cases specialists adopting a clearly defined
consulting and intervention role. In these circumstances, specialty
teams would reduce the number of inpatients for whom they have
ongoing care (specifically relinquishing their complex older
patients) and release bed capacity and trainees to generalist
teams.” (pages 41-42)
“There is extensive evidence of improved patient outcomes with the
use of early specialist care and treatment pathways for specific
acute medical conditions, including stroke and acute
coronary syndrome. This has led many national guidelines to
support admission of patients with certain defined conditions to
specialist units via fast-track pathways to specialist units.2,3 The
improved outcomes may, however, be less marked in older
patients or those with significant comorbidities. In the future
hospital, every effort will be made to enhance specialist pathways
that benefit patients, including entering the pathway direct from the
community or the emergency department (ED). Patients identified
on the acute medical unit (AMU) as meeting criteria for a specialist
pathway may see an acute physician before a specialty consultant;
however, the responsibility for continuing care resides with the
latter, who should review the patient on the day of admission.”
(page 43)
“For many patients with chronic conditions, acute exacerbations
are common. Ongoing monitoring and care provided by primary
care and specialist medical teams seek to reduce the frequency
and acuity of these acute exacerbations. For these patients, the
Medical Division of the future hospital will need to facilitate
community access to the specialist teams to support patientcentred management. Therefore the specialties will support, 7 days
a week, community services for home-based or self-management
of chronic conditions, rapid access ‘hot’ clinics or ‘frailty’ units for
immediate investigation and review, including exclusion of
conditions, fast-track pathways for proven intervention and
aftercare services, and in-reach services to all medical wards
including the Acute Care Hub or agreed pathways.” (page 43)
64 | P a g e
London 2012
(3)
Delivery of a 12/7 consultant presence on the AMU should be a
priority for all staff involved in the planning and delivery of acute
medical services. The numbers of consultants required will depend
on: the size and structure of the unit, the patient illness acuity, and
the numbers of patient contacts on a daily basis. Most units will
require continuing expansion in AMU consultant numbers.
However, integrated working arrangements combining acute
physicians with specialty/ general physicians will help to achieve
sustainable consultant rotas, optimise continuity, and ensure highquality patient care.
Other Service Attributes/ models of care
RCGP 2012 (4)
Expert generalists are essential for excellent integrated, personcentred care. New ways of working and training are required to
meet requirements of the model of excellence.
Health
Foundation/
RCGP 2011 (5)
“If generalism has a future, which the Commission believes it does,
then that future will depend on coming generations of doctors being
trained in its skills and techniques. ... trainee doctors will need to
dwell much less on narrow disease silos and to focus much more
on the breadth of possible permutations of co-morbidity ... In the
Netherlands, GPs are expected to be proficient in diagnosis and
treatment of all diseases (some 400) occurring on average in two
or more patients per 1,000. (page 20)
CWI 2015 (6)
This preliminary work describes some early future scenario
work and highlights potential risks in the system of an
oversupply of CCT doctors for hospital-based specialties. This
needs to be carefully considered and planned for.
References:
1. Royal College of Physicians London. 2013. Consultant physicians working
with patients: the duties, responsibilities and practices of physicians in
medicine. Revised 5th edition (online update). Accessed 21.7.15
2. Future Hospital Commission. 2013. Future hospital: caring for patients – A
report from the Future Hospital Commission to the Royal College of
Physicians. Chapter 4 Staffing the medical division: an increased role for the
generalist and specialist. Accessed 30.7.15
3. Royal College of Physicians London. 2012. Acute care toolkit 4: Delivering a
12 hour 7 day consultant presence on the acute medical unit. Accessed
21.7.15
4. Royal College of General Practitioners. 2012. Medical generalism: why
expertise in whole person medicine matters. Accessed 30.7.15
5. Health Foundation/ Royal College of General Practitioners. 2011. Guiding
patients through complexity: modern medical generalism.
6. Centre for Workforce Intelligence. 2015. In-depth review of the acute medical
workforce. Accessed 21.7.15
65 | P a g e
Neonatal
For the neonatal service, is there evidence that a. national, b. regional or c.
local level delivery produces the best outcomes?
Key Points:
• There is a clear indication that specialist neonatal care should be provided on
a regional level
o However this is dependent on volume
o Also dependent on distant to travel/transfer
• Neonatal care would also benefit from national standards and definitions
• Special attention should be made of areas of deprivation and links to
premature birth/anomalies
• There is also clear guidance on the staffing ratios
• Telemedicine has a clear role to play in the provision of care, it is also used
for inclusion of parents in their babies care, as well as audit and training.
Population Required
BAPM, 2014 (10)
BAPM, 2010 (8)
NICUs in the UK should admit at least 100 very low
birth weight infants per year
• NICUs in the UK should undertake at least 2000 days
of respiratory support per year
• All UK NICUs should comply to existing standards of
nurse to baby ratios and cot occupancy as well as
those related to family and parent quality of
experience
• Units with more than 7000 deliveries should augment
their tier 1 medical support
• NICUs undertaking more than 2500 Intensive care
(IC) days per annum should augment their tier 2
medical cover and provide two consultant led teams
during normal hours
• Neonatal consultant staff should be available on site
in all NICUs for at least 12 hours a day and for units
undertaking more than 4000 intensive care days per
annum consideration should be given to 24 hour
consultant presence.
Nurse: Baby ratios
Intensive Care – 1 nurse: 1 baby
High Dependency – 1 nurse: 2 babies
Special Care – 1 nurse: 4 babies
•
Medical Staff – 3 tiers
Tier 1 – Junior roles
Tier 2 – Competent onsite clinician
Tier 3 – Expert
Staffing:
Special Care Unit:
Tier 1: 8 staff who may also cover paediatrics
Tier 2: shared rota with paediatrics, minimum of 8 staff
Tier 3: A minimum of 7 consultants on the on call rota with
a minimum of 1 consultant with a designated lead interest in
66 | P a g e
neonatology
(Tiers 1 and 2 may be merged where there is appropriate
skilled nursing support)
Local Neonatal Units:
Tier 1: 8 staff who do NOT cover paediatric also
Tier 2: shared paediatric rota, minimum of 8
Tier 3: Minimum of 7 consultants on the on call rota with a
minimum of 1 consultant with a designated lead interest in
neonatology
If there is significant distance between local and special care
then staffing should be enhanced
NICU:
No cross over of any staff with paediatrics:
Tier 1: Minimum of 8
Tier 2: Minimum of 8
Tier 3: A minimum of 7 consultants on the on call rota with
resident consultants on the tier 2 rota additional to this
number.
This number should be adjusted for size of NICU
MSAG, 2009 (9)
Brown, 2014 (12)
Ravelli, 2011 (13)
“There is strong evidence from primary research that
treatment in units with larger volumes is associated with
improved survival:
• Neonates <29 weeks, or <1,500g should be treated
in specialist intensive care units, especially between
12 hours and 72 hours of life
• Specialist units (providing intensive care) should
have a reasonable expectation of >50 annual
admission of neonates <1,500g
With the exception of analyses between volume and
outcome, evidence is based on policy and expert opinions,
and supports:
• Adoption of national standards for service provision
• The implementation of designated levels of care for
each neonatal unit
• Development of networked services, at a regional
level
• The need for robust routine data collection
• The optimum staffing for babies requiring full
intensive care is one baby: one nurse ratio; their
should be a dedicated neonatal consultant rota.
“GIS (Geographical Information System) mapping enables
health providers and health policy makers to better
understand maternal ground transport times to current and
future regional hospitals offering level III neonatal services”
“A travel time from home to hospital of 20 minutes or more
by care is associated with an increased risk of mortality and
67 | P a g e
Quality Indicators
NICE, 2010 (14)
adverse outcomes in women at term in the Netherlands.
These findings should be considered in plans for
centralisation of obstetric care”.
Statement 1. In-utero and postnatal transfers for neonatal
special, high-dependency, intensive and surgical care follow
perinatal network guidelines and care pathways that are
integrated with other maternity and newborn network
guidelines and pathways.
Statement 2. Networks, commissioners and providers of
specialist neonatal care undertake an annual needs
assessment and ensure each network has adequate
capacity.
Statement 3. Specialist neonatal services have a sufficient,
skilled and competent multidisciplinary workforce.
Statement 4. Neonatal transfer services provide babies with
safe and efficient transfers to and from specialist neonatal
care.
Statement 5. Parents of babies receiving specialist neonatal
care are encouraged and supported to be involved in
planning and providing care for their baby, and regular
communication with clinical staff occurs throughout the care
pathway.
Statement 6. Mothers of babies receiving specialist neonatal
care are supported to start and continue breastfeeding,
including being supported to express milk.
Statement 7. Babies receiving specialist neonatal care have
their health and social care plans coordinated to help ensure
a safe and effective transition from hospital to community
care.
Statement 8. Providers of specialist neonatal services
maintain accurate and complete data, and actively
participate in national clinical audits and applicable research
programmes.
Statement 9. Babies receiving specialist neonatal care have
their health outcomes monitored.
Gustavsson, 2015(7)
“Healthcare staff and patient experience different problems
and a collaborative approach is needed to capture all areas
requiring improvement in the patient processes”
Categorising problems into simple, complicated and complex
helps with the process and identifying appropriate
improvement interventions.
Other Service Attributes
Quality Standards
“This assessment reviews the potential cost impact and
Programme, 2010(15)
implications for commissioners and service providers of
the NICE quality standards for specialist neonatal care.”
No summary available, please see the full text.
Smith, 2010 (16)
“Neonatal deaths would be 39% lower if all areas had
the same neonatal mortality rates as the least deprived
areas… wide socioeconomic inequalities existed in
deaths due to congenital anomalies and immaturity…
and these cases accounted for more than three quarters
68 | P a g e
Isetta, 2013 (2)
Minton, 2014 (4)
Cheldelin, 2013 (3)
Watson, 2014 (5)
Models of Care
Scottish Government,
2013(1)
Scottish Government,
2013 (1)
Katsenberg, 2015 (6)
of the deprivation gap in all cause mortality”
Using an internet-based approach to monitor babies
post discharge is both more effective and less costly
compared to a hospital based follow-up, particularly
through reducing subsequent ED visits.
Using technology to improve the parent experience
while their baby is in NICU – using two-way cameras
allowing parents unable to be at the hospital a view of
their baby and communicate with their care givers. The
same technology could also be used for audit and
teaching especially for resuscitation.
The method of obtaining feedback from patients (Mail v
telephone) will determine the number of responses and
consequently the accuracy of opinion (and more
positive feedback) with telephone feedback being the
preferred method.
The single family room vrs open bay model provides for
both parent and staff satisfaction with care.
A high quality neonatal service within Scotland will
provide equity of access and equity of care through the
development of three regional Managed Clinical
Networks (MCNs). Care will be provided to all groups of
the population, taking account of all protected
characteristic groups covered by the Equality Act 2010.
The Scottish Neonatal MCNs will support an equitable
service through service agreements which ensure
appropriate care can be accessed by all babies who
require it; cross-boundary working between regions to
ensure optimal patient care; equitable provision of
support to parents and appropriate transfer and
transport of babies. (page 7)
Women likely to give birth to very preterm babies
should be encouraged to give birth at a specialist
hospital with the highest levels of neonatal care. There
is strong evidence that neonatal support can be safely
provided by non-medical paediatric staff. However, the
use of alternative models – where advanced neonatal
nurse practitioners (ANNPs) provide this support to
obstetric units instead of paediatricians – remains
limited to a very small number of hospitals in England
due to a lack of systematic workforce development. This
model has enabled obstetric units to continue on sites
where paediatric inpatient services have been closed.
From 1976 the US saw an increasing regionalisation of
care utilising a 3 tier system that required the
identifications and subsequent transfer of infant
requiring levels of care. This factored into a decline in
overall preterm infant mortality rates. Changes in the
market forces have now moved the US into a process of
deregionalisation seeing more ‘low level’ NICUs taking
care of very low weight infants. The preference is for
69 | P a g e
Nowakowski, 2012 (11)
high risk infants is for regionalisation allowing for more
accurate assessment of novel therapies in controlled
settings with uniform treatment protocols. This would
require robust triage.
Regionalised care of VLBW infants should be supported
by national standards and definitions.
References:
1. Scottish Government, 2013. Neonatal care in Scotland: a quality framework.
Scottish Government. http://www.gov.scot/Resource/0041/00415230.pdf
(Accessed 04/06/2015)
2. Isetta, V., Lopez-Agustina, C., Lopez-Bernal, E., et al, 2013. Cost
effectiveness of a new internet-based monitoring tool for neonatal postdischarge home care. Journal of Medical Internet Research 15:2:e38.
Accessed 31/07/2013
3. Cheldilin, LV., Dunham, S., Stewart, V., 2013. NICU patient satisfaction: how
you measure counts. Journal of Perinatology 22: pp324-326. Accessed
31/07/2015.
4. Minton, S., Allan, M. Valdes, DO., 2014. Teleneonatology: a major tool for the
future. Pediatric Annals 43:2. Accessed 01/08/2015
5. Watson, J., Gibbon, S., York, E., Robson, K., 2014. Improvements in staff
quality of work life and family satisfaction following the move to single-family
room NICU design. Advanced in Neonatal Care 14:2: pp129-136. Accessed
01/08/2015
6. Katsenberg, ZJ., Lee, HC., Profit, J. Effect of deregionalized care on mortality
in very low-weight infants with necrotizing enterocolitis. JAMA Pediatrics
169:1:pp26-32. Accessed 31/07/2015
7. Gustavsson, SMK., Improvements in neonatal care; using experience-based
co-design. International Journal of Health Care Quality Assurance 27:5”
pp427-438. Accessed 31/07/2015
8. British Association for Perinatal Medicine, 2010. Service standards for
hospitals providing neonatal care, 3rd edition. Accessed 31/07/2015
9. Maternity Services Action Group (MSAG): Neonatal services sub group: review
of neonatal services in Scotland, 2009. The Scottish Government. Accessed
31/07/2015.
10. British Association for Perinatal Medicine, 2014. Optimal arrangements for
neonatal intensive care units in the UK including guidance on their medical
staffing: a framework for practice. Accessed 31/07/2015
11. Nowakowski, L., Barfield, WD., Kroelinger, CD., et al., 2012. Assessment of
state measures of risk appropriate care for very low birth weight infants and
recommendations for enhancing regionalised state systems. Maternal Child
Health 16:pp217-227.
12. Brown, SA., Richards, ME., Elwell, EC., Rayburn, WF., 2014. Geographical
information system for mapping maternal ground transport to level III care
neonatal centers. American Journal of Perinatology 31:287-292.
13. Ravelli, ACJ., Jager, KJ., de Groot, MH., et al., 2011. Travel time from home
to hospital and adverse perinatal outcomes in women at term in the
Netherlands. BJOG: An International Journal of Obstetrics & Gynaecology
118:4:pp457-465. Accessed 01/08/2015
14. NICE quality standard [QS4], 2010. Specialist neonatal quality standard.
Accessed 01/08/2015. Accessed 01/08/2015
70 | P a g e
15. Quality Standards Programme, 2010. NICE cost impact and commissioning
assessment: quality standards for specialist neonatal care. National Institute
for Health and Clinical Excellence. Accessed 01/08/2015
16. Smith, LK., Monktelow, BN., Draper, ES., et al., 2010. Nature of
socioeconomic inequalities in neonatal mortality: population based study.
BMJ 341:c6654. Accessed 01/08/2015
71 | P a g e
Neurosurgery
For neurosurgery services, is there evidence that a. national, b. regional or
c. local level delivery produces the best outcomes?
Key Points:
• The evidence suggests that a concentration of specialists within a single site
improves patient outcomes.
• There is evidence on the number of beds, units and consultants per
population e.g. for a population of 5 million 4 units of 6 consultants would be
required.
• Given the numbers provided a regional or national approach would be
required.
• To improve patient outcomes the time to treatment for head/brain injuries in
the emergency department is key, and timely transfer to specialist service.
Population Required
Safe Neurosurgery,
2000(1)
NHS England, 2013(2)
Desai, 2012(3)
Quality Indicators
NICE, 2014(4)
30 beds per million population has to be viewed as the
minimum safe standard in 2000; 4 dedicated
neurosurgical intensive therapy unit (NITU) beds per
million population are now regarded as the safe
minimum standard
The minimum requirement for full 24 hour consultant
led service is 1 Whole Time Equivalent (WTE)
neurosurgeon per 200,000 population. Small units
serving populations of 1.0 to 1.2 million should have a
minimum of six consultant neurosurgeons.
A minimum of 30 neurosurgical Level 1 and 2 beds are
required per million population to ensure timely and
equitable access to inpatient care and to maintain a safe
service.
Neurosurgical units must be staffed by nursing and
allied healthcare professional with specific training in the
clinical neurosciences and neurosurgery.
All units require a minimum of two fully resourced
dedicated operating theatres and immediate access to
an emergency (National Confidential Enquiry into
Patient Outcome and Death (NCEPOD) theatre.
A higher density of neurosurgeons is related to a
reduced number of deaths due to motor vehicle
accidents
•
•
•
People attending an emergency department with a
head injury have a CT head scan within 1 hour of a
risk factor for brain injury being identified.
People attending an emergency department with a
head injury have a CT head scan within 8 hours of
the injury if they are taking anticoagulants but have
no other risk factors for brain injury.
People attending an emergency department with a
head injury have a CT cervical spine scan within 1
hour of a risk factor for spinal injury being
72 | P a g e
Birmingham NHS(5)
Shah et al, 2013(6)
NHS England, 2013(2)
NHS England, 2013(8)
indentified.
• People attending an emergency department with a
head injury have a provisional written radiology
report within 1 hour if a CT head or cervical spine
scan is performed
• People with a head injury who have a Glasgow
Coma Scale (GCS) score of a 8 or lower at any time
have access to specialist treatment from a
neuroscience unit.
• People who are in hospital with new cognitive,
communicative, emotional, behavioural or physical
difficulties that continue 72 hours after a traumatic
brain injury have an assessment for inpatient
rehabilitation.
• Community-based neuro-rehabilitation services
provide a range of interventions to help support
people (aged 16 and over) with continuing cognitive,
communicative, emotional, behavioural or physical
difficulties as a result of a traumatic brain injury.
• Post acute phase rehabilitation for children and
young people.
Time from emergency admission with sub-arachnoid
haemorrhage to surgery or coiling, including cases
where intervention was deferred for medical reasons.
Re-admission rates should not be used as indicators of
quality for neurosurgical services.
pp.2-4 gives a comprehensive list of NICE clinical
guidance on neurosurgical procedures including coil
embolisation, deep brain stimulation and head injury
p.2 gives a list of standard paediatric neurosurgical
services which form the basis for this contract.
Other Service Attributes:
Royal Free London &
Transfer of service from local NHS to a national
UCLH NHS, 2012(7)
specialist neurosurgery services – greater density of
neurosurgeons on one site (some reference is also
made to Quality Indicators to promote this as a model)
References:
1. Safe Neurosurgery 2000. A report from the Society of Neurological Surgeons.
(Accessed 01/06/2015 – although this reference is fairly old it is still listed as a
current publication on the website)
2. NHS England, 2013. D03/S/a NHS standard contract for Neurosurgery (adult)
Schedule 2 – The Services – A. Service Specification. NHS England, Department
of Health (Accessed 01/06/2015)
3. Desai A, Bekelis K, Zhao W, et al, 2012. Increased population density of
neurosurgeons associated with decreased risk of death from motor vehicle
accidents in the United States. Journal of Neurosurgery 117(3):599-603.
(Accessed 01/07/2015)
4. NICE, 2014. NICE quality standard [QS74] Head Injury. (Accessed 01/07/2015)
5. University Hospitals Birmingham (No date provided). Neurosurgery quality
indicator. (Accessed 01/07/2015)
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6. Shah MN, Stoev IT, Sanford DE, et al, 2013. Are re-admission rates on a
neurosurgical service indicators of quality care? Journal of Neurosurgery
119(4):1043-9. (Accessed 01/07/2015)
7. Royal Free London NHS Foundation Trust, University College London NHS
Foundation Trust, 2012. Proposed changes to neurosurgery provision in North
Central London. Paper for the JHOSC meeting on 28th May 2012. (Accessed
01/06/2015)
8. NHS England, 2013. E09/S/a NHS standard contract for Paediatric Neurosciences:
Neurosurgery Schedule 2 – The Services – A. Service Specifications. NHS
England, Department of Health. (Accessed 22/06/15)
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Ophthalmology
For ophthalmology services, is there evidence that a. national, b. regional
or c. local level delivery produces the best outcomes?
Key points:
• hospital ophthalmology services stretched to capacity
• rates of avoidable sight loss rising (due to rising numbers of older people and
rising numbers of health conditions leading to sight threatening conditions)
• sight threatening conditions are more prevalent amongst those in areas of
socioeconomic deprivation as well as older people and those in particular races)
• services are fragmented because of reliance on private-sector optometrists
• proposed solutions include increased funding to primary care sector, redirecting
resources towards areas of socioeconomic deprivation, and improving pathways
between optometrist/ophthalmologist/GP
NB Some of the results in this table lie outwith the last 5 years because
ophthalmology services have developed since a service review which was
commissioned in 2004
Population Required
Malik, 2013(14)
•
•
•
•
•
•
•
•
•
•
UK Public Health Outcomes Framework for England
2013 – 16 published – outcome measures include
preventable sight loss
However efficiency savings announced of £20 billion in
next 3 years
Variation in expenditure identified in ophthalmology
across the country
UK Vision Strategy published in 2008 – collaboration
between wide range of professionals and supplemented
at local level
Knowledge gap exists about patient outcomes
Burden on eye care services increasing
Ophthalmic procedures account for 6% of procedures
performed by NHS – geographical variation
Drug costs - major issue in future (eg drugs for age
related macular degeneration approved by NICE)
Role of clinicians essential in future for allocating
resources
Improving primary care structures is vital – plus
stronger networks of care between community and
hospital
Population approach –
• Aim – to address inequalities
• Integration requires network of organisations and
professionals
• Resources focused on those with greatest need
• Programme budgeting and population planning to allow
for investment in correct areas
75 | P a g e
Achieving
Commissioning
Excellence, 2013(1)
•
•
•
•
•
•
•
•
•
•
College of Optometrists,
2014(26)
•
•
•
•
•
•
•
“Eye care services lend themselves to new ways of
working, for example, moving services traditionally
provided in hospital to the community, streamlining
pathways to remove unnecessary steps, and
introducing new roles in acute care settings”.
Eye disease is more common in older people; some
conditions are more common in ethnic groups; evidence
is growing for a socio-economic link with eye disease
Diabetes, smoking – related to eye disease
The condition-specific pathways show opportunities for
improving efficiency
The UK Vision Strategy sets the direction for improving
standards, and eye care is one of the four clinical
priorities adopted by the Royal College of General
Practitioners for 2013-16
Gloucestershire as an example of an area which
redesigned cataract services, with ‘substantial’ increases
in efficiency
in conjunction with Royal Colleges, some hospital
departments have re-engineered the pathway to cope
with rising growths in demand, as well as introducing
new outpatient department roles
locally agreed arrangements in conjunction with private
sector
it is suggested that commissioners (in England) may
wish to consider establishing a lead contractor role, and
commissioning the whole service (rather than its
elements), as well as establishing clinical networks that
involve the whole pathway, as well as working with
communities in dealing with prevention
NHS England experiences varying costs across the
regions for hospital eye care services (eg costs of
surgery)
Numbers of those affected by sight loss predicted to
rise by 22% by 2020, and to rise by almost double by
2050 – main factor is ageing population
Costs set to increase due to demographics
Ophthalmology has third highest attendances at outpatient clinics
Demand for hospital eye emergency services rising
PEARS scheme (Primary Eye-care Assessment and
Referral Service), is an enhanced service offered by
participating optometrists for dealing with certain eye
conditions. Scheme has been introduced in various
areas in England and Wales
Lack of integration of services – local consultations
identified people waiting up to 2 years to be seen by
local teams following local eye clinic referral
A project is being developed in 3 areas of England to
assist with commissioning of eye services
76 | P a g e
•
•
•
UK Vision Strategy,
2014(35)
•
•
Ratnarajan, 2013(22)
•
•
•
•
•
•
Ratnarajan, 2013(21)
•
•
•
•
•
•
“What can London learn from other cities globally about
improving the quality of healthcare?”
o “Models of community eyecare, based on
national pathways”
Scotland is rolling out a programme using Electronic
Referral with Digital Images System – photograph of
people’s eyes can be emailed to hospital department
Increased promotion in form of public health campaigns
(as over half of sight loss is preventable)
UK Vision Strategy published in 2008 as response to
VISION 2020 aims to eliminate avoidable blindness by
2020
Guidance as a result of project run in 3 areas of
England – guidance and also support tools to assist all
involved to maximise outcomes for the local community
NHS Act of 1951 did not integrate optometry services
into the NHS and introduced charging for glasses
Describes the evolution of eye care services in UK, as
well as gaps which exist in services today
Socially deprived are not being identified
Targeted surveillance of the high-risk and enhanced
service delivery systems at the primary and secondary
care interface may help to bridge this gap between
optometry and ophthalmology
NHS Diabetic Eye Screening Programme introduced, but
similar initiatives have yet to be introduced to the other
referral categories (cataract, glaucoma, macular
degeneration)
Author raises question of re-organization of the delivery
of eye health
Eye health service disintegrated because primary eye
care function delegated to opticians
Poor communication exists between primary
(optometry) and secondary (hospital) care –can lead to
mismanaged follow-up care
Geographical distribution of opticians away from poorer
areas – those with eye disease may not be identified
Greater demand because of ageing population
Glaucoma is the most common reason for referral to
ophthalmology departments in UK – optometrists could
play more of a role thereby reducing burden on hospital
eye services - optometrists with extra training have
started to deal with these patients but the quality of
such schemes varies – plans to address this currently
by providing evidence on current schemes and creating
a national framework and clinical guidance (NHS
England)
Policy changes in Scotland and Wales have already
allowed optometrists to play more of a role
77 | P a g e
UK Vision Strategy,
[2013?](33)
•
•
•
•
•
•
•
•
ISD, 2013(12)
•
•
•
•
•
•
Association of
Optometrists, 2012(2)
•
UK Vision Strategy launched 2008
Sight loss and eye health costs £8 billion each year
(RNIB, 2013a)
Community initiatives have been set up to tackle
inequalities
Across the UK there is variation in spending, treatment
and quality of service for eye conditions
In England, groups are working at a local level to
deliver the UK Vision Strategy
Service redesign has been identified in different
geographic areas
Relatively small amounts spent on
promotion/prevention
Three major causes of avoidable sight loss: glaucoma,
age-related macular degeneration and diabetic
retinopathy – rates tracked since 2012
Provides information about trends in NHS eye
examinations across Scotland from 2006/07 to 2013/14
The report provides figures for the patient journey and
shows that 80% of patients were dealt with in a
primary care setting without further investigation
The report provides a breakdown of figures for each
NHS Board area in Scotland
The figures reveal that there is an increase in the
number of patients recorded with sight-threatening
conditions (“Between 2006/07 and 2013/14, the
recorded numbers of patient clinical conditions
(diabetes, glaucoma /hypertension or is over 40 and
has a relative who suffers from glaucoma) have
continued to increase”)
Report shows that the number of referrals to a GP has
decreased during this timeframe
The highest-ever number of eye examinations was
recorded in 2013/14 and most patients were not
referred for further investigation
Report summary states that
o blindness and partial sight costs Scotland over
£2 billion annually
o the benefits of free eye exams are approx £440
million annually
o nearly 300,000 extra people have eye
examinations annually
o there are around 155,000 people in Scotland
with low vision, and this figure is predicted to
rise (as the incidence is higher in older people
and the average age in Scotland is predicted to
rise). The increased incidence of diabetes will
also place pressure on low-vision services
o The aim of the new eye examination was to
move the balance of care towards optometrists.
78 | P a g e
o
o
However no study has confirmed whether there
has been an overall saving to the NHS
The Access Economic Report predicts the
proportion of conditions to be remediable to be
between 60% and 84%
The full benefits are unlikely to be felt or
measurable for many years
Scottish Executive,
2005(32)
•
It is recognised that different approaches will need to
be taken at the local level to account for geographical
differences
World Health
Organization, 2015(39)
•
•
Global strategy aiming to eliminate avoidable blindness
The report provides an estimate of approx 2 million
people who live with significant sight loss in the UK
(25,000 are children)
Challenge to eliminate avoidable blindness by 2020.
•
Blanchet, 2014(5)
•
“WHO Eye Health Strategy states that integration needs
to be combined with health system strengthening,
moving away from a disease-specific approach”
Turner, 2011(34)
•
Coordination of eye services with better integration of
ophthalmology and optometry roles may improve
efficiency of services for patients
Audo, 2010(3)
•
•
•
Country facing shortage of ophthalmologists
Ageing population
Proposed development of local initiatives to ensure
equity of access
Increase numbers of orthoptists
Co-operation between public and private sector
•
•
Northern Ireland
Executive, 2011(19)
•
College of Optometrists,
2011(27)
•
•
•
•
•
Most sight loss preventable
Major inequalities in eye health, eg poorer
socioeconomic groups, people with learning difficulties,
older people
Poorer socio-economic groups more likely to have
problem with ophthalmic health and less likely to access
services
Optometrists can play key role
N. Ireland has a high number of optometrists compared
to rest of UK
Proposed increased role for GPs
Improved IT links
•
•
UK Vision Strategy – an initiative to unite the sector
Eye health is one of four UK-wide priorities from Apr
•
•
•
Royal College of General
Practitioners, 2015(25)
52,000 people in Northern Ireland living with sight
problems
Encourages partnership approach to make best use of
services
79 | P a g e
•
Perumal, 2011(20)
•
•
2013 – Mar 2016
UK GP eye health network formed
o Share best practice/management strategies
o Develop care pathways with local providers
o Improve access to premises for patients
o Collaboration at all levels
Looked at demographics, patterns of referral and
clinical characteristics of patients attending an
emergency eye service in New Zealand in major
teaching hospital
Workload at emergency eye service in New Zealand
could be reduced by managing some cases in primary
care/outpatient departments
De Korte, 2014(9)
•
•
Compares care in US and Dutch hospital
Local differences are important when considering
quality indicators/international comparisons
Mitsch, 2014(15)
•
Austrian survey which describes how advances in
imaging methods allow greater collaboration between
eye clinic and the independent ophthalmologist’s office
•
Benefit to using wider range of organisational models,
as in other sectors
Example of good practice - Moorfield’s eye hospital
offer range of ophthalmology services through clinics in
London and outwith
Clinical Outcomes
King’s Fund, 2014(29)
•
RNIB, 2014 (36)
NHS England initiative – highlights the roles of disease prevention
and community management
Quotes Sir Muir Gray as saying that healthcare should be
provided from the point of view of populations in need, rather
than from the view of hospitals or health centres, and that eye
health should be looked at from a population perspective
Project developed in 2012 by UK Vision Strategy Team re
provision of eyecare services
• This established the needs of the local population in
regard to eye care services
• Eye health established as a priority
• Service provision mapped in 3 trial areas
• Recommends what is available and where there are gaps
in local services
• Awareness of changes within NHS – align work to all
decision making structures at local, regional and national
levels
• Embed eye care in wider services and strategies
• Keep up to date with national and local initiatives
• Relevant to whole of UK and outwith
National developments (see Tool 11) can be used at a local level
• (eg three conditions identified as the main public health
80 | P a g e
•
RNIB, 2014(24)
•
•
•
Scottish Executive,
2005(32)
•
•
•
•
•
•
•
•
•
•
•
NHS Primary Care
Contracting, 2007(17)
•
•
•
•
•
Venerus, 2013(37)
•
•
•
challenge in healthcare: glaucoma, age-related macular
degeneration, diabetic eye disease)
Eye health identified as a uk-wide RCGP clinical priority
In Wales, waiting list targets are prioritised over followup appointments
This has led to delays in seeing patients for follow-up,
which has meant that patients have lost their sight
while waiting for appointments
RNIB propose new systems to ensure that eye clinics
can prioritise patients based on need
March 2004 – ophthalmology services to be reviewed
(long waiting lists/recognition that demand outstripped
capacity)
Some conditions that are treated in hospital could be
dealt with in the community
Recognition that there is an Increase in eye related
disease after the age of 75 years
Many eye conditions are avoidable
A recognition that it is more cost-effective to prevent
eye conditions than to treat them
optometrists have equipment and skills that could be
utilised
Service provided by optometrists/ophthalmic assistants
could be utilised to relieve pressure on GP/hospital eye
services
optometrists to carry out extended eye examination
which is to be free in Scotland
Services improved by creation of schemes such as GIES
in Glasgow, which taps into existing optometric
resource
Extended eyecare networks to introduce preventive
eyecare services in the community
Service to include development of coordinated multidisciplinary professional groups.
Examines service redesign and commissioning
Quality assurance issues with data
Drive to integrate commissioning across the whole of
the patient pathway, as eye care issues are related to
eg smoking/obesity
Series of eye care pathways developed which focus on
developing primary care services to relieve pressure on
secondary care
and available to view via Department of Health website
The paper comments on emerging evidence which
shows that investing more money in primary healthcare
and community services reaps benefits across the NHS
Eye health is an example of an area where communitybased diagnosis and care saves money
A series of eye health community pathways that have
81 | P a g e
•
•
•
•
•
Hayden, 2012(10)
•
•
•
•
•
•
•
•
•
Scottish Executive,
2006(30)
•
•
•
•
•
been developed in England are saving money and
providing patients with better options
Opticians have specialist equipment and skills that are
utilised to assess/diagnose eye conditions
Patients are referred to opticians by GPs, or patients
self-refer
Patients are triaged by optometrists
This reduces pressure on hospital eye services
One quote estimates that since the development of the
specialist pathways in England, the saving to secondary
eye services amounts to £400,000
The UK Vision Strategy, the Vision 2020 and RNIB
identified inequality as an explicit priority
Changing demographics in the UK predict a rise in the
number of serious and preventable sight problems
(estimated between 40-80% (Access Economics 2009)
More timely access to diagnosis and treatment will free
up primary and specialist health services and ultimately
reduce costs
Recognises that timely access to diagnosis and
treatment aids in reducing rates of avoidable sight loss
to those at risk
Uses information from five localities throughout UK
(including Scotland) with populations vulnerable to
avoidable sight loss
Studies the figures or glaucoma and diabetic
retinopathy in these localities to identify barriers to care
and to develop interventions
Identified that individuals access eye care in response
to symptoms
Physical access/mobility can be an issue
Recommendations from the study include:
o better links in the community (to promote
prevention and encourage people to participate)
o more seamless secondary care
In 2004 there was a review of eyecare services in
Scotland. This was in response to a recognition of the
demands on hospital services, and the realisation that
many patients attending hospital could be
diagnosed/treated in the community
The aim is to encourage development of integrated
service
Proposes using ‘the optometry network’ to deliver an
‘extended eye examination’
Proposes that this will make more efficient use of health
resources and provide better clinical outcomes with less
steps in patient journey
The proposal to produce national standards which could
be adapted on a local basis was met with strong
support when the interim report was published in 2005
82 | P a g e
•
•
College of Optometrists,
2010(28)
•
•
•
NHS Scotland, 2007(18)
•
•
NHS England, 2014(16)
•
•
•
•
Healthcare Improvement •
Scotland, 2014(11)
•
key elements:
o Integrated model of health and social care
o Local performance management/accountability
o Involvement of service users
Community health partnerships will be key to
implementing the review at the local level
The Centre for Change and Innovation in Scotland
produced patient pathways for a range of eye
conditions. Several schemes have been established
such as the GIES scheme (Glasgow Integrated Eyecare
Scheme), where patients are referred to an accredited
GIES optometrist for care and management. The
optometrist continues to care for the patient, or refers
to the hospital eye service (HES). The GP and
optometrist may retain the patient’s care within the
community jointly.
“Philip, Cowie and Olson (2005) reviewed the effect of
the newly implemented grading model for referrals to
ophthalmology services in Scotland. Three new levels
of referral are now utilised in Scotland …
The final report recommends taking an “integrated,
patient-centred approach to designing eye care services
for adults and children”
Pathways were developed in 2007 and should be
adapted for local needs
The aim of the guidelines is to make full use of
community expertise, and to encourage collaboration
between the professional groups
Separate ‘Call to Action’ reviews held by NHS England
for general practice, community pharmacy, dental
services and eye health
Focus on preventive approach
Review of current system in process –
patients/public/professionals invited to contribute to
survey which closes Sep 2014
Cost to the UK economy of £22 billion per year
In 2006, NHS Grampian introduced a new model of
care for eye services at the same time as the GOS
contract was introduced in Scotland
Complaint was made and directed to Healthcare
Improvement Scotland
o Complaint raised about patient safety concerns
not being addressed
o Complaint raised about audit measures
o Community optometrists lack skills to recognise
emergencies/prescribe medications
o Delays for patients requiring emergency
treatment
83 | P a g e
•
Review was undertaken by HIS, which identified areas
of good practice and areas of improvement
Bosanquet, 2010(7)
•
Community eye care
Borooah, 2013(6)
•
•
•
Outpatients constitute 10% of hospital outpatients
Pressures on outpatient services
Changes to regional ophthalmic service serving 400,000
in Fife
Electronic referral introduced/improved two-way
communication
Pilot rolled out to entire region, benefits across Fife
Resulted in reduced waiting time
Saved appointments, estimated saving of £239,580 per
annum
12 of 14 Scottish health boards reported intention to
connect to network that would allow electronic referral
Improves use of existing capacity
Implications for other UK regions
•
•
•
•
•
•
•
Day, 2010(8)
•
•
•
•
•
Jamous, 2014(13)
•
•
Wright, 2015(40)
•
Recognition that eye health of entire population needs
to be considered and not just those who are referred
Existing glaucoma services mapped in Leeds UK to
establish scale of health inequalities
Existing services plus need were identified
Location of opticians was not uniform
Service restructure should target the communities
which are under-represented – outreach primary care
services should be developed rather than relying on
high street opticians
Australian study – predicted stretching of capacity in
ophthalmology
Proposed model of intregration between practitioners
(GPs, optometrists, ophthalmologists) with the aim of
reducing inappropriate referrals
Describes a model of care utilising virtual technology –
avoids delay in referral
Other Service Attributes
Scottish Government,
2010(31)
•
Scottish government has invested 6.6 million over 10
year period to invest in an electronic patient referral
system, launched in 2010
King’s Fund, 2014(29)
•
Integrated IT systems improve care
References:
1. Achieving Commissioning Excellence, 2013. Commissioning effective and efficient
services to reduce avoidable sight loss. ACE. (Accessed 01/07/2015)
84 | P a g e
2. Association of Optometrists, 2012. The economic impact of free eye examinations
in Scotland . (Accessed 30/06/2015)
3. Audo I, 2010. Current challenges of ophthalmology in France. Archives of
ophthalmology 128(10):1358-1359. (Accessed 01/07/2015)
4. Ayling J, 2015. Where next for GOS? Optician February 2015. (Accessed
01/07/2015)
5. Blanchet K, Gilbert C, De Savigny D, 2014. Rethinking eye health systems to
achieve universal coverage: the role of research. The British journal of
ophthalmology 98(10):1325-1328. (Accessed 01/07/2015)
6. Borooah S, Grant B, Blaikie A et al, 2013. Using electronic referral with digital
imaging between primary and secondary ophthalmic services: a long term
prospective analysis of regional service redesign. Eye 27(3):392-397. (Accessed
01/07/2015)
7. Bosanquet N, 2010. Liberating the NHS: eye care [Homepage of Imperial College
London]. (Accessed 30/06/2015)
8. Day F, Buchan JC, Cassells-Brown A et al, 2010. A glaucoma equity profile:
correlating disease distribution with service provision and uptake in a population
in Northern England, UK. Eye 24(9):1478-1485. (Accessed 01/07/2015)
9. De Korte CE, De Korne DF, Martinez Ciriano JP et al, 2014. Diabetic retinopathy
care – an international quality comparison. International journal of health care
quality assurance 27(4):308-319. (Accessed 01/07/2015)
10. Hayden C, 2012. The barriers and enablers that affect access to primary and
secondary eye care services across England, Wales, Scotland and Northern
Ireland: a report to RNIB by Shared Intelligence: RNIB Community Engagement
Projects. (Accessed 30/06/2015)
11. Healthcare Improvement Scotland, 2014. Service review of NHS Grampian eye
health network. (Accessed 30/06/2015)
12. Information Services Division, 2013. General Ophthalmic Services Statistics:
updates of existing pages as at 31st March 2013. (Accessed 30/06/2015)
13. Jamous KF, Kalloniatis M, Boon MY et al, 2014. The short-sighted perspective of
long-term eye health-care. Clinical and experimental optometry 97(6):565-567.
(Accessed 01/07/2015)
14. Malik AN, Cassels-Brown A, Wormald R et al, 2013. Better value eye care for the
21st century: the population approach. British journal of ophthalmology
97(5):553-557. (Accessed 01/07/2015)
15. Mitsch C, Bolz M, Sacu S et al, 2014. OphthalNet Vienna: constructive quality
assurance and resource optimization in ophthalmology. Studies in health
technology and informatics 198:156-163. (Accessed 01/07/2015)
16. NHS England, 2014. Improving eye health and reducing sight loss - a 'Call to
Action' . (Accessed 30/06/2015)
17. NHS Primary Care Contracting, 2007. Step-by-step guide to commissioning
community eye care services. (Accessed 30/06/2015)
18. NHS Scotland, 2007. Ophthalmology patient pathways. (Accessed 01/07/2015)
19. Northern Ireland Executive, 2011. Eyecare provision consultation launched .
(Accessed 30/06/2015)
20. Perumal D, Niederer R, Raynel S et al, 2011. Patterns of ophthalmic referral and
emergency presentations to an acute tertiary eye service in New Zealand. New
Zealand Medical Journal 124(1340):35-47. (Accessed 01/07/2015)
21. Ratnarajan G, Wormald R, 2013. Equity and prevention of blindness with a
disintegrated eye health service. Perspectives in public health 133(1):7.
(Accessed 01/07/2015)
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22. Ratnarajan G, Wormald R, Astbury N, 2013. The NHS Act of 1951; is it time to
re-act? Eye 27(6):685-687. (Accessed 01/07/2015)
23. Royal National Institute for the Blind, 2009. Low vision service outcomes: a
systematic review. (Accessed 30/06/2015)
24. Royal National Institute for the Blind, 2014. Real patients coming to real harm.
(Accessed 30/06/2015)
25. Royal College of General Practitioners. Eye health. (Accessed 30/06/2015)
26. College of Optometrists, 2014. UK Vision Strategy Submission for London Health
Commission call for evidence. Joint response. (Accessed 30/06/2015)
27. College of Optometrists, 2011. A strategy for eyecare services in Northern
Ireland. (Accessed 30/06/2015)
28. College of Optometrists, 2010. UK Eye Care Services Project. Phase one:
systematic review of the organisation of UK eye care services. (Accessed
30/06/2015)
29. King’s Fund, 2014. Future organisational models for the NHS: perspectives for
the Dalton review (Accessed 30/06/2015)
30. Scottish Executive, 2006. Review of community eyecare services in Scotland: final
report. (Accessed 30/06/2015)
31. Scottish Government, 2010. Eyecare integration. (Accessed 30/06/2015)
32. Scottish Government, 2005. Review of eyecare services in Scotland: interim
report. (Accessed 30/06/2015)
33. UK Vision Strategy, [2013?]. The UK vision strategy case for change 2013-2018:
evidence and achievements. (Accessed 01/07/2015)
34. Turner AW, Mulholland WJ, Taylor HR, 2011. Coordination of outreach eye
services in remote Australia. Clinical & experimental ophthalmology 39(4):344349. (Accessed 01/07/2015)
35. UK Vision Strategy, 2014. UK Vision Strategy launches eye care commissioning
guidance. (Accessed 30/06/2015)
36. Royal National Institute for Blind People, 2014. Driving local change for effective
and efficient eyecare services: sharing our learning from the Commissioning for
Effectiveness and Efficiency (CEE) project. RNIB. (Accessed 30/06/2015)
37. Venerus K, 2013. Community services. An alternative vision for commissioning.
Health service journal 123(6342):23-25. (Accessed 01/07/2015)
38. World Health Organization, 2015. Universal eye health: a global action plan 20142019. (Accessed 30/06/2015)
39. World Health Organization, 2015. VISION 2020: the right to sight. (Accessed
30/06/2015)
40. Wright HR, Diamond JP, 2015. Service innovation in glaucoma management:
using a Web-based electronic patient record to facilitate virtual specialist
supervision of a shared care glaucoma programme. British journal of
ophthalmology, 99(3):313-317. (Accessed 01/07/2015)
86 | P a g e
Oral & Maxillofacial Surgery
For Oral and Maxillofacial Services, is there evidence that a. national, b.
regional or c. local level delivery produces the best outcomes?
Key Points:
• No clear recommendation is made regarding national, regional or local service
delivery
• In Northern Ireland with a population of 1.8 million, a hub-and-spoke model
is recommended (5)
• A regional approach is recommended for England (3).
Population Required
Centre for
The Royal College of Surgeons of England (RCSEng) and the
Workforce
British Association of Oral and Maxillofacial Surgery (BAOMS)
Intelligence, 2011(1) estimates that the ratio of consultants to population should be
1 full-time equivalent (FTE) consultant to 200,000 population.
This estimated level has fallen since the RCSEng 2005 report
Developing a Modern Surgical Workforce, when it was 1 per
150,000. This estimated ratio is expected to be exceeded
based upon projected increases to Certificate of Completion of
Training (CCT) holder numbers. (page 3)
Royal College of
Surgeons of
England, 2012(2)
The British Association of Oral and Maxillofacial Surgeons
(BAOMS) recommend a consultant workforce ratio of
1:150,000 population. (page 27)
British Association of
Oral and
Maxillofacial
Surgeons & Royal
College of Surgeons
of England, 2014(3)
Currently there are approximately 16 oral & maxillofacial
surgeons in the UK who undertake the range of more complex
surgical interventions …. This level of provision is probably
appropriate to meet current demand while maintaining the
skills and experience of individual surgeons. Some patients
with complex TMJ cases should be optimally managed via a
multidisciplinary specialist service, which has defined access to
an appropriately trained surgeon as well as restorative
dentistry, chronic pain management and psychological
support. (page 5)
The number of patients who need the more complex
interventions [temporomandibular joint disorders] are
relatively small. In order to make most efficient use of the
services required and to maintain the level of experience and
skill necessary to provide good quality surgical care for this
small group of patients, regionally based services should be
commissioned. (page 5)
Betsi Cadwaladr
University Health
Board, 2012(4)
Consultant led specialist services in Orthodontics and
Maxillofacial Surgery are provided at all three District General
Hospitals. The Maxillofacial Surgery Service, however, is a pan
North Wales Service with Ysbyty Glan Clwyd serving as the
hub and other locations as satellites. (page 47)
Northern Ireland
The current model of Oral and Maxillofacial Surgery services in
87 | P a g e
Department of
Health, Social
Services and Public
Safety, 2012(5)
July 2012 was two hubs, with one with six spokes (Ulster
Hospital Dundonald), and one with four spokes (Altnagelvin
Area Hospital). There were a total of 7 wte consultants [p.
24]. The number of consultants needed if scaled to the N.I.
population of 1.8m should be 9 wte if abiding by BOAS & RCS
guidelines of 1:200,000. (page 59)
Multidisciplinary teamworking occurs between the specialties
of Orthodontics, Restorative Dentistry and Oral and
Maxillofacial Surgery but some of the orthodontists have
reported problems accessing the surgical component of patient
care. This presents challenges because the succession and
timing of the various stages of treatment is very important
(page 38)
The challenges:
The differing local models and the varying use of skill mix
between OMFS and Oral Surgery. Waiting lists are long,
especially for complex procedures such as orthognathic
surgery (page 39)
In the option appraisal process for OMFS, a multiple hub
model with treatment centres with clinical facilities and staff to
which patients would travel; and could include one, or more,
spokes, to which consultants would travel to treat patients
scored the highest. The same model scored the highest for
Oral Surgery within the context of a mixed OS/OMFS unit. The
criteria used in the option appraisal scoring were: quality of
service provision, sustainability, value for money, timeliness,
ease of implementation. (page 80-81)
The consultation report recommendations were as follows:
Oral Surgery: Single hub based at the Dental Hospital/School,
Belfast operating as an oral surgery service as defined in the
service budget agreement with the HSCB. Oral surgeons
should also work as a significant part of the teams based at
the OMFS hubs as described above and as recommended in
the MEE Review of Oral Surgery Services and Training. Close
multi-disciplinary team working links should be developed
especially within the wider OS/OMFS/OM team model. The oral
surgery service at the Belfast Dental Hospital will provide a
complementary service to the oral medicine service also based
at the Belfast Dental Hospital. (page 90)
Clinical Outcomes
Royal College of
Surgeons of
England, 2011(6)
This document provides a table of generic oral and
maxillofacial surgery standards (page 66) – see Appendix 1. It
refers the reader to the British Association of Oral and
Maxillofacial Surgeons (www.baoms.org.uk) for more specific
guidance and support.
Royal College of
Surgeons in Ireland,
2013(7)
The following provide generic oral and maxillofacial surgery
standards. For more specific guidelines, see the British
Association of Oral and Maxillofacial Surgeons
(www.baoms.org.uk).
88 | P a g e
Best practice
1. There must be specific facilities with appropriately trained
staff to manage OMFS unscheduled care patients, on a 24hour basis and available on site within 60 minutes.
2. Defined referral processes are available to divert
appropriate semi-urgent referrals into an ambulatory care
setting, with sufficient daytime review and theatre facilities.
3. Daily wards rounds are carried out by senior trainees (BST3
or HST1) with consultant cover.
4. Outcomes for acute OMFS surgical practice are audited,
using routinely collected data. (page 95)
British Association of
Oral and
Maxillofacial
Surgeons & Royal
College of Surgeons
of England, 2014(3)
Outcome data is available for those patients undergoing more
complex procedures (e.g. joint replacement). Users can
access further procedure information based on the data
available in the quality dashboard to see how individual
providers are performing against the indicators. This will
enable commissioners to start a conversation with providers
who appear to be 'outliers' from the indicators of quality that
have been selected. The Procedures Explorer Tool available
via the Royal College of Surgeons website at
http://rcs.methods.co.uk/pet.html
The quality dashboard provides an overview of commissioned
specialist activity commissioned from the relevant pathways,
and indicators of the quality of care provided by surgical units.
It is available via the Royal College of Surgeons website at
http://rcs.methods.co.uk/dashboards.html (page 6)
Quality Indicators
British Association of
Oral and
Maxillofacial
Surgeons & Royal
College of Surgeons
of England, 2014(3)
The provider must submit patient outcomes data to the British
Association of TMJ Surgeons (BATS).
The provider must show adherence to the NICE TMJ
replacement guidelines and complete the NICE audit tool for a
proportion of cases.
Length of stay for TMJ Joint Replacement – a mean LOS of 3
days should be demonstrated.
Revision rates for TMJ Joint replacement within 5 years of
surgery should be <10% and outliers should be monitored for.
(page 7)
British Association of
Oral and
Maxillofacial
Surgeons & Royal
College of Surgeons
of England, 2013(8)
Providers should demonstrate collection of data for
orthognathic outcome audits including patient satisfaction
surveys.
Providers should submit data to the National Facial and Oral
Research Centre (NFORC). (page 6)
Gloucestershire
Hospitals(9)
Oral and maxillofacial surgery – quality indicators:
• Percentage of emergency admissions with fractured
mandible who have surgery same day or the next day
• Post –operative orbital observations
• Third molar audit outcome audit
89 | P a g e
Birmingham
NHS(10)
Maxillofacial surgery quality indicator:
• Percentage of emergency admissions with fractured
mandible who have surgery same day or the next day.
Models of Care
Harper, 2005(11)
In London, with a resident population of 7.2 million, a detailed
geographical simulation model was developed which enabled
planners to consider a number of OMFS service configurations
and evaluate their impact on providers, variations in caseload,
travelling distances and times for patients, and thus inform
consultation over change. The research confirms that any inpatient service rationalization which concentrates care in one
designated hub (main centre) per sector, involves a significant
increase in caseload for the designated hub. Average travelling
distances and times for in-patient admissions also increase
significantly. However, it does suggest that current
commissioned provision of day surgery patterns may not be
well aligned to the geographical distribution of need for
services, resulting in many patients travelling further than
necessary for day surgery treatment. These may be overcome
by sending patients to their local centre, which may be out
with their sector of residence. (abstract)
British Association of
Oral and
Maxillofacial
Surgeons & Royal
College of Surgeons
of England, 2014(3)
The specialist management of TMJ disorders requires a range
of diagnostic investigations such as MRI scanning; fine cut
computerised tomography (CT scan) & stereo lithographic
modelling. (page 5)
The service should have access to restorative dentistry,
rheumatology, psychology, psychiatry, chronic pain service,
neurology, ENT, physiotherapy, ideally in a multi-disciplinary
setting. (page 5)
Medical Education
England Dental
Programme Board,
[2010](12)
Commissioners should review local arrangements for the
provision of OS services. Where there is a high level of
referrals to secondary care departments of OMFS, steps
should be taken to identify which categories of patients could
be treated in a primary care setting and, where practicable,
make alternative provisions for the management of these
referrals. The alternative provisions should enhance access
and offer efficiency gains without any reduction in the quality
of service. (page 8)
OMFS departments are managing a significant amount of OS
work, some of which could be moved elsewhere, to free up
time to focus on complex care. (page 10)
Other Service Attributes
Workforce
Velayutham,
2013(13)
With increasing life expectancy, the number of older people
who will be treated by maxillofacial units will increase. This is
primarily due to patients falling and sustaining facial trauma.
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Planning must ensure optimisation of patient care and
implementation of appropriate services to ensure that
inpatient stays do not increase appreciably.
Training
Joint Committee on
Surgical Training,
2015(14)
This document provides details of quality indicators for
surgical training in general and in oral and maxillofacial
surgery specifically. Covers teaching time; study time;
educational facilities; number of consultant supervised
sessions per week for all OMFS trainees and the opportunity to
operate for ST3/5 and 6/7; and attend training courses on
management and training and education for ST6/7. See
Appendix 2 for further details.
Northern Ireland
Department of
Health, Social
Services and Public
Safety, 2012(5)
There should be the opportunity and flexibility to provide
undergraduate teaching opportunities at the clinical sites
outwith the dental hospital/school. Postgraduate specialist
training opportunities in both oral surgery and oral and
maxillofacial surgery needs to be provided at all sites so that
the skill mix across Northern Ireland is developed to treat both
the more routine oral surgery cases and the complex
maxillofacial cases in the most effective and efficient manner.
Centre for
Recommends that no change is made to either the number of
Workforce
training posts or the current geographical distribution of
Intelligence, 2011(1) training places over the next three years. (page 4)
Patient
satisfaction
Kanatas, 2010(15)
Systematically reviewed the literature to identify validated
questionnaires that are suitable for collecting patient-reported
outcomes in OMFS. The number of subsite-specific
questionnaires identified were: cleft lip and palate (1),
craniofacial surgery (2), dentoalveolar surgery (6), distraction
osteogenesis (1), facial aesthetic surgery (4), facial pain (1),
head and neck cancer (14), maxillofacial injury (3), oral
medicine and oral mucosal disorders (2), orthognathic surgery
(1), pre-prosthetic surgery and dental implants (15), skull base
surgery (7), temporomandibular joint (2).
Cost
Garg, 2010(16)
Investigated operating time and in-patient length of stay for
the three most common orthognathic procedures at six
maxillofacial units in the UK. Patients who have a single jaw
procedure can expect an operating time of 2 h, and a one or
two night stay in hospital postoperatively. Those who have a
bimaxillary procedure can expect an operating time of 3.5 h
with one to three nights in hospital postoperatively.
British Association of As a regional model is recommended in this commissioning
Oral and
guide, it was noted that patients may therefore need to travel
91 | P a g e
Maxillofacial
Surgeons & Royal
College of Surgeons
of England, 2014(3)
in order to access the high quality specialist care. (page 5)
Northern Ireland
Department of
Health, Social
Services and Public
Safety, 2012(5)
The multiple hub model would necessitate travel to treatment
centres by both patients and consultants. (page 80)
References:
1. Centre for Workforce Intelligence, 2011. Oral and Maxillofacial Surgery
(OMFS). (Accessed 22/07/2015)
2. Royal College of Surgeons of England, 2012 Surgical Workforce 2011: A
report from The Royal College of Surgeons of England in collaboration with
the surgical specialty associations. (Accessed 15/07/2015)
3. British Association of Oral and Maxillofacial Surgeons, Royal College of
Surgeons of England, 2014 Commissioning guide: Temporomandibular joint
disorders. (Accessed 15/07/2015)
4. Betsi Cadwaladr University Health Board, 2012. Local Oral Health Plan 2013 –
2018 (Accessed 15/07/2015)
5. Northern Ireland Department of Health, Social Services and Public Safety,
2012. Regional review of consultant led hospital dental services. (Accessed
15/07/2015)
6. Royal College of Surgeons of England, 2011 Emergency Surgery: Standards
for unscheduled surgical care. Guidance for providers, commissioners and
service planners. (Accessed 15/07/2015)
7. Royal College of Surgeons in Ireland, 2013 Model of Care for Acute Surgery:
National Clinical Programme in Surgery (Accessed 15/07/2015)
8. British Association of Oral and Maxillofacial Surgeons, Royal College of
Surgeons of England, 2013. Commissioning guide: Orthognathic Procedures.
(Accessed 15/07/2015)
9. Gloucestershire Hospitals NHS Foundation Trust. Oral and Maxillofacial
surgery – quality indicators. (Accessed 04/06/2015)
10. University Hospitals Birmingham NHS Foundation Trust. Maxillofacial surgery
quality indicator. (Accessed 04/06/2015)
11. Harper PR, Phillips S, Gallagher JE, 2005. Geographical simulation modelling
for the regional planning of oral and maxillofacial surgery across London.
Journal of the Operational Research Society 56(2):134-143 (Accessed
15/07/2015)
12. Medical Education England Dental Programme Board, [2010] Review of Oral
Surgery Services and Training (Accessed 22/07/2015)
13. Velayutham L, Sivanandarajasingam A, O’Meara C et al, 2013. Elderly
patients with maxillofacial trauma: the effect of an ageing population on a
maxillofacial unit’s workload. British Journal of Oral and Maxillofacial Surgery,
51(2):128-32. (Accessed 16/07/2015)
14. Joint Committee on Surgical Training, 2015. JCST Quality Indicators for
Surgical Training - Oral & Maxillofacial Surgery. (Accessed 15/07/2015)
92 | P a g e
15. Kanatas AN, Rogers SN, 2010. A systematic review of patient self-completed
questionnaires suitable for oral and maxillofacial surgery. British Journal of
Oral and Maxillofacial Surgery, 48(8):579-90. (Accessed 22/07/2015)
16. Garg M, Cascarini L, Darryl MC et al, 2010. Multicentre study of operating
time and inpatient stay for orthognathic surgery. British Journal of Oral and
Maxillofacial Surgery, 48(5):360-363. (Accessed 22/07/2015)
93 | P a g e
Orthopaedics
For orthopaedic services, is there evidence that a. national, b. regional or
c. local level delivery produces the best outcomes?
Key Points:
•
•
•
•
•
There are few recommendations on local, regional, or national delivery of
orthopaedic services.
British Orthopaedic Society recommends one consultant per 15,000
population.
Higher volumes of procedures lead to better outcomes, even for high-volume
common procedures.
Some procedures have minimum recommended annual volumes but others
need to be established.
Ring-fencing of beds, theatres and staff is recommend for elective
orthopaedic procedures.
Population Required
CfWI, 2010(4)
The British Orthopaedic Association recommends one FTE
consultant to 15,000 population (down from one FTE to 25,000
population) (page 2)
Note: although this document was published in 2010, the
evidence is from 2005.
Briggs, 2015(1)
Revision surgery should be considered on a regional basis with
experienced surgeons at a smaller number of locations. (page 22)
There is clear evidence that complication rates reduce
significantly once a minimum of 35 primary hip arthroplasties are
performed annually by each surgeon. (page 18)
There is some evidence that each surgeon should carry out 20-30
unicondylar knee replacements for better results, but specific
guidance is required from the orthopaedic specialist societies.
(page 18)
NHS
Commissioning
Board, 2013(5)
There is a strong link between higher volumes of cases, either by
surgeon or hospital, and better outcomes (revision rates,
infections, patient outcomes, patient satisfaction, staff
satisfaction)
The minimum numbers may be low for some procedures, but
even for large volumes (in excess of 1000 per annum) there is
evidence that outcomes continue to improve. (page 4-5)
British
Orthopaedic
Association
Professional
Practice
In England and Wales, the changes to service provision and
providers means that a simple “head count” of NHS consultants
doesn’t give an accurate picture of the workforce needed. (page
53)
94 | P a g e
Committee
2014(3)
Quality Indicators
Briggs, 2015(1)
“PROMS are a critically important way of measuring outcome and
patient experience ... PROMs would be enhanced if additional
metrics relating to a number of specifically orthopaedic
complications could be added to the case mix adjustment
criteria.” (page 30)
Royal Free
The clinical quality indicators for trauma and orthopaedics are:
London NHS
1. Fractured hip (admission to an orthopaedic ward within
Foundation Trust,
four hours, surgery within 36 hours, pressure ulcer
2015(7)
prevention, pre-operative assessment by an
orthogeriatrician, assessment of bone health, and falls risk
assessment prior to discharge)
2. Infection rates after elective joint replacement
3. Open tibial fractures being treated in accordance with the
British Orthopaedic Association Standards for Trauma
guidelines (BOAST4) (British Orthopaedic Association
2009)
Other Service Attributes
Briggs, 2015(1)
There is strong evidence that having ring-fenced orthopaedic
beds, theatres and staff brings clinical advantages (reduced
infection rates, shorter length of stay, fewer cancellations). The
evidence supports the view that infection rates rise if the ringfence is broken (page 33)
NHS
Commissioning
Board, 2013(5)
The recommendation for a network model doesn’t mean that all
complex or specialist procedures should be done at a single
centre, rather that the network provides expertise, support,
resources, and governance to ensure orthopaedic care is
delivered to an appropriate standard throughout the network.
(page 12)
NICE, 2012(6)
A model of care was developed, which moved care from the
hospital to the community, including pre- and post- discharge
care in the community. (page 2)
References:
1. Briggs T, 2015. A national review of adult elective orthopaedic services in
England: Getting it right first time. British Orthopaedic Association. (Accessed
08/07/2015)
2. British Orthopaedic Association Professional Practice Committee, 2014.
Consultant Advisory Book. (Accessed 08/07/2015)
3. British Orthopaedic Association, 2009. BOAST 4: The management of severe
open lower limb fractures. (Accessed 08/07/2015)
4. Centre for Workforce Intelligence, 2010. Medical Specialty Worforce factsheet :
Trauma and orthopaedic surgery. (Accessed 08/07/2015)
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5. NHS Commissioning Board, 2013. NHS Standard Contract for specialised
orthopaedics (adult), Schedule 2 – the service a. service specifications. D/10/S/a.
(Accessed 08/07/2015)
6. NICE, 2012. Orthopaedic enhanced recovery programme to reduce length of
hospital stay: QIPP case study. (Accessed 08/07/2015)
7. Royal Free London NHS Foundation Trust, [no date given]. Trauma and
orthopaedics clinical quality indicators. (Accessed 08/07/2015)
96 | P a g e
Out of Hours Services
For out of hours services is there evidence that a. national, b. regional or c.
local level delivery produces the best outcomes?
Key points:
• The Scottish Government Taskforce states that weekend care requires
looking at new models of care, and should be supported by sustainable
workforce and appropriate infrastructure across the week.
• The Healthcare Financial Management Association states that the cost of
implementing seven day services is typically 1.5% to 2% of the total income,
or a 5% to 6% addition to the cost of emergency admissions.
• The Royal College of General Practitioners has produced figures to show that
GP care costs less than hospital care, and increases in GP workforce is
associated with decreased mortality.
• Continuity of care is vital. Patient feedback shows that people prefer to deal
with familiar healthcare professionals rather than with out of hours services
over the phone.
Population required
Scottish Government(1)
RCGP(2)
RCP(3)
Clinical outcomes
Scottish Government(1)
“Improvements to care provided at weekends must be
built on a sustainable workforce supported by
appropriate infrastructure across the week. So while we
recognise the importance of making best use of the
resources we have, we need to look at new models of
care rather than just stretching our existing resources
across seven days.” (page 15)
Figure 12: General practice as a driver of more cost
effective care
- A year of care by a GP costs 10% of a day’s stay
in hospital
- An increase of just one GP per 10,000 population
is associated with a 6% decrease in mortality
- General practice delivers 90% of patient contacts
in NHS for 10% of the overall health budget
- More GPs per head of population is associated
with lower all-cause mortality (page 40)
“Delivery of a 12/7 consultant presence on the AMU
[acute medical unit] should be a priority for all staff
involved in the planning and delivery of acute medical
services. The numbers of consultants required will
depend on: the size and structure of the unit, the
patient illness acuity, and the numbers of patient
contacts on a daily basis. Most units will require
continuing expansion in AMU consultant numbers.
However, integrated working arrangements combining
acute physicians with specialty/ general physicians will
help to achieve sustainable consultant rotas, optimise
continuity, and ensure high-quality patient care.” (page
5)
Achieving sustainability and seven day services will
97 | P a g e
AMRC(4)
Other service
attributes
RCGP(2)
Scottish Government(1)
require a whole system approach. This will focus on:
- Ensuring that all patients requiring clinically urgent or
emergency healthcare have timely access to an
appropriate clinical team who can determine and deliver
their care.
- Ensuring that all such patients have access to
appropriate investigations and tests when they are
required.
- Ensuring that all patients have continuity of care
including the capacity to be discharged and supported in
their discharge from hospital seven days per week.
- Achieving the best possible outcomes and experience
for patients by using available resources in a sustainable
manner." (page 2)
“The Academy of Medical Royal Colleges has developed
three patient-centred standards to deliver consistent
inpatient care irrespective of the day of the week. These
standards reflect the importance of daily consultant
review, and the consequent actions, to ensure
progression of the patient’s care pathway.
Standard 1: Hospital inpatients should be reviewed by
an on-site consultant at least once every 24 hours,
seven days a week, unless it has been determined that
this would not affect the patient’s care pathway.
Standard 2: Consultant-supervised interventions and
investigations along with reports should be provided
seven days a week if the results will change the
outcome or status of the patient’s care pathway before
the next ‘normal’ working day. This should include
interventions which will enable immediate discharge or
a shortened length of hospital stay.
Standard 3: Support services both in hospitals and in
the primary care setting in the community should be
available seven days a week to ensure that the next
steps in the patient’s care pathway, as determined by
the daily consultant-led review, can be taken.” (page 3)
“The evidence shows that continuity of care – especially
for those who are older, have long-term disease or have
multimorbidity – improves health outcomes and reduces
the need for hospital care ... In general practice,
‘generalism’ makes little sense without continuity of
care.” (page 5)
“To deliver our aims for patient/service user
involvement we will have a patient/service user
workstream. We are discussing how this might be
achieved with the national Person-Centred Steering
Group.” (page 4)
“A strong theme that has emerged is that services
should be configured to ensure that people receive the
98 | P a g e
HFMA(5)
care they need in the most appropriate location to
deliver that care.” (page 15)
“Next Steps” include:
• review the services provided in the 29 sites that
undertake acute surgery to ensure that the models of
care are sustainable while maintaining appropriate care
in local hospitals.
• consider how the effectiveness of ward rounds at
weekends can be improved to provide better patient
care.
• undertake a review of district nursing.
• co-ordinate further work to support the sustainability
of Scotland‟s six Rural General Hospitals.
• continue to link to the range of national activity that is
supporting the development of sustainable seven day
services
• explore new models of care such as community hubs
and the greater use of community hospitals with a view
to developing pilots. (page 18-19)
• costs of implementing seven day services vary [They
are] typically 1.5% to 2% of total income, or a 5%
to 6% addition to the cost of emergency
admissions.
• investment at the ‘front-end’ of the hospital (accident
and emergency departments and admissions units
with supporting diagnostics) can pay for itself in
some trusts, by reducing unnecessary admissions
and shortening lengths of stay.
• the move to seven day services does appear
achievable, but it may be too expensive and
unsustainable for all existing hospitals to move all
their current range of services to a seven day basis.
Reconfiguration of services may substantially
reduce the cost, but this has not been tested in this
research.
• it could make financial sense to ‘sweat the assets’ by
using expensive equipment more at weekends, but
only where the total workload is growing or it is
consolidated across fewer providers. (page 3)
• the main cost driver is the recruitment of additional
consultants. These costs are unavoidable if most
hospitals providing services need a greater
consultant presence at weekends, but they could be
greatly reduced if fewer trusts provided emergency
services in certain specialties.
• a change to weekend pay premiums would make
seven day services more affordable, but not costneutral as most of the cost comes from employing
more, highly paid, medical staff.
• seven day services would increase the demand for
staff groups that are already hard to recruit, for
example radiologists and acute physicians.
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RCGP(2)
RCGP(2)
Collaborative working across trusts could help to
mitigate this cost. (page 4)
“The requirement for GPs to have overall responsibility
for their patients 24/7 would have major contractual,
political and professional implications, and the old
system of out-of-hours care would not be acceptable to
the vast majority of the workforce – especially given the
intensity and complexity of work within hours.
However, a system must be found to allow the
restoration of personalised care to those patients
with complex needs or at the end of their lives, in and
out of hours. Extended teams, crosspractice or
federation provision, named out-of-hours leads, and
shared electronic records are all possible solutions.”
(page 29)
“In the 12 month period from September 2010–11,
consultant numbers rose by 3.5% WTE. In the same
period, GP numbers rose by just 0.2% WTE.” (page 23)
“The shortage of GPs is not evenly distributed across
the country, with shortages more apparent in areas of
highly deprived communities (where consultation rates
and complexity are higher).” (page 24)
“Between 2010 and 2011, the total number of qualified
nurses, midwives and health visitors working in
community services in England decreased by 1995 FTE.
Over the same period, the number of district nurses
declined by 10%, bringing the total lost between 2001
and 2011 to 3590, a reduction of 34%.” (page 25)
Scottish Government(6)
Scottish Government(7)
“In the USA, primary care generalism has seen a steep
decline over the last few decades, with this being
responsible for a reduction in the number of GPs.
Compared to 1942 when half of US doctors were GPs,
by 1989 the proportion of primary care doctors (now
comprising a mix of family physicians, general adult
internists and paediatricians) had fallen to one in eight,
with the drop being most marked in rural areas.” (page
26)
“For out-of-hours services we found that the services
which people used had a strong effect on their
experience: people had less positive experiences of out
of-hours services provided over the phone. This could
be because people may find phone consultations with
unfamiliar health care professionals more difficult than
face-to-face consultations which often involve familiar
primary care staff.” (page 2)
“... results for out of hours questions are slightly less
positive than in the previous survey. The overall rating
of out of hours care has fallen slightly from 72%
positive in 2011/12 to 71% in this survey.”
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“Of patients surveyed, 25 per cent had tried to get
medical help, treatment or advice, for themselves or
someone they were looking after, when their GP surgery
was closed.” (page 41)
References:
1. Scottish Government, 2015. Sustainability and Seven Day Services Taskforce
interim report. (Accessed 22/07/2015)
2. Royal College of General Practitioners, 2013. The 2022 GP: compendium of
evidence. (Accessed 22/07/2015)
3. Royal College of Physicians, 2012. Acute Care Toolkit 4. Delivering a 12-hour,
7-day consultant presence on the acute medical unit. (Accessed 24/07/2015)
4. Academy of Medical Royal Colleges, 2012. Seven day consultant present care.
(Accessed 24/07/2015)
5. Healthcare Financial Management Association, 2013. NHS Services, Seven
Days a Week Forum. Costing seven day services: the financial implications of
seven day services for acute emergency and urgent services and supporting
diagnostics. (Accessed 22/07/2015)
6. Scottish Government, 2013. Scottish patient experience survey of GP and
local NHS services 2011/12. Volume 3: Variations in the experiences of
primary care patients. (Accessed 24/07/2015)
7. Scottish Government, 2014. Health and care experience survey 2013/14.
Volume 1: National results. (Accessed 27/07/2015)
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Paediatric (specialist & regional/local)
For paediatric services, is there evidence that a. national, b. regional or c.
local level delivery produces the best outcomes?
Key Points:
These results combine specialist and regional/local paediatrics, because current
thinking generally links them (eg. See Imison, C (2014) page 89: "Centralisation of
paediatric services has been on the agenda for almost 20 years, driven by trends in
paediatric activity and a desire to maintain trainees’ exposure to less common
childhood diseases"). The references found had a mixture of information on different
types of unit. The one reference that specifically mentioned small rural paediatric
units did not make a staffing recommendation based on population, but instead
suggested a minimum of "6 WTE consultants". (Royal College of Paediatrics & Child
Health (2011b), page 3).
Population
Imison, 2014(1)
Royal College of
Paediatrics and Child
Health, 2011 & 2015(2)
Centre for Workforce
Intelligence, 2010(3)
“There is little evidence, outside of professional
consensus, to guide the appropriate level of medical
staffing – in particular the balance between senior and
junior doctors, and medical versus specialist nursing staff.
There is little research to guide an optimal configuration
of paediatric services. Constraints on the paediatric
workforce are key drivers of future configuration, with
more evidence needed about safe staffing models for
ambulatory services. The limited evidence available
suggests there is scope for paediatric services to shift
further towards a primary/community care-based model.”
(page 91)
“Paediatric inpatient units need to be staffed by paediatric
consultants and the appropriate level of specialist
paediatric nursing. There is little evidence, outside of
professional consensus, to guide the appropriate level of
medical staffing – in particular the balance between senior
and junior doctors, and medical versus specialist nursing
staff. There is little research to guide an optimal
configuration of paediatric services. Constraints on the
paediatric workforce are key drivers of future
configuration, with more evidence needed about safe
staffing models for ambulatory services. The limited
evidence available suggests there is scope for paediatric
services to shift further towards a primary/community
care-based model.” (page 90)
The RCPCH documents from their Facing the Future
programme of work advocate a system of "consultant
delivered care" via rota working and Managed Clinical
Networks to link Tertiary centres and DGC/small & rural
units.
The British Association for Community and Child Health
recommends 4.5 FTE community consultants per 300,000
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Dunhill, 2013(4)
Royal College of
Surgeons, 2012(5)
Royal College of
Paediatrics and Child
Health, 2012(6)
RCSE, 2007(8) ;
NPH, 2010(9) ;
NPH, 2010(10) ;
CSL, 2011(11) ;
Department of Health,
2003(12)
Clinical outcomes
Imison, 2014(1)
Department of Health,
2003(12)
Royal College of
Paediatrics and Child
Health, 2015(2)
population. This would equate to 783 FTE community
paediatric consultants in England (based on ONS
estimates of the population in 2010). The College reports
that because of the location of tertiary specialist centres in
the UK (a disproportionate number are in London and
other metropolises) it is very difficult to achieve this
equality. Tertiary centres account for almost one-third of
all paediatric consultant staff. The College also suggest
the level of consultant retirements in England will have
more impact on the community paediatricians than other
subspecialties of paediatrics. (page 2)
The majority model for paediatrics in Scotland is of a
combined service, with acute and community paediatrics
co-managed as a single service. This is the preferred
model.
There are currently 2.8WTE trained CCH doctors per
100,000 population in Scotland (2.4WTE in England).
(page 1)
The British Association of Paediatric Surgeons (BAPS)
recommends a consultant workforce ratio of 1:250,000
population. (p35)
"The presence of senior doctors in hospitals has been
associated with lower mortality and morbidity in all
specialties. For this reason, staffing paediatric units
cannot be planned on the basis of ‘x’ doctors per ‘y’
number of children in the population but on the basis of
full coverage of a 24/7 rota." (page 10)
There is some information about minimum number of
cases required in DGHs to retain the skill of consultants
(especially surgical specialties). The general
recommended model seems to be for centralisation of
specialist services to tertiary centres, but that routine care
should take place where possible "as close to home as
possible" for the service to be as child centred as possible,
with close links with tertiary centres. (refs 8-12)
“Centralisation of paediatric services has been on the
agenda for almost 20 years, driven by trends in paediatric
activity and a desire to maintain trainees’ exposure to less
common childhood diseases.” (page 89)
“The reconfiguration of clinical services: what is the
evidence?” (Imison, 2014) references the 2003 DoH doc
"Getting the right start" as the most recent national
standards.
The most recent standards document. This emphasises
the need for consultant presence at peak times, and that
children admitted with an acute medical problem should
be seen by a consultant within 14 hours (page 4)
“Five key recommendations:
1. Reduce the number of inpatient sites
2. Increase the number of consultants
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3. Expand significantly the number of registered children’s
nurses
4. Expand the number of GPs trained in paediatrics
5. Decrease the number of paediatric trainees.” (page 4)
Other service attributes:
References:
1. Imison C, et al, 2014. The reconfiguration of clinical services: what is the
evidence? King’s Fund. (Accessed 29/06/2015) See also: page summarising the
findings of this publication on paediatric services:
http://www.kingsfund.org.uk/projects/reconfiguring-clinical-services/paediatric
(Accessed 29/06/2015)
2. Royal College of Paediatrics and Child Health, 2011a. Improving the standard of
care of children with kidney disease through paediatric nephrology networks :
report of a working party of RCPCH. British Association for Paediatric Nephrology
& NHS Kidney Care. (Accessed 29/06/2015) ; Royal College of Paediatrics and
Child Health, 2015. Facing the future : standards for acute general paediatric
services 2015. (Accessed 29/06/2015) ; See also: Royal College of Paediatrics
and Child Health. Facing the future : standards for acute general paediatric
services (Accessed 29/06/2015)
3. Centre for Workforce Intelligence, 2010. Medical specialty workforce factsheet :
paediatrics. (Accessed 29/06/2015)
4. Dunhill Z, 2013. Developing a community child health service for the 21st century:
a report for the Children & Young People’s Health Support Group. Scottish
Government. (Accessed 29/06/2015)
5. Royal College of Surgeons, 2012. Surgical workforce 2011: a report from the
Royal College of Surgeons of England in collaboration with the surgical specialty
organisations. (Accessed 29/06/2015)
6. Royal College of Paediatrics and Child Health, 2012. Consultant delivered care :
an evaluation of new ways of working in paediatrics. (Accessed 29/06/2015)
7. British Society for Paediatric Endocrinology and Diabetes, 2011. European
training syllabus in paediatric endocrinology and diabetes. (Accessed 29/06/2015)
8. Royal College of Surgeons of England, 2007. Surgery for children: delivering a
first class service. (Accessed 29/06/2015)
9. National Paediatric Hospital Development Board, 2010. A new National model of
care for paediatric healthcare in Ireland. (Accessed 29/06/2015)
10. National Paediatric Hospital Development Board, 2010. High level framework
brief, National Paediatric Hospital, part 2 A&B. (Accessed 29/06/2015)
11. Commissioning Support for London, 2011. Children & young people’s project:
London’s specialised children’s services – guide for commissioners. (Accessed
29/06/2015)
12. Department of Health, 2003. Getting the right start: national service framework
for children – standard for hospital services. (Accessed 29/06/2015)
13. Royal College of Paediatrics and Child Health. (2011b) Quality and safety
standards for small and remote paediatric units. (Accessed 29/06/2015)
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Primary Care Services
For primary care services is there evidence that a. national, b. regional or
c. local level delivery produces the best outcomes?
Key points:
• Any evidence located here would be secondary to the pending results of the
national review.
• The evidence suggests that any re-configuration should be on a system wide
basis
o Some evidence from NHS England favours reconfiguration of services
into larger units, but this may be influenced by local NHS reforms.
• Care should be taken to preserve links to local communities.
• The focus for improvement appears to be on evening and weekend care
o The use of consortia and telehealth may provide some benefit.
Optimal population levels
Scottish Government,
Note: The Scottish Government is running a review of
2015(1)
out of hours primary care, due to report in late
summer 2015. The review covers:
• Care expected at night and at the weekend
• Current best practice
• Ensuring a high quality and safe experience for
patients and health professionals
• Core requirements for service at night and at the
weekend, including roles and skills needed
• Where service delivery of out-of-hours makes sense
on a ‘Once for Scotland’ basis, and where local
variation is needed
• Pilots to test new models
Imison, 2014(8)
The proposals reviewed by NCAT [the National Clinical
Advisory Team] reflected the policy direction of
delivering ‘care closer to home’ and included:
• developing primary care services and
community-based services – often as part of
whole system reconfiguration
• changes to intermediate care beds – opening
or reopening, or providing on fewer sites
• consolidating primary care services. (page 26
onwards)
NHS England, 2014(2)
“This report focuses on general practice and the
central role we want it to play in wider local systems
of primary care ... It describes the kind of general
practice we want to see in the future, and the work
needed to develop the necessary clinical and
organisational models. It sets out the key ways in
which this will be led locally, and then outlines the
work underway nationally to support it.” (page 3)
“ … we believe that general practice will need to
operate at greater scale … general practice will need
to preserve and build on its traditional strengths of
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providing personal continuity of care and its strong
links with local communities.
Smith, 2013(3)
UK Government, 2014(4)
Clinical outcomes
ISD Scotland(5)
Many practices in England are already looking to
adopt new approaches to self care, communications
technologies and clinical collaboration. They are also
exploring ways of improving clinical effectiveness,
safety and patient experience. These often involve
looking more broadly at primary care and other
community-based services. This is about a bigger
perspective and ambition, and a step change in
partnership working, both across practices and with
their community partners.” (page 9)
Report contains several examples of services for
populations of over 50,000, with a mixture of small
and large sub-units. The examples include:
community health organisations, community health
organisations with inpatient facilities, regional and
national multi-practice organisations, marginalised
groups, networks or federations, and specialist
primary care. They conclude that no single model for
delivery should be advocated outside the local
context.
Case studies include:
“Eight networks of GP practices covering
approximately 30–40,000 patients were formed in
Tower Hamlets PCT in 2006 to improve the quality of
general practice for selected long-term conditions.”
(page 41)
“The Vitality Partnership has brought together seven
GP practices and 40 GPs (15 partners and 25 salaried
GPs) into a merged partnership that services 51,000
patients in Central and West
Birmingham.” (page 49)
“Over the last ten years, GPs in the Netherlands have
formed “GP Posts” - consortia to collectively cover out
of hours care
–GP posts are physical locations, staffed by GPs, open
in the evening and at night, on weekends and bank
holidays
–Patients with an urgent care need are triaged over
the phone and, if necessary, are seen in the post or
visited by the GP
–Almost all GPs in the Netherlands (98-99%) are part
of a GP post
–There are 124 posts in total, each covering a
population of around 130k – but individual sizes vary”
(page 2)
The Quality and Outcomes Framework (QOF) is the
annual reward and incentive programme detailing GP
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Health and Social Care
Information Centre(6)
Department of Health,
2014(7)
Imison, 2014(8)
King’s Fund, 2014(9)
practice achievement results. These pages include
links for results in Scotland.
QOF information and results for NHS England.
“The NHS Outcomes Framework is a set of 68
indicators which measure performance in the health
and care system at a national-level ... designed to be
a set of outcomes that together form an overarching
picture of the current state of health and care services
in England. Indicators ... are grouped into five
domains”
Domain 1 – preventing people from dying prematurely
Domain 2 – enhancing quality of life for people with
long-term conditions
Domain 3 – helping people to recover from episodes
of ill health or following injury
Domain 4 – ensuring that people have a positive
experience of care
Domain 5 – treating and caring for people in a safe
environment and protecting them from avoidable
harm (Background, page 3. Details, page 8-19)
“A significant proportion of hospital beds are occupied
by frail older people and people with long-term
conditions who would be more appropriately cared for
in the community. For some conditions, admissions
can be avoided with more proactive care, and in many
cases, length of stay could be reduced if there were
more services to support rehabilitation and discharge
…
… there is a lot of evidence to suggest that it can be
hard for community-based initiatives, including
changes to primary care, to significantly reduce
hospital admissions.
Delivering improvement seems to require new ways of
working across a system, including within hospitals,
supported by good continuity of primary care. Even
with successful implementation, there is little evidence
to suggest that more community-based models of
care will generate significant savings. Future
workforce projections also present challenges to
community-based models of care.” (page 27)
Recommendations to national bodies include:
• National bodies should work with providers
and researchers to develop and implement a
roadmap for improving quality measurement in
community services
• Produce a robust workforce plan and strategy
• Support local initiatives to benchmark data and
develop shared indicators
Recommendations to local bodies include:
• Take the initiative locally to improve how
quality is measured and monitored. Learn
107 | P a g e
King’s Fund, 2011(10)
Royal College of General
Practitioners(11)
King’s Fund, 2011(10)
from other services and sectors.
• Engage community services staff in the
process. (page 37-38)
The main data sets for measuring and/or comparing
the quality of care in general practice:
* Data sets of patient records - aggregated data
sets of individual patient records derived from GP
computer systems in a sample of practices.
* Hospital Episode Statistics (HES) - records of all
patients in England using inpatient and outpatient
hospital services, with details of GP registration and
referring GP.
* General Practice Patient Survey - a data set
derived from surveys run by the Department of Health
to assess patients’ access to and experience of GP
services.
* The Quality and Outcomes Framework - a data
set used as a pay for performance mechanism in
general practice for performance against clinical,
organisational, patient experience and additional
services indicators.
* Prescribing Indicators and Comparators - a
data set produced by the NHS Information Centre for
benchmarking prescribing patterns across practices.
(page 33)
Sources of quality indicators for use in general
practice:
* Indicators for Quality Improvement (IQI) - an
evolving menu of more than 200 quality indicators
across a broad range of services, developed by the
NHS Information Centre, to support benchmarking
and enable local clinical teams to examine specific
areas in need of quality improvement. Based across
three quality domains (safety, effectiveness and
patient experience).
* NHS comparators - a resource that contains
about 200 indicators from QOF, GPPS and HES data,
with results available for PCTs, acute trusts and
individual practices.
* Practice profiles - several public health
observatories have developed practice profiling tools
that provide a range of indicators, including from QOF
and other routine data sources, for individual
practices. (page 34)
“The RCGP Practice Accreditation award is a
thoroughly tested framework that enables practice
teams to improve their organisational quality of care.”
* Quality is complex and multidimensional. No single
group of indicators is likely to capture all perspectives
on, or all dimensions of, quality in general practice.
* Clinical outcomes are the ultimate measure of
108 | P a g e
Imison, 2014(8)
quality, but good outcomes can be achieved only if
there is agreement on what they are and if
appropriate structures and processes for achieving
them are in place. (page 43)
Table showing a summary of evidence on the impact
of community-based initiatives on
unplanned admissions (page 30)
Table showing the impact of primary care factors on
unplanned admissions (page 31)
Both show mixed results.
NHS England, 2014(2)
Care Quality Commission,
2014(12)
Bridgewater Community
Healthcare NHS Foundation
Trust(13)
Other service attributes:
Scottish Government,
2015(1)
“Why do community initiatives often fail to have the
impact anticipated? Poor implementation is a key
obstacle to community-based initiatives achieving
significant impact on rates of admission … There are
also risks of supply-induced demand. The key to
reducing the use of acute beds lies in changing ways
of working across a system, including changes within
hospitals, rather than piecemeal initiatives.” (page 31)
“[with partners] NHS England has established the
National Network of Quality in Primary Care to define
and promote quality in primary care … standards that
describe the key characteristics of high-quality
primary care in the following domains:
a) clinical effectiveness, including (i) reducing
avoidable mortality; (ii) improving quality of life for
people with long term conditions; (iii) providing swift
and effective responses to acute illness or injury;
b) patient experience, including experience of access;
c) patient safety.” (page 18)
“On all inspections, CQC asks five key questions about
a service:
•Is it safe?
•Is it effective?
•Is it caring?
•Is it responsive to people’s needs?
•Is it well-led?”
These questions are also used in the approach in NHS
England – Improving general practice : a call to action
(ref. no. 2)
“A collaborative self-funded programme was initiated
in 2012 by a core group of community NHS trusts in
England” ... aim to focus on patient-reported
outcomes and services delivered. Draft outcomes are
presented for comment.
The review “will address issues such as recruitment
and retention of GPs, staff availability, especially
during peak holiday times, consistency of service and
the public’s expectations of the service.”
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Department of Health,
2010(14)
Gilbert, 2013(15)
Reports that “primary care performance
improvements are associated with some modest but
measurable improvements in
subsequent outcomes and costs.” (page ii)
“In future there will be a much greater emphasis on
professionals working as teams for the benefit of the
patient and an increased use of technology over faceto-face care. There will be an increase in the diversity
of roles that deliver primary care services ... To
deliver high quality care for all, general practice needs
a well-trained, properly staffed, multidisciplinary
primary care workforce, aligned with its population’s
health needs.” (page 52)
“In the future, more and more patients will be treated
outside of the hospital setting and training
programmes will change to reflect this” (page 54)
“Trainees will also need greater exposure to primary
care settings and as a greater focus is placed on
prevention of ill health and maintaining health and
wellbeing of the population, there will be a need for
training to focus on health education.” (page 54-55)
Kings Fund, 2011(10)
“we need to develop a training programme for health
care support workers to equip them with the skills to
undertake more diverse and integrated roles within
primary care.” (page 55)
“We recommend that practices routinely collect and
act on patient feedback on their experiences of care,
using simple technologies that are available in the
practice … Groups of practices can then use this data
for benchmarking and improvement and, where
appropriate, to identify and challenge poor
performance. “ (page 110)
(also includes case studies in NHS England on page
113-115)
References:
1. Scottish Government, 2015. Review of out-of-hours primary care (Accessed
19/06/2015)
2. NHS England, 2014. Improving general practice: a call to action. Phase 1 report.
NHS England.(Accessed 22/06/2015) (click first link – “Emerging findings report”)
3. Smith J, Holder H, Edwards N, et al, 2013. Securing the future of general
practice: new models of primary care. Research report. King’s Fund ; Nuffield
Trust (Accessed 22/06/2015)
4. UK Government, 2014. Exploring international acute care models. International
comparisons of selected service lines in seven health systems. Annex 11 – Case
studies : GP posts in the Netherlands. Evidence Report, October 27th, 2014
(Accessed 22/06/2015)
5. ISD Scotland: Quality and outcomes framework (QOF) : general practice
(Accessed 22/06/2015)
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List of indicators: https://isdscotland.scot.nhs.uk/Health-Topics/GeneralPractice/Publications/2014-09-30/2014-09-30-QOF-Report.pdf?99056643248
(Accessed 22/06/2015)
6. Health and Social Care Information Centre: Quality and outcomes framework.
Health and Social Care Information Centre (Accessed 22/06/2015)
7. Department of Health, 2014. NHS outcomes framework 2014/15. Department of
Health (Accessed 26/06/2015)
8. Imison C, Sonola L, Honeyman M, et al, 2014. The reconfiguration of clinical
services : what is the evidence? King’s Fund (Accessed 22/06/2015)
9. King’s Fund, 2014. Managing quality in community health care services. King’s
Fund. (Accessed 26/06/2015)
10. King’s Fund, 2011. Improving the quality of care in general practice: report of an
independent inquiry commissioned by the King’s Fund. King’s Fund. (Accessed
26/06/2015)
11. Royal College of General Practitioners: Practice accreditation and quality practice
award. (Accessed 26/06/2015)
12. Care Quality Commission, 2014. The Care Quality Commission and the
Healthwatch network : working together. CQC. (Accessed 26/06/2015)
13. Bridgewater Community Healthcare NHS Foundation Trust : [National indicator
development project, pilot]. Draft Indicators – Feedback Opportunity. (Accessed
26/06/2015)
14. Department of Health, Health Foundation, 2010. Do quality improvements in
primary care reduce secondary care costs? The Health Foundation. (Accessed
26/06/2015)
15. Gilbert J, 2013. Transforming primary care in London. General practice: a call to
action. NHS England (Accessed 19/06/2015)
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Radiology
For radiology services, is there evidence that a. national, b. regional or c.
local level delivery produces the best outcomes?
Key point:
•
For radiology the evidence suggests that a move to networked delivery of
services will be needed to cope with increasing demand and staff shortages.
Population Required
Royal College of
Radiologists, 2014 (4)
The Royal College of Radiologists, in response to the rising
demand for imaging services and shortfall in staffing,
propose “that existing radiology services should collaborate
to form networks of expertise serving a population of
several million rather than a few hundred thousand as at
present. A grouping of say 150-200 radiologists would have
the capacity to provide continuous 24 hour cover across the
range of required specialties.” (page 2)
The position paper goes on to describe an example network
involving six hospitals. They suggest a minimum of five
hospitals would be required to achieve economies of scale.
They stress that this is not a ‘hub and spoke’ model; rather
each hospital is an equal partner. They note that all
hospitals would retain their own imaging service but the
reporting of acquired images would be networked. (page 45)
National Imaging
Board, 2010(3)
This guidance concludes that the evidence base suggests
that “the quality of IR services at night and over weekends
must be the same as that expected during the normal
working day. Where out of hours services are being
implemented co-ordinated weekend services should be
planned for sufficiently large populations to ensure that IR
skills are maintained and job plans are acceptable.” (page
18)
Clinical Outcomes
National Imaging
Board, 2010(3)
This guidance states that if practicable a local
Interventional Radiology service should be provided. It
notes that this is not always possible for smaller hospitals,
suggesting that it should be possible to create an imaging
network similar to existing cancer, trauma and stroke
networks. (page 7, 15)
The guidance also notes that that for some procedures such
as transjugular intrahepatic portosystemic shunts (TIPS),
patients should travel to a few dedicated centres which
undertake enough cases to sustain expertise. (page 7)
See full text for further guidance on 24/7 service delivery,
9-5 delivery within a network and out of hours service
112 | P a g e
delivery.
National Imaging
Board, 2010(2)
This report recommends that a “3 tier paediatric radiology
network services model based on trauma networks and
utilising PACS & teleradiology effectively should be
developed.” (page 15)
“A typical level 3 Paediatric Imaging department would
support a minor injury unit, outpatient, or primary care
service but not under take specialised examinations for
ambulatory or inpatients. Level 3 departments should not
be independent but operate as a satellite unit linked to a
Level 2 or level 1 department for advice and support.”
(page 7)
“A level 2 department is likely to reside in a “district general
hospital” environment. It will usually provide imaging
facilities to support a paediatric clinical service from within a
general radiology department.” (page 7)
“Specialist paediatric imaging department would provide
level 1 services. These would form the specialist centre for
a paediatric imaging network and would usually reside in a
children’s hospital or major teaching centre.” (page 9)
See full text for further recommendations for each tier of
the network.
British Society of
Interventional
Radiology, 2014(1)
This report states that use of “Networked delivery models
will be essential to improve access to interventional
radiology.” (page 4)
The report cites the East Midlands network as an example
of good practice. (page 17)
Other Service Attributes
Workforce
Royal College of
Radiologists & the
British Society of
Interventional
Radiologists, 2014(5)
“The RCR believes an increase of 25 trainees per year is
realistic and the minimum necessary. Even with this
increase, it is likely that service reconfiguration may be
required to sustain a safe IR service across England.” (page
16)
References:
1. British Society of Interventional Radiology, 2014. Providing access to
interventional radiology services, seven days a week. NHS Improving Quality.
(Accessed 01/07/2015)
2. National Imaging Board, 2010. Delivering quality imaging services for
children. Department of Health. (Accessed 01/07/2015)
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3. National Imaging Board, 2010. Interventional radiology: guidance for service
delivery. Department of Health. (Accessed 01/07/2015)
4. Royal College of Radiologists, 2014. Radiology in the UK - the case for a new
service model. (Accessed 01/07/2015)
5. Royal College of Radiologists, British Society of Interventional Radiologists,
2014. Investing in the interventional radiology workforce: the quality and
efficiency case. (Accessed 01/07/2015)
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Stroke
For stroke services, is there evidence that a. national, b. regional or c. local
level delivery produces the best outcomes?
Key Points:
• Stroke care in Scotland should be provided at the local level. In the urban
areas there may be some scope for centralising services as has been done in
London. In the rural areas benefits may be achieved by utilising TeleStroke
care from these urban specialist centres.
• As references 5 and 7 show stroke care standards across Scotland are still in
the development stages so there is still a lot of work to be done to improve
services. Also reference 16 shows there are areas within stroke care – better
support for sufferers and carers which need future development.
Population required
Newton, 2013(1)
British Association of
Stroke Physicians,
2011(2)
NHS England, 2015(3)
Quality indicators
NICE, 2010(4)
Scottish Government,
2014(5)
Jauch, 2013(6)
A hospital serving a population of 300,000 admits about
500 acute stroke patients each year (page 255)
A population of 60M requires … 350 whole time
equivalent consultants. Most physicians cover more than
stroke, so figure is calculated at 513 stroke specialists
required for UK population (page 1)
In urban areas the evidence suggests that concentration
of specialist care benefits the quality of care e.g. in
London 32 stroke units were consolidated into 8 specialist
ones achieving a 17% reduction in 30-day mortality and
7% reduction in patient length stay (page 22)
Pre Hospital Care
“People seen by ambulance staff … who have .. sudden …
neurological symptoms, are screened using a validated
tool to diagnose stroke or transient ischaemic attack”
(page 9)
Public campaign to raise awareness of stroke symptoms
(page 14)
Early identification of stroke/TIA by SAS/NHS 24, primary
care and hospital emergency departments (page 14)
Public stroke education (page 871-873)
Stroke patients are dispatched at the highest level of care
available in the shortest time possible.
The time between the receipt of the call and the dispatch
of the response team is <90 seconds.
EMSS response time is <8 minutes (time elapsed from
the receipt of the call by the dispatch entity to the arrival
on the scene of a properly equipped and staffed
ambulance).
Dispatch time is <1 minute.
Turnout time (from when a call is received to the unit
being en route) is <1 minute.
The on-scene time is <15 minutes (barring extenuating
circumstances such as extrication difficulties).
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Travel time is equivalent to trauma or acute myocardial
infarction calls (page 873)
Scottish Stroke Care
Audit Steering
Committee, 2013(7)
Filho, 2014(8)
Monitor, 2014(9)
Where ground transport to nearest stroke capable
hospital greater than 1 hour use of air transport is useful
(page 874)
Hospital Care
90% of all patients admitted to hospital with a diagnosis
of stroke are admitted to the stroke unit on the day of
admission, or the day following presentation at hospital,
and remain in specialist stroke care until in-hospital
stroke-related needs are met.
90% of patients have CT/ MRI imaging within 24 hours of
admission
90% of patients are screened by a standardised
assessment method to identify any difficulty swallowing
safely due to low conscious level and/ or the presence of
signs of dysphagia on the day of admission before the
patient is given any food/ drink or oral medication.
Aspirin is given on the day of admission or the following
day for all patients in whom a haemorrhagic stroke, or
other contraindication, as specified in the national audit,
has been excluded.
80% of new patients with a stroke or TIA are seen within
4 days of receipt of referral to the neurovascular clinic.
The MCN monitors the delay between arrival at the first
hospital and administration of the bolus of recombinant
plasminogen activator. 80% of patients receive the bolus
within one hour of arrival.
80% of patients undergoing carotid endarterectomy for
symptomatic carotid stenosis have the operation within
14 days of the stroke event (page 1-7)
Time is of the essence in stroke care
Thromolysis – therapeutic window - 4.5 hours onset
Early triage of the patient to CT or MRI scan is critical –
within 24 hours, 3 , 6 and 12 hours discussed as time
limits for different type of scans.
Cardiology and other monitoring required
Acute theraopy – alteplase -3 hours post onset – time
limit not to be used post 4.5 hours
Antithrombics – within 48 hours onset
Stroke unit care — Evidence suggests that patients with
acute stroke have better outcomes when admitted to a
hospital unit that is specialized for the care of patients
with all types of acute stroke
Access
▪Direct admission to specialist stroke unit and
thrombolysis assessment and treatment
▪Admission to acute stroke unit ≤4 hrs when arrival is out
of hours
▪Seen by stroke consultant/ associate specialist ≤24 hrs
▪<1 week wait to carotid endarterectomy post TIA
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Jauch, 2013(6)
Royal College of
Physicians, 2012(10)
▪Maximum one hour travel time to acute stroke care unit
Process
▪Transfer to specialist stroke rehab unit (following acute
treatment phase) if required
▪Diagnosis with validated tool and transfer to specialist
stroke unit ≤1hr if positive
▪Brain imaging ≤1hr of arrival
▪Swallow screen ≤4hrs
▪Specialist rehabilitation assessment ≤24hrs , with full
MDT rehab assessment ≤72hrs , and MD goals and plan
≤5 days
▪Transfer to specialist stroke rehab unit (following acute
treatment phase) if required
▪≤45 mins active therapy 5 days/week, if required
▪Incontinence assessment and care plan ≤2 weeks, if
required
▪Screening for mood disturbance and cognitive
impairment ≤6 weeks
▪Follow-up ≤72hrs by specialist stroke rehabilitation team
for all patients discharged with residual stroke-related
problems
▪Named point of contact for carers
▪Thrombolysis ≤1hr Input
▪Minimum service requirements for hyper-acute stroke
unit:
–Hyper acute stroke services need to be co-located with
critical care and neurological services, and have 24/7
access to neuroradiology (page 2)
Models of Care
Recommends integrated stroke care system consisting of:
Primary Stroke Centers, Comprehensive Stroke Centers
(3M pop),and Acute Stroke Ready Hospitals (page 875876)
A. All community medical services and ambulance
services (including call handlers) should be trained to
treat patients with symptoms suggestive of an acute
stroke as an emergency requiring urgent transfer to a
centre with specialised hyperacute stroke services.
B. All patients seen with an acute neurological syndrome
suspected to be a stroke should be transferred directly to
a specialised hyperacute stroke unit that will assess for
thrombolysis and other urgent interventions and deliver
them if clinically indicated.
C. All hospitals receiving acute medical admissions that
include patients with potential stroke should have
arrangements to admit them directly to a specialist acute
stroke unit (onsite or at a neighbouring hospital) to
monitor and regulate basic physiological functions such as
blood glucose, oxygenation, and blood pressure.
D. All hospitals admitting stroke patients should have a
specialist stroke rehabilitation ward, or should have
immediate access to one.
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E. All ‘health economies’ (geographic areas or
populations covered by an integrated group of health
commissioners and providers) should have a specialist
neurovascular (TIA) service able to assess and initiate
management of patients within 24 hours of transient
cerebrovascular symptoms.
F. There should be public and professional education
programmes to increase awareness of stroke and the
need for urgent diagnosis and treatment (page 19)
(page 22)
NHS Midlands and East,
2012(11)
HyperAcute Stroke care staffing (page 15)
Staffing Numbers:
Hyper acute services provide minimum staffing ratios of:
• 6 BASP thrombolysis trained physicians on a rota
24/7
• 2.9 WTE nurses per bed to comply with 8-:20
trained vs. untrained skill mix
• 0.73 WTE Physiotherapist per 5 beds (respiratory
& neuro)
• 0.68 WTE Occupational Therapists per 5 beds
• 0.68 WTE S&LT per 10 beds
• Access to social worker
Acute Stroke care Staffing (page 21)
Staffing numbers:
Acute and rehabilitation service should have a
multidisciplinary team comprising of:
• Nurses: 1.35 per bed (65:35 trained to untrained
skill mix)
• Physiotherapists: 0.84 WTE per 5 beds
• Occupational Therapists: 0.81 WTE per 5 beds
• Speech & Language Therapists: 0.91 WTE per 10
beds
• Psychologists
• Dieticians
• Social Workers
Access is available to a range of additional professionals
including those in:
• Clinical Psychology
• Oral health
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• Orthoptics
• Orthotics
• Pharmacy
Note: where combined stroke units are used, it is
expected that beds are designated as hyper acute and
acute, then staffed according to the hyper acute service
standards outlined.
Discharge team staffing (page 28)
A stroke ESD multidisciplinary team composition should
include as a minimum (WTE per 100 cases per year)
• Occupational Therapy (1)
• Physiotherapy (1)
• Speech and Language Therapy (0.4)
The stroke ESD team has access to support from:
Stroke physician (0.1)
• Nurse (0-1.2)
• Social worker (0-0.5)
• Rehabilitation assistant (0.25)
• Clinical Psychology
• Dieticians
• Orthotics
• Orthoptics
• There are coordinated stroke skilled ESD teams
working in partnership with local authorities and
other health and third sector providers
ESD team meets weekly as a minimum to plan and
manage patient care
Community rehabilitation teams staffing (page 31)
Workforce:
• There are established stroke skilled,
multidisciplinary community rehabilitation teams.
Composition of the team should include as a
minimum:
o Physiotherapist
o Occupational therapist
o Speech and language therapist
o Community nursing (as appropriate)
o Social care
o Rehabilitation assistants
o Clinical Psychology (as appropriate)
• The community rehabilitation team has access to
support from:
o GO
o Dieticians
o Orthotics
o Orthoptics
o Vocational rehabilitation
• Initial assessment of the stroke patient is carried
out by a qualified professional (some of the care
may be delivered by rehabilitation assistants
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Monitor, 2014(9)
under the supervision of a qualified therapist).
International comparisons
Netherlands
▪Stroke care in the Netherlands is delivered in almost all
hospitals
▪In the Netherlands there exist stroke networks (CVA
Zorgketens) to coordinate stroke care between acute and
primary care as well as rehabilitation services
▪Currently almost all hospitals provide stroke care
–Stroke services are currently being provided by almost
all (94) hospitals, with patients per hospital varying from
only a few to over 1,000 a year
–All hospitals delivering stroke care claim to have an ESOcompliant stroke unit, meeting standards such as at least
4 beds, 24/7 access to a CT and MRI, and a
multidisciplinary treatment team (page 9)
Ontario, Canada
The Ontario Stroke System organises care for the entire
province
–Stroke services in Ontario are organised as a single
“system” (the Ontario Stroke System) which is made up
of 11 regional integrated clinical networks (supporting
patients in 14 LHINs)
–Each region serves approx 1m patients
–The stroke networks are a collaborative partnership that
span the full stroke pathway (from primary prevention
through to post-stroke rehabilitation and secondary
prevention) with a remit that includes providing equitable
access and improvement in outcomes
▪Within each region acute care is organised into three
tiers
–A regional stroke centre offering 24/7 access to a
specialist stroke team and services including brain
imaging, thrombolysis, interventional radiology and
neurosurgery. The regional hub also provides expert
advice (including interpretation through telemedicine),
transfer coordination, and leadership to lower tiers
–One or more district/enhanced district stroke centres
offering thrombolysis on-site, including through use of
telemedicine to access expert interpretation and advice
not available on site, or through established transfer
protocols
–Secondary prevention centres
–Plus partnership agreements with community hospitals
and rehabilitation units (page 11)
Sweden
Most acute hospitals in Sweden have stroke units and
provide stroke care
–In Stockholm Country, all the acute hospitals provide
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stroke care
–Of the 72 hospitals in Sweden that receive stroke
patients, 90% complies with the national guidelines for
stroke units (page 13)
Germany
There are >250 certified acute stroke units across
Germany organised into 2 tiers with minimum volume,
size and service thresholds for each:
–101 Comprehensive Stroke Centres
–157 Primary Stroke Centres
▪Patients end up in stroke centres due to the referral
process with the ambulance rather than strict
requirements
–Designated stroke units are required to have established
a referral process for ambulance services (in the region)
to deliver the patient directly to the most appropriate unit
–Consequently, while hospitals without a stroke
designation can in theory provide acute stroke, in practice
it would be unusual for care to take place outside of the
designated centres
▪Post-acute care is delivered by a much broader group of
providers
–Some regions and providers may have established
networks for post-acute care but there is wide variation
and no national standard
▪In some areas, ambulance services (staffed with
physicians and specialist equipment) provide extensive
pre-hospital care for acute stroke (page 15)
Arkansas USA
▪Acute stroke care is delivered by a state-wide and statesponsored telestroke network which connects smaller and
more remote acute hospitals across the state with
specialist tertiary centres. The network offers 24/7 stroke
triage via telemedicine to support rural Emergency
Departments delivering stroke care. Neurologists at two
tertiary hospitals interview patients and review CT scans
using real-time video conferencing. (See next page for
details).
▪The network is led by 4 Joint Commission certified
Advanced Primary Stroke Centers. These sites must meet
standards, as defined by the Joint Commission, follow
approved Clinical Practice Guidelines, and systematically
measure performance and participate in performance
improvement
▪Arkansas has four Joint Commission certified Stroke
Rehabilitation centers. These are are all based at
specialist rehabilitation hospitals, and not at acute
hospitals
▪The state Acute Stroke Task Force is tasked with
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improving stroke care. The state has not enacted state
Primary Stroke Center legislation (as recommended by
the CDC), but has completed the following improvement
initiatives
–Developed a model stroke program in the state covering
prevention, acute care, rehabilitation and follow-up care
–Initiated discussions on the status of the current level of
stroke provision including gaps in stroke care and barriers
to change
–Working to develop a stroke registry (page 17)
Victoria, Australia
Acute stroke services are currently often sub-scale with
many hospitals offering acute stroke care, with low
volumes of patients and limited expertise/facilities
Stroke Unit Trialists’
Collaboration, 2013(12)
▪Victoria is in the middle of implementing a regional
strategy to create three distinct service tiers
–Comprehensive stroke centres: provide regional
leadership and referral pathways (with primary centres
and adjacent regions); >350 acute strokes/yr; specialist
stroke unit; 24/7 CT, thrombolysis and neurosurgery1
–Primary stroke centres: >100 acute strokes/yr; 24/7 CT
and thrombolysis1
–Basic hospital service: <100 acute strokes/yr; have clear
transfer arrangements
▪Victoria (state Dept of Health) is encouraging the
development of different strategies to address historically
poor access in remote areas
–Access to an acute stroke centre (with imaging and
thrombolysis) within 60 mins by ambulance from all areas
of the state (94% achieved)
–Clear transfer protocols to get patients to higher tier
services as soon as possible
–Use of telemedicine to facilitate the delivery of brain
imaging and thrombolysis in remote
areas where volume of patients and on-the-ground
expertise is more limited (page 19)
Organised stroke unit care is a form of care provided in
hospital by nurses, doctors and therapists who specialise
in looking after stroke patients and work as a coordinated team. This review of 28 trials, involving 5855
participants, showed that patients who receive this care
are more likely to survive their stroke, return home and
become independent in looking after themselves. A
variety of different types of stroke unit have been
developed. The best results appear to come from those
which are based in a dedicated ward (page 2)
Since the original publication of this review, stroke
services in many developed countries have undergone
substantial reorganisation in line with national strategies
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Morris, 2014(13)
and clinical practice guidelines to enable improvements in
access to stroke unit care. More recently, stroke services
in many countries have been further reorganised to
reflect a two-tiered (or hub-and-spoke) model of care in
which a central ’comprehensive stroke centre’ (or ’hyperacute stroke unit’) is equipped with facilities for acute
intravenous or intra-arterial treatments, intensive
monitoring, advanced imaging and neurosurgery. These
then serve a number of ’primary stroke centres’ or stroke
units within a hospital network or geographical location.
Although this approach seems almost intuitive to many
stroke clinicians, it has never been formally tested in
randomised controlled trials. Until such trials are
available, stroke services should ensure that every stroke
patient receives the core service characteristics identified
in the randomised trials (page 18)
Redesign of stroke services in London and Greater
Manchester. In London 30 hospitals centralised to 8 main
centres providing stroke care. In Manchester 3
hyperacute centres, with 10 district stroke centres. All
pre-existing hospitals continue to provide stroke care
(page 2)
Conclusion: A centralised model of acute stroke care, in
which hyperacute care is provided to all patients with
stroke across an entire metropolitan area, can reduce
mortality and length of hospital stay (page 1)
Hunter, 2013(14)
For rural areas: “On a different point, while the results
were consistent when we included patients living in rural
areas, they might be less relevant to services in rural
settings. The greater travel times in rural areas make
centralisation challenging and might necessitate other
solutions, such as telemedicine, whereby consultation and
triage can be conducted remotely by a stroke physician in
a specialist stroke unit” (page 5)
A centralized model for acute stroke care across an entire
metropolitan city appears to have reduced mortality for a
reduced cost per patient, predominately as a result of
reduced hospital length of stay (page 1)
In a pooled sample of 307 patients ‘before’ and 3156
patients ‘after’, survival improved in the ‘after’ period
(age adjusted hazard ratio 0.54; 95% CI 0.41–0.72). The
predicted survival rates at 90 days in the deterministic
model adjusted for national trends were 87.2% ‘before’
% (95% CI 86.7%–87.7%) and 88.7% ‘after’ (95% CI
88.6%–88.8%); a relative reduction in deaths of 12%
(95% CI 8%–16%). Based on a cohort of 6,438 stroke
patients, the model produces a total cost saving of £5.2
million per year at 90 days (95% CI £4.9-£5.5 million;
£811 per patient) (page 1)
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Müller-Barna, 2014(15)
Stoke Association,
2013(16)
Royal College of
Physicians, 2012(10)
Scottish Government,
2014(5)
Delivering appropriate stroke care in rural areas is a
major public health challenge – TeleStroke Unit networks
may be a useful model. Describes project in Germany.
10 year evaluative study. Results – over study period
Telestroke treatment rose from 19% to 78%. Times to
treatment reduced from 150-120 minutes, and door to
needle times from 80 to 40 minutes (page 2739)
Stroke survivors need their emotional needs looked after
as well as physical needs. This study looked at the
experiences of survivors and carers. There is a lot of
stress on carers. Both groups need psychological support
and this should be incorporated into stroke services (page
5)
Each specialist stroke rehabilitation service should in
addition:
• have an education programme for all staff
providing the stroke service
• offer training for junior professionals in the
specialty of stroke (page 23)
Priority 4: Developing a skilled and knowledgeable
workforce
Aim: A trained and competent workforce ensures health
and social care staff in contact with people affected by
stroke have the knowledge and skills to deliver personcentred, safe and effective stroke care.
Background: The 2009 clinical standards recognised the
need for stroke units to be able to demonstrate that their
staff underwent appropriate training. This priority builds
on this further recognising the need for appropriate levels
of training across the wider health and social care
workforce. A current project led by the National Advisory
Committee for Stroke (NACS) and the Stroke
Improvement Team to measure the correlation between
training provision and performance of the Stroke Care
Bundle and door to needle time will provide evidence on
training provision.
Actions: Health and social care staff in hospital and
community settings are trained to an appropriate level
depending on whether their contact with people affected
by stroke is: occasional (stroke awareness), regular (core
competencies) or in the context of specialist services
(specialist competencies).
• All NHS Boards utilise the education training
template to accurately identify training delivery
and demonstrate appropriate level of training; and
• NHS Boards use the information collated from the
education template to identify and address
training needs at all levels (page 17)
References:
1. Newton, H, 2013. Stroke medicine IN Royal College of Physicians Consultant
physicians working with patients: the duties, responsibilities and practice of
124 | P a g e
physicians in medicine. London, Royal College of Physicians, p255-261. (Accessed
22/06/2015)
2. British Association of Stroke Physicians, 2011. Meeting the future challenge of
stroke. Stroke medicine consultant workforce requirements 2011–2015.
(Accessed 22/06/2015)
3. NHS England, 2015. Five year forward review. (Accessed 22/06/2015)
4. National Institute for Health and Care Excellence, 2010. Stroke quality standard.
(Accessed 22/06/2015)
5. Scottish Government, 2014. Stroke improvement plan. (Accessed 22/06/2015)
6. Jauch EC et al, 2013. Guidelines for the early management of patients with acute
ischemic stroke: a guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke; a journal of cerebral circulation,
44(3):870-947. (Accessed 22/06/2015)
7. Scottish Stroke Care Audit Steering Committee, 2013. Scottish stroke care
standards. (Accessed 22/06/2015)
8. Filho J, Koroshetz WJ, 2014. Initial assessment and management of acute stroke.
UpToDate/Wolters Kluwer. (Accessed 22/06/2015)
9. Monitor, 2014. International comparisons of selected service lines in seven health
systems: annex 4 review of service lines: stroke. (Accessed 22/06/2015)
10. Royal College of Physicians, 2012. National clinical guideline for stroke. (Accessed
22/6/2015)
11. NHS Midlands and East, 2012. Stroke services specification. (Accessed
22/06/2015)
12. Stroke Unit Trialists’ Collaboration, 2013. Organised inpatient (stroke unit) care
for stroke. Cochrane Database of Systematic Reviews 2013, Issue 9. (Accessed
24/06/2015)
13. Morris S et al, 2014. Impact of centralising acute stroke services in English
metropolitan areas on mortality and length of hospital stay: difference-indifferences analysis. BMJ 349. (Accessed 24/06/2015)
14. Hunter RM, 2013. Impact on clinical and cost outcomes of a centralized approach
to acute stroke care in London: a comparative effectiveness before and after
model. PLOS One 8 (Accessed 26/06/2015)
15. Müller-Barna P, 2014. TeleStroke units serving as a model of care in rural areas:
10-year experience of the TeleMedical project for integrative stroke care. Stroke
45(9):2739-44. (Accessed 24/06/2015)
16. Stroke Association, 2013. Feeling overwhelmed: the emotional impact of stroke.
(Accessed 24/06/2015)
125 | P a g e
Surgical specialties
Key Points:
• There has been an increasing sub-specialisation of General Surgery with
some sub specialities becoming a specialisation in its own right.
• Surgery is linked in with other areas and is dependent on the Emergency
Department, Theatres and Anaesthetics.
• With the increase in sub-specialities it is important surgeons maintain their
General surgery training.
Population Required
Royal College of
Surgeons
Surgical
workforce,
2011(1)
Cardiothoracic Surgery – a total of 330 Consultants in England
Ratios:
General Surgery 1:25,000
Oral and Maxillofacial Surgery 1:150,000
Otorhinolaryngology 1:86,000
Paediatric Surgery 1:250,000
Plastic Surgery 1:100,000
Centre for
Workforce
Intelligence,
2011(2)
“Generalist versus the specialist: there is the increasing desire for
general surgeons to increased levels of subspecialism which have
been shown to improve outcomes for elective case patients.
However, a significant level of General Surgery activity is for
emergency activity. Both workforce planners and general
surgeons need to ensure acute General Surgery activity is suitably
resourced.” (page 15)
Association of
Surgeons of
Great Britain and
Ireland, 2012(3)
Emergency Surgery :
“a duty team typically needs at least 3 and preferably 4 personnel
(CCT, MRCS, core and foundation).” (page 19)
BOMSS, 2012(4)
“The core professions/disciplines within the MDT should at least
comprise
• Specialist bariatric Surgeon(s)
• Bariatric Nurse Specialist(s)
• Specialist Bariatric Dietitian(s)” (page 3)
“unmanageable numbers of patients are a real concern of larger
mergers between hospitals” (page 25)
“Bariatric Unit .. will comprise 3 consultant bariatric surgeons with
sufficient anaesthetic cover, supported by 3 half time equivalent
dietitian and 3 half time equivalent specialist nurses.” (page 13)
“Bariatric Centres. At a bariatric centre there should be at least 5
operations a week … the world literature suggests that an
establishment of 4 surgeons will deliver high quality with a
volume of 400 a year.” (page 14)
Royal College of
Surgeons of
England, 2010(5)
“Most surgical procedures performed on children are elective,
relatively straightforward and performed in the DGH.” (page 1)
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“Children account for nearly 25% of the population in the UK.
They require access to routine surgical and anaesthetic care at a
location that is easily accessible to them and their family and that
meets the appropriate standards.” (page 1)
Imison, 2014(6)
“Units providing 24/7 acute (emergency) surgery should ensure
early consultant review and assessment (ie, within 12 hours)
There should be consultant surgeons and anasthetisists available
24/7 to supervise operations on emergency surgical patients.
Acute surgical services should be supported by a dedicated
emergency theatrea, appropriate critical care services, acute
medicine and diagnostic services including interventional
radiology.
Outcomes for emergency surgery cary considerably between
units. While centralisation of services may be one way of
improving outcomes, the relationship between volume and
outcomes is complex. There is also evidence that systematic
application of improvement techniqueses, as well as high-quality
peri-operative assessment and post-operative care, are key
drivers of improvement.
The emerging field of telemedicine has the potential to improve
access to specialist opinion and enhance the treatment of acutely
ill patients.” (page 51)
Clinical Outcomes
Centre for
Workforce
Intelligence,
2011(2)
“General surgery has significant interactions with other surgical
specialities, emergency medicine, theatre teams and surgical
ward staffing. General surgery workforce planning needs to
consider the cross-speciality and cross-profession impacts that
may occur due to changing training numbers.” (page 2)
“The CfWI position on training numbers is that while weighted
capitation has some use, decision makers also need to consider
the quality of training in the regions and the accessibility of care
for patients.” (page 3)
Association of
Surgeons of
Great Britain and
Ireland, 2012(3)
“A strong case might be made for defining different types of
hospital based upon patient risk and complexity. It will be clear
there is a case for sub-specialisation, but offset by the need for
local services where possible and a distribution of work which
allows surgeons to maintain skills safely.” (page 26)
“Smaller and remote hospitals have particular issues .. They tend
to have much more of a ‘consultant delivered’ service…Decisions
about overall care of the patient are invariably taken both at a
higher level, and possibly earlier too. Senior involvement at an
early stage is pivotal to the care of the more seriously ill, and the
smaller hospital has a possible advantage here.” (page 27)
Other Service Attributes
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Royal College of
Surgeons of
England, 2010(5)
“The general surgical syllabus requires all general surgeons to
receive training in the management of common childhood
surgical emergencies during their DGH attachments. (page 4)
“Development of general surgeons and urologists with expertise
in paediatric surgery can be provided during specialist training or
post-CCT proleptic appointment.
The training programme director should ensure availability of
training in general paediatric surgery. By developing a network,
paediatric surgical training capacity is identified.” (page 4)
“If preventative steps are not taken now, there will be a
substantial deficiency of general surgeons and urologists capable
of providing a safe local GPS service in the near future. This
would go against the NHS stated policy to deliver care as close to
the patient’s home as possible.” (page 5)
References:
1. Surgical workforce, 2011. A report from The Royal College of Surgeons of
England in collaboration with the surgical specialty associations. The Royal
College of Surgeons of England 2012. (Accessed 24/06/2015)
2. Centre for Workforce Intelligence, 2011. Medical speciality workforce
summary: general surgery. (Accessed 24/06/2015)
3. Association of Surgeons of Great Britain and Ireland, 2012. Issues in
professional practice: emergency general surgery. (Accessed 29/06/2015)
4. British Obesity and Metabolic Surgery Society, 2012. Providing bariatric
surgery. BOMSS standards for clinical service guidance on commissioning.
(Accessed 29/06/2015)
5. Royal College of Surgeons of England, 2010. Ensuring the provision of
general paediatric surgery in the district general hospital: guidance to
commissioners and service planners. (Accessed 29/06/2015)
6. Imison C, Sonola L, Honeyman M et al, 2014. Acute Surgical Services. The
reconfiguration of clinical services: what is the evidence?, Chapter 8. King’s
Fund. (Accessed 24/06/2015)
128 | P a g e
Urology
For urology services, is there evidence that a. national, b. regional or c.
local level delivery produces the best outcomes?
Key points:
•
•
•
•
•
•
•
Most published information refers specifically to urological cancer services
Local urological cancer teams should serve populations of 250,000 to 500,000
(reducing to 200,000 in rural areas).
Specialist urological cancer teams should serve populations of no less than
one million.
Teams providing radical surgery for prostate and bladder cancer should serve
populations of at least one million and carry out at least 50 operations per
annum.
Supra-network testicular cancer or penile cancer teams should serve
populations of at least two or four million respectively.
One American study found that having more than 2 urologists per 100,000
population had no increased benefit on urological cancer mortality.
The NICE quality standards for UTI in under-16s, urinary incontinence in
women, and lower urinary tract symptoms in men specifies services should
be integrated across the care pathway.
Population Required
NICE, 2002(5) ;
NHS England, 2013(1)
“Radical surgery for prostate and bladder cancer should
be provided by teams typically serving populations of one
million or more and carrying out a cumulative total of at
least 50 such operations per annum. Whilst these teams
are being established, surgeons carrying out small
numbers (five or fewer per annum) of either operation
should make arrangements within their network to pass
this work on to more specialised colleagues.” (page 6)
Local urological cancer team
“In general, local urological cancer teams should serve
populations of 250,000 to 500,000, but the minimum
figure may be closer to 200,000 in large sparsely
populated areas. “ (page 26)
Specialist urological cancer teams
“All operations carried out by any particular team should
be carried out in a single hospital, which should also
provide post-operative care and host the MDT meetings.
In larger cancer networks (those providing services for
urological malignancies for populations of two million or
more), a second specialist team may be established,
provided the population served by each of the teams is no
less than one million.” (page 29)
Supra-network specialist teams
“Patients with testicular or penile cancer should be
129 | P a g e
managed by specialist testicular cancer or penile cancer
teams working at the supra-network level. Such teams
should serve up to four networks, with a combined
population base of at least two million for testicular cancer
and four million for penile cancer.” (page 30)
Odisho, 2010(6)
In 2472 non-rural US counties with more than zero
urologists (0.1-2) there was a statistically significant
reduction in cancer-specific mortality for each of three
cancers (prostate, bladder, and kidney). However,
increasing density greater than two urologists per 100,000
people had no statistically significant impact on mortality
for any of the tumors studied.
Clinical Outcomes
NICE, 2002(5)
“One, two and five-year survival rates for each type of
cancer, adjusted for case-mix.
Audit of outcomes of treatment, including detailed
information on case-mix.” (page 39)
Other Service Attributes
NICE, 2013a(3)
“The quality standard for urinary tract infection in infants,
children and young people under 16 specifies that services
should be commissioned from and coordinated across all
relevant agencies encompassing the whole urinary tract
infection care pathway for this population. A personcentred, integrated approach to provision of services is
fundamental to delivering high quality care to infants,
children and young people with a urinary tract infection.”
(page 7)
NICE, 2015(2)
“The quality standard for urinary incontinence in women
specifies that services should be commissioned from and
coordinated across all relevant agencies encompassing the
whole continence care pathway. A person-centred,
integrated approach to providing services is fundamental
to delivering high-quality care to women with urinary
incontinence.” (page 9)
NICE, 2013b(4)
“The quality standard for LUTS specifies that services
should be commissioned from and coordinated across all
relevant agencies encompassing the whole LUTS care
pathway. A person-centred, integrated approach to
providing services is fundamental to delivering high
quality care to men with LUTS” (page 8)
NICE, 2002(5)
Key recommendations
“All patients with urological cancers should be managed
by multidisciplinary urological cancer teams. These teams
should function in the context of dedicated specialist
services, with working arrangements and protocols agreed
130 | P a g e
throughout each cancer network.
Members of urological cancer teams should have
specialised skills appropriate for their roles at each level of
the service. Within each network, multidisciplinary teams
should be formed in local hospitals (cancer units); at
cancer centres, with the possibility in larger networks of
additional specialist teams serving populations of at least
one million; and at supra-network level to provide
specialist management for some male genital cancers.”
(page 6)
References:
1. NHS England, 2013. Manual for cancer services: urology measures. NHS
England. (Accessed 24/06/2015)
2. NICE, 2015. Urinary incontinence in women. QS77. NICE. (Accessed
24/06/2015)
3. NICE 2013a, QS36: Urinary tract infection in infants, children and young
people under\ 16, NICE. (Accessed 24/06/2015)
4. NICE, 2013b. Lower urinary tract symptoms in men. QS45. NICE. (Accessed
24/06/2015)
5. NICE, 2002. Improving outcomes in urological cancer: the manual. , NICE.
(Accessed 24/06/2015)
6. Odisho, A., Cooperberg, M., Fradet, V., et al., 2010. Urologist density and
county-level urologic cancer mortality. Journal of Clinical Oncology, vol. 28,
no. 15, pp. 2499-2504.(Accessed 30/06/2015)
131 | P a g e
Vascular
For vascular services, is there evidence that a. national, b. regional or c.
local level delivery produces the best outcomes?
Key Points:
• For the Vascular Surgery service, there is good evidence that regional service
delivery produces the best outcomes for specialist vascular services.
•
The Vascular Society of Great Britain and Ireland envisions that it is likely that
some of these arterial sites will become super-specialist Tertiary Referral
Centres for complex open and endovascular surgery at a national level.
Population
Required
Imison, 2014(1)
“There is good evidence to support the concentration of
specialist vascular services in centres serving larger
populations (NHS England contract suggests 800,000) with
surgeons doing minimum volumes of activity and the centres
having the necessary critical care, radiological and surgical
support services. Telemedicine can be used to safely assess
patients with vascular problems in more remote locations,
avoiding lengthy travel to outpatient consultations.” (page 70)
“There is evidence that the centralisation of vascular services
in the United Kingdom is resulting in better outcomes.” (page
70)
Vascular Society
2012(2)
A population of 100,000 generates an average of 70 arterial
operations, 47 IR (Interventional Radiology) procedures and
81 venous operations per annum (excluding renal access
surgery). To deal with these volumes, a hospital with a
vascular service needs a minimum of one vascular surgical
specialist per 150,000 population with an equivalent number
of interventional radiologists. (page 15)
A population of 500,000 requires:• A minimum of 3 full-time clinical vascular scientists and
clerical support
• 15-20 beds dedicated to vascular patients
• At least 1 Intensive Care Unit (ITU) and 1 High
Dependency Unit (HDU) bed (page 33-34)
“When emergency assessment and treatment are necessary,
this should be available from a recognised vascular unit in
most locations in the UK within one hour of travel.” (page 43)
“It is recommended that hospitals undertaking fewer than 33
elective AAA (Abdominal Aortic Aneurysm) interventions per
year (100 over three years) should not continue to offer these
procedures.” (page 42)
132 | P a g e
Vascular Society,
2014(3)
“We anticipate significant upward pressure on the numbers of
consultant vascular surgeons needed to provide the current
level of service in the future towards 1 per 100,000
population.”(page 4)
It is recommended that units providing 24/7 elective and
emergency vascular surgery services have 8-10 consultant
vascular surgeons for safe and sustainable cover. A service
with less than 6 consultants is not considered sustainable or
safe. (page 22, 31)
Clinical Outcomes
NHS England,
2013(4)
Key vascular service outcomes are set out by NHS England
(page 15-16)
GMCCSN, 2011(5)
u Quality standards for each level of service provision have been
developed by Greater Manchester & Cheshire Cardiac and
Stroke Network (GMCCSN), mapped to national and local
recommendations.
Vascular Society,
2013(6)
The suggested scope for commissioning vascular services is
set out by the Vascular Society. Outcome measures include
the use of Hospital Episode Statistics (HES ) data on arterial
interventions and independent sources, such as the AAA
Quality Improvement Programme, Healthcare Quality
Improvement Partnership UK carotid endarterectomy audit
and NHS Abdominal Aortic Aneurysm Screening Programme
(NAAASP) (page 5)
Other Service Attributes
Workforce
Vascular Society,
2014(3)
The Vascular Society estimates that “we may need to train and
appoint as many as 291 new Consultant Vascular Surgeons in
the United Kingdom over the next 10 years to maintain the
status quo in respect to the current level of service. To provide
a complete 7-day service for vascular surgery we may also
need an additional 275 Consultant Vascular Surgeons. If we
are to meet the minimum projections of future demand we
may need to increase NTNs (National Training Numbers) in
Vascular Surgery significantly from the current allocation of 20
per annum.” (page 36)
Vascular Society,
2012(2)
“Patients with vascular disease should expect to be managed
by vascular specialists, both electively and as an emergency.”
(page 9)
Vascular specialists should not be expected to manage general
surgical emergencies and general surgeons should no longer
manage vascular emergencies (page 11-12)
133 | P a g e
“Elective and emergency vascular surgical and IR services
should be developed and coordinated jointly.” (page 12)
“In Scotland, details regarding the pattern and number of
training positions for future interventional radiologists are
under consideration by the Specialty Training Advisors, NES
(NHS Education for Scotland) and the Scottish Governments
Health Directorates SGHD)” (page 29)
Vascular Society,
2014(7)
Vascular consultants are likely to spend about 40% of their
time at non-arterial sites for outpatient clinics and day case
lists, so it is recommended that each non-arterial site is
allocated a minimum of 2 vascular surgeons. At least one
Vascular Specialist Nurse (VSN) is required at each non-arterial
site, preferably rotating with equivalent staff at the arterial
site. (page 3)
Thompson, 2015(8)
“Anaesthesia for all patients undergoing major vascular
surgery should be provided by a consultant experienced in
vascular anaesthesia” (page 1)
Patient Satisfaction
Vascular Society,
2012(2)
To achieve equality of access to elective care, patients should
be able to consult a vascular specialist at their local hospital,
but are normally willing to travel to receive specialist care
(p.14,48)
Imison, 2014(1)
“A 2008 analysis showed that in the United Kingdom, if
aneurysm surgery was performed in centres with a record of
demonstrable safety and a threshold of 33 procedures per
year, the number of hospitals performing aneurysm repairs
would drop from 242 to 48 and travel times would increase by
28 minutes relative to the nearest hospital (Holt et al 2008).”
(page 71)
“In a study of 262 individuals, 92 per cent were willing to
travel for at least an hour beyond their nearest hospital to
access a service with a lower peri-operative mortality rate
(Thompson et al 2011).” (page 71)
Cost
Imison, 2014(1)
“We could find no evidence on the financial impact of
reconfiguring vascular surgery services.” (page 71)
Vascular Society,
2012 (2)
Hospitals providing high levels of interventional treatment
perform significantly fewer amputations, a greater percentage
of which are below-knee amputations, resulting in higher
levels of patient mobility and independent living (page 21)
134 | P a g e
References:
1. Imison C, Sonola L, Honeyman M et al, 2014. The reconfiguration of clinical
services: what is the evidence? The King’s Fund. (Accessed 23/06/2015)
2. Vascular Society of Great Britain and Ireland, 2012. The provision of services
for patients with vascular disease. The Vascular Society of Great Britain and
Ireland.(Accessed 23/06/2015)
3. Vascular Society of Great Britain and Ireland, 2014. Vascular surgery UK
workforce report 2014. The Vascular Society of Great Britain and Ireland.
(Accessed 23/06/2015)
4. NHS England, 2013. 2013/14 NHS standard contract for specialised vascular
services (adult) A04/S/a. NHS England.(Accessed 23/06/2015)
5. NHS Greater Manchester & Cheshire Cardiac and Stroke Network, 2011.
Quality standards for the provision of vascular services 2011. GMCCSN.
(Accessed 23/06/2015)
6. Vascular Society of Great Britain and Ireland, 2013. Scope: vascular disease.
2013. The Vascular Society of Great Britain and Ireland (Accessed
23/06/2015)
7. Vascular Society of Great Britain and Ireland, 2014. The provision of services
for patients with vascular disease. The Vascular Society of Great Britain and
Ireland. (Accessed 23/06/2015)
8. Thompson, JP, Danjoux, GR and Pichel, A, in association with the Vascular
Anaesthesia Society of Great Britain and Ireland, 2015. Guidelines for the
provision of anaesthetic services. Chapter 15: vascular anaesthesia services.
Royal College of Anaesthetists.
(Accessed 23/06/2015)
135 | P a g e
Appendices
Appendix 1: Search protocol for Second Search, instructions for ESS team
1. Assess the initial search results and select any further material from those sources
which was not included first time round.
2. Start the second search, using some or all of these sources:
•
•
•
•
•
•
•
•
Google or equivalent search engine
Health Management Online
(http://www.healthmanagementonline.scot.nhs.uk/health-managementlibrary.aspx)
OVID HMIC
OVID Medline
The King’s Fund (www.kingsfund.org.uk)
Relevant professional organisations, eg. Royal Colleges
Scottish Government (www.gov.scot)
Healthcare Improvement Scotland
(www.healthcareimprovementscotland.org/)
This is not a comprehensive search, so try to identify and summarise key sources
and stick to the timescales. Please contact either MK or CD if you need any advice
or support in the process.
Key words (combine and truncate as appropriate):
Q1. optimal / population / consultants adj per / consultants adj ratio / whole time
equivalent / wte / full time equivalent / fte / workforce / minimum standard / safe
standard
Q2. quality / health AND improvement / indicator / measure / standard / outcome
Q3 a. workforce or staff
b. patient AND experience / satisfaction / feedback
c. health / social AND cost / finance / budget/
Inclusion criteria
• documents published 2010 onwards
• UK
• countries with comparable health systems (US, Canada, Europe, Aus & NZ)
• reviews, research, large-scale studies
• policy documents and legislation - local, regional, national
• news and opinion from reputable organisations e.g. Royal Colleges
• English Language
Exclusion criteria
• Pre 2010 (unless still current)
• Non-comparable health systems (e.g. developing world)
• News, opinion pieces (unless from reputable organisation, see above)
136 | P a g e
Please note:
•
•
•
•
•
•
relate to population sizes in NHS Scotland - e.g. a US state could be close in
number to our national population (5 million), and London is bigger
check terminology (eg. differences between UK and US health organisations)
size of service may vary between specialties, eg. number required per head
of population to justify forming a new service model could vary between a
more common category (eg. breast cancer) and a less common (eg. specialist
paediatrics)
national = 5 million (i.e. population of Scotland)
regional = 1-3 million (eg. West of Scotland)
local = one hospital or one smaller area (e.g. smaller health board)
Peer support:
MK and CD did the original searches, and can be contacted for advice.
137 | P a g e
Appendix 2: Burns staffing
Burn Treatment Capacities per Population in the USA, Austria, Germany, Switzerland
and the European Union (Data collected in 2009)
Population
(Millions)
Burn units
Burn beds
Burn ICU beds
% of Burn ICU
beds relative to
total Burn beds
Population
(millions) that 1
burn unit serves
Burn beds per 1
million inhabitants
Burn ICU beds per
1 million
inhabitants
United
States of
America
309
Austria
Germany
Switzerland
European
Union
8
82
8
495
124
1799
4
18
14
37
265
174
4
24
22
181
2572
795
78%
66%
92%
31%
2.5
2
2.2
2
2.7
5.8
2.3
3.2
3
5.2
Information
not available
1.8
2.1
2.8
1.6
Information
not available
Information
not available
Adapted from: Vogt, PM, Busche, MN, 2011. Evaluation of infrastructure, equipment
and training of 28 burn units/burn centers in Germany, Austria and Switzerland.
Burns 37 p.257-64. (Accessed 01/07/2015)
Required staffing levels and support services
Adult Burn
Centre
Adult Burn
Unit
Adult Burn
Facility
Paediatric
Burn
Centre
Paediatric
Burn Unit
Clinical Lead / Head of Burn Care Service.
The clinical lead should have time
allocated for this role in their job plan.
Nursing Lead for Burn Care Service
The lead nurse must have time allocated
for this role in their job plan.
Therapy Lead for Burn Care Service
The therapy service lead must have time
allocated for this role in their job plan.
Research & Development Lead
Consultant surgeons - Centres
Burn specific consultant led clinical care 24
hours a day, 7 days per week. It is
suggested that 6 consultant burn surgeons
are required to maintain a sustainable
rota.
138 | P a g e
Paediatric
Burn
Facility
Adult Burn
Centre
Adult Burn
Unit
Adult Burn
Facility
Paediatric
Burn
Centre
Paediatric
Burn Unit
Consultant surgeons - Units
Burn specific consultant led clinical care 5
days per week during the working day.
The provision of consultant led burn care
must be supplemented by sufficient plastic
surgeons to provide consultant led care 24
hours a day, 7 days per week. It is
suggested that 3 consultant burn surgeons
are required to maintain a sustainable
rota.
Consultant surgeons – Facilities
A consultant plastic surgeon should be
available 24 hours a day, 7 days per week.
Other surgical staffing
At least one ST3 or above (or equivalent)
doctor who has completed initial stage
training in plastic surgery should be
available at all times.
Critical care nursing for registered nurses
There must be sufficient appropriately
qualified registered nurses to provide
critical care to burns patients.
Emergency anaesthetic support – adults
An anaesthetist (ST3 or above) available
within 10 minutes & a consultant
anaesthetist available within 30 minutes
Emergency anaesthetic support – children
An anaesthetist (ST3 or above) available
within 10 minutes & a consultant
paediatric anaesthetist available within 30
minutes
Planned anaesthetic support – Centres
and Units. Consultant anaesthetists with
experience in burn care and who have
identified sessions in their job plan must
be available for ward and out-patient
procedures
Paediatric medical staffing
In-patient services for children should
comply with standards published by the
Paediatric Intensive
Care Society:
a) 24 hour cover by a consultant
paediatrician who is able to attend within
30 minutes and does not have
responsibilities to other hospital sites
b) a clinician with competences in
resuscitation,
stabilisation and intubation of children
should be
available on site at all times
c) 24 hour resident cover by a clinician
trained to, or training at, the equivalent of
paediatric medicine RCPCH level 2
139 | P a g e
Paediatric
Burn
Facility
Adult Burn
Centre
Adult Burn
Unit
Adult Burn
Facility
Paediatric
Burn
Centre
Paediatric
Burn Unit
competences or above.
Registered nurse - adults
The nursing establishment should contain
sufficient registered nurses to meet the
NBCR B level nurse
recommendation associated with staffing a
Burn Care Service. The level of registered
nurses required for burn patients requiring
critical care must adhere to both the NBCR
B guidelines and the national guidelines
associated with critical care.
Registered nurses – children
The nursing establishment should contain
sufficient registered nurses to meet the
NBCR B level nurse
recommendation associated with staffing a
Burn Care Service and the
recommendations detailed in the
guidance published by the Paediatric
Intensive Care Society.
Physiotherapy and Occupational Therapy
services – Centres and Units
There must be access to the following
burn specific services:
a) Physiotherapy services seven days per
week
b) Occupational therapy services seven
days per week
Staff providing these services must be
members of the burn care team and have
burn specific time allocated in their job
plan.
Dietetic services – Centres and Units
There must be access to a dietetic service
five days per week. Staff providing these
services must be members of the burn
care team and have burn specific time
allocated in their job plan.
Play services – Centres and Units
There must be access to a play service
provided by a play specialist seven days
per week. Staff providing these services
must be members of the burn care team
and have burn specific time allocated in
their job plan.
Physiotherapy and Occupational Therapy
services – Facilities
There must be access to the following
burn specific services:
a) Physiotherapy services seven days per
week
b) Occupational therapy services seven
days per week
Staff providing these services may be part
140 | P a g e
Paediatric
Burn
Facility
Adult Burn
Centre
Adult Burn
Unit
Adult Burn
Facility
Paediatric
Burn
Centre
Paediatric
Burn Unit
of the burns,
plastic surgery or trauma services.
Dietetic services – Facilities
There must be access to a dietetic service
five days per week. Staff providing these
services may be part of the burns, plastic
surgery or trauma services.
Play services – Facilities
There must be access to a play service
provided by a play specialist seven days
per week. Staff providing these services
may be part of the burns, plastic surgery
or trauma services.
Provision of a psychological care service
for patients, their families and/or carers
The service must provide psychological
care to burn injured patients, their families
and/or carers. This must include initial and
ongoing assessment, monitoring of
psychological status and the delivery of
psychological interventions during the
whole of the burn pathway.
There are appropriately trained health
professionals to provide a psychological
care services for patients, their families
and/or carers - Centres and Units
The service must have appropriately
trained health professionals available to
provide psychological care to burn injured
patients and their families. Staff providing
these services should have specific time
allocated to their work with the Burn Care
Service.
There are appropriately trained health
professionals to provide a psychological
care services for patients, their families
and/or carers – Facilities
The service must have access to
appropriately trained health professionals
to provide psychological care to burn
injured patients, their families and/or
carers. Staff providing these services
should have specific time
allocated to their work with the Burn Care
Service.
Psychological support services for
members of the burn care team.
The following services should be provided
for all members of the burn care team to
maintain their welfare:
a) access to a confidential
support/counselling service
b) regular in-house debriefing sessions
Social care support
141 | P a g e
Paediatric
Burn
Facility
Adult Burn
Centre
Adult Burn
Unit
Adult Burn
Facility
Paediatric
Burn
Centre
Paediatric
Burn Unit
There must be an identified health/social
care worker, with training in social/health
care systems and practice, to assist burn
patients, their families and/or carers with
social and welfare issues. The
health/social care worker must be part of
the burn care team and attend the burns
MDT Meetings.
Burn care outreach service
The service must provide an integrated
nursing and therapy service which can
facilitate the delivery of specialised burn
care and advice to patients, their families
and /or carers in an area other than the
acute hospital environment providing
specialised burn care.
Administrative and clerical support
Administrative, clerical and data
management support must be available to
the Burn Care Service.
Adapted from: National Network for Burn Care (2013) National Burn Care Standards.
National Network for Burn Care (NNBC). (Accessed 01/07/2015)
Appendix 3: Cancer searches further sources
Large Volume:
1. Institute of Physics and Engineering in Medicine, Society and College of
Radiographers and Royal College of Radiologists. Guidance on the
management and governance of additional radiotherapy capacity. London:
Royal College of Radiologists. 2013. (Accessed 01/07/2015)
2. Adams P, Hardwick J. Embree V, Sinclair S, Conn B, Bishop, J,
2009. Literature review: models of cancer services for remote and rural
communities. Sydney: Cancer Institute NSW. (Accessed 01/07/2015)
3. Royal College of Radiologists, 2014. Clinical oncology UK workforce census
report 2013. Royal College of Radiologists. (Accessed 01/07/2015)
4. Royal College of Radiologists, 2012. Guide to job planning in clinical oncology.
Royal College of Radiologists. (Accessed 01/07/2015)
5. Tsianakas V; Robert G; Maben J; Richardson A; Dale C; Griffin M;
Wiseman T, 2012. Implementing patient-centred cancer care: using
experience-based co-design to improve patient experience in breast and lung
cancer services. Supportive Care in Cancer. 20(11):2639-47. (Accessed
01/07/2015)
6. Mistry M, Parkin DM, Ahmad AS, Sasieni P. Cancer incidence in the United
Kingdom: projections to the year 2030. British Journal of Cancer 2011;
105(11):1795–1803. (Accessed 01/07/2015)
142 | P a g e
Paediatric
Burn
Facility
Small Volume:
1. British Society for Standards in Haematology, Haemato-Oncology Taskforce,
2010. Facilities for the treatment of adults with haematological malignancies:
'Levels of Care'. (Accessed 01/07/2015)
2. Institute of Physics and Engineering in Medicine, Society and College of
Radiographers, Royal College of Radiologists, 2013. Guidance on the
management and governance of additional radiotherapy capacity. (Accessed
01/07/2015)
3. Adams P, Hardwick J. Embree V, et al, 2009. Literature review: models of
cancer services for remote and rural communities. Sydney:
Cancer Institute NSW. (Accessed 01/07/2015)
4. Royal College of Radiologists, 2014. Clinical oncology UK workforce census
report 2013. (Accessed 01/07/2015)
5. Royal College of Radiologists, 2012. Guide to job planning in clinical oncology.
(Accessed 01/07/2015)
6. Kumar P, Singh S, Goddard JC, et al, 2012. The development of a
supraregional network for the management of penile cancer. Annals of the
Royal College of Surgeons of England 94(3):204-9. (Accessed 01/07/2015)
7. Groene O, Chadwick G, Riley S et al, 2014. Re-organisation of oesophago-
gastric cancer services in England and Wales: a follow-up assessment of
progress and remaining challenges. BMC Research Notes 7:24. (Accessed
01/07/2015)
8. Dalley C, Basarir H, Wright JG et al, 2015. Specialist integrated
haematological malignancy diagnostic services: an Activity Based Cost (ABC)
analysis of a networked laboratory service model. Journal of Clinical
Pathology 68(4):292-300. (Accessed 01/07/2015)
143 | P a g e
Appendix 4: Planning Tools
Imison et al, 2014 (See Key resources on Pg.6)
Primary forces for driving change are Workforce and Cost, Secondary
forces are quality and technology secondary forces. Notable by its
absence is Access, though this will be impacted by any change
initiated by any of the other forces.
Forces likely to contribute to the failure of any reconfiguration are
public or clinical opposition. The public in particular are likely to focus
on loss of access.
Using these driving forces as a basis a search was undertaken to locate any tools, which could be used to support decision-making in these
areas. Please note that this is a preliminary search using limited sources only.
Workforce
Centre for Workforce
Centre for Workforce
Centre for Workforce
NHS Scotland
Skills for Health.
Intelligence: Care
Intelligence Horizon
Intelligence workforce
Workforce Planning
Workforce
pathways: improving
scanning app
comparison tool
Community. Nursing &
reconfiguration planning
http://www.cfwi.org.uk/ http://www.cfwi.org.uk/ midwifery workload and tool
care through workforce
products
products
https://tools.skillsforhea
planning across
workforce planning
This app enables you to This workforce
lth.org.uk/reconfiguratio
organisations, 2012.
tools
http://www.cfwi.org.uk/ explore ideas about
comparison tool
http://www.knowledge. n/
care-pathways
what the future might
compares the workforce scot.nhs.uk/workforcepl The Workforce
Toolkit to conduct
hold and understand
nationally (England)
anning/resources/nursin Reconfiguration
factors influencing the
and by LETB area, and
g-and-midwiferyworkforce planning
Planning Tool, originally
health and social care
provides comparative
workload-andbased on a care
designed by NHS
workforce.
data to assist decision
workforce-planningpathway. Its aim is to
Plymouth, shows the
encourage integrated
workforce planning.
Cost
NHS England. Any town
http://www.england.nhs
.uk/2014/01/24/anytown/
This toolkit uses high
level health system
NHSRightCare
http://www.rightcare.n
hs.uk/index.php/resourc
ecentre/
This is an established
programme of NHS
makers in defining local
strategies and plans in
the context of wider
national and regional
drivers.
tools.aspx
current and proposed
skill mix of staff in post
for any given service
and the associated pay
costs. The tool also
displays a current and
future skill mix index,
and percentages of
senior staff (band 5 and
above) and senior staff
(band 8 and above).
The tool is designed to
support NHS managers,
heads of service and
workforce planners in
planning and costing
changes to their skill
mix for service delivery
redesign. It also
provides a concise
depiction of costed skill
mix change proposals
for use with senior
managers and
commissioning bodies.
National Institute for
Health and Clinical
Excellence. NICE 'do
not do'
recommendations.
https://www.nice.org.u
Scottish Government.
Health and Social Care
Integration Public
Bodies (Joint Working)
(Scotland) Act 2014.
Guidance on Financial
Nuffield Trust. Setting
priorities in health,
2011
http://www.nuffieldtrus
t.org.uk/sites/files/nuffi
eld/setting-priorities-in-
There are currently 12
tools, covering
community, mental
health, theatres,
emergency
departments, neonatal,
maternity, specialist
nurses and children's
services. The Nursing
and Midwifery
Workforce Workload
Planning Programme
has facilitated local
implementation within
Boards thereby assuring
the tools are applied
systematically across
the whole of the
healthcare system in
Scotland. This has been
supported with the
development of a
Nursing and Midwifery
Workload and
Workforce Planning
Toolkit.
145 | P a g e
modelling & allows
clinical commissioning
groups to map how
interventions could
improve local health
services and close the
financial gap.
The toolkit includes five
connected modules:
1. A methodology
guide which introduces
the work of the Any
town project and
explains the principles
and methodology
behind the project and
the model. It describes
how the interventions
were selected and the
detailed methodology of
how the model
calculated the results
2. An urban model
module
3. A suburban model
module
4. A rural model
module
5. A further
information guide which
provides information on
the case studies used
for the interventions.
These guides are
England. Tools include:
Commissioning for
Value packs
These use existing data
about Programme
Budget spend, Health
Outcomes and
healthcare variation to
identify the best “value
opportunities” which
CCGs may want to
priorities in their
strategic commissioning
planning.
Atlases and Tools
Lists UK and
international
healthcare-related
Atlases of Variation that
are available online,
including
NHSRightsCare’s own
‘NHS Atlas of Variation
in Healthcare Series’.
Also lists the available
online analytical tools
for reducing
variation, with a focus
on the healthcare
investment/commissioni
ng tools.
k/proxy/?sourceurl=htt
p://www.nice.org.uk/usi
ngguidance/donotdorec
ommendations/index.js
p
During the process of
guidance development
NICE's independent
advisory bodies often
identify NHS clinical
practices that they
recommend should be
discontinued completely
or should not be used
routinely. This may be
due to evidence that
the practice is not on
balance beneficial or a
lack of evidence to
support its continued
use. It is these
recommendations that
have been pulled
together into the ‘do
not do'
recommendations
database.
Planning for Large
Hospital Services and
Hosted Services, 2014.
http://www.gov.scot/Re
source/0046/00465642.
pdf
The guidance covers:
a) A method for
establishing the amount
to be set aside for the
services that are
delivered in a “large
hospital”, as defined in
the Act – i.e. showing
consumption by
partnership residents;
b) A method for
quantifying and
reporting performance
for the financial
consequences of
planned changes in
capacity as they relate
to “set aside” budgets
for large hospitals,
which may be: (i)
steady state i.e. the
strategic plan results in
no changes to
consumption of services
in scope / is designed
to avoid increases in
consumption (ii)
increased consumption
health-research-reportsep11.pdf
Use of decision tools in
priority setting by PCTs
- Lean prioritisation tool
-Prioritisation tool
developed in
partnership with
stakeholders
-Multi-criteria
scorecards including the
Portsmouth Tool (often
a modified version) and
locally-developed
scoring tools
-SHAPE (Strategic
Health Asset Planning
and Evaluation) and
NHS comparators
-Population risk
stratification tools
-Surveys and patient
questionnaires
-McKinsey Dashboard
analysis
-Cost-effectiveness
analysis and cost–
benefit analysis.
146 | P a g e
intended to provide a
high-level ‘starter for
ten’ to assist with initial
planning,
Technology
Access
Quality
The Advisory Board
Company.
Telemedicine in the era
of population health
management: a
framework to evolve
your thinking.
http://ns.advisory.com/
Health-Care-IT-AdvisorTelehealth-StrategyFramework
A framework that shows
the relationship
between telemedicine’s
complexity and its
implementation. Also
looks at the benefits of
telemedicine (especially
under risk-sharing
arrangements),
considerations for
making the business
case, and action steps
for developing a
telemedicine strategy
No relevant tools found
NHS Institute for
Innovation and
Improvement. Modelling
(iii) decreased
consumption
Nuffield Trust. The
impact of telehealth and
telecare: the whole
system demonstrator
project.
http://www.nuffieldtrus
t.org.uk/ourwork/projects/impacttelehealth-and-telecareevaluation-wholesystem-demonstratorproject
Quality Improvement
Hub.
Building a quality
Quality Improvement
Hub.
2020 framework for
147 | P a g e
and simulation
http://www.institute.nhs
.uk/quality_and_service
_improvement_tools/qu
ality_and_service_impro
vement_tools/modelling
_and_simulation.html
Lists a number of
simulation and
forecasting tools that
can be used to test and
experiment with
changes, and predict
short and long term
changes in demand.
improvement structure
http://www.qihub.scot.
nhs.uk/knowledgecentre/qualityimprovementtopics/building-aquality-improvementinfrastructure.aspx
This programme aims
to provide a better
understanding on the
current arrangements
for QI (infrastructure)
within NHS boards in
Scotland & give a
clearer direction for
future QI infrastructure
in NHS boards and
nationally.
quality, efficiency and
value
http://www.qihub.scot.
nhs.uk/quality-andefficiency/2020framework-for-qualityefficiency-andvalue.aspx
Outlines the
approaches, tools and
techniques that
experience has shown
to be most successful in
delivering improved
quality alongside better
value.
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