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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 â 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 Kingâs 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 â 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 â 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 â 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 âat riskâ 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 âat riskâ 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 burnsâ casualties. NNBC, 2013(6) The National Burn Care Standards 2013 sets out the recommended levels of staffing and support services required for:ď Adult and Paediatric Burn Centres ď Adult and Paediatric Burn Units ď 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 factorsâ%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 patientâs 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 â 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 2003â2011. 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 (100â150 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 1â3 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 â 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 200,000â250,000 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 200,000â250,000 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 âa cohesive thoracic aortic vascular service and an active multidisciplinary teamâ, 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) âAlthough 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 Kingâs Fund suggested that dermatology does not need dedicated beds, except perhaps in the tertiary centres.â (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 2009â10 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: âIn 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) Kingâs 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.â Dermatology clinical quality indicators are: ⢠Eczema ⢠Psoriasis ⢠Quality of life in inflammatory skin conditions In GP Practices âThere is scope for quality measurement in diagnosis and referral, but most indicators will serve only as âtin openersâ (designed to prompt further investigation) rather than âdialsâ (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 measureâ 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 Fâs 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 Kingâs 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, Kingâs 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) 24 | P a g e 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 âA 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 â centralisation should not become the end in itself. â (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) âEvery urgent care centre should be part of a polysystem to enable wider integration and efficient delivery of care.â (page 3) âPolysystem â 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.â (page 7) âThrough 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.â (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 âhigh riskâ 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 hoursâ 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, personâs own home or as an in-patient, according to the personâs 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 personâs normal residence should be possible within 24 hours, seven days a week â 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. âProposed 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.â (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 â including patient journey/ flow, management of older people & delayed discharge, place of care, front door and senior decision making, 7 day working. The Kingâs Fund, 2015(13) âAlthough 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 âmajorsâ 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. â (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) âThe 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 âexit blockâ 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 âpatient flowâ throughout the hospital is vital and many of the issues highlighted in the RCPE statement on this issue are still outstanding.â NHS England, 2014(16) âAcross 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.â (page 4) New care model - urgent and emergency care networks More and more people are using A&E â with 22 million visits a year. [overall] the NHS responds to more than 100 million urgent calls or visits every year. Proposed changes: âMaking 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.â (page 21-22) RCPE 2013(17) âIt 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.â RCGP, 2013(18) âNo 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.â 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 (âday caseâ) 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 Unitâs (AAUâs) 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. Kingâs 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. Kingâs 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 âwhole systemâ 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 âhard to reachâ patient groups, and the need to provide an equitable service across the area, while recognising individual solutions may differ depending on the localityâs 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 â this allows good governance, enables good use of servicesâ 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. Kingâs 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 âwho cares for patientsâ 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) âFour 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.â (page 5) âUrgent 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.â (page 7) âWe expect mental health assessments to be conducted at the urgent care centre by local mental health service providers.â (page 27) âIdeally, 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.â (page 28) âWe 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. ..â (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 Kingâs 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 Kingâs 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 Kingâs Fund, 2012. Emergency hospital admissions for ambulatory care sensitive conditions â identifying the potential reductions. (Accessed 13/06/2015) 23. The Kingâs 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 â a whole system approach. (Accessed 09/07/2015) 25. Primary Care Foundation, NHS Alliance, 2011. Breaking the mould without breaking the system â 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. Kingâs Fund, 2010. Avoiding hospital admissions â 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 â 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 â 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 âmoreâ specialist ENT is delivered at either a regional or national level, whilst the majority âminorâ 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 â 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) âA 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 specialtyâ 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 PAâs 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 âassociate specialist equivalentâ 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 âSHOâ 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 â 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 Collegeâs position on the future of the delivery of womenâs healthcare. The central message, for this piece of work, is summed up by the following recommendation: âWomen need a specialist workforce that is able to work in integrated clinical teams, providing care locally where possible. Tomorrowâs 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 âlocalised where possible, centralised where necessaryâ becomes the norm.â 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. Tomorrowâs 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 Kingâs Fund, Volume and outcomes 2014(1) âThe limited evidence on hospital size and quality shows no clear link between size and outcomes ... â˘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 âBetween 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 âgeneral hospitalâ in the European Union that in 2011 served a population of 54,000. (page 29) Clinical Outcomes The Kingâs Fund, 2014(1) âThe link between volumes of care and outcomes does not necessarily demonstrate a causal relationship â 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). ⢠âThe 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 othersâ (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 âcritical access hospitalsâ 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).â (page 22) Imison, 2015(2) âThe 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 âOn 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 outcomesâ (Posnett 2002, page 1065).â âThe 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 âidealâ catchment population for a hospital.â (page 28) Other Service Attributes The Kingâs Fund, 2014(1) Workforce (including the impact on quality) ⢠âAcute 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).â (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).â (page 23) Access âA 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 âdistance decayâ effect under which distance from hospital services reduces patientsâ 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).â (page 24) Technology ⢠âTelehealth 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).â (page 24) The role of clinical networks ⢠âNetworks offer a way of making the best use of scarce specialist expertise, standardising care, improving access, and reducing any âdistance decayâ effects that can result from the concentration of specialist services in large centres (Edwards 2002). âIn successful networks of care built around specialist childrenâs hospitals, children will receive the best quality of care as close to where they live as possibleâ (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).â (page 24) Key clinical and service interdependencies âThere 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...â (page 25) 51 | P a g e Relevant college guidance âBig 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 evidenceâ. (Academy of Medical Royal Colleges 2007)â (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 âA 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 âde minimisâ 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..â (page 29) Models of care NHS England 2015(3) âNHS 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 âback officeâ with other 52 | P a g e similar hospitals not necessarily located in their immediate vicinity. These type of âhospital chainsâ 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 â 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 ânew care models â viable smaller hospitalsâ). References: 1. Kingâs Fund, 2014. The reconfiguration of clinical services: what is the evidence? Kingâs 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 â 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) .... âto 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%.â [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. âIn general, the Consultant/Patient ratio should not exceed a range between 1:8 â 1:15 and the ICU resident/patient ratio should not exceed 1:8.â (page 4) The Nurse /patient ration should not exceed 1:1, or 1:2 (dependent on level of care) (page 7) âA Consultant in Intensive Care Medicine must be immediately available 24/7, be able to attend within 30 minutes and must undertake twice daily ward roundsâ. (page 5) ⪠The provision of critical care is fairly similar across the regions considered. â In England as well as internationally, critical care is provided through intensive care units (ICUs) that specialise in treating critical cases. â Many countries have defined 3 different levels of intensive care units. â 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. â Victoria, Ontario, the Netherlands, and Sweden all set different staffing and size requirements for the three ICU levels â In England only the nurse ratios are dependent on patient acuity. ⪠Where internationally comparable standards exist, England generally has more lenient requirements â England requires only 1 consultant per 15 patients, while Germany, the Netherlands and Sweden have set stricter standards. â 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. â In England, geographically remote ICUs should have an established review/referral relationship with a larger centre. â In Victoria and Ontario, the requirements for referral agreements only hold for lower level care units. â 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. â Victoria has a central coordinating body working with all public and private hospitals in the state to coordinate critical care capacity. â 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 â In the Netherlands, insurers are looking to centralise critical care services and reduce the number of hospitals with ICUs from 91 to 50 â In Toronto critical care services are centrally organised and rely on transfers â however the facilities operate at âĽ95% 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 âintensivistâ 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) âgiven 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 estimateâ . (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 âoffers improved processes of care and staff satisfaction and decreased ICU complication rate⌠and hospital costs, but no change in ICU or hospital mortalityâ 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 â review of service lines: critical care. UK Government (Accessed 28/06/2015) 56 | P a g e 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: ⢠âFormalised systems of trauma care, in which care for the most complex patients is centralised into a small number of trauma centres, improve patient outcomes.â Kingâs Fund (1) pg.60 Population Required National Audit Office, 2010(2) âInternational research shows that for a hospital to develop and maintain optimal skills in major trauma it would need to see 650 cases per year.â (page 30) Royal College of Surgeons of England, 2009(3) âIt 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 15â 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 2â3 million people.â (page 11) Clinical Outcomes National Audit Office, 2010(2) âThe 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.â (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) âWe 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.â (page 4) Kingâs 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. Kingâs 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) 59 | P a g e 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 Collegeâs position on the future of the delivery of womenâs healthcare. The central message, for this piece of work, is summed up by the following recommendation: âWomen need a specialist workforce that is able to work in integrated clinical teams, providing care locally where possible. Tomorrowâs 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 âlocalised where possible, centralised where necessaryâ becomes the norm.â 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 Kingâs 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. Tomorrowâs 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. Kingâs 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 63 | P a g e 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) âPatients 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.â (pages 41-42) âThere 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.â (page 43) âFor 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 âhotâ clinics or âfrailtyâ 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.â (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) âIf 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 â 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 â 1 nurse: 1 baby High Dependency â 1 nurse: 2 babies Special Care â 1 nurse: 4 babies ⢠Medical Staff â 3 tiers Tier 1 â Junior roles Tier 2 â Competent onsite clinician Tier 3 â 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) âThere 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. âGIS (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 servicesâ âA 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 careâ. 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) âHealthcare staff and patient experience different problems and a collaborative approach is needed to capture all areas requiring improvement in the patient processesâ Categorising problems into simple, complicated and complex helps with the process and identifying appropriate improvement interventions. Other Service Attributes Quality Standards âThis 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.â No summary available, please see the full text. Smith, 2010 (16) âNeonatal 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 mortalityâ 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 â 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 â where advanced neonatal nurse practitioners (ANNPs) provide this support to obstetric units instead of paediatricians â 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 âlow levelâ 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 27:5â 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 â 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 â 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 â The Services â 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) 73 | P a g e 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 â The Services â A. Service Specifications. NHS England, Department of Health. (Accessed 22/06/15) 74 | P a g e 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 â 16 published â 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 â 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 â 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 â plus stronger networks of care between community and hospital Population approach â ⢠Aim â 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) ⢠⢠⢠⢠⢠⢠⢠âEye 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 settingsâ. 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 â 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 âsubstantialâ 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 â 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 â 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) ⢠⢠⢠⢠⢠⢠âWhat can London learn from other cities globally about improving the quality of healthcare?â o âModels of community eyecare, based on national pathwaysâ Scotland is rolling out a programme using Electronic Referral with Digital Images System â photograph of peopleâs 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 â 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 âcan lead to mismanaged follow-up care Geographical distribution of opticians away from poorer areas â 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 â 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 â 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 â 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 (âBetween 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 increaseâ) 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) ⢠âWHO Eye Health Strategy states that integration needs to be combined with health system strengthening, moving away from a disease-specific approachâ 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 â 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 â 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 ophthalmologistâs office ⢠Benefit to using wider range of organisational models, as in other sectors Example of good practice - Moorfieldâs eye hospital offer range of ophthalmology services through clinics in London and outwith Clinical Outcomes Kingâs Fund, 2014(29) ⢠RNIB, 2014 (36) NHS England initiative â 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 â 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 â 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 âthe optometry networkâ to deliver an âextended eye examinationâ 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 patientâs care within the community jointly. âPhilip, 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 âintegrated, patient-centred approach to designing eye care services for adults and childrenâ 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 âCall to Actionâ 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 â 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 â outreach primary care services should be developed rather than relying on high street opticians Australian study â 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 â 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 Kingâs 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 â 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) 85 | P a g e 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. Kingâs 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 âŚ. 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) â 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 â 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 â quality indicators: ⢠Percentage of emergency admissions with fractured mandible who have surgery same day or the next day ⢠Post âoperative 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. 90 | P a g e 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 â 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 â 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, OâMeara C et al, 2013. Elderly patients with maxillofacial trauma: the effect of an ageing population on a maxillofacial unitâs 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 âhead countâ of NHS consultants doesnât give an accurate picture of the workforce needed. (page 53) 94 | P a g e Committee 2014(3) Quality Indicators Briggs, 2015(1) âPROMS 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.â (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 doesnât 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) 95 | P a g e 5. NHS Commissioning Board, 2013. NHS Standard Contract for specialised orthopaedics (adult), Schedule 2 â 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) âImprovements 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.â (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 dayâs 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) âDelivery 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.â (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) âThe 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 patientâs 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 patientâs 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 patientâs care pathway before the next ânormalâ 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 patientâs care pathway, as determined by the daily consultant-led review, can be taken.â (page 3) âThe evidence shows that continuity of care â especially for those who are older, have long-term disease or have multimorbidity â improves health outcomes and reduces the need for hospital care ... In general practice, âgeneralismâ makes little sense without continuity of care.â (page 5) âTo 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.â (page 4) âA 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.â (page 15) âNext Stepsâ 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 Scotlandâs 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 âfront-endâ 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 âsweat the assetsâ 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. 99 | P a g e RCGP(2) RCGP(2) Collaborative working across trusts could help to mitigate this cost. (page 4) âThe 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 â 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.â (page 29) âIn the 12 month period from September 2010â11, consultant numbers rose by 3.5% WTE. In the same period, GP numbers rose by just 0.2% WTE.â (page 23) âThe 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).â (page 24) âBetween 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%.â (page 25) Scottish Government(6) Scottish Government(7) âIn 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.â (page 26) âFor 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.â (page 2) â... 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.â 100 | P a g e âOf 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.â (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) 101 | P a g e 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 traineesâ 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) âThere is little evidence, outside of professional consensus, to guide the appropriate level of medical staffing â 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.â (page 91) âPaediatric 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 â 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.â (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 300,000 102 | P a g e 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 âxâ doctors per âyâ 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) âCentralisation of paediatric services has been on the agenda for almost 20 years, driven by trends in paediatric activity and a desire to maintain traineesâ exposure to less common childhood diseases.â (page 89) âThe reconfiguration of clinical services: what is the evidence?â (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) âFive key recommendations: 1. Reduce the number of inpatient sites 2. Increase the number of consultants 103 | P a g e 3. Expand significantly the number of registered childrenâs nurses 4. Expand the number of GPs trained in paediatrics 5. Decrease the number of paediatric trainees.â (page 4) Other service attributes: References: 1. Imison C, et al, 2014. The reconfiguration of clinical services: what is the evidence? Kingâs 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 Peopleâs 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 peopleâs project: Londonâs specialised childrenâs services â guide for commissioners. (Accessed 29/06/2015) 12. Department of Health, 2003. Getting the right start: national service framework for children â 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) 104 | P a g e 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 âOnce for Scotlandâ 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 âcare closer to homeâ and included: ⢠developing primary care services and community-based services â often as part of whole system reconfiguration ⢠changes to intermediate care beds â opening or reopening, or providing on fewer sites ⢠consolidating primary care services. (page 26 onwards) NHS England, 2014(2) âThis 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.â (page 3) â ⌠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 105 | P a g e 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.â (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: âEight networks of GP practices covering approximately 30â40,000 patients were formed in Tower Hamlets PCT in 2006 to improve the quality of general practice for selected long-term conditions.â (page 41) âThe 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.â (page 49) âOver the last ten years, GPs in the Netherlands have formed âGP Postsâ - consortia to collectively cover out of hours care âGP posts are physical locations, staffed by GPs, open in the evening and at night, on weekends and bank holidays âPatients with an urgent care need are triaged over the phone and, if necessary, are seen in the post or visited by the GP âAlmost all GPs in the Netherlands (98-99%) are part of a GP post âThere are 124 posts in total, each covering a population of around 130k â but individual sizes varyâ (page 2) The Quality and Outcomes Framework (QOF) is the annual reward and incentive programme detailing GP 106 | P a g e Health and Social Care Information Centre(6) Department of Health, 2014(7) Imison, 2014(8) Kingâs Fund, 2014(9) practice achievement results. These pages include links for results in Scotland. QOF information and results for NHS England. âThe 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 domainsâ Domain 1 â preventing people from dying prematurely Domain 2 â enhancing quality of life for people with long-term conditions Domain 3 â helping people to recover from episodes of ill health or following injury Domain 4 â ensuring that people have a positive experience of care Domain 5 â treating and caring for people in a safe environment and protecting them from avoidable harm (Background, page 3. Details, page 8-19) âA 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.â (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 Kingâs Fund, 2011(10) Royal College of General Practitioners(11) Kingâs 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 patientsâ 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) âThe RCGP Practice Accreditation award is a thoroughly tested framework that enables practice teams to improve their organisational quality of care.â * 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) âWhy 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.â (page 31) â[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.â (page 18) âOn all inspections, CQC asks five key questions about a service: â˘Is it safe? â˘Is it effective? â˘Is it caring? â˘Is it responsive to peopleâs needs? â˘Is it well-led?â These questions are also used in the approach in NHS England â Improving general practice : a call to action (ref. no. 2) âA collaborative self-funded programme was initiated in 2012 by a core group of community NHS trusts in Englandâ ... aim to focus on patient-reported outcomes and services delivered. Draft outcomes are presented for comment. The review âwill address issues such as recruitment and retention of GPs, staff availability, especially during peak holiday times, consistency of service and the publicâs expectations of the service.â 109 | P a g e Department of Health, 2010(14) Gilbert, 2013(15) Reports that âprimary care performance improvements are associated with some modest but measurable improvements in subsequent outcomes and costs.â (page ii) âIn 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 populationâs health needs.â (page 52) âIn the future, more and more patients will be treated outside of the hospital setting and training programmes will change to reflect thisâ (page 54) âTrainees 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.â (page 54-55) Kings Fund, 2011(10) âwe 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.â (page 55) âWe 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. â (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 â âEmerging findings reportâ) 3. Smith J, Holder H, Edwards N, et al, 2013. Securing the future of general practice: new models of primary care. Research report. Kingâs 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 â 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) 110 | P a g e 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? Kingâs Fund (Accessed 22/06/2015) 9. Kingâs Fund, 2014. Managing quality in community health care services. Kingâs Fund. (Accessed 26/06/2015) 10. Kingâs Fund, 2011. Improving the quality of care in general practice: report of an independent inquiry commissioned by the Kingâs Fund. Kingâs 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 â 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) 111 | P a g e 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 âthat 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.â (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 âhub and spokeâ 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 âthe 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.â (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 â3 tier paediatric radiology network services model based on trauma networks and utilising PACS & teleradiology effectively should be developed.â (page 15) âA 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.â (page 7) âA level 2 department is likely to reside in a âdistrict general hospitalâ environment. It will usually provide imaging facilities to support a paediatric clinical service from within a general radiology department.â (page 7) âSpecialist 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 childrenâs hospital or major teaching centre.â (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 âNetworked delivery models will be essential to improve access to interventional radiology.â (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) âThe 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.â (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) 113 | P a g e 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) 114 | P a g e 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 â 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 âPeople seen by ambulance staff ⌠who have .. sudden ⌠neurological symptoms, are screened using a validated tool to diagnose stroke or transient ischaemic attackâ (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). 115 | P a g e 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 â therapeutic window - 4.5 hours onset Early triage of the patient to CT or MRI scan is critical â within 24 hours, 3 , 6 and 12 hours discussed as time limits for different type of scans. Cardiology and other monitoring required Acute theraopy â alteplase -3 hours post onset â time limit not to be used post 4.5 hours Antithrombics â within 48 hours onset Stroke unit care â 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 âŞDirect admission to specialist stroke unit and thrombolysis assessment and treatment âŞAdmission to acute stroke unit â¤4 hrs when arrival is out of hours âŞSeen by stroke consultant/ associate specialist â¤24 hrs âŞ<1 week wait to carotid endarterectomy post TIA 116 | P a g e Jauch, 2013(6) Royal College of Physicians, 2012(10) âŞMaximum one hour travel time to acute stroke care unit Process âŞTransfer to specialist stroke rehab unit (following acute treatment phase) if required âŞDiagnosis with validated tool and transfer to specialist stroke unit â¤1hr if positive âŞBrain imaging â¤1hr of arrival âŞSwallow screen â¤4hrs âŞSpecialist rehabilitation assessment â¤24hrs , with full MDT rehab assessment â¤72hrs , and MD goals and plan â¤5 days âŞTransfer to specialist stroke rehab unit (following acute treatment phase) if required âŞâ¤45 mins active therapy 5 days/week, if required âŞIncontinence assessment and care plan â¤2 weeks, if required âŞScreening for mood disturbance and cognitive impairment â¤6 weeks âŞFollow-up â¤72hrs by specialist stroke rehabilitation team for all patients discharged with residual stroke-related problems âŞNamed point of contact for carers âŞThrombolysis â¤1hr Input âŞMinimum service requirements for hyper-acute stroke unit: âHyper 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. 117 | P a g e E. All âhealth economiesâ (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< 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 118 | P a g e ⢠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 119 | P a g e Monitor, 2014(9) under the supervision of a qualified therapist). International comparisons Netherlands âŞStroke care in the Netherlands is delivered in almost all hospitals âŞIn the Netherlands there exist stroke networks (CVA Zorgketens) to coordinate stroke care between acute and primary care as well as rehabilitation services âŞCurrently almost all hospitals provide stroke care âStroke 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 âAll 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 âStroke services in Ontario are organised as a single âsystemâ (the Ontario Stroke System) which is made up of 11 regional integrated clinical networks (supporting patients in 14 LHINs) âEach region serves approx 1m patients âThe 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 âŞWithin each region acute care is organised into three tiers âA 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 âOne 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 âSecondary prevention centres âPlus partnership agreements with community hospitals and rehabilitation units (page 11) Sweden Most acute hospitals in Sweden have stroke units and provide stroke care âIn Stockholm Country, all the acute hospitals provide 120 | P a g e stroke care âOf 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: â101 Comprehensive Stroke Centres â157 Primary Stroke Centres âŞPatients end up in stroke centres due to the referral process with the ambulance rather than strict requirements âDesignated 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 âConsequently, 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 âŞPost-acute care is delivered by a much broader group of providers âSome regions and providers may have established networks for post-acute care but there is wide variation and no national standard âŞIn some areas, ambulance services (staffed with physicians and specialist equipment) provide extensive pre-hospital care for acute stroke (page 15) Arkansas USA âŞAcute 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). âŞThe 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 âŞArkansas has four Joint Commission certified Stroke Rehabilitation centers. These are are all based at specialist rehabilitation hospitals, and not at acute hospitals âŞThe state Acute Stroke Task Force is tasked with 121 | P a g e 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 âDeveloped a model stroke program in the state covering prevention, acute care, rehabilitation and follow-up care âInitiated discussions on the status of the current level of stroke provision including gaps in stroke care and barriers to change âWorking 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 Trialistsâ Collaboration, 2013(12) âŞVictoria is in the middle of implementing a regional strategy to create three distinct service tiers âComprehensive 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 âPrimary stroke centres: >100 acute strokes/yr; 24/7 CT and thrombolysis1 âBasic hospital service: <100 acute strokes/yr; have clear transfer arrangements âŞVictoria (state Dept of Health) is encouraging the development of different strategies to address historically poor access in remote areas âAccess to an acute stroke centre (with imaging and thrombolysis) within 60 mins by ambulance from all areas of the state (94% achieved) âClear transfer protocols to get patients to higher tier services as soon as possible âUse 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 122 | P a g e 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 âcomprehensive stroke centreâ (or âhyperacute stroke unitâ) is equipped with facilities for acute intravenous or intra-arterial treatments, intensive monitoring, advanced imaging and neurosurgery. These then serve a number of âprimary stroke centresâ 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: âOn 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 unitâ (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 âbeforeâ and 3156 patients âafterâ, survival improved in the âafterâ period (age adjusted hazard ratio 0.54; 95% CI 0.41â0.72). The predicted survival rates at 90 days in the deterministic model adjusted for national trends were 87.2% âbeforeâ % (95% CI 86.7%â87.7%) and 88.7% âafterâ (95% CI 88.6%â88.8%); a relative reduction in deaths of 12% (95% CI 8%â16%). 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) 123 | P a g e 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 â TeleStroke Unit networks may be a useful model. Describes project in Germany. 10 year evaluative study. Results â 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 2011â2015. (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 Trialistsâ 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 â 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) âGeneralist 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.â (page 15) Association of Surgeons of Great Britain and Ireland, 2012(3) Emergency Surgery : âa duty team typically needs at least 3 and preferably 4 personnel (CCT, MRCS, core and foundation).â (page 19) BOMSS, 2012(4) âThe core professions/disciplines within the MDT should at least comprise ⢠Specialist bariatric Surgeon(s) ⢠Bariatric Nurse Specialist(s) ⢠Specialist Bariatric Dietitian(s)â (page 3) âunmanageable numbers of patients are a real concern of larger mergers between hospitalsâ (page 25) âBariatric 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.â (page 13) âBariatric 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.â (page 14) Royal College of Surgeons of England, 2010(5) âMost surgical procedures performed on children are elective, relatively straightforward and performed in the DGH.â (page 1) 126 | P a g e âChildren 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.â (page 1) Imison, 2014(6) âUnits 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.â (page 51) Clinical Outcomes Centre for Workforce Intelligence, 2011(2) âGeneral 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.â (page 2) âThe 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.â (page 3) Association of Surgeons of Great Britain and Ireland, 2012(3) âA 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.â (page 26) âSmaller and remote hospitals have particular issues .. They tend to have much more of a âconsultant deliveredâ serviceâŚDecisions 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.â (page 27) Other Service Attributes 127 | P a g e Royal College of Surgeons of England, 2010(5) âThe general surgical syllabus requires all general surgeons to receive training in the management of common childhood surgical emergencies during their DGH attachments. (page 4) âDevelopment 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.â (page 4) âIf 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 patientâs home as possible.â (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. Kingâs 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) âRadical 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.â (page 6) Local urological cancer team âIn 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. â (page 26) Specialist urological cancer teams âAll 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.â (page 29) Supra-network specialist teams âPatients 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.â (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) âOne, 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.â (page 39) Other Service Attributes NICE, 2013a(3) âThe 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.â (page 7) NICE, 2015(2) âThe 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.â (page 9) NICE, 2013b(4) âThe 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 LUTSâ (page 8) NICE, 2002(5) Key recommendations âAll 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.â (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) âThere 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.â (page 70) âThere is evidence that the centralisation of vascular services in the United Kingdom is resulting in better outcomes.â (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) âWhen 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.â (page 43) âIt 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.â (page 42) 132 | P a g e Vascular Society, 2014(3) âWe 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.â(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 âwe 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.â (page 36) Vascular Society, 2012(2) âPatients with vascular disease should expect to be managed by vascular specialists, both electively and as an emergency.â (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 âElective and emergency vascular surgical and IR services should be developed and coordinated jointly.â (page 12) âIn 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)â (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) âAnaesthesia for all patients undergoing major vascular surgery should be provided by a consultant experienced in vascular anaesthesiaâ (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) âA 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).â (page 71) âIn 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).â (page 71) Cost Imison, 2014(1) âWe could find no evidence on the financial impact of reconfiguring vascular surgery services.â (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 Kingâs 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 Kingâs 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 â 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 â adults An anaesthetist (ST3 or above) available within 10 minutes & a consultant anaesthetist available within 30 minutes Emergency anaesthetic support â children An anaesthetist (ST3 or above) available within 10 minutes & a consultant paediatric anaesthetist available within 30 minutes Planned anaesthetic support â 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 â 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 â 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 â 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 â 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 â 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 â 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 â 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 â 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):1795â1803. (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 âvalue opportunitiesâ 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 NHSRightsCareâs own âNHS Atlas of Variation in Healthcare Seriesâ. 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 âdo 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 âlarge hospitalâ, as defined in the Act â 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 âset asideâ 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 costâ benefit analysis. 146 | P a g e intended to provide a high-level âstarter for tenâ 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 telemedicineâs 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. 148 | P a g e