4. WHY SPECIALISATION MATTERS - 
AND WHAT WE PROPOSE TO MAKE ITS BENEFITS MORE AVAILABLE

Patient care can be extremely complicated. The patient expects – and has a right to expect – that decisions made concerning their care will be of the highest quality, and that practical treatments will be competently carried out. No individual practitioner – whether Doctor, Nurse or other healthcare professional, has the specialist knowledge and experience of all aspects of medicine to enable them to provide this level of care for every patient.

Over the years, specialisation within health services has developed. Many healthcare staff who care for patients, particularly in our acute hospitals, work in one area (or a few related areas) of the comprehensive range of clinical services provided. These areas of medical care or groups of services are called clinical specialties, and examples include orthopaedics, cardiology (heart disease), ophthalmology (eye problems), oncology

(cancer services) and paediatrics (child health). Staff train to become specialists in a specific clinical specialty to enable patients to be provided with the best and most appropriate professional care and treatment. Even within these specialties there is further specialisation. For example in orthopaedics, some consultants specialise in hips, others in knees, or shoulders, or hands and so on.

There is growing evidence that the best results in treatment are achieved when patients are treated by specialists (not necessarily just doctors but a whole multi-disciplinary specialist team). This is now widely recognised for some cancers (such as breast or digestive system). In medicine there is some sub-specialisation – some physicians offer particular expertise in, say, diabetes or in cardiology. An acid test here is how knowledgeable NHS staff behave – they will usually seek to get themselves into the hands of a specialist best equipped (knowledge, skills, back-up team and so on) for their illness. We should be ensuring that every patient gets into the most appropriate hands – automatically and not depending on the patient having some inside knowledge about the system. But at the moment specialists are often scattered between different hospitals – tough luck then if he or she is absent when you most need them.

So the challenge is how to provide better continuity of specialist skills being available when they are needed. We need better cover for specialists to deal with out of hours emergencies and routine absences (holiday, study leave etc). Without better cover there is more likelihood of patients not being managed by consultants with the most appropriate expertise.

The Senate of Surgery of Great Britain and Ireland says that for a population of 450,000 the general surgery consultant team should consist of 15 general surgeons to cover the sub-specialties of vascular, breast, endocrine, upper gastro-intestinal, hepato-biliary surgery, lower digestive system ...... will provide at least two consultants per major sub-specialty, enable (cancer) site specific specialisation and allow a four surgeon emergency vascular rota in addition to a general surgical rota.

[Similar principles are proposed for other surgical specialties]

The EU Working Time Directive applies to consultants and we should not organise our system on the wholly unreasonable presumption that specialists will inevitably forego their rights voluntarily. The supply of specialists cannot multiply dramatically in a few short years, so the best way of achieving better cover is to create larger teams of specialists rather than perpetuating the smaller teams currently spread between separate hospitals. Larger teams create more opportunity for better organising the work programmes of individuals. This means there can be dedicated cover for emergencies at any one time, less interruption of planned elective work by the demands of emergencies and scope for consultants to undertake programmed ambulatory care in locally accessible centres without spending their days shuttling back and forth between individual hospitals trying to cover all aspects of their responsibilities simultaneously.

The pattern of services we propose tackles this challenge. It creates larger teams and

allows them to programme their work in just this way.

For general surgery and general medicine the aim is to create three core services in each specialty serving three main population zones of the city in a way that gets us much closer to the size of population proposed by the Senate of Surgery, the BMA and other sources of national clinical opinion. If we do not create these core service teams we will fall well short of the population sizes now being advised.

So for each of medicine and surgery there would be:

- a team serving the Southside 347,000 population

- a team serving the north and east 340,000 population

- a team serving the west 226,000 population

The Southside teams would conduct their acute in-patient work at the Southern

General, day case surgery at the Victoria Infirmary and outpatient care at both the Southern General and at the Victoria Infirmary. The West Glasgow teams would undertake all of their work at Gartnavel. The organisation of the north and east teams needs further debate during the consultation period. Ambulatory care would be provided at both Stobhill and the GRI (with Stobhill as the main focus for day surgery). How best to organise the in-patient service and to achieve the desired pattern by the middle to end of the decade will be identified by consultation in late summer 2000.

The proposed pattern for other specialties is as follows:

Specialty

Current

Pattern

Proposed future

of in-patient base

And to be locally accessible in ambulatory care?

Comments

Maternity

GRI, Southern General, Queen Mother’s Hospital

GRI and new Southside hospital at Southern General

Locally accessible ante-natal care

Decision on principle of reducing to two units has already been the subject of consultation. Proposed future is linked to proposals to relocate all Yorkhill’s services to the Southside.

Urology

Southern General,

GRI, West Glasgow, Stobhill

• No change in South

• One in-patient centre

in North

/

Precise location in the north to be subject to consultation over coming months.

Vascular Surgery

Consultants work in all 6 existing hospital sites

• Southside vascular

service based at

Southern General

• One in-patient base

North of the river

/

In-patient base north of the river will depend on logistical practicalities as between GRI and Gartnavel

 

 

Orthopaedics

Consultants currently do in-patient work in all existing 6 hospital sites

• Southside orthopaedic

service co-located

with A & E\trauma

service at Southern

General

• North Glasgow

orthopaedic service

co-located with A & E\

trauma service at GRI

 

/

New pattern allows both dedicated cover for trauma and adequate cover in sub-specialisms (hips; knees; hands; upper limbs; spine; feet)

Ophthalmology

Gartnavel

Stobhill (2 beds only)

Southern General

This specialty is now predominantly ambulatory care. Further discussion needed on how and where to provide the few

beds needed to support

a Glasgow ophthalmology service

/

 

ENT

Southern General

(Victoria Infirmary)

Gartnavel (24 beds)

Stobhill (12 beds)

• Southern General

• In North Glasgow bed

requirement is

expected to fall to

around 12 beds by

  1. Need further

discussion about where to provide these 12 beds

 

 

 

/

Modern facilities for Southside ENT in-patient service currently under construction at Southern General. Decision to transfer ENT beds from Victoria Infirmary to Southern General already reached after consultation.

Dermatology

Southern General

Western Infirmary

This specialty is moving

Inexorably towards being predominantly ambulatory care. Future in-patient requirements to be met within overall hospital bed complements.

/

 

Gynaecology

Consultants currently do in-patient work at all existing sites except the Western Infirmary

• Southside in-patient

service to be located

at Southern General

• North Glasgow in-

patient service to be

co-located with

Maternity service at

GRI

/

• Southern General and GRI in-

patient beds will be in modern

facilities.

• Gynaecological cancer

services to have stronger

connections with Beatson

Oncology Service.

• Current West Glasgow clinical

team re-locates to the

Southern General.

Breast Surgery

Consultants currently based at GRI, Stobhill, Western Infirmary, Victoria Infirmary and Southern General. Scattered too thinly

• 1 unit at Southern

General

• 1 unit at Gartnavel

 

 

 

 

 

 

 

 

 

 

 

These would be immediate access services with dedicated teams, diagnostic and operating capacity. Needs concentration to be able to offer this immediacy of specialist service. The key accessibility issue here is more focused on speed and right skills, and not on locality.

Nephrology

Gartnavel

GRI ) *

(Stobhill) )

* Decision to

concentrate

north-east

nephrology at

GRI now being

implemented

following earlier

consultation.

  • 1 unit at Southern

General

  • 1 unit in North Glasgow

 

/

Provision of service in the South is a new development. Nephrologists consider there should be two units in Glasgow. So if there is one in the South, there will be one in the North (precise location to be subject to discussion during consultation period).

Renal dialysis will be locally available – detailed arrangements to be debated during consultation period.

Clinical Haematology

GRI

Victoria Infirmary

Western Infirmary

Southern General

/

In North Glasgow preferable for clinical haematology to be co-located with Beatson Oncology Centre.

In Southside clinical haematology service needs to have an in-patient base.

Maxillo-facial Surgery

Southern General

(Canniesburn)

Southern General

Capital scheme to implement 1996 Acute Strategy decision is underway. Will allow maxillo-facial surgery to move from Canniesburn. Also provides significant service to other West of Scotland Boards

Regional Services

1. Neurosciences

Southern General

No change

Neurology currently being considered

Already in modern facilities

2. Spinal Injuries

Southern General

No change

No

Already in modern facilities

3. Beatson Oncology Centre

Western Infirmary

Western Infirmary

May be shared care with local physicians\

surgeons

Relocated into modern facilities, move to Gartnavel later in the decade.

4. Cardiothoracic Surgery

GRI and Western Infirmary

Western Infirmary

To be considered

Concentrated as a single centre in modern facilities

5. Infectious Diseases

Gartnavel

No change

No

Already in modern facilities

6. Homoeopathy

Gartnavel

No change

No – but many GPs have homoeopathy training

Already in modern facilities

7. Plastic Surgery\Burns

GRI (Canniesburn)

GRI

/

Current capital scheme provides modern facilities. Allows closure of Canniesburn

8. Renal Transplantation

Western Infirmary

No change, unless consultation suggests it should be on the same site as North Glasgow’s nephrology service.

Nephrology /

Already in modern facilities

Want to know more? To see our list of on-line and printed leaflets click here.

 

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