19. GRI \ STOBHILL PARTNERSHIP

Stobhill Hospital and Glasgow Royal Infirmary have been providing health care together to the population of the North and East of Glasgow for decades.

Throughout various changes in NHS organisation the hospitals have sometimes been linked and at other times they have been separate – but they have never lost sight of their joint aim of delivering health services to the local community.

The plan to Modernise Glasgow’s Hospitals is an opportunity for a new chapter with even more co-operation and partnership.

Partnership in Practice

This will build on the experience and good examples in both hospitals. For years Stobhill has had a Casualty Department. Glasgow Royal Infirmary has an Accident and Emergency Department. Our plans for the pattern of health care in the North and East build on both these different approaches.

• Stobhill’s successful model of a Casualty Department will become more widespread throughout Greater Glasgow. This allows an increased role for Nurses in treating those patients with injuries which do not need a doctor’s attention.

• Glasgow Royal Infirmary will develop into one of Greater Glasgow’s two Trauma Centres.

For years some specialties which are in both Glasgow Royal Infirmary and Stobhill have operated as one department:

In Ophthalmology (eyes) all the patients in the North and East of the city who need eye surgery go to Stobhill for their operation.

Orthopaedics has also been working in partnership for years. All orthopaedic Trauma (accident) patients from the North and East are treated at Glasgow Royal Infirmary. Those who live in the Stobhill area return to Stobhill to be cared for after their operation.

One of the elements in our plans is for this to go a stage further. Orthopaedic in-patient services are proposed to be concentrated at Glasgow Royal Infirmary.

This has been talked about for some time. We are proposing that it should happen now because specialisation within orthopaedics and the impact of regulations on doctors’ working hours make it extremely difficult to meet our obligations for providing the best outcomes for patients with doctors not working beyond safe and legal limits.

Our leaflets on "Why Specialisation Matters" and "Impact of Regulations on Doctors’ Working Hours" tell you more about this.

Partnership at times of change

The partnership between Stobhill and Glasgow Royal Infirmary has changed over the years to cope with new pressures. Over the last eighteen months the two hospitals worked together to concentrate renal (kidney) in-patient services at Glasgow Royal Infirmary. The hospitals had two separate units before but these were too small to continue on their own. Both units needed money to be invested to improve facilities. As a result of the two hospitals working together the people of the North and East now have an in-patient service which is large enough:

to provide a good service

to deal with staffing problems

to attract investment to improve services

It is only the in-patient service which is being concentrated, however – the very large renal dialysis service is continuing at Stobhill.

In the same way two years ago the eye casualty service for all patients in the North and East was concentrated at Stobhill. This recognised the importance of Stobhill as the major base for the ophthalmology service.

Now there are new pressures for change. Specialisation in surgery and the impact of regulations restricting the number of hours doctors work are the two main ones and are described more fully in other leaflets. But there are other drivers for change. The impact of new technologies and medicines are changing the way illness is diagnosed and treated. What used to take days, laborious programmes of tests and quite ‘heavy’ surgery can now often be done in a single day using equipment and approaches which are quicker, safer and require much less recovery time. It is these changes which make the proposed new Ambulatory Care Centre for Stobhill so important. Around 90% of all patient experiences of going to Stobhill are ‘same day’ experiences:

 

No.

%

Attending Out-Patient Clinics

147,253

61.4

Day cases

13,175

5.5

  160,428  

Casualty attendances

52,410

21.8

In-patient cases

27,104

11.3

  239,942

100

These figures exclude day hospital attendances, out-patient ECG and x-ray investigations and out-patient physiotherapy attendances – all of which would further increase the statistical balance towards ambulatory care rather than in-patient care.

The Ambulatory Care Centre will allow these to be organised in a patient-friendly way. It will be more efficient too. It will guarantee a long term role as a major provider of health services at Stobhill for years to come – ending the blight of uncertainty that has hung over the hospital for years.

Our leaflet "Ambulatory Care – What is it?" tells you more about this new approach to providing so many of a hospital’s services.

Although we want to provide as much local access to ambulatory care services as we can, it is likely that many patients in the East of Glasgow will want to use the modern Ambulatory Care facilities at Stobhill once they are built.

Co-operation and sharing

One of the reasons for our plan to Modernise Glasgow’s Hospitals is because we recognise that expensive equipment and specialist expertise cannot be available everywhere. Patients in the North and East are aware of this. Patients from Stobhill have been going to Glasgow Royal Infirmary for years to make use of the specialist services there. They are referred by staff at Stobhill to their colleagues at Glasgow Royal Infirmary.

The doctors at Stobhill and Glasgow Royal Infirmary have been working together to provide out of hours cover in a range of specialties like Urology and Vascular Surgery. This has helped both hospitals to cope with the increasing pressures brought about in the past by the need to reduce junior doctors hours and by changes in the way doctors are trained. The new regulations apply to senior doctors’ hours and continuing pressure to reduce junior doctors’ hours even further mean that we need to concentrate these in-patient services on one site because we can no longer sustain separate cover and rotas across so many sites.

Partnership in future

The plan to Modernise Glasgow’s Hospitals means that health services throughout Greater Glasgow will be working in partnership with different sites offering different services. They will complement one another. Not all sites will be trying to do everything.

The Glasgow Royal Infirmary\Stobhill Partnership will be an important part of this. It is able to build on years of effective working to show that this approach can benefit patients and staff delivery the service they want.

The plan to Modernise Glasgow’s Hospitals suggests how we might build on this positive partnership.

Stobhill’s Ambulatory Care Centre ("ACAD") offers more opportunities for the

GRI\Stobhill partnership to grow.

Planning for the ACAD is looking at how patients from both the North and the East might go to Stobhill for ambulatory care rather than to Glasgow Royal.

This means that they will benefit from this exciting new model of care in the brand new facility. The North Glasgow Trust will be consulting locally on how the new ACAD will meet local expectations – it is important that local people have confidence that it will be "fit for purpose".

Even more day surgery will take place at Stobhill and it is likely that more people from the East will also go there for day surgery. Stobhill already has a prominent role in providing this. It was the first hospital in Scotland to build a unit specifically for day surgery.

Stobhill’s ACAD also means that, for people in the North of the area, 90% of their contacts with hospital will continue to be local and as accessible as they are at present.

These services would mostly be accommodated in a brand-new unit, although where good facilities already exist (such as renal dialysis) they would still be provided from their existing accommodation.

The pattern of service between Stobhill’s Casualty and the GRI’s A & E\Trauma Centre would remain as it is now, except that the GRI service would have better consultant staffing and would be operating in brand-new facilities now being built.

The knotty issue that we need to explore during this consultation period involves in-patient services. The two hospitals have been working in partnership in many different ways in recent years but the impact of specialisation, falling lengths of in-patient stay in hospital, the switch from in-patient diagnosis and treatment to ambulatory care and the effect of working hours regulations have brought us to the point of needing to look clearly into the future and to plan for it properly.

The future for in-patient services

When the current building scheme under construction at the GRI is finished, the GRI will have 600 beds in modern facilities. It will also have 500 beds in old buildings, 219 of which will be empty when the new scheme is complete. Stobhill has 401 acute beds – all of them in old buildings. Bed numbers in the surgical specialties will continue to fall in future years as new surgical, imaging (x-ray) and other techniques come into use.

The 340,000 people living in North and East Glasgow equate to an expected need for acute in-patient beds by 2005 of around 1020.

The question of how to meet those needs between the GRI and Stobhill has been a highly contentious matter. The 600 modern beds and some upgraded older wards will provide a high quality base for in-patient services in:

The specialties which currently have in-patient beds at Stobhill are:

 

 

   

Number of Beds   

Number of cases (1998\99)

General medicine *

222

15,180

General surgery

91

5,314

Orthopaedics

19

806

Gynaecology

38

1,989

Ophthalmology

2

570

ENT (ear, nose and throat)

6

1,050

Urology

18

1,593

Intensive Care

5

234

 

* Includes haematology, respiratory medicine, assessment of the elderly, coronary care unit.

For some of these specialties the trends in future bed requirements, the need to create specialist teams big enough to assure specialist presence in emergencies, the obligation to reduce doctors’ working hours down to legal limits and the need to ensure adequate support for the major Accident and Emergency\Trauma service means that only one in-patient centre can be maintained in North Glasgow – with another one in the South. Ambulatory Care in these specialties would still be provided locally – i.e. at Stobhill.

These specialties are:

- Orthopaedics

The need to provide more consultant cover for emergencies and better

supervision and training of juniors means that it is no longer possible, within European

Union working hour limits, to provide round the clock cover on three separate in-patient

sites in North Glasgow. Only one in-patient centre can be satisfactorily sustained in

this way. Keeping more than one site will spread the presence of specialists within

orthopaedics (hands; knees, hips; upper limb etc) too thinly and will make waiting lists

longer. Since orthopaedics needs to be located on the same site as major Accident

and Emergency\Trauma – the single site would be at the GRI.

In-patients Day cases Out-patients

1998\99 1998\99 1998\99

Stobhill 806 90 8,395

GRI 3,178 458 27,071

West Glasgow 3,619 723 21,807


Proposed future All GRI Stobhill No change

Gartnavel

- Gynaecology

Like orthopaedics there is strong medical advice to support change from the present five in-patient sites in Glasgow to two – one North and one South. Since gynaecology shares most of its medical staff with obstetrics it makes sense for the North Glasgow in-patient gynaecology service to be alongside the new Maternity Unit at the GRI. It is also helpful to have emergency gynaecology staff working alongside the major Accident and Emergency service.

In-patients Day cases Out-patients

1998\99 1998\99 1998\99

Stobhill 1,989 1,811 12,519

GRI 1,337 1,998 16,837

West Glasgow 1,668 1,367 10,587


Proposed future All GRI No change No change

- Ophthalmology

There are already as many day cases as in-patients in ophthalmology (2461 in-patients North Glasgow in 1998\99, 2312 day cases) and the balance will continue to shift in favour of day cases. With an average length of stay of 1.4 days, the 570 in-patient cases at Stobhill need 798 bed days in a year – equivalent to less than 3 beds. The 1891 cases at Gartnavel require less than a normal ward total of beds.

The need to create a single in-patient centre is compelling. The day case work (over 1100) and out-patients (over 9000 attendances a year) would continue to be locally provided at Stobhill. There needs to be a debate and consultation about where the in-patient beds for ophthalmology should be and the North Glasgow Trust will lead this.

- Urology

The same problems of providing 24 hour cover to three separate in-patient units also apply in this specialty, where the balance between in-patient and day case work is very similar to ophthalmology (5,802 in-patient cases, 5,588 day cases in the North Glasgow Trust). The in-patient work needs to be on one site – the question is which.

Current in-patient numbers are Stobhill 1,593 cases, GRI 2,124 and West Glasgow 2,085. Day case work and out-patients would continue on all 3 sites.

- Ear, Nose and Throat (ENT)

A similar story again. With only 3,300 in-patient cases per year between Stobhill, GRI and West Glasgow and with an average length of stay of 2.5 days, only one ward of beds is needed in North Glasgow. Providing 24 hour cover on more than one site is stretching medical staffing quite unnecessarily. The North Glasgow Trust will lead a consultation exercise to consider where a one-site base for in-patient services might be.

The issue which then arises is what the future holds for general medicine and general surgery.

If the advice of Royal Colleges is followed then the 340,000 people of North and East Glasgow should be served by a single general surgical service with adequate cover between specialties within general surgery. A single team for emergency work would certainly be able to cover the general surgical emergency work arising each day in North and East Glasgow – at the moment there are two. Since these need to cover 24 hours they add to the problem of excessive working hours and reduce the amount of time available to tackle waiting list work. So the pattern is wasteful, makes waiting times longer than they need to be and makes it more difficult to be confident that a specialist is available when needed.

There needs to be debate and consultation within North and East Glasgow whether the pattern should or should not be changed to a single in-patient general surgical service based necessarily at the GRI in support of the major Accident and Emergency service. Out-patients and day case surgery would be available in the new Ambulatory Care Centre at Stobhill as well as at the GRI. In 1998\99 there were 3,008 day cases and 14,838 out-patient attendances at Stobhill compared with 5,314 in-patient cases.

General medicine provides a much bigger service at Stobhill (over 15,000 in-patients a year). The key question to consider is whether general medicine could remain an in-patient service at Stobhill if general surgery in-patient work were based at the GRI. The North Glasgow Trust will organise debate and consultation on the whole question.

Our leaflets on

Ambulatory Care

Why Specialisation Matters

Minimally Invasive Technologies – Keyhole Surgery and the Like

Impact of Regulations on Doctors’ Working Hours

all provide more information about the significance of these issues for this particular debate.

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