Modernising Glasgow's Acute Hospital Services
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RECONFIGURATION OF ACUTE SERVICES IN GLASGOW

Board Meeting
Tuesday, 20th February, 2001
CHIEF EXECUTIVE
Board Paper No.

RECOMMENDATION:

  1. The Board is asked to note progress on taking forward the action decided at the December meeting of the Board.
  2. The Board is asked to endorse the paper that has been published for consultation on some early changes in the location of some in-patient services on the Southside.

1. INTRODUCTION

1.1  The December, 2000 Board meeting agreed a range of actions aimed at sustaining momentum on those areas where there was agreement and finding a transparent and inclusive way of addressing those issues where there was disagreement.

1.2  This paper summarises the progress made since the December meeting.

2.  APPROVAL TO PROCEED TO OUTLINE BUSINESS CASE STAGE
 

2.1  The Board agreed to seek the approval of the Scottish Executive Health Department to proceed to Outline Business Case stage for:

    1. the unification of the Western Infirmary and Gartnavel onto a single site at Gartnavel.
    2. a single in-patient hospital for the Southside, plus an Ambulatory Care Centre at the Victoria Infirmary campus. The option appraisal element of this work would address the existing lack of agreement regarding the location of the in-patient site. (This is reported on more fully later in this paper)
    3. further capital investment for the north and east of Glasgow. The option appraisal element of this would explore the continuing fundamental disagreement about service models. (This is reported on more fully later in this paper)
2.2  A response from the Scottish Executive is still awaited. In the meantime Trusts are starting to assemble the basic information that would be needed for option appraisals and Outline Business Cases.
3.  PROJECT MANAGEMENT

3.1  The North Glasgow Trust arranged for Trust senior managers who had been involved in the Edinburgh Royal Infirmary, Law and Hairmyres PFI projects to brief Glasgow managers about the lessons they had learned. Among their advice was:

    1. the need to develop project management capacity very early in the process.
    2. the desirability of ensuring a consistent basis for specialist financial advice for the host Health Board and the participating Trusts.
    3. the importance of early work on re-engineering the design of clinical services so that their implications for building design were well defined at the outset. It is crucial to be clear and specific about what is wanted in design terms before potential consortia partners commit themselves to suggestions about building solutions.
3.2  The Scottish Executive Health Department sponsored a meeting between GGNHSB and Glasgow Trust Chief Executives and Finance Directors on the one hand and Partnerships UK on the other. Partnerships UK is the successor to what started life as the HM Treasury PFI Task Force. It has been set up by the Government to assist public sector bodies in the best possible procurement practice in using PFI\PPP. It concentrates on large, complex and risky projects and aims to ease the regulatory processes by maintaining close relationships with government departments, the Scottish Executive Finance Department, HM Treasury and Ministers. It offers participation in project steering group arrangements, bringing hands-on experience with other major PFI\PPP projects. Its participation is at the decision-making level rather than as mere advisers.

It was clear that Partnerships UK’s involvement in the procurement process for capital for acute services reconfiguration in Glasgow might offer some benefits. Partnerships UK listened to an account of the current state of progress in Glasgow and will liaise with the Scottish Executive in deciding whether the circumstances are ready and appropriate for their involvement.

3.3  It is clear that as soon as Scottish Executive approval is given for proceeding to Outline Business Case stage GGNHSB and the Trusts need to speedily agree:
    1. an overall project steering mechanism.
    2. overall project arrangements for whole-Glasgow project direction.
    3. the appointment of a single source of financial and legal advice.
    4. consideration of arrangements for specialist advice on town planning, traffic analysis, site investigation and architectural considerations.
    5. site-specific project management arrangements.
4.  A & E SERVICES PLANNING
4.1  Membership of the planning group has now been agreed. The first meeting of the group is now being convened.

4.2  The terms of reference of the group are as follows:

"The Health Board decided in December that although there will be important operational planning to be pursued in each of the acute Trusts, there are some key principles that need to be addressed on a pan-Glasgow basis. It will also be necessary to monitor – and where necessary guide - aspects of operational planning. The A & E Services Planning Group will exercise that role.

It will be for the A & E Services Planning Group to establish its own modus operandi when it meets. In the meantime the broad purpose of the Group is reasonably clear:

a)  it needs to map what the key service planning issues are and in what timescale they need to be tackled.

      Some of these issues will be associated with the major reconfiguration of hospitals and hence their timing will be driven by that. For instance the GRI capacity issue will not impact until firstly, the new Southside Hospital is built and the Victoria A & E service then converts to a Minor Injuries Unit and secondly, unless transfer of medical and surgical receiving away from Stobhill occurs. We need, however, to size the GRI (and other hospitals’) capacity issue over the next few months so that capital investment requirements can be included in the Outline Business Cases due to be compiled over the next 9 months or so.

      There will be other issues of service improvement that are not dependent on the major capital programmes associated with hospital reconfiguration. We need to identify what these are, what priority they have and how we can implement them.

b)  in view of the recent uncertainty over the work done so far on expanding capacity at the GRI, the Group will want to hear what has been done so far and what else needs to be done to achieve a satisfactory conclusion.

c)  as part of its knowledge base, the Group will want to identify and collect patient activity data in a form that allows well-informed judgements to be made about future service design.

d)  the Group will not only need to oversee the specification of a comprehensive range of front door services for accidents and emergencies for Glasgow, it will also need to contribute to the identification of the in-patient capacity needed to complement those ‘front door’ services.

e)  as part of the process of shaping future service models, the Group will at some point need to understand the nature of the current service at Stobhill and how it will evolve in the future.

f)  the Group will need to identify clearly who is tasked to explore particular issues and how the various strands of work come together in some coherent and timely decision-making.

g)  the Group will need to ensure that the work initiated by the specialist group on Children’s A & E Services is adequately connected to the overall whole-Glasgow picture.

h)  the Group will need to consider what needs to be done to develop clinical protocols, how to make the right connections into the work of primary care and what information should be provided to help the public understand what different strands of service have to offer and how they relate to each other.

i)  the Group needs to ensure that implications for ambulance services are properly planned on a whole-Glasgow basis.

Although some of this work is urgent there are other elements which will take longer to pursue (items (h) and (i), for example). We should therefore expect that the work of the Group will extend and evolve over many months.

As far as membership of the Group is concerned it will inevitably be quite large, in order to reflect the range of interests. It is also likely that sub-groups will need to be formed to look at specific issues at some stage.

The membership has been agreed as follows:

This amounts to around 30 members – which emphasises the point that we will need to establish Sub-Groups! We can also expect that during the Group’s work we will need to involve orthopaedic surgery, radiology, paediatrics and perhaps other specialties. The Group will need to decide how best to organise that when necessary."

5.  BED NUMBERS
5.1  Membership of the Steering Group has now been agreed. The first meeting of the group is now being arranged.

5.2  The terms of reference of the group are as follows:

a) To examine and establish the overall parameters within which the number of beds to be provided in the reconfiguration of acute services will be determined. These will reflect:

b)  To incorporate the implications of parallel work by the A & E Services Planning Group on the expected future changes in flows of accident and emergency admissions.

c)  To ensure that sensitivity analysis is undertaken to model potential variations in future trends for medical emergency admissions.

d)  To review the outcome of specialty by specialty analysis and discussion within Trusts, to calibrate those outcomes against the issue of the revenue affordability of acute services reconfiguration and to direct the principles and parameters of any necessary further iterations if affordability becomes a problem.

e)  To develop a communications plan to support the work.

The membership of the Group is as follows:

i) Chief Executives (Maggie Boyle, Robert Calderwood, Chris Spry).
ii) ISD
iii) The relevant Trust manager who is co-ordinating the detail of the work within each Trust.
iv) An LHC representative.
v) The Chairman of the Hospital Sub-Committee.
vi) The Chairman of each Medical Staff Association and one other clinician from each hospital agreed with the Chairman.

It is suggested that at the first meeting of the group there should be a presentation by North Glasgow Trust of the work done so far. We can then consider what timescales and methods would best meet the needs of specialty by specialty discussion within the Trusts given the different stages in their deliberations so far."

 

6.  CHILD AND MATERNAL HEALTH SERVICES
6.1  Following several meetings between the Chief Executives of GGNHSB and Yorkhill the suggested arrangements for exploring the issues are now beginning to emerge.

6.2  Essentially we propose establishing a Steering Group which will be independently facilitated, working towards one or more option appraisal workshop events involving a larger range of representative groups including patient support groups and the public. Stakeholders from the West of Scotland and beyond will be involved due to the specialist nature of many of Glasgow’s hospital services for children.

6.3  The aim is for the analysis and conclusions generated by this process to be available for subsequent public consultation. However, there will be a communications plan developed to support the option appraisal process so that transparency and information are maintained throughout.

6.4  Several clear stages can be seen for the option appraisal process:

Stage 1:

Assemble basic information

• 10 Yorkhill Principles

• GGNHSB paper on Child and Maternal Health dated 15\12\00

• Data on catchment population\ clinical activity \ birth projections

• Maternity:

- the factual story so far
- neighbouring Health Boards’ plans
- activity data
- accommodation requirements
- opinions about service inter-

dependencies

 

 

 



Stage 2: Interrogation and

building understanding

 

• Interrogation of and briefing about Stage 1 material

• Starting to identify relevant quality and service issues

• Identify desired benefits and likely criteria against which options will be judged

                                                                                                                                                            

Stage 3: Generating the options

• Identify all possible options
• Gather basic information about each

    • estates feasibility
    • access and traffic issues
    • other factors

• Reality check on options

Stage 4: Option appraisal Workshop(s)

• Assign weightings for benefits\criteria
• Score options against criteria
• Consideration of consequential comparison of options

Stage 5: GGNHSB consideration

and public consultation

6.5  The aim is for the Steering Group to oversee Stages 1 to 4 and to advise GGNHSB and the Trust how the detail of Stage 4 in particular can be organised.

6.6  The composition of the Steering Group is proposed as:

Yorkhill clinicians representing:

neonatology )
obstetrics and fetal medicine )
tertiary services ) Say 7
local paediatric services )
clinical support services )

 

Primary Care perspective

GP rep. on Child Health Strategy Group ) 2
Medical Director of Primary Care Trust )

Childrens, mothers and families reps.

2
Greater Glasgow Partnership Forum 2
Yorkhill Partnership Forum 1
Local Health Council representative 1
University representative 1
MSP 1
1

Trusts\GGNHSB

Yorkhill  2
GGNHSB  1
South Glasgow  1
North Glasgow  1

The Steering Group would be independently facilitated.

6.7  At an early stage it would need to consider how the wider group of stakeholders should be engaged in the processes, particularly at Stages 2 and 4. These other stakeholders would include:
    1. Health Boards elsewhere in Scotland.
    2. A wider range of childrens, mothers and family groups.
    3. Local authorities.
    4. Other MSPs.
    5. A wider range of clinicians in primary care and in other Glasgow hospitals.
6.8  Two questions which have already been raised in discussions with interested parties since December are:
    1. why are we undertaking this process at all?
    2. won’t the previous Health Board decisions to reduce from 3 maternity delivery units to 2 have a disproportionate effect on the outcome?

The answers which have been given to these questions go as follows:

    1. there were two triggers for this process. Firstly, GGNHSB felt that at a time when major investment on reshaping Glasgow’s hospitals was in prospect it would be negligent not to consider the question of whether that investment should include new facilities for children which co-located them on the same site as adult services. Secondly, the Yorkhill Trust itself came forward with proposals for major capital investment on the Yorkhill site at £65 million. Investment of that magnitude would effectively commit Glasgow to the Yorkhill site for 30 or more years. Moreover investment on that scale could not be committed without a full option appraisal which could not exclude the possible alternative of co-location on an adult site.
    2. the GGNHSB decision on maternity delivery units was based on careful consideration of the principles and expected birth numbers by the Maternity Services Liaison Committee and ensuring public consultation on the basis of principle rather than location. It represents current policy and cannot be simply "expunged from the record". It can however be interrogated and tested during Stage 2 of the process.
6.9  The next stages are to finalise the identification of Steering Group members, appoint an independent facilitator, identify a Project Manager (jointly accountable to the Chief Executives of GGNHSB and Yorkhill Trust) and start to assemble the material needed for Stage 1.

For the purposes of the latter (and to support later Stages) there will need to be an internal resource group composed mainly of Yorkhill and GGNHSB personnel, but drawing on expertise and information from other Trusts.

7.  SOUTH GLASGOW: LOCATION OF NEW IN-PATIENT FACILITIES
7.1  A similar process needs to apply in the case of the site option appraisal element for South Glasgow.

7.2  The following schematic shows the sequence of what has to be done:

Stage One

INFORMATION\DATA

- Functional content
• Patient volumes
• Bed numbers
• Service\department schedules
• Design Guide norms

- Preliminary work on operational policies and efficiencies

- Site appraisals

• acquisition issues
• space
• ground conditions
• access
• architectural massing
• town planning constraints

- Traffic analysis

- Capital and revenue cost profiles

- Risk assessment

 

Stage Two

BENEFITS CRITERIA

- Define service objectives

- Specify relevant benefits criteria

• Clinical
• Users
• Environmental
• Value for money etc.

- Agree weightings

 

Stage Three

OPTION APPRAISAL WORKSHOP(S)

- (Normally) one workshop BUT could be .....

- ..... multiple Stakeholder scoring events

Concluding Workshop

- with community involvement

7.3  Much of the material for Stage 1 will, in this case, need to be gathered and assembled by specialist firms appointed competitively by the Trust.

7.4  Thought is being given as to whether the Stage 2 – which will need to be independently facilitated by a specialist consultant – should be conducted on a whole-Glasgow basis (for adult services), since the same benefits criteria are relevant north and south of the river. (The access criteria can be defined in a way that can subsequently be adapted to testing specific options for specific geographies of access). This would save expense but more importantly might ensure that the crucial process of weighting criteria is not hijacked by any sectional interest seeking to ensure that its own interests prevail over all others. As long as it was conducted transparently and with genuine inclusiveness it would be not only robust but also, hopefully, able to command everyone’s confidence before options are scored against criteria.

7.5  Stage 3 will need, somehow, to involve an extremely wide range of legitimate stakeholders:

  • clinicians (hospital and primary care)
  • local authorities
  • MSPs
  • community representatives

The Reference Group will need to consider how that can best be organised.  They will probably need to take the advice of specialist consultants with experience in option appraisal workshop techniques.

7.6  The Local Health Council has identified its nominee for membership of the Reference Group. At a recent meeting with members of the All-Party Group of (South Glasgow) MSPs, the MSPs offered to identify three (or possibly four) MSPs willing to commit the time needed for the work of the Reference Group.

7.7  Others, such as East Renfrewshire Council and the Health Services Forum – South-East, have sought membership of the Reference Group but it is increasingly clear that it is involvement in Stage 3 (coupled with transparency in Stages 1 and 2) which will best meet their needs. It is important to emphasise that preparation for involvement in Stage 3 would entail significant prior preparation, involving briefings, interrogation of data, etc.

7.8  The next steps entail the appointment of specialist consultants to deal with Stage One and to organise Stages Two and Three. We will need to agree the arrangements for these appointments with the Reference Group. A meeting of the Reference Group will be organised as soon as the MSP nominations are known.

8.  STRENGTHENING CLINICAL CAPACITY IN SOUTH GLASGOW: PROPOSALS FOR EARLY CHANGES PENDING MAJOR NEW BUILD

8.1  As the preceding section makes clear it is essential that the process of option appraisal as part of the development of the Outline Business Case is as transparent and systematic as possible.

8.2  However, the new facilities will not be available for at least five years. We need to ensure that in the intervening period the available hospital facilities in South Glasgow are able to deal satisfactorily with current pressures.

8.3  There are five specific changes we wish to propose for implementation in 2001 and 2002.

    1. A need to increase capacity for general medicine at the Victoria Infirmary. We want to open a net increase of 38 beds for general medicine at the Victoria Infirmary.
    2. In order to create space at the Victoria Infirmary for general medicine we propose to create a single in-patient gynaecology unit for the Southside at the Southern General (but no change to out-patients or day cases).
    3. We want to strengthen the Southside’s breast surgery service by concentrating its in-patient facilities at the Victoria (involving change in the location of 5 beds and affecting about 100 patients a year currently treated at the Southern General).
    4. We want similarly to strengthen the vascular surgery service by concentrating its in-patient facilities at the Southern General (involving change in the location of 5 beds and affecting about 240 patients a year currently treated at the Victoria Infirmary).
    5. Associated with the concentration of in-patient gynaecology services we propose to include concentration of the West Glasgow in-patient gynaecology service with that proposed for the Southern General.
8.4  These proposals do not prejudice the outcome of the South Glasgow site option appraisal process.

8.5  These proposals have been clearly in the public domain since last September and were included in a public consultation document at that point. They are subject to a second phase of public consultation since the Health Council requested elucidation of certain specific points that it decided in December were not covered in the September documentation. In view both of the urgency to expand capacity in general medicine at the Victoria for next winter and the proposals having been in the public domain since September, we are proposing a consultation period of just over 6 weeks as allowed for by the 1975 circular which governs such consultation. The paper was circulated to interested parties last week, with the request that comments be made by Wednesday, 4th April, 2001.

8.6  A copy of the consultation paper is attached as Annex A.

9.  WEST GLASGOW

9.1  The Trust is developing a project timetable for working up the Outline Business Case for this element in the Greater Glasgow strategy.

9.2  The Trust’s ability to make progress will be constrained until decisions have been made about overall Project Steering and Project Management arrangements. See Section 3.

10.  NORTH AND EAST GLASGOW
10.1  GGNHSB has committed itself to ensuring that an Outline Business Case for further capital investment to provide a sustainable in-patient service configuration for north and east Glasgow is conducted in a way that addresses the messages coming out of consultation so far.

10.2  Since there is no agreed service model for the north and east (unlike the Southside and the broad content of the West Glasgow development), the option appraisal element of the Outline Business Case will need to explore four options:

    1. GRI as the site for all in-patient services for the north and east. Stobhill has ACAD but no acute beds.
    2. GRI shut. Stobhill re-built as the sole hospital for north and east Glasgow.
    3. GRI retains a specialist services role. Stobhill redeveloped as a district general hospital for north and east Glasgow.
    4. the ‘do minimum option’. GRI and Stobhill remain as they are but brought up to an estate condition that meets basic health and safety and plant replacement requirements.

In each of these options, the new ACAD for Stobhill is a common feature.

10.3  There is conceptual clarity about the service models and hence functional content of the hospitals in options (a) and (b). In option (d) there is reasonable clarity, although the future of the small surgical specialties (ophthalmology, ENT, orthopaedics, gynaecology and urology) would need to be addressed since it cannot be assumed they remain viable in their present configuration.

10.4  There is no current clarity about what option (c) really means as a service model. For such an option to have any realistic chance of success in an option appraisal it needs to:

i) avoid requiring any more new build at GRI.
ii) avoid leaving existing modern facilities at GRI unused but not disposable.
iii) use none of the old buildings at GRI for clinical purposes.

Since the GRI’s new buildings will provide for around 547 beds (Queen Elizabeth Building 237; Maternity 110; Emergency Receiving\Plastic Surgery Block 200), it will not be straightforward to find a clinically coherent "bundle" of specialist services that could be located there. Work on thinking through what this model might be is in hand, led by the Trust.

10.5  Beyond this there remains the question of how to organise the option appraisal process itself. The process elements are a combination of those already displayed for Child and Maternal Health Services and the South Glasgow location option appraisal but more complex than each of them. The number of potential stakeholders (MSPs, local councils, Social Inclusion Partnerships, trade unions, clinical specialties, Local Health Care Co-operatives, community councils, Local Health Council, University etc) runs into the hundreds. It is not possible to organise an option appraisal through ‘open space’ techniques. Nor do numerous multiple workshops, citizens’ juries etc., necessarily deliver a workable product either.

10.6  The Trust’s assembly of data to be used for option appraisal purposes will be constrained until specialist consultants can be appointed for elements of it. This requires decisions on the issues explored in Section 3 on Project Management.

10.7  Almost certainly we need to take advice from specialists in option appraisal workshop techniques to help us to understand how to navigate an intrinsically complex technical process through the crowded archipelago of stakeholders identified in 10.5 above while simultaneously reassuring inhabitants of that archipelago that they have a real influence on the bridge of the vessel.

11.  OTHER WORK
11.1  A start has been made on identifying what would be involved in creating a single dermatology in-patient centre for Glasgow.

11.2  Work done last year on nephrology and gynaecological oncology will be reviewed in the next few weeks.

11.3  A detailed projection of possible capital investment requirements (involving national "pool" capital or PFI\PPP) has been shared with the Scottish Executive Health Department. a response is awaited. It includes proposals for significant investment in improving radiology\imaging services and laboratory services.

11.4  Progress on the planning process for the replacement of the Dental Hospital will be reviewed shortly.

 

CJS\FEB
14.2.01

Last modified: August 15, 2002

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