Greater Glasgow NHS Board
Acute Services

THE FUTURE OF GLASGOW’S HOSPITAL SERVICES

REPORT ON FIRST PHASE OF CONSULTATION

 

4.  AMBULATORY CARE

    1. In our proposals we observed that 85% to 90% or more of the patient encounters with the acute hospital services was now on a "walk-in, walk-out, same day" basis. These include out-patient clinics; diagnostic tests such as x-ray or ECG; out-patient physiotherapy, speech therapy and the like; day surgery and minor injury attendance at Accident and Emergency Departments. The jargon term for this type of work is "Ambulatory Care". Leaflets 6 and 7 explained the background.
    2. We confirmed that the GRI, Gartnavel and the Southside in-patient centre would provide ambulatory care services on site to complement their in-patient work. This has been welcomed by all of those commenting on this aspect of our proposals.
    3. We also suggested that in order to meet the public’s wish to preserve as much local access to hospital services as possible, we should build new purpose-designed Ambulatory Care Centres at both Stobhill and the Victoria Infirmary. We demonstrated how such units would provide around 90% of the hospital services currently used by local people at those sites. (See leaflets 16 and 19)
    4. The suggestion that there should be "stand-alone" Ambulatory Care Centres at Stobhill and the Victoria Infirmary has attracted opposition on several grounds:
    1. the concept of Ambulatory Care Centres is said by some to be "untried".
    2. more particularly some clinicians have expressed concern that patient safety might be compromised if day surgery or interventional radiology are undertaken on a site with no in-patient beds or intensive care back up if complications arise. Some MSPs, the Local Health Council, Area Medical Committee and members of the public have picked up on this issue and are adding their voices to the issue.
    3. some clinicians argue that doing some of their ambulatory care work on one site and their in-patient working on another constitutes "split-site working" which they regard as inefficient and undesirable.
    4. some clinicians fear that the stand-alone Ambulatory Care Centres might result in inefficient duplication or triplication of expensive radiological, endoscopic and laboratory equipment.

 

  1. Are Ambulatory Care Centres "untried"?

No. Ambulatory Care is what we already do now. Around 90% of hospital work is ambulatory care. An Ambulatory Care Centre is simply a purpose-designed setting that allows ambulatory care to be undertaken more efficiently, in a pleasant environment, providing greater scope for a "one-stop" experience of diagnosis and treatment for more patients. Our present hospitals have developed so haphazardly that they defeat the aim of organising the patient’s experience efficiently and as pleasantly as possible. For us not to seek to provide facilities that are organised around the needs of the patient, exploiting new equipment and technologies and giving staff teams a more satisfying holistic relationship with patients is unthinkable.   Nor do the design challenges take us into uncharted territory.

Our present "tried and tested" models of organisation are frankly too often a mess.  They include services and equipment that fail to insulate the interests of elective patients against the dominating needs of emergency patients. They result in delays.  They entail multiple visits when one or two would suffice. They entail long treks around confusing corridors and between different buildings.

Purpose-built Ambulatory Care Centres solve these problems. They enable investment to be made in facilities and services that will transform the patients’ experience for the better.

  1. Are day surgery and interventional radiology unsafe without back-up of in-patient services?

The scarcity of stand-alone Ambulatory Care Centres in the UK, the lack of published data on complication rates, and to-day’s more exposed medico-legal position of doctors have caused some doctors to express this anxiety.

There is a stand-alone Ambulatory Care day surgery service at Bexhill in Sussex which has operational links to the Conquest Hospital in Hastings (around 7 miles away). It has undertaken 14,000 day cases, of which only 71 (0.5%) have required transfer to Hastings. Admissions are usually for the side effects of anaesthesia or pain medication and are usually confined to nausea and vomiting. Annex 4 provides a report compiled following a visit to the Unit.

Data provided by Stobhill shows that in 1998\99 out of 12,045 day cases 105 (0.87%) were subsequently admitted to an in-patient bed. The reasons included:

20 "social reasons"
24 experienced post-operative nausea and vomiting (usually due to analgesia).
7 were classified as "under recovered".
2 were kept in for "observation".
14 were described as "unfit".
7 were experiencing pain.
2 had vision problems.

1 needed to be intubated.
8 were described as having a medical, heart or
blood pressure problems.

6 were bleeding.
1 had their operation abandoned.

13 needed further investigation or surgery.

What is not clear is whether any of these could have been avoided through improved routines for screening for suitability for selection for day surgery in the first place. Nor is it clear how many of them required intervention by doctors as opposed to routine post-operative observation and care by nurses on an extended day basis. (The Stobhill Day Surgery Unit closes at 7.00 p.m.)

Similarly it is not clear how many of them were so unwell or serious that transport by ambulance to another hospital would have been considered if there had been no on-site beds (i.e. the Bexhill\Hastings arrangement).

However, given the number of admissions at Stobhill for social reasons or because a bit more time was needed to recover from analgesia it is likely that a stand-alone Ambulatory Surgery service at Stobhill with recovery beds open later into the evening (or overnight, as in the proposal for the Victoria Infirmary Ambulatory Care Centre) would entail only a similar transfer rate to in-patient beds as is experienced at Bexhill (0.5% of 12,045 cases would be 60 transfers – just over one case a week and a rate of transfer 58 times less than experienced by West Glasgow patients in their current use of West Glasgow hospitals’ split-site working).

Clinical audit data from the Victoria Infirmary indicates that in the last six years no day surgery patients have needed to be transferred into Intensive Care. In the UK many surgeons, who also work in the NHS, undertake significant in-patient surgery in private hospitals with no on-site intensive care facilities.

In the USA there are around 1,300 free-standing Ambulatory Care Centres which are neither based on hospital sites nor merely what the Americans call "office-based" (i.e. undertaking very minor procedures in a doctor’s consulting rooms). The great majority of these undertake endoscopies and day surgery in ENT, gastroenterology, ophthalmology, urology, orthopaedics and general surgery. Many are twenty to thirty minutes away from the link in-patient hospital (source: Ambulatory Systems Development Consulting – Website http://www.asdconsulting.com).  It is clear that such centres are seen as a rapidly growing part of the American healthcare scene (ibid). The Federated Ambulatory Surgery Association (FASA) in the USA reports a high level of patient satisfaction. A survey undertaken by the US Department of Health of 837 patients who had cataract extraction with intraocular lens implant, upper gastrointestinal endoscopy, colonoscopy or bunion-removal showed that patients preferred out-patient surgery to in-patient stays, 98% expressed satisfaction with the service and post-operative care was not a problem for most patients (see www.fasa.org/aschistory.html). FASA also report that only 9.6% of surgery centres offered 23 hour post-surgical recovery care.

GGNHSB understands why clinicians feel cautious in to-day’s climate but we do not think the concept of day surgery in stand-alone Ambulatory Care Centres should be discarded, particularly since it is so widespread in the USA, a country with the highest level of medical litigation and extensive accreditation regimes. We have now made a contact in the USA and will arrange for clinicians and other interested parties to visit some hospitals to examine issues of risk management at first hand.

  1. "Split-site Working"

"Split-site working" is understandably an emotive term. In Glasgow it has gained particular resonance from the wholly unsatisfactory patterns of care and working arrangements experienced in West Glasgow where many patients have to be transferred between the Western and Gartnavel in mid-episode of care and where staff also find themselves shuttling backwards and forwards between the two sites.

The creation of the New Western Infirmary at Gartnavel, with its own on-site Ambulatory Care Service will mean that physicians and surgeons based there will not experience "split-site working " (although some specialists based at Gartnavel may very well do clinics or provide expert advice\support at other hospitals elsewhere in Glasgow or further afield as part of a Managed Clinical Network).

However, the contention that stand-alone Ambulatory Care Centres at Stobhill and the Victoria Infirmary would cause "split-site working" needs closer examination.

    1. For patients attending the Victoria or Stobhill Ambulatory Care Centre only a tiny proportion might find themselves transferred to the Southside in-patient centre or GRI respectively (e.g. those experiencing problems after day surgery – see above – or those who attend an out-patient clinic but are then assessed as needing immediate in-patient admission – relatively few in number). A level of transfers such as this is nothing like the volume and seriousness experienced currently by West Glasgow hospitals’ patients.  (The Ambulance Service carries 3,500 patients per year between the West Glasgow Hospitals).
    2. Patient Records will need to transfer between hospital sites if a patient is, say, attending the Ambulatory Care Centre but later has to be admitted as an in-patient to , say, the Southside in-patient centre either electively or as an emergency. By the time the new pattern of service is implemented the NHS in Scotland will surely be well down the path of electronic records and any remaining logistics involving paper records ought to be amenable to good organisation.
    3. Staff movement between sites is inefficient and disruptive if it has to take place erratically or several times during a working day. However, the creation of larger clinical teams will mean that for most staff their work can be more adequately planned on a weekly or monthly basis and the designation of teammembers to concentrate on emergency cover on a programmed basis will free other team members from the clashes between emergency and elective work which is currently such a blight. Thus if a consultant is programmed to spend a day at, say, the Stobhill Ambulatory Care Centre we would not expect him or her to be called back to the GRI to deal with an emergency.
    4. Having a programme of work which takes staff to different hospitals on different days can rightly be regarded as "multi-site working" but that does not entail the disruptions caused by the "split-site working" as typified by the current Western\Gartnavel arrangement.

    5. Duplication of equipment is theoretically a possibility in any situation but one that can only be addressed at a later stage of planning. The essence of an improved service for patients requires smartly scheduled access to equipment. The Ambulatory Care Centre model will be dealing with the vast majority of patients and each Centre will have equipment to meet its needs. It is the concentration of in-patient work onto fewer sites which will reduce the risks of duplication of equipment for what they need. We have already made the point that because Ambulatory Care Centres insulate their patients from the pressures of urgency associated with in-patients, they experience fewer delays, cancellations and costs (to the NHS and to its patients) which such inefficiency causes.

The NHS has experienced at least two decades of seriously inadequate investment in new equipment. There are encouraging signs that the problem is now being addressed, driven by a governmental determination that the experience of patients must be transformed for the better.

 

    1. So how does all this affect GGNHSB’s view on stand-alone Ambulatory Care Centres?

Our commitment to them reflects our desire that patients should have as much local access to as many services as possible. The concept of stand-alone Ambulatory Care Centres would, in particular, protect this aspect of service quality for the current users of service at Stobhill and the Victoria Infirmary – areas where issues of local access are particularly important to local people, judging from the comments received during the consultation.

We do not think the concept of day surgery at these Centres should be discarded.  GGNHSB would not wish to put in place arrangements which cannot be managed safely.  We will organise further work and enquiry to look at risk management arrangements in the USA which is a highly litigious society and takes risk management very seriously.

We do not think the "day surgery tail" should wag the "Ambulatory Care dog". For the two hospitals the total amount of day surgery amounts to only around 5% or less of the expected Ambulatory Care Centre workload. We certainly do not think the provision of Ambulatory Care Centres for the two sites should be lost even if, as a result of more tightly defined selection of suitable patients, slightly less day surgery were done than we previously estimated.

We think the convenience of local access for patients for most services is more important than eliminating a pattern of multi-site working for staff, especially since that multi-site working should be well programmed. Both the proposed stand-alone Ambulatory Care Centres would be located in, or close to, populations with high levels of socio-economic deprivation, for whom ease of access is very important.

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