Greater Glasgow NHS Board
THE FUTURE OF GLASGOW’S HOSPITAL SERVICES
REPORT ON FIRST PHASE OF CONSULTATION
4. AMBULATORY CARE
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.
- Are Ambulatory Care Centres "untried"?
No. Ambulatory Care is what we already do now. Around 90% of hospital work
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.
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.
6 were bleeding.
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.
- "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.
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.
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.
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.
Greater Glasgow NHS Board