Greater Glasgow NHS Board
Acute Services

THE FUTURE OF GLASGOW’S HOSPITAL SERVICES

REPORT ON FIRST PHASE OF CONSULTATION

NORTH GLASGOW SERVICES - CONTEXT

Sections 12 and 13 of this paper address a great deal of detail about proposals for change that have been developed during the consultation debate. We asked the North Glasgow Trust to develop specific proposals and that is what they have now done.

It is important not to let the detail obscure the fact that there is a strong degree of consensus within the Glasgow NHS about some major directions and principles:

The areas of disagreement during debate have concerned:

 

12. THE GRI \ STOBHILL PARTNERSHIP

  1. Leaflet 19 described the way in which the partnership between these two hospitals has been evolving and what its further direction was likely to be. The proposal to create an Ambulatory Care Centre at Stobhill was seen as a fundamental guarantor that Stobhill would have a long term future as a busy hospital, ensuring that 90% of local people’s present contacts with the hospital would continue to be as local and accessible at Stobhill as they are now.

We identified that the future of in-patient services, especially in the smaller specialties of orthopaedics, gynaecology, ophthalmology, ENT and urology, was unlikely to be sustainable in the light of increasing specialisation, restrictions on doctors’ working hours, and continuing reductions in already small bed numbers as lengths of stay reduce and day surgery increases. We concluded that general surgery would likely face similar pressures causing it to need to integrate onto one in-patient  site at the GRI to provide a service for a population of 340,000 people. We asked whether people felt general medicine would be sustainable in the absence of general surgery.

  1. Responses from clinicians have confirmed both our analysis of the smaller specialties and our prognostications about the future of general surgery and general medicine. The Stobhill Medical Staff Association wrote:

"The concept of a 3 acute hospital solution to Glasgow is recognised as being the best way forward but only in our view with 3 genuinely new built hospitals in modern facilities".

The Medical Staff Association’s reservations are not about concept but about modernity of buildings and timescales. They went on to write:

      "it was felt unanimously that acute medicine and surgery could not exist without each other, partly because of implications of associated anaesthetic back-up and intensive care unit. The meeting unanimously rejected any plans that would involve maintaining medicine in the Stobhill site without surgery".

  1. General medicine and general surgery are seen as complementary in the arrangements for acute receiving. A patient might be referred with a vague diagnosis.  If medical tests did not reveal a condition treatable by a physician, there could be a need for the patient to referred to a surgeon for investigation. Equally patients admitted for surgical treatment might also need medical care.

    If there were no general surgery on site, then there would be no in-patient operations, thus reducing the activity in intensive care. This level would be so small that any intensive care unit would not be considered suitable for training of doctors and would have difficulty attracting staff. The unit could not function. This would leave general medicine on site without intensive care which would be clinically undesirable.

    These interactions between acute in-patient services are rather "internal" but they serve to demonstrate that the two specialties, general medicine and general surgery, need to work together for as long as a site operates as an acute receiving site.  Therefore, for as long as Stobhill remains an acute in-patient site they should both be there.

  2. The model that there should be three in-patient sites for Glasgow – two in the North and one in the South – has been the subject of debate off and on in Glasgow for years. If there is agreement that there should be a single General Surgery service in the North and East, leaflet 19 made clear this would necessarily have its in-patient base at the GRI in support of the major Accident and Emergency service. This can only be achieved, however, when the GRI can provide suitable facilities for both in-patient general medicine and general surgery for North and East Glasgow, allowing those specialties to move together from Stobhill. Until that can be achieved they should remain at Stobhill.
  3. In its response the North Glasgow Trust is quite clear on these points and it is worth quoting this part of their response in full:
    1. "The debate in the North, especially in the North East, has concentrated on the future of in-patient facilities at Stobhill. The Trust has been explicit in its discussion at meetings that the outcome of the proposals will be the transfer of all in-patient services from Stobhill, principally to Glasgow Royal Infirmary but some to Gartnavel. The Trust wishes to register that it supports this move. The Trust recognises two points. Firstly, much of the detail of the distribution of specialties needs to be worked out with clinicians and this work is in progress.  Secondly, many of the Stobhill’s community expressed regret at what they perceive as a loss of service. They expressed favourable views of the service provided by Stobhill over the years. The Trust is well aware of the high esteem in which Stobhill is held by its community which reflects on the staff who have worked there.

      In the debate with many of the Stobhill catchment area and with its staff the Trust has been clear that the outcome of these proposals inevitably means that there will be no in-patient facilities at Stobhill within seven years. This fact needs to be the subject of wider and explicit consultation. The Trust takes the view that the proposals set out in the Acute Services Review not only provide clarity about the future of Stobhill but do so in a way which means that that future can be a pioneering and innovative one for the future of health care".

GGNHSB notes the point about consultation. We would hope that the principle of consolidation of in-patient medicine and surgery principally to the GRI but probably with some GPs deciding to make referrals to Gartnavel, can be agreed and approved at the conclusion of this current consultation process. However, we recognise that the public and staff must feel confident that the precise timing and circumstances of such a move are satisfactory. The key requirements are that a satisfactory standard of accommodation and access to diagnostic, theatre and other support services can be provided at the GRI (and Gartnavel). The Trust estimates that it will be able to offer this "within seven years". We do not expect it to be feasible in much less than seven years unless there are unforeseen changes in circumstances.

We therefore propose that the transfer of general medicine and general surgery be approved in principle but that there be further local consultation in due course to confirm that the implementation arrangements meet the tests of adequacy.

  1. In the meantime general medicine and general surgery will remain together at Stobhill Hospital. For much of their remaining time there they would be operating in tandem with the new Ambulatory Care Centre on site. This will help the local population to develop confidence in the significance, quality and accessibility of the Ambulatory Care Centre as a major and enduring feature of Stobhill’s long term future as a busy hospital site.
  2. We note the view held by some doctors that Stobhill should close altogether. For example, The Area Medical Committee’s comments appear to imply this, supporting "early closure of Stobhill General Hospital ..... when accommodation fit for the purpose is provided for Stobhill’s patients at the remaining site".

    We do not subscribe to this view. Our objective is that as many services should be as locally accessible as possible. By locating an Ambulatory Care Centre at Stobhill, the Health Board and the Trust will be able to achieve around 90% of all patient contacts remaining local.

  3. During consultation debate about the plans for the GRI often focused on shortcomings of this site. These criticisms have sometimes been expressed so forcefully that it would be possible to overlook the fact that the GRI has been a busy hospital providing a service to the people of Greater Glasgow – and beyond – for decades.

The debate also overlooks the fact that it is not possible to plan in a vacuum. We need to take account of recent developments and those in progress. In the North and East commentators often asked why the consolidation of in-patient facilities should take place on the GRI and not Stobhill where people saw more room for expansion.  At public meetings the North Glasgow Trust explained that Glasgow Royal Infirmary would have to form a major component of any future plan for acute services. Two major developments costing a total of £60 million will be completed there within the next two years. There can be no question that this level of investment of public money could be written off. We cannot plan to leave these developments before they are even opened.

The Trust also pointed out that the impact of the completion of this investment on the GRI site will be considerable and will address some of the criticism directed at the hospital. The existing A & E Department will be demolished, opening up the site.  There will be a new site road system. Space will be created for a multi-story car park.  Importantly, a nucleus of relatively new buildings will be created around the Alexandra Parade end of the GRI site. Further development here enables services to be moved out of the old buildings on the site. All clinical activity would then take place in buildings the oldest of which would be twenty-five years old.

  1. A conclusion that the GRI will be the in-patient site for general surgery and general medicine for the North and East of Glasgow within seven years means that the planning for other in-patient specialties currently at Stobhill needs to be pursued in detail. This requires decisions to be made now, so that the resources for detailed planning can now be committed. A great deal of discussion has taken place on the future distribution of these services. In some cases, those discussions go back years but have never reached a conclusion.

A major synchronised planning of logistics is required of North Glasgow to ensure that the transfer of specialties takes place in an organised manner, when space is available elsewhere, when capital is available and, quite simply when it makes sense to implement the change in order to bring about the benefits for patients. All of this has to be achieved while maintaining the service.

Not all of the changes can take place at once. Therefore, although we consider that the bulk of general medicine and general surgery in-patient services will remain at Stobhill for some seven years, faster progress can and should be made with other specialties, especially those with smaller numbers of beds. The way that the benefits of consolidation, larger clinical teams, better infrastructure and medical cover can be secured across the North Glasgow Trust is described in the next few paragraphs. In each case it is essential to remember that out-patient and day case patients will continue to access their own local hospitals at Stobhill, the GRI and West Glasgow.

  1. The consolidation of the orthopaedics in-patient service for the North and East at Glasgow Royal Infirmary has been the subject of discussion for nearly ten years.  Agreement was reached by clinical staff many years ago on the need to achieve it.  Actual implementation has always been hindered by operational and management problems.  The orthopaedic clinicians of the North and East have co-operated across the two sites by arranging to carry out in-patient planned surgery at both the GRI and Stobhill with all trauma (accident and emergencies) treated at the GRI. These clinicians are also unanimously in favour of the single in-patient unit for orthopaedics in North Glasgow. They see it as necessary to improve the service. Specifically consolidation will enable them:
  1. to develop departments with expertise in the various sub-specialties (hands, knees, shoulders, hip replacement, trauma and so on).
  2. to work more closely with related disciplines such as rheumatology and plastic surgery.
  3. to provide the best training opportunities for junior doctors, nurses and para-medical staff.

There is an opportunity to bring about the long delayed move of in-patient orthopaedics from Stobhill to the GRI very early in 2001. Adequate ward and theatre capacity has been identified within Glasgow Royal Infirmary which would enable this move to take place but also increase day care capacity, thereby reducing waiting times. It would entail the transfer of 17 orthopaedic beds at Stobhill. The number of in-patient cases at Stobhill in 1998\99 was 806 (compared with 90 day cases and 8,395 out-patient attendances which would remain at Stobhill).  The average length of stay for Stobhill orthopaedic in-patients was 5.4 days.

Staff have been fully involved in the planning for this move.

  1. In the case of gynaecology there is general agreement that Gynaecology and Obstetrics should be on the same site wherever possible. Many of the clinicians work in both specialities and there are clinical links between the two specialties.

The North Glasgow Trust has identified a location in the Queen Elizabeth Building at the GRI which would be suitable for gynaecology. The location needs some capital investment to convert it to clinical use and once this is complete, in-patient gynaecology would be in modern, fit-for-purpose accommodation, 30 beds and the necessary theatre capacity It will also be close to the Obstetrics Department which is opening in 2001.

As the alternative location and the capital to make the necessary changes have been identified, there is no good reason to delay the move of in-patient gynaecology from Stobhill. The service and its patients will benefit from a move to new accommodation. The Stobhill Gynaecology service currently has 1989 admissions per year which would be affected by the transfer to the GRI. The move of gynaecology in-patients does not adversely impact on the specialties which will be remaining at Stobhill for the medium term. There is a need to conclude some discussion about where best to locate the in-patient gynaecological oncology service which is a regional component of the present Stobhill service. That discussion will continue during October\November, 2000.

GGNHSB hopes that there can be agreement to this transfer early in 2001, so that the transfer can be implemented by 2002. Planning for this transfer has been less advanced than for orthopaedics but staff will be closely involved in planning for implementation.

  1. An Ophthalmology specialty review group set up by the North Glasgow Trust advised in early 2000 that all out-patient services should be maintained on the sites they are at present. They also proposed that there should be one adult in-patient site for Ophthalmology for the whole of Glasgow. The review group did not at that stage identify a site for this.

The review group felt that consolidation would open the way for increasing sub-specialisation and also allow the introduction of different models of care which would ensure a wider spread of expertise. This could speed access for patients to someone suitably qualified to treat their condition, whether this be an optometrist or a nurse practitioner as well as a member of medical staff. This sub-specialisation would see these different models adopted for the glaucoma, corneal and diabetic eye services. It would allow city-wide medical cover to be provided. GGNHSB believes that the key to achieving these ambitions is to encourage greater collaboration among the North and South Glasgow clinical teams, to monitor the progress of these new service models and let the future disposition of in-patient facilities be driven by the pace of change in clinical practice.

In the meantime there is a pressing practical reason for the transfer of in-patient Ophthalmology from Stobhill. In practice, there are only two designated in-patient beds for Ophthalmology at Stobhill (although sometimes three beds are in use).  These are located in the Orthopaedics ward. Once Orthopaedics moves then these two beds would have to be transferred in any case. Transfer at that stage (early 2001) to join the other in-patient service in North Glasgow, at Gartnavel, makes sense. It would improve out of hours cover for Ophthalmology for North Glasgow as a whole because of the single-site presence of SHOs working a rota which complied with regulations.

This change would affect some 570 in-patient cases treated per year at Stobhill, with an average length of stay of 1.4 days. There is capacity at Gartnavel where there are 24 ophthalmology beds (equivalent to a potential capacity of 7,400 bed days per year at 85% occupancy) and two in-patient theatres. In 1998\99 there were 1,891 in-patients at Gartnavel with and average length of stay of 2.2 day (equates to 4,160 bed days). The annual theatre hours requirement was 3,200 hours, which equates to around 67 hours per week. The current Stobhill workload would require some 8,000 bed days and 700 theatre hours (equates to around 15 hours per week). There will need to be discussion to fine tune use of total theatre capacity between day case and in-patient theatres. The patients would also have the benefit of care from trained specialist nursing and junior medical staff in a more sustainable way than can be achieved with two beds located on an orthopaedic ward remote from the main ophthalmology centre.

The day case work (over 1,100) and out-patients (over 9,000 attendances per year) would continue at Stobhill.

  1. A specialty review for urology was also set up by the North Glasgow Trust and has reported. The review group examined a range of options for the number of sites and also the distribution of services at each of the sites. There is agreement that out-patient services should remain dispersed at all the sites in North Glasgow. While the preferred option for the in-patient service was for this to be on one site, there remains further work to be done to identify the site for this and to reach agreement on the interaction with day surgery services.

It is clear, however, that as with other smaller specialties currently at Stobhill, the North Glasgow Trust will seek to transfer in-patient Urology to link it principally to the GRI in-patient Urology service. This will affect a total of 1,593 in-patient cases per year, using 20 beds (16 beds in ward 6 plus 4 beds in the Gynaecology Ward which are used for female Urology patients only).

Although it is not yet clear whether this should be a transitional stage to a single in-patient Urology service in North Glasgow, it is clear that there are benefits in terms of sub-specialisation and junior doctors’ rostering of out-of-hours cover which mean that within the next three years in-patient Urology in North Glasgow will only be provided from the GRI and Gartnavel and not at Stobhill. The practical logistics of achieving the transfer of the in-patient service from Stobhill can only be worked out as part of the wider jigsaw of achieving change across the North Glasgow Trust but GGNHSB hopes that there can be agreement to the principle of transferring the service from Stobhill into capacity to be provided at GRI and Gartnavel.

  1. ENT is the only other small specialty (i.e. in terms of bed numbers) at Stobhill (it has 6 designated beds although at times when other beds are available move patients are admitted) . Again it has been the subject of a specialty review in North Glasgow.  This review considered the possibility of one in-patient ENT centre for the whole of Greater Glasgow but decided at this stage that it was more practicable to have one service for the North and one for the South. The North Trust will be planning to achieve this consolidation by the transfer of the in-patient service currently provided from 6 ENT beds at Stobhill to Gartnavel when the opportunity arises during the other changes being planned between Stobhill and Gartnavel. The implications of this transfer on beds and theatre capacity need to be worked through but this can be achieved in 2001\2. It would affect 1,050 in-patient cases per year with an average length of stay of 2.5 days.
  2. Although the implementation jigsaw for change across the whole of the North Glasgow Trust is quite complex and not yet clear (because the major elements involving the transfer of services from the Western Infirmary to Gartnavel require large scale capital investment), the pathway to change involving Stobhill’s acute in-patient services is much clearer:

    by or in 2001

• In-patient orthopaedics to the GRI (facilities now available).

• In-patient ophthalmology to Gartnavel (using existing Tennant Institute facilities).

by or in 2002

• In-patient gynaecology to the GRI (capital available to convert accommodation in the Queen Elizabeth Building. Future of gynaecological oncology requires further discussion).

• In-patient ENT to Gartnavel (still requires detailed planning but only 6 beds and around 945 theatre hours per year at approximately 20 hours per week to be accommodated as part of wider jigsaw of change at Gartnavel).

by or in 2003

• In-patient Urology to GRI and (requires a detailed and practicable Gartnavel plan to be developed)

by 2007\8

• In-patient general medicine and (when robust and funded plans have general surgery to GRI (some been developed to meet the tests of to Gartnavel) adequacy)

  1. Before moving on to consider the position for services in West Glasgow we wish to re-state here that one of the issues emerging from the consultation has been the concern expressed by people in the East End about their sense of being too remote from many services. During one meeting, for example, a man argued that in addition to the Glasgow Royal Infirmary there should be a new District General Hospital built on the site of the former Belvidere Hospital. Many more people pointed to the cost of public transport to the GRI or to the difficulty of using two different buses if they had to go to Stobhill.

    While it is not feasible to produce a proliferation of new District General Hospitals located in Glasgow’s more outlying areas and estates, we can and should seek to extend the role and capacity of primary care so that fewer people have to travel to hospitals or Ambulatory Care Centres in the first place. It should be possible to provide more local access to physiotherapy and other advice and treatment from nurse practitioners and professions supplementary to medicine. It should also be possible to provide better support to primary care in managing many chronic diseases. Similarly an enhanced "nurse treatment room" service on a "turn up and be treated" basis would reduce pressure on GPs themselves and give patients an alternative to going to the GRI when they feel they need that sort of service.

GGNHSB commits itself to working with LHCCs and the Social Inclusion Partnership to explore these possibilities for the East End of Glasgow.

 

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