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:

 

  1. SERVICES IN WEST GLASGOW

A single site service

In leaflet 18, Better Access for West Glasgow Residents, we described the long-standing plan to transfer services from the Western Infirmary to Gartnavel. We made clear that this remained an essential objective. There has been little disagreement with the view that there should be a single in-patient site for West Glasgow for general medicine and general surgery and their sub-specialties. This will end the arrangements which see patients being shuttled backwards and forwards between the two sites during a single stay in hospital, often on more than one occasion. No one has disagreed with the need to achieve this.

    1. Gartnavel will become the in-patient site for West Glasgow for general medicine and general surgery. For the first time it will be an acute receiving hospital with the ability to treat medical and surgical emergencies referred by GPs.
    2. Gartnavel will also for the first time be able to treat people who have minor injuries which previously would be treated in an A & E Department at the Western Infirmary. The addition of acute receiving and minor injuries unit to Gartnavel brings both these services into a location more widely accessible to the population of West Glasgow than the existing Western Infirmary. Gartnavel will also become the acute in-patient centre for specialties such as Ophthalmology and ENT. These developments will build on the other developments which have taken place at Gartnavel and which are described in leaflet 18:

      - The Brownlee Centre which opened in June, 1998.

      - The new Homoeopathic Hospital building.

      - A new Ophthalmology Department.

      - A new Out-patient Radiotherapy Unit.

      - The new Scottish National Blood Transfusion Service facility.

    3. Earlier in this paper we describe the debate there has been about Accident and Emergency Services. We recognise that the majority of medical and public opinion in West Glasgow would wish there to be an Accident and Emergency Service at Gartnavel. However, our analysis in Section 5 of this paper sets out why we believe that the need for ‘gold standard’ A &E services to deal with moderately to seriously injured patients can be met by two centres in Glasgow rather than three and why the Southern General is the best strategic location for the second such unit if the GRI is the other.
    4. We go on in Section 5 to analyse the range of numbers of patients we would expect to use a Minor Injuries Unit at Gartnavel. Based on the detail provided in Annex 6 our expectations would be as follows:

      Current level of attendance at Western Infirmary = 55,000 per year.
      Of these, 1,200 are children whom we would expect in future to go to Yorkhill or to be treated by primary care.
      Another 12,000 are GP referrals. We would expect these to go to Gartnavel.
      Some 8,600 are adult 999 ambulance cases. We would expect most of these to go to the Southern General (the balance to GRI).
      We would expect between 13,300 and 19,900 to go to the Minor Injuries Unit at Gartnavel.
      Of the others we predict that no more than 6,600 would go to GRI (probably significantly fewer than this). The larger number would go to the Southern General.
      So, of the present 55,000 attendances at the Western Infirmary our prediction for the future is that they would go instead to:
      Gartnavel 25,300 to 31,900
      Yorkhill or primary care 1,200
      GRI or Southern General 21,900 to 28,500

 

    1. During consultation, people have raised anxieties about where they would be taken if they had a heart attack. The advice of the Accident and Emergency Sub-Committee on this issue is:
    2. "It is recognised that (GP referred emergency) patients who have been assessed as stable by their GP and referred for in-patient assessment can be safely admitted via (medical and surgical) receiving units and that this is the current practice elsewhere. All un-assessed 999 self-referral patients, together with physiologically unstable patients and those that deteriorate in transit should be admitted and assessed by A & E staff in a fully equipped department  medical and surgical receiving at hospitals without full A & E services should be limited to GP-referred stable patients".

      GGNHSB has asked the A & E Sub-Committee to explain their advice more fully since others have said that they would expect patients with "obvious heart attack symptoms" to be taken to the medical receiving unit at Gartnavel. Their reply will be published when it is received.

    3. In this context it is worth reminding ourselves what the travel time differences are.

The road pattern is such that anyone travelling from west of Anniesland will currently approach the Western Infirmary from there, either along the Great Western Road, cutting through to the Western Infirmary at some point or along the Clydeside Expressway or Dumbarton Road. Those coming from the Maryhill area or beyond will use Bearsden Road to Anniesland Cross or Clevedon Road or Maryhill Road, then cutting across Great Western Road at some point.

Thus although Gartnavel provides the shortest time, the Southern General provides a 3 minute improvement compared with present experience of going to the Western Infirmary.

For people currently living close to the Western Infirmary, for whom the present ambulance journey may be only 5 minutes or less, the future journey time to the Southern General would be around 10 minutes (measured from the Partick end of Byres Road) which is still significantly less than experienced by many patients in Greater Glasgow being taken to the present pattern of A & E Departments. 

All of these times were measured in normal driving conditions, not in blue light conditions.

    1. The other major area of debate during consultation has been the issue of whether there should be a separate orthopaedic service at Gartnavel or whether there should be a single orthopaedic service for the whole of the North Glasgow Trust with its in- patient facilities located at the GRI.
    2. In our consultation proposals we indicated our preference for a single North Glasgow service with all of its in-patient services at the GRI, but undertaking out-patient and day case surgery work at all three sites (GRI, Gartnavel and Stobhill).

      The Area Medical Committee in saying that it was "unable to support the withdrawal of in-patient orthopaedic services from the Gartnavel site" did so because it was "unconvinced that the change from five A & E sites to two can be safely managed in the current climate" and the presence of on-site orthopaedics is essential to the viability of an A & E service.

      The Orthopaedic Sub-Committee itself did not submit a response to the consultation, almost certainly because opinion within it is divided. The orthopaedic surgeons at the GRI, Stobhill and Southside favour a "two orthopaedic unit" configuration for Glasgow. Those in West Glasgow advocate a "three unit" configuration.

    3. The arguments in favour of a single trauma and orthopaedic unit in North Glasgow as described by the orthopaedic surgeons from the GRI and Stobhill are:
    1. it allows departments to be developed with expertise in the various sub-specialty areas of orthopaedics, including upper limb surgery, hand surgery, spinal surgery, lower limb surgery, complex trauma surgery and bone tumour surgery.
    2. it provides the best possible training environment for junior doctors, nurses and paramedical staff.
    3. it provides the most robust platform from which to co-operate with related disciplines, notably rheumatology, plastic surgery and oncology.
    4. it provides the strongest possible basis for a University department of orthopaedics.
    5. it complies most easily with the requirement to reduce junior doctors’ hours.
    1. The arguments against, advanced by the West Glasgow orthopaedic surgeons are a mixture of comment about the overall principles of our proposals:

and points specific to orthopaedics:

  1. It is important to look closely at the arguments for and against. The issues around stand-alone Ambulatory Care Centres, Minor Injuries Units and the capacity of the GRI A & E Department are addressed earlier in this paper (see paragraphs 4.6, 5.6 and 5.22\23 respectively).
  1. The issue of ‘blocked beds’ is undoubtedly important and is being addressed in conjunction with colleagues in Social Work services. Glasgow has many fewer ‘blocked beds’ to-day than it did two years ago and we intend to achieve further reductions. The consultation exercise about the reconfiguration of acute services cannot include every angle and cross-connection with other strategies – those wanting to be assured about such issues need to look at the Health Improvement Programme.
  1. The question of "split-site working" is discussed in paragraph 4.7 of this paper but also needs to be seen in the context of how a larger unit might be organised. 

The West Glasgow orthopaedic service has a potential complement of eight consultant orthopaedic surgeons, the GRI\Stobhill service would have nine when fully staffed. (The South Glasgow orthopaedic service will have twelve consultants). 

The creation of larger teams provides scope to organise clinical commitments more confidently against the disruption caused by leave and other absence than is feasible in a smaller unit. It also provides more scope to cover trauma adequately by pairing consultants in a "buddy" system with improved continuity of patient care and more flexible receiving duties. At the same time this should maximise the amount of time available for clinics and elective operating.

In leaflet 10 (on Doctors’ Working Hours) we gave an illustration of how this could work in practice.

The advice of general and orthopaedic surgeons is that single in-patient surgical and orthopaedic units on the Southside could each comfortably manage their emergency workload with single emergency teams in each specialty.

Every day on both sites in the South, we currently have 2 emergency orthopaedic teams, that is theatre nurses, anaesthetists and surgeons available to perform emergency operations. The reduction to a single emergency team would free up that resource to perform elective work and reduce our waiting list for elective procedures in orthopaedics. This would free up enough time to do, for example, 500 extra hip replacements in a year. 

If we illustrated this point in terms of hours, an example might be as follows:

If each hospital has consultant emergency presence in the hospital from, say, 9 a.m. to 7 p.m. each day then the difference in requirement for consultant surgeon time is as set out below. It is expressed in very simple terms but it serves to illustrate the point:

9 a.m. to 7 p.m. dedicated time for emergency work = 3,650 hours per year.

So, 2 orthopaedic units with emergency cover require 7,300 hours a year whereas a single team\unit could do the same job using only 3,650 hours. Moving from 2 to 1 releases 3,650 hours a year to be used to reduce non-emergency waiting times without any adverse effect on ability to deal properly with emergencies. An individual consultant complying with EU working hours regulations can work 2,016 hours per year. So 3,650 hours is equivalent of nearly two consultants’ clinical working time

There are many different ways of organising work programmes. An illustration of how moving from two separate orthopaedic services in South Glasgow to one could be expected to lead to significant benefits has been produced during the consultation period:

Possible Activity Gains from One-site Model

Assume 12 consultants, of whom 8 will have a trauma commitment and 4 will not. Each surgeon will work 26 fixed sessions per month, of which a basic 20 will be as follows:

TRAUMA SURGEONS
4 ortho clinics 8 elective theatres 4 fracture clinics 4 trauma theatres

ELECTIVE SURGEONS
8 ortho clinics 12 elective theatres

The balance of 6 sessions\consultant\month will comprise Day Surgery sessions, elective theatre sessions and special interest clinic sessions in proportions designed to fit each consultant’s individual practice.

This will generate a total of 72 sessions, which assuming an equal split will lead to:24 day surgery sessions 24 elective theatres 24 special interest clinics

Assume each surgeon is available for 10 months (40 weeks). 
Assume 16 patients are seen at each New OP clinic and half the Ortho clinics are for new patients.
Assume 12 patients are seen at each Special Interest clinic. 

In one year 5,120 patients will be seen at New OP clinics and 2,880 patients will be seen at the Special Interest clinics. This makes a total of 8,000 New OPs per year.

The total number of elective theatre sessions will be 1,360 per year.

This compares with current practice (where each surgeon does 8 elective theatres per month and 4 new patient clinics per month) as follows:

                                                      Status quo new model

New OPs per year                               7,680    8,000
Elective theatre sessions per year          960   1,360

It is understood that the British Orthopaedic Association advocates 12 new patients per clinic in Teaching Hospitals (as opposed to 16 in this illustration) but the difference in productivity potential between status quo and new model remains significant even if applying a lower rate of new patients per clinic.

It is difficult to see why similar gains could not be achieved in patient activity (with all its benefits for reducing waiting times) in North Glasgow. This would need to take account of the larger trauma commitment from combining the workload for the entire North Trust. It is estimated that when combined with the increasing number of hip fractures in the elderly and pathological fractures from the Beatson Oncology Centre, this would require two Consultant teams working in two theatres, at least during the normal working day. Only one Consultant would be required for overnight cover but at junior staff level there would be a need for duplication to provide cover to both the elective and trauma wards as well as providing orthopaedic support to the A & E Department. For these reasons the move from two orthopaedic units to one would not result in a significant saving in junior staff on-call rotas.

What it does do is provide an opportunity of creating a large team of at least 16 consultants with better cover for absences due to leave and more flexible work programmes.

It is this efficiency which generates so many opportunities to strengthen sub-specialisation, increase patient numbers, reduce waiting times and increase the richness of training and research opportunities for staff by providing the basis for a University Department of Orthopaedics.

  1. What of the issues of access for patients? The current activity profile of the West

Glasgow service is:

Per year
Out-patient attendances  21,807 Would be at Gartnavel
Day case surgery cases 723  Would still be at Gartnavel
In-patient admissions  3,619  Most of the trauma cases would go to the Southern General. Elective cases would be undertaken at GRI.

Most trauma patients are ambulance borne and for them access is not an issue. For elective patients the issues become those of car parking and public transport access at the GRI , which we addressed in paragraph 6.4 of this paper. The number of patients affected is very similar to the numbers of patients who have to travel to a single centre in the city already for some services, such as neurosurgery (3,250 per year), plastic surgery (3,500), paediatric surgery (4,700) – certainly not as convenient as having a service on one’s local doorstep but not an unusual experience when the benefits for patient care lead to some centralisation. In the case of orthopaedics the benefit to patient care derives from more robust continuity in sub-specialisation service provision and significant reduction in waiting times caused by the more efficient management of trauma demand.

    1. In the case of elderly patients and their elderly visitors there is an issue which needs to be addressed regardless of where hospitals are located and that concerns the speed and effectiveness of rehabilitation services and discharge planning. We acknowledge the need to devote effort and resources to improve NHS (and local authority) performance in this area. Elsewhere in this paper we have examined the predicaments of visitors (see paragraph 6.12). Most West Glasgow trauma admissions would go to the Southern General which has adequate car parking space, is more accessible to more parts of West Glasgow than is the Western Infirmary and whose public transport links can be greatly improved by our proposal to sponsor a regular shuttle bus link to the Partick Station rail\bus interchange.
  1. The issue of synergy with other specialties is difficult to get right in Glasgow since its size and the unavoidable need for some specialties (such as neurosurgery, plastic surgery and maxillo-facial surgery) to be highly concentrated onto single sites means that perfection is unattainable. (Clearly at the GRI there would be excellent synergy between orthopaedics, A & E services and plastic surgery). In the case of Gartnavel the key necessary synergy is with cancer services.

For the Orthopaedic Oncology service there is a need to provide out-patient clinics, diagnostic imaging with CT and MRI and a biopsy service in close proximity to the main Beatson Oncology Centre. This leaves a difficult decision on where to site the in-patient services for the small number of patients requiring major tumour surgery. On balance the expert opinion from the specialists in orthopaedic oncology would prefer this to be with the major orthopaedic service because of the need to utilise specialised theatre facilities, equipment and instrumentation. These would be expensive to duplicate for a relatively small, but demanding, workload. It would also provide the additional advantage of easy access and collaboration with the Plastic Surgeons at GRI. However, this would create an additional need for the patients with pathological fractures from cancer deposits in bone to be transferred from the Beatson Centre to GRI for their surgery. The current estimates are that there would be 2 – 3 patients each week with this problem.

  1. The final issue concerns the rostering of junior doctors in orthopaedics. The cost of paying for four emergency rotas when two would be quite adequate is not insignificant given the now punitive cost of junior doctors’ out of hours working. In the case of orthopaedics in North Glasgow the current cost of 31 junior doctors is £1.2 million per year. If the present rota pattern continues unchanged, by 2002 the cost will have increased by £890,000 (i.e. almost doubled). It is urgent that the number of rotas is not sustained at this level, since we would be paying hundreds of thousands of pounds unnecessarily for no benefit to patients.

Our conclusion therefore is to maintain the proposition that there should be one single orthopaedic team for North Glasgow with its in-patient service located at the GRI, undertaking out-patient and day case work at all three hospitals (GRI, Gartnavel and Stobhill).

    1. In leaflet 18 and in leaflet 21, Radiotherapy : Linear Accelerators – A Patient’s Guide, we proposed that the Beatson Oncology Centre should remain on the Western Infirmary site while the general medicine and general surgery services were transferred to Gartnavel. We saw this as a temporary measure, lasting no more than ten years. Most responses have urged us to accelerate this process. In its response the North Glasgow Trust sums up the position thus:
    2. "Discussion within the Trust had raised doubts that the Trust can sustain the delivery of cancer services over two sites for as long as ten years. These doubts have been reinforced by the action taken by the Trust to address the lengthening waiting lists for radiotherapy treatment. This led the Trust to accelerate the programme for the introduction of the three new linear accelerators at Gartnavel. These will now come into operation by December, 2001, eight months earlier than originally achievable.

      Previously the more gradual commissioning programme for these machines would have meant they would have provided out-patient treatment to compliment the in-patient service provided from the Beatson Oncology Centre located at the Western Infirmary. The accelerated programme will mean that the provision of in-patient radiotherapy will be possible at Gartnavel earlier than planned. It would be provided from two sites, Gartnavel (from the new machines) and the Western Infirmary (from the existing machines).

      The Trust does not believe that the provision of in-patient radiotherapy services from two sites is sustainable. Therefore, the Trust believes that the total service will need to be relocated to be close to the new machines sooner than originally planned. This would also satisfy the need for cancer services to be located close to surgery".

      We agree with these arguments.

      The Trust is now accelerating its planning and the development of an Outline Business Case for the transfer of these services from the Western Infirmary to Gartnavel General Hospital. The Trust plans to achieve this within the next five years. The Beatson Oncology Centre will be relocated within that time with all its services then provided from Gartnavel.
    3. This change of plan has an impact on one other element of the proposals. This relates to the centralisation of Cardiothoracic Surgery. Leaflet 20 "Why Centralise Cardiothoracic Surgery?" explained the reasons for the plan to bring together in one unit the services currently provided at the GRI and at the Western Infirmary. The objective of centralisation has not been questioned during the consultation. The proposal has been generally welcomed.
    4. The proposal to locate the centre on the Western Infirmary site was made because it was already the location of one of the two elements of the service. It also ensured that, together with the continued presence of the Beatson Oncology Centre, greatest use was made of the relatively modern buildings at the Western Infirmary. Finally, it freed space in the GRI for other moves in the complex series of specialty transfer across North Glasgow.

      As the Beatson Oncology Centre is now to be transferred earlier than planned at first, there is a question of whether the Western Infirmary site can sustain only one service, the Cardiothoracic Centre, for up to 10 years. The North Glasgow Trust has yet to work through the implications of this with the clinicians and others. There might be a need to relocate this service earlier than originally suggested.

      Notwithstanding the timing of the move to Gartnavel, however, we propose to plan for a single Cardiothoracic Centre in North Glasgow. This will still be in two stages with an initial consolidation to the Western Phase 1 building and subsequent relocation to Gartnavel. The question of how long that subsequent relocation will take will be addressed during the next two months.

    5. What of the position of other specialties at Gartnavel? We have already indicated in Section 12 that we propose to designate Gartnavel as the in-patient centre for the North Glasgow Ophthalmology and ENT services (with out-patient and day case work at all three hospitals).
    1. Gynaecology currently based in West Glasgow faces the same clinical logic referred to earlier in relation to the Southside and North and East Glasgow which favours co-location with both obstetrics and urology. It also faces the same issues of declining bed numbers and inefficient rostering requirements for junior doctors. Co-location with obstetric services is not possible at Gartnavel. Creating a larger single site location for in-patient gynaecology at the GRI would require more space than is available there.

The debate sponsored by the North Glasgow Trust has confirmed an already emerging view that the most sensible way forward would be to co-locate the current West Glasgow gynaecology service with the single gynaecology service being proposed for South Glasgow (see paragraphs 11.30 to 11.33 for details).

The outcome of consultation on the choice of whether to locate Glasgow’s second maternity delivery unit at the Southern General or at Yorkhill cannot be anticipated. If the outcome is to choose the Southern General than co-location of gynaecology with both obstetrics and urology would be achieved. If the outcome is to choose Yorkhill, the obstetrics and gynaecology team supporting its operation would be separated from the Southern General by a relatively short journey through the Clyde Tunnel (approximately 10 minutes).

The issue of timing is set out in paragraph 11.32. Synchronised transfer of the West Glasgow and Victoria Infirmary in-patient gynaecology services to the Southern General in the Autumn of 2001 would avoid gynaecology having to make a double move (from the Western Infirmary to Gartnavel and then to the Southern General).

We therefore propose that in-patient gynaecology should transfer from the Western Infirmary to the Southern General as soon as the necessary upgraded ward and theatre capacity has been provided (hopefully by the Autumn of 2001). Out-patient and day case work will continue to be done in West Glasgow.

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