ANNEX 5

URGENT SPECIALTY MANOEUVRES IN SOUTH GLASGOW

(Extract from September, 2000 Health Board Paper)

We have also thought hard about how to deal with a number of pressing clinical service issues that need to be addressed in the period between now and the completion of the major capital investment later in the decade:

  1. an urgent need to ensure that the Victoria Infirmary has stronger capacity to deal with the rising tide of medical emergency admissions during the next few years.
  2. concentrating haemato-oncology (cancer of the blood and lymphatic systems) services.
  3. concentrating gynaecology in-patient services.
  4. concentrating breast cancer surgery.
  5. concentrating in-patient vascular surgery services.

The biggest single clinical pressure at the Victoria Infirmary for years has been its lack of capacity to deal satisfactorily with medical emergency admissions. In part that was due to inadequate staffing (mainly medical and nursing) and a need for improved organisation. The Trust has been addressing these issues in the last 12 months, with significant additional financial support from GGNHSB. However, the problem will remain intractable for as long as there are too few medical beds. At present medical patients continue to "board out" in the wards of other specialties, principally general surgery. This makes it more difficult to manage the patients efficiently and it also causes significant disruption to general surgery, making it more difficult to improve waiting list performance.

Unfortunately the Victoria Infirmary does not have any vacant wards which can simply be staffed and re-opened. In order to tackle the problem, and put the hospital onto a sound footing for the remaining years of its acute in-patient role, we suggest the following sequence of changes should take place:

  1. It is already the case that when in-patient ENT moves to newly created accommodation at the Southern General in 2001 (a move already agreed following earlier consultation), an adult ENT ward of 24 beds will become vacant at the Victoria Infirmary.
  2. It is proposed also that in-patient gynaecology should be concentrated at the Southern General Hospital by the autumn of 2001. The benefits and implications of this are explained more fully below. This transfer from the Victoria Infirmary will free up ward 12A (25 beds).
  3. It is already the case that within the Victoria Infirmary general medicine bed complement 12 beds are allocated (in a 12 bed ward) for haemato-oncology. However, it is often the case that 3 or 4 haemato-oncology patients are also placed in another 11 bed general medical ward across the corridor.

Our proposal aims to produce a significant improvement in the Victoria general medicine capacity, simultaneously provide some small easement for general medicine capacity at the Southern General and improve quality of service for Southside haemato-oncology patients.

The current haemato-oncology ward at the Victoria Infirmary has single rooms with positive and negative ventilation systems to reduce risks of infection in patients whose treatment may make them vulnerable to infection. The ward across the corridor does not have this and haemato-oncology patients are placed alongside other patients with a range of general medical conditions. Haemato-oncology in-patients at the Southern General Hospital currently use 5 beds within a general medical ward. The proposal is to convert the ward adjacent to the existing haemato-oncology ward at the Victoria Infirmary so that an integrated unit for the whole of the Southside with suitable facilities and environment can be dedicated to this patient group. The cost of conversion would be around £200,000. This would affect 124 in-patient haemato-oncology admissions per year that currently go to the Southern General who would in future go to the Victoria for in-patient and day case care (375 attendances per year). Their routine out-patient consultation would continue at the Southern General.

This conversion would allow the concentration of haemato-oncology staff expertise in the Southside and would allow better cover for staff absences.

This manoeuvre would free up 5 extra beds for general medicine at the Southern General but would reduce the Victoria’s designated general medical bed complement by 11 beds (slightly less in terms of current availability for general medicine), but ..........

  1. .......... general medicine’s bed complement would be increased by allocating to it the wards vacated by gynaecology (25 beds) and adult ENT (24 beds). There would thus be an extra 38 beds for the designated general medicine bed complement. GGNHSB would provide the revenue necessary for this expansion. This should provide significant easement of the Victoria Infirmary’s difficulties in absorbing general medical workload and should significantly reduce the level of patients boarding out in general surgical wards. Waiting list performance will also benefit therefore.

We believe these changes would provide enormous benefit to the Victoria Infirmary and its busiest acute services.

As already indicated, this manoeuvre depends on a ward being vacated by gynaecology. What is the rationale for this and what are its implications?

Firstly the clinical logic flows from the advice of the Area Sub-Committee in Obstetrics and Gynaecology which favours co-location of gynaecology with obstetrics (maternity services) and urology. As is the case with other surgical specialties there are also trends towards the development of sub-specialisation within gynaecology which are particularly difficult to accommodate at a time when legal and regulatory constraints on doctors’ working hours (senior and junior doctors) are tightening. As specialisation continues so does the importance of ensuring as much continuity and strength in depth among the dedicated nursing team (and other staff) for gynaecology, many of whom also develop specialist knowledge and skills.

The Glasgow-wide proposal for gynaecology envisages in-patient gynaecology being located at the Glasgow Royal Infirmary and the single in-patient hospital for the Southside. Ambulatory Care would continue to be provided at the Victoria Infirmary,

Stobhill and Gartnavel (as well as at GRI and the Southside hospital), although the Gynaecologists share the caution of some other surgeons about day-surgery in stand- alone centres (an issue discussed earlier in this paper).

There are strong reasons for proceeding with the concentration of in-patient gynaecology on the Southside at the earliest opportunity:

      1. It allows the benefits of a larger clinical team (specialisation and better staffing cover) to be secured without waiting several years.
      2. It allows use to be made of currently idle ward space at the Southern General.
      3. It creates sorely needed space to expand general medicine at the Victoria Infirmary.
      4. It allows in-patient gynaecology services to be relocated from West Glasgow at an early opportunity, thereby freeing up room for manoeuvre to facilitate the highly desirable service changes that would release West Glasgow acute services from their present wholly unsatisfactory pattern of split-site services for in-patients during their episode of care.
      5. It will save about £300,000 a year, mostly as a result of a reduction in junior doctors’ rota commitments and from more efficient use of beds. GGNHSB is currently underwriting that excess cost and no longer having to do so will allow that £300,000 to be spend on expanding general medicine capacity at the Victoria Infirmary.

The impact of these changes for patients would be as follows:

 

Out-patient Attendances

Day Cases

In-patient episodes

TOTAL

Southern General

9,361

985

1,909

 

Victoria Infirmary

9,746

1,296

2,390

 

Western\Gartnavel

10,587

1,367

1,668

 

No change

29,694

3,648

1,909

35,251

Change

Nil

Nil

4,058

4,058

The total bed days in hospital for the 4,058 patients affected by change (based on data in the 1998\99 Blue Book) is 9,450, an average of 2.3 days per patient.

These figures assume that the patient population currently attending the West Glasgow hospitals would in future have their in-patient stays at the Southern General. GPs would be able to refer their patients to the GRI\Stobhill service if they wished for clinical or other reasons.

How could the concentration of gynaecology in-patient services be achieved?

There is currently one 25 bed gynaecology ward at the Victoria Infirmary and one 25 bed gynaecology ward at the Southern General (located in the Maternity Block). There is also a vacant 25 bed ward in the Southern General Maternity Block.

The Trust would propose to upgrade the existing and vacant wards (Wards 40 and 49) in the Maternity Block at a cost of £1.2 million (£600,000 per ward). The service would also need to be supported by a triple theatre suite by the time gynaecology from West Glasgow joined the concentrated service. A site exists adjacent to the gynaecology wards in which to locate this.

If capital funding is available, this work could be started in the Spring of 2001, allowing gynaecology to vacate its ward at the Victoria Infirmary by the Autumn of 2001, it time for general medicine to occupy it before the winter of 2001\2.

The detail of the scheme to create a triple theatre capacity to accommodate the current West Glasgow in-patient workload would depend on whether the Southern General or Yorkhill was the location of the second of only two maternity delivery services in Glasgow (an issue subject to separate consultation – see Section 15).

Whatever the outcome of that, there is site space in which the necessary theatre capacity could be created. If the need to expedite changes to split-site working for medicine and surgery between the Western and Gartnavel pointed to the desirability of transferring in-patient gynaecology from there to the Southern General in late 2001\2, theatre time would need to be accommodated. According to the 1998\99 Blue Book the number of operating theatre hours is as follows:

Day cases

(Hours per year)

In-patient cases

(Hours per year)

Total needed at SGH

Victoria

Stays at Victoria

1,912

1,912

SGH

394

1,336

1,730

West Glasgow

Stays in West Glasgow

1,334

1,334

 

 

 

4,976

4,976 hours equate to 103 theatre hours per week over a 48 week work year, which for 3 theatres equates to 34 hours per week each (7 hours per day).

The two upgraded wards would provide space for 50 beds. The transfer of in-patient

Gynaecology from the Victoria Infirmary would see one of the two wards working on a day a week basis and one on a 5 day a week basis. When the West Glasgow service moved both wards would work on a 7 day a week basis.

 

VI

SGH

Western\Gartnavel

a) In-patient episodes

2,390

1,909

1,668

b) Average length of stay (days)

2.0

2.8

2.8

c) Beds days per year (a x b)

4,780

5,345

4,670

d) Victoria and Southern General combined (bed days)

10,125

 

e) All combined (bed days)

14,795

First phase (Victoria and Southern General combined)

25 beds @ 7 days per week x 85% occupancy =

  7,756 bed days

25 beds @ 5 days per week x 85% occupancy =

 5,525 bed days

13,281

Second phase (West Glasgow service included

50 beds @ 7 days per week x 85% occupancy = 15,512 bed days

This analysis demonstrates that the configuration provides sufficient capacity.

As far as staffing implications are concerned there would be a reduction in the number of Senior House Officer posts in gynaecology, but with the reduced number working in a pattern consistent with the new national agreement on working hours and pay.

The interim arrangement of one ward working 7 days a week and the other 5 days would require fewer nurses than at present but this will be more than compensated by the increase in general medical beds at the Victoria Infirmary. In overall terms the net change in capacity is created by re-opening the closed Ward 49 and increasing theatre capacity at the Southern General. There will be no fewer overall jobs in nursing, professions allied to medicine, ancillary or administrative\clerical at the Victoria and slightly more overall at the Southern General.

The impending transfer of ENT in-patient services to the Southern General creates an opportunity to achieve a significant early improvement in the breast surgery service by concentrating its in-patient element at the Victoria Infirmary.

Currently there is a breast unit staffed by two consultant surgeons and their teams with high quality accommodation at the Victoria Infirmary – single rooms in a dedicated ward with its own team focused on a specific group of patients needing great sensitivity at a difficult and worrying time. At the Southern General one consultant surgeon specialises in breast surgery and the in-patients are managed within the general surgical bed complement.

The existing children’s ENT ward at the Victoria is located next to the Breast Unit. It is proposed that in the summer of 2001 it be converted (approximate cost £200,000) to the standard of the Breast Unit. Together the two wards would form an integrated Breast Unit to provide the in-patient care for the Southside breast service.

It would:

      1. create a 3 consultant team, giving better absence cover.
      2. strengthen the multi-disciplinary specialist breast care team.
      3. create a ward environment purpose-designed for all Southside breast surgery patients needing in-patient treatment.
      4. create a bed complement protected from emergency admission pressures, thereby reducing the risk of late cancellation of booked admissions.
      5. use a dedicated elective theatre, also protected from emergency admission pressures.
      6. create the capacity at the Southern General to allow a similar strengthening of the in-patient vascular surgery service (see below).

Out-patient clinics and day case surgery would continue to be undertaken a both the Victoria Infirmary and the Southern General.

The number of patients affected would be around 100 per year which in future would go to the specialist unit at the Victoria Infirmary rather than to the Southern General.

There would be no net change in staffing, although some change in the base hospital of a small number of staff would occur.

The creation of a single in-patient Breast Unit at the Victoria Infirmary would create the capacity at the Southern General simultaneously (i.e. in the second half of 2001) to form a single integrated vascular surgery service whose in-patient work would be based at the Southern General (out-patients and day cases still provided at the Victoria Infirmary).

The key features of this service would be:

    1. the creation of a 3 consultant team (compared with the current pattern of 2 at the Southern General and 1 at the Victoria Infirmary).
    2. a dedicated in-patient area for vascular surgery created at the Southern General, with a trained dedicated nursing team.
    3. more in-patients would be in closer proximity to the specialist Vascular Laboratory (mainly using ultrasound imaging) located at the Southern General (there is currently no dedicated equivalent at the Victoria).
    4. the Southside vascular service would be better placed to play a leading role in the South Clyde Vascular Network currently being developed with vascular service clinicians in hospitals in Argyll and Clyde.

Emergency vascular surgery could still be undertaken when necessary at the Victoria Infirmary by the surgeons going to the patient rather than vice versa. This is already the arrangement in Glasgow, where vascular surgeons work as a specialist network to cover out-of-hours emergencies.

The number of in-patients affected would be around 240 per year who would be treated at the Southern General rather than at the Victoria Infirmary.

There would be no significant impact on staff other than possibly a change of hospital base for a small number.

Last modified: August 15, 2002

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