Modernising Glasgow's Acute Hospital Services
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OUTCOME OF SECOND PHASE OF CONSULTATION

1.  INTRODUCTION – A VIGOROUS PATTERN OF DEBATE

1.1  In September 2000 Greater Glasgow NHS Board (GGNHSB) reflected on the outcome of 5 months consultation on how best to reshape Glasgow’s hospital services. The proposals had five aims:

  1. Modern facilities for a better patient experience.

  2. Creating larger specialist teams of doctors in order to assure more continuous availability of specialists and to tackle new requirements governing the working hours of senior and junior (trainee) doctors.

  3. Maintaining local access for as much as possible.

  4. Creating a pattern of hospital services that made sense across Glasgow as a whole.

  5. Levering in major capital investment in a way that was affordable.

1.2  The existing pattern of Glasgow’s hospital services is complex. Six major adult acute hospital sites. Some specialties currently present on all sites, some on five sites, some on four, others on three, a small number on two and a couple on one. Institutional loyalties are strong. Staff are intensely committed to their own hospital (but many also equally mindful of the wider needs of their own specialty or service across Greater Glasgow as a whole). Local communities fiercely value their access to their local hospital (but are also aware of how much needs to be done to overcome decades of under-investment in new hospital facilities for Glasgow).

1.3 The significance of increasing specialisation in surgery and medicine and the implications of working hours legislation on senior and junior doctors alike are widely understood. Changes in clinical practice have swung the balance of clinical work in some specialties – especially the surgical services – more towards ambulatory care ("walk-in, walk-out, same day" services). These challenges make the status quo untenable.

1.4  Although GGNHSB’s proposals for change were emphatically not finance-driven, they have to be financially realistic. The NHS financial regime is essentially formula- based, so Greater Glasgow has to plan intelligently within a circumscribed financial framework. Certainly its plan should be ambitious but it should recognise its many other obligations in fields such as primary care, mental health, child and maternal health, care of the elderly, services for disabled people, addiction services and so on.

1.5  Against this background it is hardly surprising that there are numerous permutations of what different sectional groups or different parts of the population of the conurbation would like to see. The general public would almost certainly prefer to see all or most of the existing hospitals re-built on their existing sites, offering the same (or a wider) range of services as they currently do. Some sections of opinion within the general public recognise that the present number of hospitals offering the same service as they do now is untenable and see the solution as shutting one or more hospitals – albeit that the hospital(s) to shut should not be their own particular local hospital.

1.6  Other interested parties have different perspectives again. For example Strathclyde Passenger Transport point out that concentration of in-patient sites will inevitably worsen access for some people. They also point out that retaining workload on existing hospital sites does nothing to improve public transport access. It says "few hospitals in the Greater Glasgow area are best located to maximise public transport access". However, Strathclyde Passenger Transport has not said what locations in Glasgow would maximise public transport access.

1.7  The majority opinion among hospital doctors is that there should ideally be only three hospitals – two north of the river and one south. And they would prefer to do all of their own work on one individual site, without having to travel to other sites to do part of their work.

1.8  Greater Glasgow’s neighbours face similar instabilities of their own due to changes in clinical practice, specialisation and pressures on working hours. They are mindful of the fact that what GGNHSB does or does not do could have knock-on implications for their own hospitals’ capacity to re-shape for the future.

1.9  Since September the debate has continued. There has been further discussion and correspondence with a number of MSPs (and MPs), meetings with the Local Health Council, debate within the professional advisory machinery, a number of additional public meetings and meetings with Community Councils. Many letters have been received. Further work has been done on some of the issues identified in September.

1.10  Against the background of conflicting opinion it was inevitable that debate would continue to be vigorous. There is no "ideal solution" lying out there which, if only it could be discovered, would both attract universal acclaim and be practically feasible. There are those who would argue that the hunt for a hidden "ideal solution" should continue. However, clinical opinion – and some public opinion – is so frustrated by the two decades already spent on this quest that it now wishes to see implementation of the important areas of agreement that have in fact been confirmed during the consultation.

1.11  Dr. Dunnigan, writing in support of the views expressed by the Health Service Forum (South-east), makes the point that "Vision-based planning is not enough". He is right but GGNHSB is firmly of the view that the starting point for planning should be vision-based. In other words, what is the best pattern for achieving as much as possible of what the clinician consensus for the future says while at the same time recognising what the public want? The two strands cannot be made identical. Firstly although strong clinical consensus has emerged it is not unanimous and it is fragile because of doctors’ concerns about the compromises the Health Board feels it needs to make to accommodate as much of public opinion as it reasonably can. The resulting dissonances emerging from the world of clinical opinion makes it more difficult for public opinion to gauge what clinical opinion actually is. And the more anxious public opinion is about future proposals, the more difficult it is for the Health Board to find a tenable point of compromise. A vicious circle ensues.

1.12  The Greater Glasgow Local Health Council, in its response said:

"While the media and others tend to highlight those areas of controversy which the Acute Strategy has thrown up, it is the Health Council’s view that the consultation Process has been worthwhile. It has identified a number of areas of common agreement as well as a number of issues where there are important qualifications highlighted as a result of the consultation exercise. The fact that the consultation process has resulted in some measure of agreement on important issues and at the same time highlighted areas of concern should not be seen as negative but rather the healthy and appropriate consequence of a proper consultation exercise."

1.13  Although the search for a vision of what the service should be is difficult in the extreme, that does not make it the wrong foundation for planning. The quest for the vision has involved thousands of hours of dialogue, analysis and reflection, comparing the strengths and weaknesses of different patterns. It has been supported by quantitative analysis, albeit not in the detail one would only find in an Outline Business Case or Full Business Case. However, that illustrates the "chicken and egg" nature of the planning dilemma. You cannot proceed to those stages in the absence of a broad service strategy – or vision of what you are trying to achieve. With the exception of the Health Services Forum (South-east), most of the responses to consultation have usually ignored the quantitative analyses put into the public domain – except on the two issues of bed numbers (where initial errors were highlighted quickly and where much work is being done to get the analysis right – see Annex 7) and estimated capital costs (which are based on Design Guide norms and which cannot be more reliably refined without being authorised to proceed to Business Planning stages).

1.14  During the debate some people have criticised the documents produced by GGNHSB because they do not incorporate analysis of issues such as the continuum of care for elderly people, the inter-relationship between primary and acute care or the importance of community development in tackling problems caused by socio-economic deprivation.

The reason for this is that such areas of service policy and development are complex in their own right and if incorporated into this consultation exercise would have overwhelmed it with yet more detail and caused confusion about what the focus for consultation actually is. The place to see where all these crucial interactions work is the Board’s Health Improvement Programme (HIP), published each year. Over the past 3 years the HIP has gone into considerable detail on these issues and sought to demonstrate how they relate to each other. More recently GGNHSB has been working with the Greater Glasgow Primary Care Trust to develop a strategy for Primary Care. This is now in its final stages of drafting and is already on the threshold of implementation through both a series of projects developed by each Local Health Care Co-operative and a programme to improve the infrastructure of primary care.

1.15  This paper provides further reflection following this second period of consultation. It considers what GGNHSB should do next in pursuing a process of significant improvement in the pattern of Glasgow’s hospital services.

1.16  An analysis of some of the detailed arguments raised in response to the second phase of consultation is included at Annex 3. The responses themselves are at Annex 2.

2.  BRINGING SHAPE OUT OF THE DEBATE

2.1  It is important to reflect that three apparently contradictory strands in the consultation point not to an irreconcilably confrontational outcome to the process but to the fact that everyone is in fact listening to, and learning from, each other. The fact that the debate is noisy and sometimes quite wounding should not undermine that insight.

2.2  Firstly, GGNHSB has had to maintain the basic clarity of what the fundamental choices are. Without that clarity of reference point, searching debate becomes either muted or confused. (That is evidenced by the fact that in the first phase of consultation GGNHSB was posing questions about north-east Glasgow rather than making proposals. Debate was sparse. Only when proposals were developed in time for the second phase of consultation did debate become focused).

2.3  Secondly, as some of the issues have become better understood, the weight of professional opinion has begun to shift in favour of some of the key elements in the GGNHSB proposals. This can be seen in the responses of the Area Medical Committee and the Area Nursing and Midwifery Committee. The Local Health Council too has confirmed areas of agreement in the GGNHSB proposals. But at the same time these commentators have pointed to aspects of anxiety over important issues of detailed planning which usually involve a complex mixture of principle and operational capacity. Examples include the question of whether there should be two Accident and Emergency Departments or three. The issue of anaesthetic and surgical risk management in day surgery in a free-standing Ambulatory Care Hospital is another. Coming through loud and clear is the importance of people having confidence in the integrity, competence and affordability of the next stages of planning.

2.4 The third strand is that of public opinion. On the face of it the picture is one of implacable public hostility to "the plan". But it would be wrong to generalise. The reality is very complex. The vast majority of people have been silent in the debate. Some of the most vocal describe themselves as a ‘campaign’ and a danger in campaign postures is that they become locked in one position. It is evident that some people do not understand what the proposals actually mean (many, for example, still believe that the Victoria Infirmary will close – lock, stock and barrel – which is not what GGNHSB have proposed). Yet it is apparent too that many people do understand some of the underlying forces which are driving change (specialisation, doctors’ hours etc). Some of the points people are making (about the care with which any centralisation of medicine and surgery from Stobhill to the GRI should be planned, for example) are ones that GGNHSB recognised in September but the significance of what GGNHSB said in September may not yet have been recognised.

2.5  So why do these three strands not point to an irreconcilable confrontation at this stage?

The reason is that areas of disagreement or lack of confidence tend to overshadow areas where there is consensus.

a)  The areas of agreement are as follows: GGNHSB’s original five aims (see paragraph 1.1) are generally supported.

b) There should be a single in-patient hospital for the Southside (the argument is about where it should be).

c)  There should be a concentration of adult Accident and Emergency Departments from the present four to either two or three.

d)  Creating a single-site New Western Infirmary on the Gartnavel site is a matter of some urgency.

e)  The concept of purpose-designed Ambulatory Care Centres, focused on the needs of patients, is eagerly embraced in Glasgow and there is an emerging consensus that if provided on a stand-alone basis they can be valuable in maintaining valued local access for a wide range of services and are safe in terms of the anaesthetic and surgical practice required for their agreed range of day surgery procedures (See Annex 4).

f)  The need to reduce the number of maternity delivery units from three to two is accepted but the decision on how to do it needs to be seen in the context of assuring strong local community-based ante-natal and post-natal services.

g)  We have reached a fork in the road requiring us to reflect on how best to plan for future child and maternal health services. We can either sustain the Royal Hospital for Sick Children on its present site (with or without maternity services on site) or re-locate the Yorkhill services in their entirety on the same site as an adult hospital during a period when the opportunity will arise.

h)  There is a recognition that many of the smaller specialties urgently need to concentrate their in-patient services onto fewer sites.

i)  The Dental Hospital and School building cannot be sustained for much longer. A new location needs to be decided.

j)  In implementing change in the acute services they should attract additional revenue investment but not at the expense of what the ‘fair share’ of service improvement in primary and community care, mental health, children’s health, learning disabilities, addictions, services for people with disability and public health improvement measures would add up to financially.

k)  The need to invest in fundamental change in Glasgow is urgent. Glasgow has suffered too long from repeated failures to reach agreement about change.

2.7  This is a formidable area of common agreement

2.8  What are the areas of disagreement or lack of confidence?

a)  The location for the Southside in-patient hospital (and its implications for the need for a stand-alone Ambulatory Care Hospital at the Victoria Infirmary site).

b) Whether there should be an Accident and Emergency Department at Gartnavel or not. The balance of clinical (medical and nursing advisory) opinion supports two and has set out the conditions which need to be met to ensure satisfactory operation of such a pattern.

c)  The issue of bed numbers remains unresolved. Work by the North Glasgow Trust to revise the methodology to respond to concerns raised in the first phase of consultation has only recently been completed and people have not been able to review it. Bed numbers remain an issue of great sensitivity in the NHS generally. There is a consensus in Glasgow that we need to get this right but further time is needed to secure consensus about the numbers themselves.

d)  The issue of affordability has not yet been demonstrated sufficiently widely to build a strong platform of confidence. Some commentators argue that the original capital estimates were too low. The capital cost profiles have been revised by the Trusts but not yet more widely scrutinised. The re-phasing of capital investment in West Glasgow could cause a bunching of revenue consequences that needs to be tested in further stages of Business Case planning.

e) The answers to the questions about the location of hospital services for child and maternal health and the Dental Hospital have not been systematically explored. A process is needed to examine these questions in a way that secures as much collective confidence as possible.

f) The question of the future role of Stobhill remains unresolved. The majority of clinical advice is that there should be three in-patient hospitals in Glasgow – the GRI, Gartnavel and one on the Southside. Local opinion in and around Stobhill maintains either disagreement with that advice (i.e. they argue that there should be four in-patient hospitals in Glasgow) or that GGNHSB should be planning to discontinue any further development of the GRI, build a large new hospital at Stobhill and then abandon the GRI, concentrating all the services for the north and east Glasgow at Stobhill. There are others who accept the logic of the Area Medical Committee’s advice but argue that any move of in-patient general medicine and surgery from Stobhill should only take place if and when everyone can be confident that the workload could be satisfactorily managed at the GRI. (This was the position GGNHSB took in September, 2000).

g) There is clearly a lack of confidence in the capacity of managers to plan and to manage the processes of change. This is most clearly described in the comments of the Area Medical Committee but it is a theme which has been raised in many forums.

2.9  What does this analysis mean for GGNHSB’s decision-making processes and timetable?

The way forward is to build on the areas of agreement and to work to resolve the areas of disagreement and lack of confidence. The only alternative is to abandon any proposals for fundamental change – which would be disastrous for Glasgow.

To understand what this means in practice we need to think what the sequence of events might be. We also need to recognise that although different strands need to be addressed in a variety of different ways, in the end the total strategy needs to hang together as a coherent whole. That is because the scale of capital investment is so large that detailed governmental scrutiny of the major Outline Business Cases cannot be undertaken in isolation one from the other.

3.  THOUGHTS ON MAKING TANGIBLE PROGRESS REFLECTING AREAS OF AGREEMENT

3.1  There are three strategically significant capital investments on which there is already widespread consensus:

a)  the creation of a new Western Infirmary at Gartnavel enabling the closure of the existing Western Infirmary site.

b)  the building of an Ambulatory Care Centre at Stobhill.

c)  the principle of a single Southside in-patient hospital.

3.2  What needs to be done to move these forward?

Gartnavel

3.3 In broad terms the majority of the additional functional content at Gartnavel is clear and agreed:

a)  provision of additional beds on site to allow transfer of medical and surgical in-patient services from the Western Infirmary.

b)  Intensive Care, Coronary Care and High Dependency Nursing facilities.

    c)  provision of sufficient Ambulatory Care capacity to allow transfer of out-patient clinics, diagnostic and rehabilitation services from the Western Infirmary.

    d)  creation of an Emergency Receiving Centre with a capacity and facilities to manage at least 12,000 GP referrals, and 20,000 Minor Injuries cases per year (consistent with Scenarios 3 and 5 of Annex 6 of GGNHSB’s September, 2000 paper).

    e)  linear accelerator, treatment planning, in-patient beds and associated facilities to complete the transfer of the Beatson Oncology Centre.

    f)  facilities for the creation of a single West of Scotland Cardiothoracic Centre, allowing transfer of services from the Western Infirmary and GRI.

    g)  expansion of laboratory facilities consistent with North Glasgow Trust’s laboratory services strategy.

h)  additional car parking.

3.4 The planning challenge for the site is to absorb these additional services in a design solution which is functionally effective and efficient and which satisfies whatever town planning and traffic requirements are determined by the City Council. The next step is for the Scottish Executive to authorise the North Glasgow Trust to proceed to the next step of capital planning – namely the production of an Outline Business Case.

3.5  If approval to proceed to Outline Business Case were given in February, 2001, it would be possible to have it ready for submission to GGNHSB by September, 2001, with subsequent submission to the Scottish Executive for the necessary governmental scrutiny, alongside parallel work undertaken for the South Glasgow Outline Business Case. In Annex 8 on Affordability we identify how the affordability of the Southside and Gartnavel Outline Business Cases are interdependent with savings that are achievable through reconfiguration elsewhere, including North Glasgow as a whole.

3.6  The need for the Trust to maintain a fast-track approach to completing the Outline Business Case lies in the widespread agreement on the importance of:

a)  Completing the second phase of linear accelerator capacity and associated in-patient and out-patient accommodation at Gartnavel.

b)  Integrating acute medical and surgical in-patient services wholly at Gartnavel, to end the bane of split-site working between the Western Infirmary and Gartnavel.

Stobhill Ambulatory Care Centre (ACAD)

3.7  This has already received Outline Business Case approval. Capital investment procurement is underway and subject to approval of a Full Business Case should be completed and in use by 2003. GGNHSB has already committed itself to meet recurring revenue costs of up to £1.1 million per year.

3.8  This timetable means that the Ambulatory Care Centre will be in operation alongside acute medical and surgical in-patient services at Stobhill. The ACAD includes a casualty facility and its model of service is sustainable without change for as long as its current medical staffing remains in post and acute medicine, surgery and anaesthetic services continue at Stobhill.

3.9  Is there any long term risk in investing in the ACAD prior to achieving definitive certainty about Stobhill’s long term future for in-patient services? We do not think so. If medical and surgical in-patient services did transfer away from Stobhill in due course the Ambulatory Care Centre would be both viable and clinically safe as a stand-alone facility in offering continuing local access to a wide range of services for its surrounding population.

Southside in-patient hospital

3.10  The proposition that there should be a single Southside in-patient hospital has almost universal support. Southside MSPs have expressed support, the Area Medical Committee reminds us that it has supported the concept since 1996, and the Local Health Council has urged the Board to pursue a much needed new hospital for the Southside.

3.11  In the debate on location the majority of opinion urges the Health Board to find a "central location" – the MSPs, Health Council and Area Medical Committee have all promoted this view.

3.12  In its September, 2000 paper GGNHSB reviewed the choices against 21 relevant factors. It concluded that the Victoria Infirmary\Queens Park Recreation site option falls due to its weaknesses on 12 of the factors. It recognised the weight of public opinion favouring the Cowglen option and so focused its choice between Cowglen and a combined Southern General Hospital\ACAD at Victoria Infirmary option. It concluded, by reference to the 21 factors, that the latter option had the greatest balance of advantage. On only 4 factors did Cowglen have an advantage.

3.13  In the second phase of the debate the Area Medical Committee, having considered the Health Board’s analysis, has expressed support for a new build hospital at the Southern General Hospital site. The Area Nursing and Midwifery Committee has also supported this conclusion. The Local Health Council continue to aspire to a more central location than the Southern General and say that the opportunity (should) then be taken to provide ambulatory care on that site rather than at the Victoria Infirmary. They also say, however, that "should the Health Board decide to develop acute in-patient services at the Southern General, then it will be essential to have ambulatory care episodes provided at a stand-alone Ambulatory Care site at the Victoria Infirmary".

3.14  These comments help to confirm the amount of underlying agreement there is as to the goal for the Southside and what the nature of the choice is – i.e. a central location or the Southern General plus Victoria Infirmary ACAD.

3.15   Glasgow Trust with Mr. Rodger McConnell, Director of Development and Regeneration Services at Glasgow City Council held on 7th November, 2000. Mr. McConnell confirmed that the original GGNHSB\Trust assessment of potentially available sites described in consultation leaflet 16 (published in the Spring of 2000) was sound (namely the Southern General; Victoria Infirmary\Queens Park Recreation; Cowglen and Darnley). The only other site of anything like the necessary size was the former Freightliner Terminal between Govanhill and Hutchesontown. However, the site is bisected by Aitkenhead Road and certainly not the "centrally located site" most favoured by those who disagree with the Board’s judgement on the Southern General.

Mr. McConnell agreed that the town planning processes associated with the Green Belt involved in the Cowglen option were those set out in the September, 2000 Board paper. It will be recalled that City Council Development Control said, in a letter dated 22nd August, that the City Council’s Pollock Park Local Plan aims to "promote and maintain it as a high quality countryside area within which leisure and cultural pursuits can be undertaken without detriment to the countryside environment. In these circumstances .... serious doubts as to the viability of any proposal to develop a new hospital on this site".

3.16  The need now is to move forward in a way that harnesses the agreement that exists while at the same time addressing the area of disagreement that remains between the Cowglen and Southern General\Victoria Infirmary ACAD option.

3.17  It is important to do so on a timescale that keeps pace with that necessary to expedite the creation of new facilities at Gartnavel so that the need for the Scottish Executive to receive a coherent and mutually consistent set of Outline Business Cases in the autumn is fulfilled.

3.18  This requires eight steps:

a)  Firstly we need to be able to demonstrate at this stage broad affordability within the wider strategic framework for Glasgow. This requires some initial assumptions about functional content, including bed numbers. These issues are dealt with later in this paper.

b) Secondly endorsement of the concept by the Scottish Executive, since it will entail hospital closure and\or change of use. One option would entail closure of both Southern General and the Victoria Infirmary, the other would involve change of use of the Victoria Infirmary (with the closure of its existing buildings and building of a new ACAD\rehabilitation beds) and closure of the Mansionhouse Unit.

c) Thirdly the conduct of an option appraisal between the "do nothing", Cowglen and Southern General\Victoria Infirmary ACAD options as an early part of the Outline Business Case process. This needs to be done in an objective, systematic and transparent way. We would expect planning consultants selected by competitive tender to report to a reference group comprising representatives from the Trust management, Medical Staff Association, GGNHSB, the Primary Care Trust, the Trust Partnership Forum, Local Health Council and three MSPs (two chosen by all the MSPs representing South Glasgow constituencies and one chosen by Glasgow List MSPs).

d)  Fourthly the completion by the Trust of the Outline Business Case (OBC) which confirms the proposed functional content, including bed numbers, and estimated capital and revenue costs. We propose a single contract for construction. These conclusions will reflect the Option Appraisal element undertaken in developing the Outline Business Case. If the Southern General were confirmed as the preferred site, the scheme would include an Ambulatory Care Centre at the Victoria Infirmary in order to maintain local access for as many services as possible. Assuming that GGNHSB approves the Outline Business Case it would be submitted to the Scottish Executive for approval. The target date for consideration by GGNHSB, in order to maintain parallel momentum with Gartnavel is September, 2001.

e)  In parallel with this, the Trust would start the process of identifying the procurement partners for the scheme.

f)  After OBC approval by the Scottish Executive, a further 15 months would be necessary to produce the Full Business Case (FBC).

g)  Subject to rapid approval of the FBC, financial closure with the PPP partners would take up to 12 weeks and construction would normally start within a few weeks. If steps (a) to (f) all proceed without difficulty, a start on site would be possible in around July or August, 2003.

h)  As new facilities come on stream and are commissioned, services would move from their present location(s). On completion, all acute in-patient facilities in the Southside would be located on the single site.

3.19 Other issues needing early practical action

The other areas of agreement that require early practical action are:

a)  concentration of the smaller in-patient specialties.

b)  turning agreement in principle that examination of choices in hospital provision in child and maternal health needs urgent resolution into a process that generates a specific proposal.

c) completing a similar piece of work in relation to the Dental Hospital and School.

3.20 Concentration of smaller in-patient specialties

The proposals in the September, 2000 GGNHSB paper fell into four categories:

a)  a group of changes needing urgent implementation in South Glasgow. These affect strengthening the medical emergency admissions capacity, especially at the Victoria Infirmary, to allow it to cope better while building of the brand new hospital facilities for the Southside proceeds. The September, 2000 document set out a series of interlocking moves between the Victoria Infirmary and the Southern General involving gynaecology, haemato-oncology, breast surgery and vascular surgery. The detail of these proposals is reproduced in Annex 5. The proposals also included transfer of in-patient gynaecology from West Glasgow to the Southern General.

Surprisingly, despite that detail, the Local Health Council in its latest response neither gave a definitive response to the proposals (claiming they give insufficient information on the service level which will be available following rationalisation), nor even offered any comment on them. Disappointingly, they did not seek additional information during the consultation period.

Since the manoeuvres require capital investment if they are to be in place before the winter of 2001\2 their implementation is now a matter of pressing urgency. The Health Board requests the Health Council to review its position as a matter of great urgency, since every month of unjustified delay will directly cause real harm to the NHS ability to cope with emergency workload in South Glasgow. The number of emergency admissions is so high that delay perpetuating the present bottlenecks of capacity will affect hundreds of patients. Whatever happens about the timetable and location for the new South Glasgow in-patients, these changes and the small amount of capital expenditure they entail are crucial to ensuring that the two South Glasgow Hospitals can best mange clinical pressures in the intervening period.

b) a second group of changes related to some changes in North Glasgow. In particular these were:

i) in-patient orthopaedics from Stobhill to the GRI (17 beds).

ii) in-patient ophthalmology from Stobhill to Gartnavel (2 beds).

iii) in-patient ENT from Stobhill to Gartnavel (6 beds).

iv)  In-patient gynaecology from Stobhill to GRI (2 wards – although further discussion was needed regarding gynaecological oncology which offers a regional service).

v)  in-patient urology to GRI and Gartnavel.

The Local Health Council has declined to comment on these also, for the same reason referred to earlier. We accept that precise detail is lacking in relation to urology and gynaecological oncology. However, the September, 2000 paper did include information about orthopaedic, ophthalmology and ENT service levels and how they would be provided. The Health Council need to clearly specify precisely what information they think is lacking in relation to all of the specialties concerned.

c) the third category concerned a number of specialties where the September GGNHSB paper signalled that work to produce proposals was still in progress. These were: i) dermatology.

    1. gynaecological oncology.

    2. nephrology.

    3. the final North Glasgow configuration for urology.

Work on these has made further progress but is not yet complete. There will be consultation as soon as the proposals can be specified with sufficient clarity.

d) the fourth category concerned the transfer of in-patient orthopaedics from West Glasgow, allowing the creation of a single orthopaedic unit in North Glasgow.

This issue is inseparable from the Board’s judgement on Accident and Emergency Services (see section 5 of this paper). The earliest it could be Implemented is August, 2002, when new capacity comes on stream at the GRI.

In the meantime GGNHSB have provided a significant amount of detail Underpinning the proposal. If the Local Health Council consider that information Lacking in any of the detail that might be reasonably required they should specify It now so that no avoidable delays arise later.

Child and maternal health

3.21  There is widespread recognition of the need to explore choices. Annex 6 reviews some of the principles that need to be considered. What is needed is a process to explore the choices dispassionately in order to identify what in principle is in the best interests of child and maternal health, what conflicts there might be in balancing different areas of clinical benefit and risk, what the practical possibilities are and what the best balanced choice might be.

3.22  The topic is inevitably a sensitive one and is best examined in a way that combines:

a)  access to expertise.

b)  representation of children’s, mothers’ and families’ interests.

c)  staff Partnership Forum involvement.

d)  input by NHS management, on whom local responsibility for decision-making will fall when the process of examination is complete.

e)  observation and interrogation of the process by representatives of the wider public interest (such as the Local Health Council, MSPs and local authorities).

f)  impartial facilitation of the process.

3.23  GGNHSB would propose to establish a process that meets these characteristics. There is a degree of urgency since some of the alternatives remain open only until such time as Outline Business Cases are completed in the summer. So we need to understand whether a child and maternal health element is to be included in it or not. This means reaching some initial conclusion by March, 2001, allowing a period of consultation between April and August, 2001. In total the issue would have been explored transparently in the public domain for nearly 8 months.

3.24 Dental Hospital

The urgency on this issue relates more to the physical state of the building than to any service or educational imperatives. There are no fundamental service interconnections which would require reprovision to be an integral part of new hospital provision in South Glasgow or at Gartnavel. However, we should aim to tease out the options as soon as possible and to do so in a way that is properly inclusive and transparent. GGNHSB has therefore asked the North Glasgow Trust to suggest an appropriate planning mechanism with an aim to reaching initial conclusions by March, 2001 so that a consultation process can then ensue.

3.25 Summary

These various actions will all help to move the Glasgow NHS forward on those aspects of the future structure of acute hospital services where there is now a good platform of basic consensus. Where there are areas of current lack of agreement within these main elements, the processes suggested in each instance should allow agreement to be reached in an inclusive and transparent way. If, in the end, agreement is not forthcoming and decisions have to be made amidst continuing disagreement, at least (we hope) people will recognise that the process has been open and systematic.

4.  RESOLVING AREAS OF UNCERTAINTY, CURRENT DISAGREEMENT OR LACK OF CONFIDENCE

4.1  Earlier we identified eight areas of uncertainty, current disagreement or lack of confidence:

a)  The location for the Southside hospital.
b)  Whether there should be an Accident and Emergency Department at Gartnavel.
c)  Lack of resolution on the issue of bed numbers.
d)  The need to demonstrate affordability.
e)  The future of hospital provision for child and maternal health.
f)  A future location for the Dental Hospital.
g)  The future role of Stobhill. h) Concern about management capacity.

4.2  For the Southside Hospital, child and maternal health and the Dental Hospital we have suggested earlier in the paper processes for resolving these areas of uncertainty or lack of agreement, using the platform of underlying consensus that does exist on each issue. The following sections consider the others.

5.  ACCIDENT AND EMERGENCY SERVICES (A & E SERVICES)

5.1  This is an issue where there may almost be agreement but not quite. The Area Medical Committee says it "considers that Consultant-led Accident and Emergency Services should be developed on two sites, these being the Southern General and GRI, with acute medial and surgical receiving continuing at Gartnavel". It goes on to say that "in making this recommendation, the AMC is seeking assurance from the North Glasgow Trust that previously stated concerns regarding additional workload at GRI are being satisfactorily addressed". It makes it clear that its support is conditional on this commitment by the Trust.

5.2  The Local Health Council, while accepting the logic of one A & E Department in South Glasgow expresses reservations about there being just one in North Glasgow. It goes on to say "the size of the population in West Glasgow justifies an A & E Department situated at Gartnavel". In commenting on the Board’s preference for a two A & E model it says that it has not had enough information about the planning assumptions made in respect of the capacity of the A & E Departments (although it does not refer to the detailed scenarios contained in Annex 6 of the September, 2000 paper nor asked any questions about the numbers set out there). It also makes a similar point to the AMC regarding capacity at the GRI.

5.3  The Accident and Emergency Sub-Committee say "it would be inappropriate to have two fully appointed A & E Departments in close proximity. There should not therefore be main A & E Departments at both Gartnavel and the Southern General site". Earlier it makes it plain that its earlier advice favouring two A & E Departments in North Glasgow could not be amended in the absence of acceptable solutions to the issue of capacity at GRI. The Health Board Chief Executive met the Sub-Committee on 13th December to hear from them their views on the current state of planning on the capacity issue. It is clear that the Trust has done extensive work but not to the point of full agreement and conclusion.

5.4  The Area Nursing and Midwifery Advisory Committee support a two A & E model – one North, one South.

5.5  The need for confidence that a busier A & E Department at the GRI could be provided with sufficient capacity, including the medical and surgical beds needed to support it, is clearly the issue most prominent in the minds of those uneasy about the Board’s two A & E model. Postcode analysis of A & E attendances in the 1998 one week survey suggests that the majority of the additional workload would come firstly from south-east Glasgow (when, in due course, the A & E Department at the Victoria Infirmary moves westward to the new in-patient hospital and is replaced at the Victoria site by a Minor Injuries Unit) and secondly from Stobhill (in the event of there no longer be sustainable medical staffing in its Casualty Department and there no longer being medical and surgical receiving services there). The workload expected to flow from the eastern side of West Glasgow when the Western Infirmary A & E Department closes is less significant. Annex 6 of the GGNHSB September, 2000 paper set out the relevant assumptions and incorporated them into the calculation of various scenarios.

5.6  This confidence issue needs to be explored through the establishment of a Glasgow A & E Services Planning Steering Group comprising Health Board and Trust senior managers, representatives of the Accident and Emergency Consultants, GPs and others with expertise to contribute to the work. Initially three areas of work will be pursued:

a)  the North Glasgow Trust will bring everyone up to date with their work on GRI capacity.

b)  work with Trusts and A & E Consultants to decide what data set is needed to inform the next phase of deciding what clinical policies, staffing and other resources need to be developed to support the future pattern of A & E Departments with supporting Minor Injuries Units at other sites. This will need to take into account relationships with Primary Care and Medical and Surgical Receiving.

c)  analysis of the expected timescales for change (mostly dependent on other aspects of change in Glasgow, such as the new in-patient facilities for the Southside, the movement of acute services from the Western Infirmary to Gartnavel, the opening and enlargement of new facilities at GRI etc).

5.7  The completion of the Option Appraisal for the Southside in the summer of 2001 will overcome people’s present uncertainty about the location of the Southside A & E and hence its proximity to Gartnavel.

6.  BED NUMBERS

6.1  In September we reported that the North Glasgow Trust had initiated further work in conjunction with ISD and Clinical Directors to take a fresh look at how future bed requirements could be more sensitively modelled.

6.2  We have always said that the key objective is to get bed numbers right rather than to pursue some mechanistic target. However, it is also the case that the number of beds in a hospital or provided in a new building has a strong impact on the direct running costs. Just as it is important not to under-provide beds, so it is self-defeating to over-provide. Having too many makes the challenge of affordability of many expensive new buildings to replace depreciated old buildings all the more difficult to accommodate.

6.3  The challenge is made more complex because we need to consider future changes in population, burdens of illness, cross-boundary flow, clinical technologies and practice, and systems efficiency.

6.4  Annex 7 describes the useful progress that has been made in these matters and what more needs to be done to refine the results.

6.5  What is now necessary is to encourage debate about these most recent analyses and their implications. There will need to be a Steering Group overseeing this process with representation from the two acute Trusts, the medical advisory machinery, GGNHSB, the Local Health Council and ISD.

6.6  Consideration of the issue needs to be reviewed within a timescale that does not delay preparation of the Outline Business Cases. We should aim for a final report to be made to the Health Board on 17th April, 2001, although both Trusts will be able to reflect the implications of "work in progress" as they develop their Outline Business Cases.

7.  AFFORDABILITY

7.1  Annex 8 sets out the issues of affordability based on the most up-to-date assessment of recent experience elsewhere with PFI\PPP and equipment costs and incorporating work on capital planning feasibilities at Gartnavel and GRI undertaken by W.S. Atkins on behalf of the Trust.

7.2  Affordability is sustainable but will require careful management throughout the decade. It also means that the opportunity costs will need to be clearly understood throughout the period. The price of physical renewal of Glasgow’s hospitals is that the mission of improving service performance will rely on high quality clinical service management and flexibility in promoting change.

7.3  Once approval can be given to Outline Business Case planning the capital and consequential revenue costs will be further refined. The Option Appraisal process within the Outline Business Case stage will include a detailed equivalent comparison of the Southern General\Victoria ACAD with the (inevitably more expensive) Cowglen option and a comparison of GRI in-patients\Stobhill ACAD with GRI in-patients\Stobhill ACAD and in-patients (see section 8 below).

8.  THE FUTURE ROLE OF STOBHILL

8.1  This is the issue which appears to display the greatest gulf of disagreement.

8.2  The Area Medical Committee advice is pretty unequivocal. "The Area Medical Committee confirms its support, first given in 1996, to a reduction in adult acute in-patient sites from five to three sites. These sites are Glasgow Royal Infirmary, Gartnavel General Hospital and one site south of the River Clyde".

8.3  The Stobhill Medical Staff Association subscribe to the concept of 2 acute hospitals north of the river but that support is conditional on it being demonstrable that the two hospitals have adequate capacity (emergency receiving and elective beds, theatres, diagnostic and rehabilitation support) in genuinely fit for purpose facilities.

8.4  Local public opinion is adamant in its support of Stobhill. Some wish to see Stobhill continuing its present role, being modernised in due course. Others recognise the logic of a reduction in in-patient hospitals in Glasgow but argue that the GRI should be abandoned, with a brand new hospital built at Stobhill to combine the roles of both hospitals.

8.5  GGNHSB has supported the specific transfer of the in-patient services of the smaller surgical specialties from Stobhill (to the GRI and Gartnavel). This involves Ophthalmology (2 designated beds), ENT (6 beds), Orthopaedics (17 beds), Urology (20 beds), and Gynaecology (2 wards) and it is difficult to see how these services can be sustained in the face of the severe pressures now applying to doctors’ hours. On the other hand GGNHSB’s support for the building of an ACAD at Stobhill is a mark of long term commitment to the maintenance of general hospital services on the site (of 325,000 total patient encounters\episodes per year currently at Stobhill, the ACAD and associated out-patient capacity elsewhere on the site would maintain around 288,000 – nearly 90%).

8.6  GGNHSB shares the Stobhill Medical Staff Association’s caution about the circumstances in which people could feel confident about a transfer of in-patient medical and surgical services to GRI (and some to Gartnavel). That is why, in September 2000, GGNHSB, while expressing support for the concept of two in-patient hospitals north of the river, stipulated that such a move could not happen without further formal consultation at a time when there were tangible practical plans to allow it to happen satisfactorily.

8.7  Although there will be differences in emphasis between the perspectives of GGNHSB, the Stobhill Medical Staff Association and the Glasgow Medical Advisory Committee the underlying reality is that their positions are not divergent.

8.8  What decision-making choices does GGNHSB have at this stage?

a) It could confirm Stobhill’s long term future as a hospital with general medicine and general surgery in-patient services together with a full range of ACAD services. It would lack on-site in-patient services in other specialties but since several specialties can in future only be sustained on one or two sites in Glasgow, it is inevitable that in a three – or four – hospital Glasgow no site will have all specialties. That said the presence of an ACAD means that clinicians in most specialties would be present at Stobhill regularly during the week, available to give advice where necessary.

This would be a popular decision for the Board to make but it would be ethically dishonest if the Board genuinely felt that the trends in specialisation, bed numbers, staffing pressures etc, were inexorable. It would not be a guarantee that the issue would never arise again.

It would also be a decision that put at risk the successful submission of Outline Business Cases for the Southside and Gartnavel in September, 2001. Why? Because the scale of investment proposed will cause the Scottish Executive to review the affordability of both Cases alongside each other and within the total financial capacity of the Glasgow NHS. Work on the affordability issue so far suggests that the savings that would accrue from rationalising acute hospital infrastructure in north-east Glasgow is a key part of the total equation of affordability.

b) It could subscribe to the popular public view that a new hospital should be built at Stobhill to concentrate general acute facilities there, enabling either the abandonment of the GRI or its conversion into a specialist hospital (providing, say, plastic surgery, a single cardiothoracic surgery unit for Glasgow, women’s services and perhaps Dental Hospital facilities).

Abandonment of the GRI, with all its recent capital investment arising out of the 1996 strategy, is difficult to contemplate. Taxpayers and the Scottish Parliament would likely be most vexed at such a waste of money. The variation on this choice, using GRI as a specialist hospital, might be a reasonably popular decision with the public. It is unlikely to be seen by clinicians as having any advantages over the GRI\Gartnavel\Southside configuration since it results in more diffuse clinical relationships. The opportunity cost consequences would likely be high because we would be maintaining four rather than three large in-patient facilities in Glasgow, with all the expensive infrastructure needed to sustain each of them.

c) It could pursue its present position – a decision in principle to create two in-patient hospitals in North Glasgow (Gartnavel and GRI) but one that can be enacted without a firm and fully worked out plan of how medical and surgical in- patient services could be satisfactorily transferred from Stobhill. There would need to be consultation on such a plan.

This timing in turn means that, in effect, there has to be an Outline Business Case for change in north-east Glasgow ready to be considered alongside the South Glasgow and Gartnavel Outline Business Cases in September, 2001.

We would need to design a process whereby this work could be done in that time.

The revenue affordability and service interdependence of making progress on the Southside and at Gartnavel mean that we need to be clear about the future pattern in north-east Glasgow and to enact any necessary capital investment in time to ensure that whole-system affordability remains viable.

8.9  Of these choices (a) is untenable, might hold the Southside and Gartnavel to ransom and would be intellectually dishonest. The reason why the perceived threat to Stobhill keeps reappearing under very different local Administrations throughout the last couple of decades is because with a population served of just over 1 million, a pattern of more than four in-patient hospitals is inevitably going to become increasingly fragile and open to question. This current Health Board administration could not guarantee that its successors would not find themselves exploring the same issue. But more immediately pressing is the threat posed to the affordability of change elsewhere in Glasgow.

8.10  Choice (b), if it involved abandonment of the GRI, would be seen by the rest of Scotland as a reckless waste of public money. It would hardly create the right conditions in which Glasgow’s claims to receive accelerated benefit from the Arbuthnott funding formula (or any other discretionary financial benefit from the Scottish Executive) would be sympathetically received. Its alternative, (using GRI solely as a specialist hospital) would not, we think, be seen by the clinical world as a genuinely advantageous clinical arrangement. It would make integrated approaches to patient care for in-patients with different combinations of illness more difficult to achieve. This is not easy to achieve even in a three in-patient pattern – it is even more difficult in a four centre pattern. Choice (b) is, however, an option that could be explored within the context of the Option Appraisal component of the Outline Business Case that would need to be developed under choice (c).

8.11  Choice (c), the position GGNHSB adopted in September, is the most consistent with clinical advice. We recognise that public support is lacking. The work needed to pursue it cannot be deferred because of the issue’s impact on the affordability of the Gartnavel Outline Business Case – which coincides with the need to find the resources to implement the South Glasgow strategy.

8.12  We therefore need to set up a Planning Group with extensive clinical and staff partnership involvement. In view of the importance of local community opinion there should also be a wider reference group drawn from community representatives served by the GRI and Stobhill which can interrogate and influence the option appraisal and the clinical and other issues associated with it.

9.  MANAGEMENT CAPACITY

9.1  The consultation process has highlighted a tension. Highly detailed work on planning; designing systems; calculating staffing levels, costs and savings; and working out complex sequences of synchronised manoeuvres can only be sustained when broad strategic direction is known. If it is not, then the amount of detailed work that would be done on the full range of strategic choices multiplies geometrically and is unsustainable. Yet it is clear that the parties to consultation – staff, public, Health Council, other agencies etc – find it difficult to gain confidence in supporting particular strategic direction if they cannot see the full detail of how it will work in practice. A chicken and egg problem.

9.2  It is therefore quite a significant achievement that we have reached as much Agreement as we have. However, we must now increase our capacity to tackle the Degree of detail people want in the next stages of work.

9.3  This is a matter of:

a)  strengthening project management capacity for the Southside, Gartnavel and north-east Glasgow components.

b)  putting in place a pan-Glasgow financial modelling capacity for this whole programme of acute services development.

c)  appointing a pan-Glasgow Project Controller who oversees the whole range of interlocking projects and advises Trusts and GGNHSB accordingly.

d)  putting in place an overall Steering mechanism that keeps all the necessary elements of work under review and ensures good communications with the NHS stakeholders, MSPs and the public.

e)  securing Scottish Executive approval to move into Outline Business Case stage for South Glasgow, Gartnavel and north-east Glasgow so that the necessary consultancy expertise can be brought to bear in developing the complex Option Appraisals that are needed and the design and financial analyses to underpin them and convert them into robust Outline Business Cases.

9.4  It is particularly important that these new arrangements connect adequately to clinicians, staff partnership mechanisms and local communities. The frustrations articulated by the Area Medical Committee and others must now be resolved.

10.  SUMMARY OF DECISIONS

[Still to be drafted in the light of the Board’s reflection on these issues]

ANNEXES

1.  Contents page of the GGNHSB September, 2000 document.

2.  Responses received in the second phase of consultation.

3.  Analysis of some of the detailed arguments raised in responses to the second phase of consultation. [Still being drafted. Principal themes picked up in main paper + Annexes 4, 7 and 8]

4.  Stand-alone Ambulatory Care Centres.

5.  Urgent Specialty Manoeuvres in South Glasgow

6.  Principles for Child and Maternal Health

7.  Modelling of Bed Numbers

8.  Affordability

 

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Last modified: August 15, 2002

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