NHS GREATER GLASGOW

ORTHOPAEDICS IN NORTH-EAST GLASGOW

PROBLEMS NEEDING URGENT RESOLUTION

1. INTRODUCTION

1.1 This paper describes a significant problem in sustaining safe cover in orthopaedic services in North-East Glasgow. The Health Board and Trust have sought to resolve it through the consultation processes of the last year but without reaching a resolution.

1.2 The Stobhill Hospital Orthopaedic Consultants and their nursing colleagues have said emphatically that they cannot sustain their present unsatisfactory arrangements any longer.

1.3 In addition to explaining the problem this paper reviews the choices for resolving it and seeks comments on those choices and the preferred proposal.

2. THE PROBLEM IN A NUTSHELL

2.1 There are 17 orthopaedic in-patient beds in a single (mixed sex) ward at Stobhill. In 2000\1 572 elective patients were treated in those beds.

2.2 The three Consultant Orthopaedic Surgeons working at Stobhill also form part of the orthopaedic team at the GRI where they play their part in the trauma rota (there is no trauma service at Stobhill).

2.3 There is no out-of-hours junior doctor cover in orthopaedics at Stobhill. There are 5 'junior' SHOs at the GRI whose current rota does not comply with the national agreement for junior doctors hours. The second level cover is provided by 3 experienced SHO IIIs and 4 specialist Registrars. Their 1 in 7 rota is also currently non-compliant. In order to make the junior orthopaedic cover at GRI compliant it will be necessary to create an additional SHO post and move to a new shift pattern.

But achieving compliance at the GRI does nothing to provide out-of-hours cover at Stobhill.

2.4 Out-of-hours specialist orthopaedic cover at Stobhill therefore has to be provided by the three Consultants. In addition they also have to take their part in the GRI Consultants out-of-hours cover rota. The Consultants concerned are therefore carrying a burden which is unacceptably onerous. The only way they manage a balance between maintaining good productivity during the normal working day\week\month and avoiding excessive out-of-hours on-call commitment is to organise the Stobhill end of the commitment on an informal basis. This relies on nurses exercising a high level of discretion about when specialist orthopaedic expertise is needed, combined with a "wheel of fortune" approach as to whether any of the three Consultants are actually available when needed.

This set of arrangements has worked after a fashion in the past. But in the event of a mishap neither the Consultants nor the Trust would have a credible defence against the charge that they continued with an unreliable cover system long after they became aware that new requirements for junior doctors rosters and consultants' working hours and more demanding expectations about patient safety made it unacceptable.

-2-

2.5 The Consultants have made it clear that they cannot allow this to continue. We agree that something must be done. This paper explores the possible solutions.

2.6 There is a second factor which also threatens to bring this service close to collapse and that is the difficulty of maintaining nurse staffing on the ward. The proposal to change the organisation of orthopaedic services has been so long under debate, with still no resolution, that the nurse staffing is beginning to erode.

The ward establishment - to provide 24 hours, 7 days a week cover - is:

........ of which Current vacancies

F grade 1.5

E grade 3.5 1.5

D grade 4.1 1.0

A grade 7.1

16.2

It has so far not been possible to fill the vacancies since nurses with the skills and ambitions who would normally fill such posts are put off by the uncertainty about future arrangements for this service.

Covering these vacancies through the Nurse Bank or agencies fails to provide the continuity of skilled nursing cover which this ward and its work requires, especially given the discretion nurses have to exercise about summoning out of hours specialist orthopaedic cover.

To Sum Up

Present specialist cover - medical and nursing -

is stretched beyond acceptable limits.

3. BACKGROUND - HOW DID WE ARRIVE AT THIS POINT?

3.1 The clinical reasons for addressing problems in orthopaedic in-patient services have been in the public domain since April of last year.

WHAT WE SAID IN APRIL, 2000

Orthopaedics The need to provide more consultant cover for emergencies and

better supervision and training of juniors means that it is no longer

possible, within European Union working hour limits, to provide round

the clock cover on three separate in-patient sites in North Glasgow.

Only one in-patient centre can be satisfactorily sustained in this way.

Keeping more than one site will spread the presence of specialists

within orthopaedics (hands, knees, hips, upper limbs etc) too thinly

and will make waiting lists longer.

3.2 The document published by GGNHSB in September, 2000 confirmed the clinical reasons for wishing to proceed with change. We said:

" The consolidation of the orthopaedics in-patient service for the North and East at Glasgow Royal Infirmary

has been the subject of discussion for nearly ten years. Agreement was reached by clinical staff many years

ago on the need to achieve it. Actual implementation has always been hindered by operational and management problems.

The orthopaedic clinicians of the North and East have co-operated across the two sites by arranging to carry out

in-patient planned surgery at both the GRI and Stobhill with all trauma (accident and emergencies) treated at the

GRI. These clinicians are also unanimously in favour of the single in-patient unit for orthopaedics in North Glasgow.

They see it as necessary to improve the service. Specifically consolidation will enable them:

a) to develop departments with expertise in the various sub-specialties (hands, knees,

shoulders, hip replacement, trauma and so on).

b) to work more closely with related disciplines such as rheumatology and plastic surgery.

c) to provide the best training opportunities for junior doctors, nurses and para-medical staff.

There is an opportunity to bring about the long delayed move of in-patient orthopaedics from Stobhill to the GRI very

early in 2001. Adequate ward and theatre capacity has been identified within Glasgow Royal Infirmary which would

enable this move to take place but also increase day care capacity, thereby reducing waiting times. It would entail

the transfer of 17 orthopaedic beds at Stobhill. The number of in-patient cases at Stobhill in 1998\99 was 806 (compared with 90 day cases and 8,395 out-patient attendances which would remain at Stobhill). The average length of stay for

Stobhill orthopaedic in-patients was 5.4 days.

Staff have been fully involved in the planning of this move."

3.3 We have therefore consistently flagged up this issue and had hoped that it might

have been resolved by the period of consultation ending in December. However, it was not so resolved since the Local Health Council wanted more information on financial and staffing implications and bed numbers.

3.4 We had hoped that the clear commitment given in December to an open and transparent process for resolving the fundamental long term service strategies for acute general medicine and general surgery for North-East Glasgow (and their implications for the role of Stobhill Hospital) would allow the more immediate needs of some of the small surgical specialties to be resolved on their own separate merits.

Indeed we were heartened by letters which the Stobhill Medical Staff Association wrote in January and February of this year.

"We appreciate the need for major changes in the delivery of health care in Glasgow and are supportive of moves to centralise the smaller specialties such as ENT and ophthalmology. We also recognise the need to centralise specialties such as Orthopaedics"

(Letter to Chairman of GRI Medical Staff Association dated 25^th January, 2001)

"The Stobhill Medical Staff Association supports re-location of smaller specialties centrally ..... (we) believe very firmly that this smaller functional unit with continued medical and surgical receiving is one which has much to attract."

(Letter to Chief Executive of North Glasgow Trust dated 16^th February, 2001)

3.5 However, controversy in the public domain about Stobhill continued in the early months despite the explicit assurances given by GGNHSB about the option appraisal process in both the Board papers of December and February and in an interview with the GGNHSB Chief Executive published in the Kirkintilloch Herald on 14^th February, 2001. This caused GGNHSB to hesitate about pursuing the issue of the small specialties during the period leading up to the long range strategic option appraisal.

3.6 That hesitation was confronted by the Orthopaedic Surgeons at the beginning of May who pointed out that the time required for the option appraisal and subsequent consultation on its conclusions would prolong their unacceptable situation for a minimum of 6 to 9 months.

4. WHAT ARE THE POSSIBLE SOLUTIONS?

4.1 There are basically only two possible solutions:

a) appoint more staff.

b) concentrate the service on one site.

4.2 Appointing more staff might seem to be the obvious solution but what would it entail?

a) For a start it is not straight forward because the Stobhill service cannot be seen in

isolation from the GRI Trauma Service. Stobhill Consultants need to be part of the GRI Trauma Service in order to maintain their trauma skills. So, to institute a formal consultant out-of-hours rota for Stobhill would need to be synchronised with Stobhill Consultants taking part in the GRI trauma rota.

GRI rota

Stobhill rota GRI

Consultants

Stobhill

Consultants

b) A viable Stobhill rota interconnected with the GRI trauma rota would require at least 5 Stobhill Consultants in its own right (which would also result in a GRI trauma rota of 1 in 10 instead of the present 1 in 8).

c) But a properly organised Stobhill rota would also require junior cover at SHO and

perhaps Specialist Registrar level. For such a rota to be compliant would require a

minimum of 5 or 6 SHOs. In order for their clinical experience to include the range of

work needed to satisfy their educational requirements there would need to be

complex rostering arrangements with the GRI-based junior staff so that clinical

experience could be shared. Although this is feasible it would make the educational

supervision of the junior staff undesirably fractured.

d) Yet a team of 5 or 6 Consultants is too large to operate out of just one ward of 17 beds. The bed pool would be too small to allow flexible and efficient use of consultant time and skills. (A similar problem also currently confronts the larger team at the GRI, although their bed pool is currently larger because of the availability of trauma beds).

It would be necessary to open another ward at Stobhill and more theatre capacity.

This would require nursing staff and anaesthetists. There would also be increased

costs in secretarial support, laboratory, radiology and physiotherapy services,

surgical implants and prostheses, drugs and hotel services.

There are currently 6 unstaffed and unfunded main theatre sessions at Stobhill.

Although there is also 1 unused Day Surgery theatre session there is no available

space within the Recovery Area for additional patients. There are two unused wards

(4B and 13A), either of which could be brought back into use with minor upgrading.

(This presumes however that they are not needed to compensate for old wards which

might need to be demolished to create space for the new Ambulatory Care Hospital).

e) What would this cost? We should assume that opening up another ward and up to 6

theatre sessions would involve a doubling of the present in-patient and day case activity (orthopaedic day surgery is currently undertaken using ward and in-patient facilities since there is no space available for orthopaedics in the Stobhill day case theatres timetable).

Based on the Blue Book for 1999\2000 the costs would be:

Direct Costs per Case
	Medical	Nursing	Pharmacy	Physio etc.	Other direct care	Theatre	Labs	Total
	£	£	£	£	£	£	£	£
In-patient	168	522	264	112	71	528	61	1726
Day Cases	205	21	11	-	116	128	12	493

In 1999\2000 there were 706 in-patient cases and 181 day cases, resulting in direct

costs therefore of £1.22 million and £89k respectively. Since both activities were

using the same ward and theatre capacity we can see that the total direct cost in

1999\2000 was £1.31 million.

Opening up an additional ward and theatre capacity would more than double the

present cost because the hospital would have its own complement of orthopaedic

junior medical staff. This suggests an increased cost of something between £1.4

million to £1.5 million.

4.3 So why not do this?

There is no doubt that a doubling of Stobhill's elective orthopaedic activity would make a

big impact on orthopaedic waiting times (the whole of the North Glasgow waiting list

currently stands at around 1600 cases for GRI, Stobhill and West Glasgow combined).

The total current orthopaedic in-patient and day case activity for the North Glasgow

Trust (including trauma) is around 8500 cases per annum (based on 1999\2000 Blue

Book) - so an extra 600 to 700 cases per year at Stobhill would increase total activity by

around 7 - 8%.

The key questions are whether this is affordable and whether it is the best way of using

around £1.5 million each year.

• It certainly isn't affordable in 2001\2 since the Health Board has already

committed all its available cash and the Trust is still committed to a significant

savings programme to retrieve the remainder of its deficit.

• And it isn't a priority for 2002\3. We can say without any hesitation at all that

resolving bottlenecks in cancer and imaging services, expanding intensive care

unit capacity, improving stroke services and increasing the use of stents in

cardiology are all examples of far higher priorities for treating disease but as yet

unfunded and collectively far exceeding £1.5 million in cost. They would be a

long way ahead of orthopaedics in the queue for funding from what is available

for acute services development in North Glasgow in 2002\3.

• The benefit in reducing waiting lists would lie between 600 to 700 cases per

year. A benefit of 50% of this can be achieved by the alternative option of

concentrating the specialty at the GRI site - at a cost of around £45k per year

compared with the £1.5 million of the Stobhill option.

Many pressing priorities for cash in North Glasgow

• The March, 2001 GGNHSB agenda paper on its

financial framework set out the full range of

needs for cash.

• Around £5.5 million available for North Glasgow

service improvement in 2002\3.

• £4.4 million of this already needed for commitments

started in 2001\2. Leaves only £1.1 million for

everything else

• There are serious bottlenecks in cancer, heart and

stroke services which have an indisputable priority.

And this is not a problem that can wait until 2003\4 to be solved. It has to be resolved

now.

4.4 There may be some who say why not just appoint, say, 2 more Consultant Orthopaedic

Surgeons without increasing ward and theatre capacity? The answer is that those 5

Consultants would be supported by just 17 beds on their one ward - which is not enough

to allow them to work productively and to maintain their skills at a high level. There

would also be a reduction of theatre capacity for each surgeon unless one or more other

specialties surrendered existing staffed theatre sessions. Nor would this solution solve

the lack of orthopaedic junior doctor cover.

4.5 The alternative is to concentrate the service.

And that means it has to be at the GRI because that is where the trauma service and the

full range of A & E services are located.

How could this be done?

4.6 At present the facilities for in-patient orthopaedics at the GRI consist of:

2 trauma wards

1 elective ward - which works on a mixed sex basis

Trauma surgery is undertaken in a dedicated Theatre H.

There are 2 other theatres equipped for orthopaedic surgery, including laminar flow

facilities (Theatres M and N). Currently only Theatre M is in use. Theatre N is

immediately available for use.

There is a vacant ward of 17 beds (Ward 28) located next to the existing elective

orthopaedic ward. It is currently used for decanting but is available for use almost

immediately.

4.7 Thus concentrating the service at the GRI would have the following effect in terms of capacity:

Now

Following

change

Wards

GRI

Stobhill

3 ¹

1 ¹

4 ¹

Beds

GRI

Stobhill

Theatres

GRI

Stobhill

1 ²

3 ²

Notes: ^1. At present the ward at Stobhill and the one elective ward at GRI are mixed

sex. With concentration all wards at GRI would be used on a single sex

basis.

^2. At present the Stobhill theatre is used by orthopaedics for only 7 sessions per

week. The additional GRI theatre would be available for 10 sessions, allowing

more waiting list activity to be done. The aim is for the team of 8 Consultants

to do an additional session once a fortnight, achieving full utilisation of the

theatre capacity. Allowing for study leave and annual leave, theatre utilisation

would increase by 126 sessions per year (compared with the present). At an

average of 2.5 cases per session this would allow an additional 315 cases to be

done per year. This is containable within the bed complement, as the following

tables show:

TABLE 1

Current bed utilisation (1999\2000 Blue Book data)
	(a) In-patient cases	(b) Average length of stay	(c) Bed days	(d) Available beds	(e) Available bed days	(f) Day cases	(g) IP + DC total bed days	(h) (g) as % occupancy
Stobhill	706	5.9 days	4,166	17	6,205	181	4,347	70%
GRI	3,090	5.7 days	17,613	67	24,455	384	17,997	74%
	3,796		21,779	84	30,660	565	22,344

TABLE 2

Combined unit, with 315 extra in-patient cases per annum

(a)

Available beds

(b)

Average length of stay

(c)

In-patient cases

(d)

Bed days

(e)

Day

cases

(f)

IP + DC total bed days

(g)

(f) as % occupancy

GRI combined unit

5.9 days

4,111

24,255

570

24,825

81%

Note: If average length of stay (column (b)) were 5.7 days, percentage occupancy

(column (g)) would be 78%.

Impact on staff

4.8 The existing three Orthopaedic Consultants would undertake all their in-patient work

at the GRI but would continue to meet their existing out-patient clinic commitments at

Stobhill. Junior medical staff would benefit at Stobhill where currently House Officers

and SHOs in general surgery currently provide non-specialist cover out of hours. They

would no longer find themselves faced with orthopaedic patients of whom they had scant

knowledge and for whom they had no orthopaedic expertise to offer. The orthopaedic

junior staff would realign their pattern of in-patient work within the GRI, with an extra

SHO and a new pattern of shifts allowing a compliant rota to be worked.

The Consultant Anaesthetists who support orthopaedic surgery currently in Stobhill Hospital will continue to provide this in the GRI instead.

4.9 Nursing staff (ward and theatre) would transfer to the GRI. The number of posts

involved is:

Ward - as shown in paragraph 2.6 )

) in each case all posts would transfer

Theatre - 1.0 G grade ) to the GRI.

1.0 E grade

3.0 D grade

1.0 A grade

6.0

Nurses would benefit from the richer skill mix and professional development

opportunities available from a larger pool of staff and a wider range of clinical work.

4.10 Ancillary staff would not be affected by the move. The impact on the wider range of

support staff in the diagnostic, laboratory, therapy and medical records services would

be indirect rather than direct. No staff reductions or transfers would be involved.

There will need to be a review of secretarial support arrangements but this would not

involve any staffing reductions.

4.11 All staff have already been involved in forward planning for this option since it has long

been seen by those concerned as the only practicable solution to the problem.

Individuals would have some degree of choice as to whether they transferred from one

hospital to another with their service or remained at their present hospital. This would

be a matter of detailed consideration between managers and staff since it involves

striking an acceptable balance between service viability and continuity on the one hand

and staff preference on the other.

Financial implications

4.12 The only additional cost would be the employment of additional SHO (junior doctor) at a cost of around £45,000. No inter-Trust financial transfers are involved, which means the North Glasgow Trust is not dependent on resource being released from another Trust.

4.13 No additional capital expenditure is required.

Day Case Surgery

4.14 It has been a long-standing commitment of GGNHSB to ensure that orthopaedic day case surgery continued to be provided at Stobhill. The balance between in-patient and day case work has continued to shift in recent years.

	In-patient cases at Stobhill	Day cases at Stobhill
1998\99	806	90
1999\00	706	181
2000\01	572	222
Source: Blue Book for 1998\99 and 1999\00. North Glasgow Trust Clinical Information System for 2000\01.

4.15 The day case work at Stobhill is currently incorporated into main theatre lists rather than in the hospital's day case unit. This is because there are not enough cases to justify a regular theatre slot in the day case unit. The day case unit is fully booked for higher volumes of work in other specialties.

4.16 This means that transfer of the orthopaedic in-patient theatre capacity from Stobhill to GRI will take the day case surgery capacity with it.

4.17 The scope for increasing day surgery capacity at Stobhill needs to be reviewed as part of the wider option appraisal process due to be completed later this year. GGNHSB, the Trust and the orthopaedic surgeons themselves are committed to providing an orthopaedic day case service at Stobhill and undertake to report further on this issue as part of the option appraisal process.

5. THE IMPLICATIONS FOR PATIENTS

5.1 The Orthopaedic Surgeons are in no doubt that bringing the two portions of the North-

East Glasgow elective orthopaedic service together will offer a more robust set of

specialist orthopaedic services.

5.2 It is already the case that several aspects of specialist orthopaedic work cannot be

offered at Stobhill. They include:

- hand surgery (other than the most simple)

- anterior cruciate ligament surgery

- hip revisions

- shoulders

- trauma

These are all provided at the GRI. On the other hand there are some areas of specialist work which Stobhill's Orthopaedic Surgeons offer to a wider population than just the local Stobhill catchment. They include:

- spinal work.

- complex non-union surgery

- total knee revision

- elbows

5.3 This highlights that it is already the case that this specialty involves patients travelling from one traditional "catchment area" to another. Postcode analysis of the 572 in-patients treated at Stobhill results in the following pattern:

		%
a) Strathkelvin postcodes (e.g. Kirkintilloch, Torrance, Bishopbriggs, Lennoxtown, Twechar, Condorat)	235	41
b) The Robroyston to Maryhill Road box, north from (but including) Balornock	131	23
c) Moodiesburn and Garthamlock	37	6
d) The typical GRI catchment area (from City Centre, Townhead, to Shettleston, Parkhead, Bridgeton and Easterhouse)	34	6
e) The South-East sector (e.g. Burnside, East Kilbride, Uddingston, Cambuslang, Toryglen)	24	4
f) Southside (e.g. Pollok, Shawlands, Newton Mearns, Castlemilk, Govan, Gorbals, etc)	21	4
g) West Glasgow and Bearsden	21	4
h) Motherwell and Falkirk postcodes	37	6
i) Kilmarnock and Paisley postcodes	21	4
j) Rest of Scotland (Fife, Perth, Edinburgh, Aberdeen, Dumfries and Galloway, Gairloch)	10	2
k) Postcode unknown	1	-
	572	100

5.4 Although the impact of change is largest in the traditional Stobhill catchment area, the GRI would be a more convenient location for probably around one third of the patient population. The access issue is therefore one which adversely affects around 370 of

the 573 patients and those of their visitors who live in the same area.

5.5 What are the main features of access for the two hospitals?

a) For people who use the train for access, GRI is served by High Street

Station which is a shorter walk than Bishopbriggs station to Stobhill (½ mile compared with just over ¾ mile). A larger number of trains and routes stop at High Street (which is in turn readily accessible from the major rail hub of Queen Street).

b) For people who use buses it is more complex to generalise since it depends on the proximity of people's homes to particular bus routes. Annex A shows relevant bus routes. The Buchanan Street bus station is ¾ mile walk to GRI (or there are many buses which travel up and down Cathedral Street between the City Centre (for Queen Street and Buchanan Street).

For people travelling from Kirkintilloch to Stobhill by bus the journey time is currently 35 minutes. The alternative of travelling by bus from Kirkintilloch to GRI involves a journey of 45 minutes plus a 10 minute walk or a further bus from either Royston Road or Buchanan Street. The fare is the same (£1.25 single, £1.60 return) for either hospital, unless a second bus is used instead of the 10 minute walk for the GRI.

c) As far as car travel is concerned, access to Stobhill is off Springburn Road (with Balgrayhill Road running parallel) from the South; via Broomfield Road\

Balornock Road from the South-East; Auchinairn Road from the East and Kirkintilloch Road from the North.

Anyone who currently approaches Stobhill from the North or East would have to continue south down to the GRI via Springburn Road, a distance of just less than 3 miles, typically taking around 9 or 10 minutes (at an average journey speed of 18 mph).

d) Stobhill has ample car parking. GRI has no on-site public parking but there are usually spaces in the Castle Street car parks opposite the GRI. In future there will be a multi-storey car park at the GRI.

5.6 It is of course recognised that issues of access loom large for elderly patients and their relatives. The age profiles for Stobhill's orthopaedic work are shown below. They suggest that the issue of age is less of an issue in terms of access for this specialty than is the case in general medicine for example.

5.7 Our conclusion is that patient access is not made so much worse or difficult to deal with that it would override the patient safety issues which lie at the heart of this problem.

Elective Orthopaedic Inpatients by Age

Age Range

0 – 15

16 – 30

31 – 50

51 – 65

66 –75

75+

141

172

108

Orthopaedic Daycases Age Profile

Age Range

0 – 15	16 – 30	31 – 50	51 – 65	66 –75	75+
4	33	101	59	15	7

6 OUR PREFERRED SOLUTION

6.1 We have no hesitation in re-emphasising that the problem of cover and its potential implication for patient safety is paramount and must be resolved.

6.2 The two choices of increasing staffing at Stobhill or of concentrating the service at GRI compare as follows:

	More staffing at Stobhill	Concentrate at GRI
a) Ward space available?	Yes - unless needed to create site space for new ACAD.	Yes - Ward 28
b) Theatre space available?	Yes.	Yes - Theatre N
c) Staffing readily available?	Need to recruit 3 or 4 Consultants (orthopaedics and anaesthetics), junior doctors, ward and theatre nursing teams (in a tight nursing labour market). Difficult and slow.	Yes. Just needs one extra junior doctor.
d) Cost (revenue)	Approximately £1.5 million recurring per year.	Approximately £45k
e) Affordability?	No	Yes
f) Capital cost	Nil, except for minimal ward upgrading.	Nil
g) Impact on staff?	Uncertainty while new staffing complement builds up. No early relief.	Immediate relief of problem. No loss of employment\posts. Increased opportunities for clinical experience. Better staff cross-cover from larger pool of staff.
h) Impact on patient and visitor access	Greater capacity would draw in more patients from outside as well as inside the Stobhill catchment area.	Better for around ¯ of patients. Marginally worse for the others (but travelling to the city centre area is not an unusual feature of people's normal lives)
i) Impact on waiting list	Improvement in orthopaedics of around 600 - 700 cases per year. Equates to 38 - 44% of current North Glasgow waiting list and 7 - 8% of total orthopaedic case load.	Improvement due to greater use of theatre time. Around 315 cases per annum, which equates to around 20% of current North Glasgow waiting list and just under 4% of total orthopaedic case load.
j) Speed of implementation	Slow	Fast

6.3 This comparison shows that the GRI option rates better against criteria (a), (b), (c), (d),

(e) and (j). The two options are the same on criterion (f). On criterion (i) (impact on

waiting list) the Stobhill option yields twice as many additional cases but at an extra cost

per case of approximately £2,300, compared with £143 per case for the GRI option.

(The disparity is because the GRI option is able to use existing staff complements

whereas the Stobhill option duplicates them). The Stobhill option is better on option (h)

for two thirds of patients while GRI is better for the other third. The adverse impact on

bus travellers is limited to around 20 minutes of extra travel each way and possibly a

small increase in fares.

6.4 Our conclusion is that concentration at the GRI is the preferred solution basically because the alternative (expansion at Stobhill) is unaffordable, slow and uncertain in its prospects of successful implementation (the staff recruitment challenge is daunting). Moreover the Stobhill option delivers little advantage in the way of waiting list benefit despite the expenditure of around £1.5 million.

7. WHAT'S THE SIGNIFICANCE OF THIS FOR THE WIDER ISSUE OF

THE FUTURE OF STOBHILL?

7.1 The answer is 'None'.

7.2 The key point to emphasise for the future of Stobhill is the promise that GGNHSB has repeated on several occasions.

The GGNHSB Promise

The option appraisal for the future of acute

services in North-East Glasgow will be properly

conducted, overseen by a Reference Group of

representatives of the public.

7.3 There are four options to be considered:

(1) GRI as the single in-patient centre. Stobhill has Ambulatory Care Hospital.

(2) Shut the GRI. All North-East hospital services in a re-built Stobhill.

(3) GRI as specialist hospital. Stobhill provides district general hospital services for the North and East.

(4) Status Quo - which basically means Stobhill retains general medical and general surgical receiving, beds for the elderly and has the new Ambulatory Care Hospital. Small specialist services (such as ophthalmology, ENT, gynaecology, orthopaedics, urology) would have their in-patient base either at GRI or Gartnavel.

7.4 Orthopaedics as a specialty is not itself decisively influential in the choice to be made later this summer between the four options. The services that will be decisive, because of their size, their patient volumes, their needs for accommodation, staff and support services are general medicine, general surgery and care of the elderly. All the ambulatory care services, including a basic core of minor injuries\casualty services, are common - and therefore guaranteed - in each of the four options.

In 1999\2000 there were 23,847 in-patient cases at Stobhill. 18,445

of these (77%) were in the specialties of general surgery, general

medicine (including respiratory medicine and haematology) and elderly

assessment. By contrast orthopaedic in-patient work was 706 cases

that year - just 3% of the total in-patient work of the hospital.

Source: 1999\2000 Blue Book

7.5 Arising out of the consultation on acute services reconfiguration conducted since April, 2000, GGNHSB has confirmed that it envisages just two orthopaedic in-patient services in Glasgow - one on the Southside and one in North Glasgow. This means, as a consequence, that Gartnavel would not have an orthopaedic in-patient service but that does not significantly diminish Gartnavel's standing as a hospital.

7.6 The long term location of orthopaedics will be determined by the strategic option appraisal, not vice versa.

a) Under option 1, orthopaedics would be at GRI (but not at Gartnavel nor at Stobhill).

b) Under option 2, orthopaedics would return to Stobhill, along with

the transfer of all the other services currently at GRI.

c) Under option 3, orthopaedics would return to Stobhill, along with

the transfer of many of the other services currently at GRI.

d) Under option 4, orthopaedics would be at GRI (but not at Gartnavel nor at Stobhill).

8. COMMENTS

Individuals or organisations wishing to comment on the proposals should send their responses to:

Mr. John C. Hamilton,

Head of Board Administration,

Greater Glasgow NHS Board,

P.O. Box 15329,

Dalian House,

350 St. Vincent Street,

Glasgow, G3 8YZ.

Telephone : 0141 201 4608

Fax: 0141 201 4601

no later than Friday, 3^rd August, 2001.