|
Memorandum submitted by Dr Peter Enevoldson, Medical Director, Walton Centre for Neurology and Neurosurgery, Liverpool (CBPS 17A)
This written evidence focuses on the services provided by the Walton Centre to North Wales, but it also illustrates some broader principles relating to specialist medical service provision.
A) A brief account of the WCNN, to reflect its size and breadth. B) Qualitative and quantitative summaries of the clinical services provided by the Walton Centre for the population of North Wales. C) Some explanatory notes, in the form of Q & A's, on some commonly raised issues regarding services for these specialties. D) Notes on some important clinical issues in providing medical services for North Wales from Liverpool, coordinating with more local services. E) Some of the "non-clinical" issues which impact upon the level of service which the Walton Centre can provide for the population of North Wales, particularly regarding commissioning and service improvement plans. F) Service strategic planning. G) Comments upon the effects of withdrawal of specialist services A. Walton Centre for Neurology & Neurosurgery, Liverpool
· UK's only stand alone neurosciences trust · Integrated neurosciences service for Cheshire & Merseyside, West Lancs., IoM and North Wales · Aiming for Foundation Trust status 2008 · Adults only · Deals with any neurological/neurosurgical problems except those requiring machine for stereotactic radiosurgery (national centre in Sheffield).
Catchment Nos. of patients Total 3.5 M Outpatients 63,690 pa 1224/week North Wales 0.67M Inpatients 3,428 pa 66/week Day Cases 6,627 pa 127/week Staff
Resources•Beds: •Theatres: 5 + -ITU 10 (to increase to 18 in next 2 years) •MRI scanners: 2 -HDU 4 •CT scanners: 1 (+) -General 96 •Angiogram suites: 2 -Implant 4 •Telemetry rooms: 3 -Day cases 9 (+3)
Neurology Service "Hub & 14 spokes"
Centre: · All in-patients · All day cases · Almost all sub-specialist clinics · Some general neurology clinics · Most specialist nurses · Most teaching/training
Satellite · General neurology clinic & admin · Ward referrals
B. Clinical services provided by the Walton Centre for the population of North Wales
North Wales Neurosurgery
All surgical activity presently takes place at WCNN Elective referrals may be from GPs or more often are tertiary (from consultants in other specialties in North Wales or occasionally rest of Wales)
North Wales Neurology Service
Each Satellite: 2 neurologists -General neurology clinic & admin -Ward referral session -Teaching/training
•Wrexham Maelor: 3 days •YG (Bangor): 3 days •YGlan Clywd: 4 days •Also Countess of Chester clinics see many cross-border referrals •TOTAL:10 clinics + 10 ward referral sessions+
•Other practitioners: -MS & epilepsy specialist nurses -GP with special interest x 4 sessions •Little neuro-rehabilitation The number of days that a consultant neurologist visits each DGH is :
•Wrexham Maelor: 3 days •YG (Bangor): 3 days •YGlan Clywd: 4 days
TOTAL:10 clinics + 10 ward referral sessions+
In addition large numbers of patients (especially from Flintshire and Denbighshire) are seen in the neurology clinics (4 days each week) at Countess of Chester Hospital.
There are specialist epilepsy and multiple sclerosis clinics at Glan Clywd. Other neurology clinics are more general. There are also supporting specialist nurse services covering patients with MS and epilepsy. In addition there are clinics run by "GPs with a special interest" for patients with epilepsy.
Because of the nature of the symptoms arising from many neurosurgical and neurological conditions, many patients who eventually turn out to require neurosurgery present through the neurology clinic. This is a powerful argument for a fully integrated service.
All neurosurgical outpatient work is presently carried out at WCNN. The numbers of patients are very much less than in neurology: about one tenth the number of new patients and a quarter the number of follow ups
C. Commonly raised issues regarding services for these specialties. Why are neurosciences services best practiced from large centres?Because, for in-patient work, 1. Neurosurgery in particular can be practised most successfully and safely in large units: a. Subspecialisation of consultant neurosurgeons produces better outcomes b. Financial reasons 2. Both specialities (neurology & neurosurgery) require easy and rapid integration with each other for optimal outcomes 3. Both specialities require access to specialised diagnostic departments, which are often involved in therapeutic measures (e.g. endovascular coiling of aneurysms) 4. Both specialities, but especially neurosurgery, require routine access to neuroscience-orientated critical care beds for best results 5. The specialisation of skills needs to include nursing and allied health professionals, and diagnostics staff 6. To be compliant with EWTD, for middle grade medical staff (require at least 11 for neurosurgery rota) 7. To produce a worthwhile and comprehensive training experience for specialist trainees 8. The incidence and prevalence of individual conditions may be quite low, such that a population of 1 million is thought to be the bare minimum for a viable neurosurgical centre, and preferably 1.5 million upwards.
Why are all in-patient services in Liverpool rather than in North Wales? See above. The population of North Wales could not sustain a viable neurosurgical centre for both clinical and financial reasons. The specialist end of the neurology in-patient work relies on integration with neurosurgical and specialist diagnostic services. The less specialised in-patient work can be safely undertaken in DGHs in North Wales, and indeed the acute work of this nature is done there by the general physicians, with ward referral support from the visiting WCNN neurologist. Only those patients needing the extra facilities or skills of the staff at WCNN are transferred to WCNN.
How are out-patient services organised in North Wales?
Neurology out-patient work is performed by WCNN consultant neurologists who travel to the three DGHs in North Wales. On each visiting day the neurologist performs a clinic, does the administration arising from the out-patient work, and then goes to the wards to provide specialist neurological opinions on patients who have been admitted under the care of other consultants but in whom more neurological expertise is required. They will advise on management, which is carried out within the DGH as far as possible, but they arrange transfer to WCNN as required. After in-patient care at WCNN, such patients may be well enough to go home, but if not they are transferred back to their local Welsh DGH for rehabilitation before going home.
What are clinicians attitudes to differential waiting times?
1. In general, doctors are uneasy that there are two standards for waiting times, which are much longer for patients resident in Wales compared with those in England. They would prefer equity between patients. 2. We know that we have the capacity to reduce the waiting times for Welsh residents considerably, and eventually to the same as English, if the funding was made available. Doctors are frustrated that policy in Wales appears to be that it is satisfactory as long as Welsh minimum standards are achieved, and activity is geared to meet these and not to do anymore in that financial year. The latter are improving but more slowly that for England, and the disparity between the standards is becoming greater. 3. As clinicians, we maintain the principle that if a patient from Wales requires treatment urgently for sound clinical reasons, we will ensure treatment is carried out within a similar timeframe as for an English patient, even if "elective".
D Important clinical issues in providing medical services for North Wales from Liverpool, coordinating with more local services. i Distance. Potentially, distance might prove a problem, though WCNN employs various methods to counter this. Neurological care is delivered as close as possible to the patients' homes by running out-patient clinics at least 3 times each week in each DGH. In addition, we provide some supporting specialist nurse provision to take care out into the community for patients with epilepsy and MS. Neurological in-patients are managed under the care of local physicians with ward consultation advice from the WCNN neurologist, again at least three days each week. More complex patients, or those whose investigation or treatment requires more specialised facilities or neurosurgery are transferred to WCNN (out-patients or in-patients). After such treatment they may be well enough to go home, but if not they will be transferred back to the local hospital for further rehabilitation. In these ways, problems caused by distance are mitigated as much as possible. For a variety of reasons, there is not at present a similar "satellite model" for neurosurgery and all neurosurgical care is provided at WCNN. Many, but not all, investigations are available locally, including scanning. The recent changes of technology with the ability to send digital images electronically on the internet has dramatically improved services, with the ability for rapid referral and discussion of emergency cases, and also enabling specialist WCNN neuro-radiologist opinion in complex patients.
ii. Coordination of services
At the local level, the visiting WCNN neurologists coordinate with local services. However coordination of services at a regional level relies on discussion between WCNN and Health Commission Wales (who commission all neurological and neurosurgical services in North Wales, but not neuro-rehabilitation).
At the more clinical level, WCNN consultants integrate their services with those of other doctors in North Wales, for example liaising with the North Wales Critical Care Network, and with the North Wales Oncology Network. We participate in Risk Management processes with Welsh DGHs.
Of course, provision of both neurology and neurosurgery by one provider, WCNN, ensures integration of these two services.
iii) Engagement with patient groups WCNN consultants engage with patient groups in North Wales, and the Trust consulted with patients and public (in English and Welsh) during its Foundation Trust application process. These meetings are very popular and our speakers comment that the attendance and the welcome are better than elsewhere in our catchment area!.
E) Non-clinical cross-border issues impacting on clinical services
These relate almost entirely to commissioning, all of which is through Health Commission Wales Specialist Commissioning Team. i) Different commissioning priorities: mainly expressed as different waiting time targets, but also to a lesser extent in the range of very specialist treatments HCW is willing to fund. ii) Different mechanisms for obtaining funding on an exceptional basis or "one-off" requests for certain treatments. iii) Inability of HCW to fund "over-performance" against contract, even for emergency cases. iv) The different waiting time targets require WCNN to run two different "systems" for both out-patient and elective in-patient work. However, patients in whom the clinician decides there is a need for urgent treatment on clinical grounds are treated equally with their English counterparts.
These differences may result in confusion, resentment and frustration in doctors as well as their patients.
F. Service strategic planning
Despite the outcome of the 2005 review of the provision of neuroscience services in Wales, the situation is still not clear, with the announcement in mid-2007 of the idea that elective neurosurgical patients from North Wales might have to transfer to Morriston Hospital in Swansea. A new review group has been formed under the chairmanship of Mr James Steer, and hopefully will report later this year.
Our relationship with HCW has generally been good and constructive in past and present times. However these uncertainties make long term planning for developments in the neuroscience service in North Wales very difficult for everyone. This is extremely unfortunate in its timing, but the Walton Centre is confident that it will continue to serve all the neuroscience needs of the population of North Wales in the future, to everyone's mutual benefit, and looks forward to developing and adapting that service according to local needs and future technological advances.
G. Comments upon the effects of withdrawal of specialist services The absolute need for a "critical mass" in the provision of specialist services is widely recognised and acknowledged. Such services may have different components: for example emergency and elective services. In the case of neurosciences, there is also the split between surgical (neurosurgery) and non-surgical (neurology) services. It is undeniable that: a) the "whole is greater than the sum of the parts". Integration of services is more efficient and produces better outcomes, clinically, operationally and financially. b) removal of one part has the potential to destabilise other parts, i.e. is detrimental to the remainder. It is therefore naïve to think that removal of an elective neurosurgical service will not have adverse effects, both clinical and financial, to other elements of the neuroscience services, both English and Welsh. In particular, there must be an impact upon the emergency service for North Welsh neurosurgical patients, for whom there is no alternative provider. Similarly, it is inevitable that integration of neurology and elective neurosurgery, recognised as so valuable by practitioners, would be diminished. c) Intuitively, having achieved an essential "critical mass" to provide a service it seems perverse to then try to halve the services feeding it. d) In the case of elective neurosurgery, it is extremely doubtful that the diversion of patients from North Wales to Morriston would actually bring its throughput up to a level sufficient to sustain a viable critical mass.
14 March 2008
|
|
|||||||||||
|
|||||||||||
|
|||||||||||