PART 1

NEUROSURGICAL SERVICES in NORTH WALES

Background

Since the development of neurosurgery [surgery performed on the nervous system, especially the brain and spinal cord] as a separate specialty, patients have been referred from North Wales to Walton Hospital, [now known as The Walton Centre for Neurology and Neurosurgery] Liverpool.

A Strategic Review of Neuroscience Services for Wales was undertaken for Health Commission Wales, reporting in December 2005. It was a very comprehensive study of all aspects of neuroscience services. The key finding of the review was that the present configuration of services is inefficient and expensive.

In terms of acute services the review took account of medical workforce and training issues, sub-specialization, technological change, regulation and clinical governance. A number of recommendations were made, including a key one that there should be one neurosciences centre in South Wales, including provision of neurosurgery services for the whole of South, Mid and West Wales. The preference was that the centre should be in Cardiff. The consequence was that neurosurgery would cease to be undertaken at Morriston Hospital, Swansea. [The review also recommended that The Walton Centre should continue to provide neurosurgery services for North Wales, and should be designated as the neuroscience centre for the North Wales region].

The Minister for Health did not accept the recommendation and announced on July 4^th 2007 both neurosurgical centres in South Wales [The University Hospital of Wales, Cardiff and Morriston Hospital, Swansea] should remain open.

The Minister also announced a proposal that patients from North Wales requiring elective [non urgent] neurosurgery should be redirected to Cardiff and Swansea. This move was aimed at bolstering the viability of the Morriston unit.

The proposal has been met with considerable opposition in North Wales.

The proposal is now in abeyance, awaiting a review of Neurosciences Services in Wales being undertaken by an Expert Review Group, chaired by Mr James Steers, an eminent neurosurgeon from Scotland.

It would appear from recent press reports that the Minister is backtracking on the issue.

However, the proposal that elective neurosurgical patients from North Wales should be redirected to Morriston has not been withdrawn. Even if Mr Steers was to recommend that the current service i.e. both elective and emergency cases should continue to be admitted to The Walton Centre, the Minister is not bound to accept that recommendation.

SERVICES PROVIDED BY THE WALTON CENTRE TO NORTH WALES

The Walton Centre provides a neurosciences [neurosurgery and neurology service] to Merseyside, parts of Lancashire, North Wales and the Isle of Man, a total population of 3.2 million. It is one of the largest specialist neuroscience centres in the UK, with 118 beds, including 9 Intensive Care and 4 High Dependency beds. It has close links and shared staff with Alder Hey Children's Hospital, also in Liverpool, where children and young adults requiring neurosurgery are admitted.

The workload undertaken in 2007 was:

Outpatients 63,690

In-patients 3,428

Day patients 6,627

The figures for patients resident in Wales in 2007 were:

Neurosurgery

Outpatients - new 356

Outpatients - follow up 1609

In-patients - elective 246

In-patients - emergency 291

Neurology

Out-patients - new 3222

Outpatients - follow up 5942

In-patients - elective 105

In-patients - emergency 38

Day cases 214

Welsh residents make up approximately 20% of the total workload of The Walton Centre

Staffing

Medical staff:

13 neurosurgeons

28 neurologists, including 5 academic staff

9 neuro-anaesthetists

3 pain specialists

3 neurophysiologists

2 neuro-pathologists

The Walton Centre works closely with Alder Hey Children's Hospital, where children [and some adults up to the age of 19 with 'paediatric' brain tumours] requiring neurosurgery are admitted. Some staff are shared:

4 paediatric neurosurgeons [shared with Walton]

3 paediatric neurologists

1 paediatric neuro-physiologist [provided by Walton]

1 paediatric neuro-pathologist [provided by Walton]

"one clinical neuroscience service, 2 centres"

Nursing staff:

370 nurses. Trained to untrained ratio 2:1

15 specialist/consultant nurses

Medical Outcomes: [Success rates of treatment]

Using Risk Adjusted Mortality Rates, Walton scores well. MRSA rates are low and falling. Inspection reports have been favourable.

Long Term Support:

Approximately 300 patients resident in Wales continue to need to visit Walton on a regular basis, continuing over many years.

Patient Satisfaction Surveys:

Surveys show a high level of patient, relatives and carer satisfaction with the services provided.

Bilingual Service:

There are a number of Welsh speaking nursing staff. Arrangements can be made with two Welsh speaking Ministers of Religion to provide a translation service for patients and their carers who request it.

Sub-specialization:

There is sound evidence that for all forms of surgery, the volume of cases undertaken by a surgeon is directly related to the surgical outcome. In other words, if a surgeon undertakes 200 of a particular type of operation in a year, as opposed to 20, the results for the patient will be better.

The principle applies equally to neurosurgery. Best practice is now that all neurosurgeons have a high level of expertise in core competencies of treating head injuries, acute spinal cord compression, intracranial haemorrhage and blocked shunts, but each neurosurgeon also specializes in one of the major sub-specialty areas. At Walton these include neurovascular surgery, skull base surgery, functional neurosurgery including surgery for pain, neuro-oncology, spinal surgery and, in conjunction with Alder Hey Hospital, paediatric neurosurgery.

Neurologists also have core competencies, combined with sub-specialization. At Walton these include epilepsy, multiple sclerosis, movement disorders [most commonly Parkinson's], headaches, unusual strokes and motor neurone disorders.

Sub-specialization is needed to provide a very high level of expertise. A unit needs at least 2 people undertaking each sub-specialty because of absences due to annual leave and study leave. Fortunately, the prevalence of some of the conditions is comparatively rare. Therefore, there needs to be a concentration of a significant number of specialists, serving a large population of 2 - 2.5 million in order to maintain the sub-specialists' expertise. These conditions are achieved at The Walton Centre

Neurosupport:

Patients and their carers from North Wales are able to have access, both directly and by telephone, to Neurosupport [formerly The Glaxo Centre] in Liverpool, an independent charitable trust that provides advice, information and support to people with neurological conditions.

Future Plans:

NICE [The National Institute for Clinical Excellence] guidelines are that a patient with a severe head injury, even if no neurosurgical operation is required, should be treated in a specialist neurosurgical unit, because mortality has found to be halved compared to similar patients looked after in other hospitals.

Some clinicians in North Wales have been concerned that there have been problems transferring patients to Walton, because of pressure on beds there.

Future plans for Walton include doubling the number of Intensive Care beds from 9 to 18. This will ease the admissions from North Wales.

There are also plans to undertake more spinal work, treat more acute neurology cases and improve rehabilitation.

Consultants in North Wales hospitals would wish to see improvements in transmission of clinical images, the out of hours service for reading MRI and CAT scans and an improved neurophysiology service.

SERVICES PROVIDED by THE WALTON CENTRE in NORTH WALES

1. Neurology Support

Consultant neurologists visit district general hospitals in North Wales to undertake out-patient clinics and also ward rounds to accept referrals from other specialists and to give advice. The schedule of visits each week is:

Ysbyty Maelor, Wrexham

- 3 sessions, outpatient clinics

- 3 sessions, ward rounds

- 2 sessions by GPs with a specialist interest in neurology

Ysbyty Glan Clwyd

- 4 sessions, outpatient clinics

- 4 sessions, ward rounds

- 2 sessions by GPs with a specialist interest in neurology

Ysbyty Gwynedd, Bangor

- 3 sessions, out-patient clinics

- 3 sessions, ward rounds

2. Community Outreach Service

There are two specialist multi-disciplinary teams based in North Wales providing community support for patients with Multiple Sclerosis and Epilepsy

3. Reading Scans

There is a direct communication link between the three district general hospitals with The Walton Centre allowing CAT and MRI scans to be sent electronically, so that consultant neuroradiologists at Walton can read the scans and advise their colleagues in North Wales. Out of hours this service is currently provided by the on call neurosurgical team. This is an important facility, which is used in conjunction with telephone discussion of the patient's clinical history and condition, to aid diagnosis and to determine whether a patient can be cared for locally or a transfer to Walton is advised.

4. Neurology telephone helpline

For an hour per day a duty neurologist is available, on a dedicated telephone line, to give advice on patients with neurological problems to GPs and consultants.

OBJECTIONS TO THE PROPOSAL FOR ELECTIVE CASES TO BE REDIRECTED TO MORRISTON

North Wales patients, their relatives and carers receive a good service from The Walton Centre. It is outrageous that this service could be jeopardized, on the mistaken premise that by referring elective patients to Morriston that hospital would be bolstered and the present service secured in West Wales.

We would stress we take no position on the debate about having one or two neurosurgical centres in South Wales, but that it is an issue that has to be sorted out in the context of South Wales, leaving patients from North Wales out of the equation.

Detailed Objections

1. Time and Distance

It is glaringly obvious that the journey from towns and villages in North Wales is much greater to Swansea than Liverpool. Apart from the increased time and distance, the journey is more difficult. The cost to patients, their relatives and carers would be significantly more. It must be remembered that for patients it would not just be one journey for surgery, but at least one pre-operative and two post operative out-patient appointments.

Some of the comparative distances, times and costs are set out below

COMPARATIVE TIMES, DISTANCES AND COSTS OF TRANSPORT

FROM NORTH WALES TO WALTON AND MORRISTON

By car: [Source Automobile Association website]

Miles Time

Holyhead to Morriston 181.4 miles 4 hours 24 minutes

Holyhead to Walton 98.4 miles 2 hours 15 minutes

Difference 83 miles 2 hours 9 minutes

Bangor to Morriston 162.1 3 hours 59 min

Bangor to Walton 77.1 1 hour 49 min

Difference 85 miles 2 hours 10 min

Llandudno to Morriston 161.3 3 hours 59 min

Llandudno to Walton 62.4 1 hour 28 min

Difference 98.9 miles 2 hours 31 min

St Asaph to Morriston 157.7 3 hours 54 min

St Asaph to Walton 55.5 57 min

Difference 102.2 miles 1 hour 57 min

Wrexham to Morriston 132.2 3 hours 4 min

Wrexham to Walton 45.6 1 hour 6 min

Difference 86.6 miles 1 hour 58 min

Note: Times will vary according to time of day, road works etc

Due to the time taken to reach Morriston drivers would be advised to take one break. Add 20 minutes to the journey.

Our estimate is that the majority of people living in the counties of Wrexham, Flintshire, and Denbighshire can reach Walton by car within 1 hour; 52% of the population of North Wales [We have not included the whole population of the three counties].

Apart from the most westerly parts of Meirionnydd and Anglesey, journeys from all parts of North Wales take less than 2 hours to Walton. Estimate: 96% of the population.

By rail:

Time Cost

Holyhead to Swansea 6 hours 45 min �65

Holyhead to Fazakerley [Walton] 3 hours 24 min �23.50

Difference 3 hours 21 min �41.50

Llandudno to Swansea 5 hours 20 min �53.20

Llandudno to Fazakerley 2 hours 19 min �14.00

Difference 3 hours 1min �39.20

Wrexham to Swansea 4 hours 25 min �39.60

Wrexham to Fazakerley 1 hour 47 min �11.20

Difference 2 hours 38 min �28.40

Note: Add to the journey time to Morriston Hospital the time from Swansea railway station to the hospital, say 30 minutes. Fazakerley station is a short walk from The Walton Centre.

By coach:

Time Cost

Bangor to Swansea

Change Birmingham 9 hours 25 min � 46.50

Bangor to Swansea

Change Aberystwyth 6 hours 53 min �5.0

Bangor to Liverpool 3 hours 10 min � 16.60

Note: For Walton add 30 minutes from Liverpool. For Morriston add 30 minutes from Swansea coach station to the hospital.

2. Stress to Patients

Patients facing any form of surgery will naturally be anxious. The level of anxiety is perhaps greatest of all for patients who face neurosurgery. Although surgical techniques are well advanced and there is an increasing use of endovascular techniques [less invasive], it still means the surgeon has often to open up the skull or spine and perform procedures on the brain or spinal cord. Patients know the rehabilitation programme can be relatively long, with the possibility of some residual physical impairment.

Apart from the stress of anxiety, some patients awaiting surgery will have unpleasant symptoms such as severe headaches, difficulties in walking and suffering fits.

As well as physical and possibly psychological problems faced by patients, ill health is frequently accompanied by financial problems. A number of patients and their partners or carers will be elderly.

It is not just the stress faced by patients; there are the problems and anxieties faced by families and carers. The additional distance, time and costs involved would mean significant extra burdens on families, when a patient needs maximum support. Visiting a patient in Morriston would require an overnight stay, no matter what form of transport was used. The journey to Walton, even from Anglesey is relatively straight forward and visitors can travel and return in half a day. For visitors from North East Wales the travel is not a significant problem.

Apart from time, there is the issue of the ease of a journey. To Walton the journey is on main roads. To travel by train would involve one change and there is a railway station [Fazakerley] near the main entrance to the hospital. Journeys to Morriston involve travelling on slower, winding roads. Travel by train would also involve a journey from Swansea centre to Morriston by bus or taxi. The coach journey from North Wales involves a half hour wait in Aberystwyth. Regularity of services is also important.

Obviously journey times are dependent on traffic conditions or train delays, but in broad terms the journey time to Morriston is between 2 and 3 times that to Walton, and the cost also between 2 and 3 times more.

To subject patients, some of whom will be elderly, feeling very unwell and anxious, to the additional difficulties of travel would be inhumane. To subject their relatives and carers to all the additional unnecessary complications of travel and expense would also be inhumane.

3. Division between elective and emergency neurosurgery

In most cases it is possible to differentiate between emergency [e.g. head injuries with the risk of extra-dural [sub-dural] haematomas and patients with sub-arachnoid haemorrhages] and elective cases [e.g. slow growing tumours]. However, it is not always a clear cut separation. While on a waiting list the condition of a patient can deteriorate, requiring emergency surgery. In a small percentage of patients [1- 2%] there will be post operative complications, that require to be treated urgently. Patients suffering a complication after surgery in Morriston will almost certainly have to return to Morriston for treatment of the complication. The proposal to separate the two categories of patients would lead to confusion between the responsibilities of the two centres. We consider this division between Morriston and Walton will lead to unsafe practice.

4. Links between neurosurgery and neurology

40% of referrals to neurosurgeons are from GPs, 60% from other specialists, particularly neurologists [specialists in study and treatment of nerve systems]. These two specialties work closely together at Walton for diagnosis and treatment of patients. Neurologists from Walton also come to district general hospitals in North Wales [twenty six sessions per week in North Wales] to advise other specialists, such as general physicians and orthopaedic surgeons, and to hold out-patient clinics. This teamwork at both Walton and in North Wales is a vital component in providing effective diagnosis and treatment. It is not clear if Morriston would send a team of neurologists to provide some of the service in North Wales. What is clear is that the split between the two hospitals would create confusion of responsibilities.

5. Rehabilitation

For patients undergoing neurosurgery, the follow up and rehabilitation of patients post operatively are as important as the surgery. At present this is done initially at Walton and subsequently at Clatterbridge and various centres in North Wales. Some patients remain under the overall care of doctors at Walton for many years after they have been discharged from hospital. It is not clear if arrangements for rehabilitation and after care would be shared between the two centres. It is also not clear if elective patients from North Wales would receive their rehabilitation in Swansea. It is unlikely that it would be undertaken at the Walton Centre. There would be more scope for confusion, and extra journeys for patients and their relatives and carers from North Wales.

6. Patient choice

In England, under the "informed choice" scheme patients can choose from four hospitals for elective surgery. In Wales the policy is different in that there is no patient choice programme. However, GPs can refer patients to any hospital trust with whom the Local Health Board has a contract. All hospital trusts have to meet the maximum guaranteed Welsh waiting time for elective surgery. If a GP wants to refer the patient outside the contract then sometimes this is done on a cost per case basis.

We inquired from the Welsh Assembly whether the same arrangements applied to specialist tertiary cases, e.g. elective neurosurgery. If so, it would mean patients requiring elective neurosurgery could be referred to any hospital with whom Health Commission Wales [the body responsible for commissioning specialist tertiary services] have a contract, currently the University of Wales - Cardiff, Morriston Hospital - Swansea and The Walton Centre - Liverpool. Our reading of the situation appears logical, but to date we have not had a response to our query.

We believe the vast majority of patients in North Wales would opt to be referred to Walton. This being the case, the Minister would have to cancel the contract with Walton to admit elective patients, so forcing patients to go to Morriston. We believe this compulsion would be unprecedented in the NHS. Patients would be denied choice. The only choice left would be to be referred to Morriston or to become a private patient. This we consider to be totally unacceptable, and possibly contravenes the Human Rights of a patient. If a patient wishes to be referred to a neurosurgery centre in South Wales that should be their right, but also to Walton if they wish.

7. General Practitioners

GPs have a duty to provide the best possible service for their patients within the resources available. A GP would be forced into an ethical dilemma if they felt that due to the clinical needs of a patient and the effect on their family, it would be in the patient's interest to be referred to a neurosurgical centre much nearer their home. GPs should not be put into this position, which is completely unnecessary.

8. Ambulance Service

There would be significant extra costs for the ambulance service and also mean a significant depletion of availability of cover in North Wales.

In 2007 there were 246 patients referred for elective neurosurgery from North Wales to Walton. It is assumed half, 125, would require ambulance transport, with a paramedic and technician. The cost of such an ambulance and crew is currently �38 per hour. Each patient would need at least one pre-operative and two post operative out-patient appointment, in addition to attending for surgery. Times will vary from different places in North Wales, but an average ambulance return journey time to Walton is three and a half hours and eight hours to Morriston.

On these assumptions:

Morriston: 125 x 4 return journeys x 8 hours x �38 = �152,000

Walton: 125 x 4 return journeys x 3.5 hours x �38 = � 66,500

Extra cost: = � 85,500

These calculations are for the minimum number of journeys and take no account of extra out-patient appointments or rehabilitation. It is a very conservative estimate. In addition the loss of cover would need to be covered by extra staff and vehicles.

Carers and relatives may travel with the patient if they fulfill certain criteria. Some will not, and would face the additional costs of the longer journey by car or public transport.

9. Impact on Morriston Hospital

We would stress we are not doubting the professionalism of the staff and care given to patients in Morriston Neurosurgical Department.

Superficially it might appear that there is an advantage to Morriston if an extra 246 patients were referred there each year. However, on closer examination we would challenge this. There is the issue of possible confusion of responsibilities between Morriston and Walton, which we believe is against the principles of sound clinical governance.

Patients in North Wales would expect some element of comparability with the present service. This would involve consultant neurologists from Morriston undertaking sessions in each of the three district general hospitals in North Wales. Whereas consultants from Walton can drive over in the morning, do an outpatient session and a ward round and go back to Liverpool the same evening, consultants from Morriston would need an overnight stay, thus depleting the service in Swansea.

The Way Ahead

At least the Minister's initiative has spotlighted Neurosciences Services in North Wales and stimulated discussion. Four options have been raised:

1. A Neurosurgery Unit for North Wales?

A suggestion has been made that there should be a free standing neurosurgery unit in North Wales, possibly attracting some patients from North West England. We do not consider such a scheme could possibly be viable.

In order to justify a unit and ensure staff and equipment were fully utilized, it would need to serve a population of at least 2 million. The population of North Wales is 663,397. We consider it is extremely unlikely that patients could be attracted away from the established centre in Walton. It certainly could not be used for the basis of planning such a unit.

Such a unit would require at least 5 neurosurgeons to ensure adequate cover. If it just served North Wales, the consultants would have insufficient work. The capital costs would be very considerable and the facilities would be underused. It is extremely unlikely it would receive approval for training from the Royal College of Surgeons and there could be problems of recruiting consultant staff.

Such a unit would face the same problems as those faced by Morriston, which serves a larger population than North Wales.

2. A Neurology Centre for North Wales?

It could be argued that it would be possible to have a free standing Neurology Unit [as opposed to a comprehensive Neurosciences Unit, including neurosurgery] in North Wales. Our view is that establishing such a unit would be extremely costly and there could be problems of obtaining recognition of training from the Royal Colleges, and problems of recruitment of consultant staff. It is not clear what links there would be, if any, with Walton and how it would affect cohesive care requiring integration with neurosurgery, neuroradiology, neuropathology and neurophysiology services.

The existing neurology service now provided by Walton is good, and we would not consider a free standing neurology service would provide a significantly better [and possibly more limited] service. We do not consider it a high priority. It is certainly far less pressing than the need for improved rehabilitation services.

3. Rehabilitation Services for Neurosurgical patients

We welcome the announcement by the Minister on the 27^th February 2008, that the Frank Burns Review of Services at Llandudno General Hospital includes a recommendation to provide an 8 bedded in-patient acquired brain injury unit, which alongside the stroke rehabilitation service could build the reputation of the hospital as a neurological rehabilitation centre. Such a centre would work closely with the excellent North Wales Brain Injury Unit based at Colwyn Bay, which provides day care, advice and community support. We hope this recommendation will be supported by Mr Steers' Expert Review Group, and will eventually become a reality.

Our review has identified a fragmented rehabilitation service, with the main weakness of neurosciences services in North Wales as the lack of sub-acute rehabilitation facilities [for patients who are emerging from coma in a minimally aware or globally confused state]. Length of stay in such a unit would be 6 weeks to 3 months. Such a sub-acute unit, together with the unit at Colwyn Bay would form the hub for rehabilitation. However, these facilities would not provide a comprehensive service for the full range of rehabilitation required. We consider there is need for various agencies in North Wales to work with staff from Walton to produce a comprehensive plan. We would stress the importance of a bilingual service at the rehabilitation phase of treatment, particularly the need for intensive speech therapy.

4. Continuity with the Walton Centre

We are not claiming the service from the Walton Centre is perfect, but it provides:

- a comprehensive neurosciences service to North Wales, with a significant outreach service

- a patient centred service

- a full range of sub-specializations, backed up by comprehensive diagnostic facilities

- a close link with children's neurosurgery at the nearby Alder Hey Children's Hospital

- a commitment to North Wales, combined with a willingness to engage in a dialogue to improve services further

CONCLUSION

We consider the following action should be taken:

a. The Minister makes a formal announcement that the proposal to refer elective neurosurgical patients from North Wales to Morriston Hospital is withdrawn.

b. The Minister makes a formal announcement that the long term relationship of all North Wales neurosurgical patients being referred to The Walton Centre should continue, unless the patient prefers to be referred to a centre in South Wales.

c. Mr Steers Expert Review Group supports the proposal to develop an in-patient acquired brain injury unit at Llandudno General Hospital. The group also to consider this recommendation in the context of their wider examination of a comprehensive rehabilitation service for patients with all neurological conditions.

PART 2

THE SHIFT of POLICY by THE WELSH ASSEMBLY for TERTIARY SERVICES

We are concerned that the proposal by the Minister that elective neurosurgical patients should be referred to Morriston Hospital as opposed to The Walton Centre, is the model for all referrals of tertiary [highly specialized] cases to be to South Wales instead of hospitals in North West England.

Our evidence for this is the various decisions and statements made by the Minister.

Background

We start from the supposition that health care should be provided as near as possible to a patient's home, balanced against the need to provide this as safely as possible, and in an economical way. In this report we are concerned about acute hospital services only.

The vast majority of patients [97%] from North Wales receive their acute care at the Maelor Hospital, Wrexham, Ysbyty Glan Clwyd, Ysbyty Gwynedd and Llandudno General Hospital. There is a small minority of patients [3%] who require very specialized care that is not provided in North Wales. This care is mainly provided in Liverpool, but also in Oswestry and Manchester. The reason the services are not provided in North Wales is that the conditions they treat are relatively rare and require very specialized expertise, particularly from consultant medical staff. To be viable and to be able to attract specialist staff, such units need to serve a population of 2 to 3 million. The population of North Wales is 663,397. Over time an increasing number of conditions have been treated in hospitals in North Wales as expertise has been developed and funds made available. We firmly believe this process should continue [some of us have been involved in these developments]. However, there will remain some very specialist services it is not viable to provide in North Wales. For these services patients will continue to need to travel to specialist centres.

The main hospitals outside North Wales to which patients travel for specialist care are:

- Alder Hey Children's Hospital - Liverpool

- Christies - oncology [cancer]- Manchester

- Clatterbridge - oncology- The Wirral

- Robert Jones and Agnes Hunt - spinal injuries and specialist orthopaedics - Oswestry

- Royal Liverpool and Broadgreen - mainly cardio-thoracic

- Manchester Royal Infirmary - mainly cardio-thoracic

- Whiston Hospital - burns and plastic surgery

- The Walton Centre for Neurology and Neurosurgery

Historical Policy and Practice

Patients from North Wales have been referred to specialist hospitals in North West England for many years. In July 2000, the Acute Services Development Group [ASDG], chaired by Dr Ruth Hall the then Chief Medical Officer for Wales, reported on acute general hospital services. The report entitled "Access and Excellence" was a very thorough review taking into account patients' needs; waiting times; emergency admissions; survival rates for major illnesses; the balance between services provided locally consistent with safe and effective care; comparability of standards of care with the rest of the UK; provision of a skilled workforce; buildings; access to diagnosis; effective standards of clinical governance and acute services as part of an integrated system of health and social care.

Among other conclusions was a framework for the future scale at which acute hospitals should be planned and coordinated to be increased beyond the existing boundaries of Welsh Health Authorities and Trusts. "There are 'natural' affiliations between clinical services and existing patient flows evident in Wales, that can be developed to create new 'health economies' for acute services. These' health economies' include critically important links with acute services in England. 'Health economies' should become the focus for the development of acute services in Wales." The report continued, "'Health economies' are natural groupings and are not intended to reflect existing organizational boundaries. They reflect the critical importance of relationships with services in England and are therefore centred on the Welsh population rather than the Welsh geography". The report identified five 'health economies':

- Wales as a whole, including its links with the NHS in England, particularly in the provision of specialized health services [the latter includes relationships with specialized hospital services in London]

- North Wales, including links with Liverpool, Manchester and Chester

- Powys [Mid Wales] including links with Aberystwyth, Wrexham, Abergavenny, Merthyr and Swansea in Wales and Hereford, Shrewsbury and Birmingham in England

- South West Wales, linking services in Dyfed with those in Swansea, including Neath and Bridgend

- South East Wales, comprising Gwent and Bro Taf, including links with Bristol

Some of the names have changed, but we consider these groupings are a logical and sensible basis on which to continue to plan and provide acute services. We do not consider devolution alters the underlying common sense of the arrangements.

Action and statements by the Minister

There are a number of actions and statements by the Minister which flag up to us what appears to be a major shift in policy:

1. In the debate at the Welsh Assembly on the 4^th July, the Minister made a statement on Neurosurgery Services, " My overriding aim is to secure as many services as can be safely provided within Wales's boundaries. Of course, there will always be rare conditions and highly specialist services that can only be supported by populations greater than the population of Wales. This means that, in order to get the best possible treatment, there will always be some patients who must travel outside Wales for the services they require. However, where the Welsh population base is sufficient to support an in-country service, that is the way in which I wish to proceed. Therefore, in the case of adult neurosurgery, the approach that I now intend to adopt is one in which we will look as actively as possible at redirecting additional elective work generated inside Wales to the two centres in Swansea and Cardiff."

Our reading of the Minister's statement is that in future, the whole population of Wales will be used when assessing what acute specialist hospital services are provided in Wales. We would challenge this concept. In our view the criteria used in the past, treating North Wales as having separate links with North West England, should continue. Planning of specialist acute hospital services should be on the basis of separating the population of North Wales from the rest of the country. The geographical reality is that Holyhead is 205 miles from Cardiff and 98 miles from Liverpool. Wrexham is 133 miles from Cardiff and 41 miles from Liverpool. There are excellent specialist hospital facilities in North West England and access is much easier than to Cardiff.

Our fear is that there will be a drift to lump the whole population together to justify units in South Wales, and patients from North Wales would be redirected to Cardiff. This we believe is not in the best interests of patients, their relative and carers. It would also be a denial of patient choice. The proposal to redirect elective neurosurgical patients to centres in South Wales could be the model of things to come.

2 In the same debate, the Minister also stated "I have been struck by the fact that we have no purpose-designed spinal surgery unit in Wales". We would point out there is already the excellent Midlands Spinal Injuries Unit at the Robert Jones and Agnes Hunt Hospital at Gobowen, near Oswestry, which serves patients from the West Midlands and North and Mid Wales. The hospital serves a population of 8.5 million, staff have great experience and expertise in treating spinal injuries and liaise closely with staff in Accident Departments in hospitals in North Wales. The hospital has been rated as excellent. About 10% of admissions are from North and Mid Wales. There are over 40 Welsh speaking staff. The hospital is 21 minutes drive from Wrexham, and even from Anglesey takes less than 2 hours. If patients had to travel to a centre in South Wales, most would literally pass within half a mile of the hospital entrance, before heading south for a further three hours.

3 In the debate at the Assembly on the 4^th July, the Minister stated: "I have a problem with foundation hospitals". Hospitals in England can apply for Foundation Trust status. It is the policy in England to encourage them to do so. The advantages to the hospital are that if granted, they are allowed greater freedom from the control of their Strategic Health Authority [the equivalent of the Assembly Health Department], have an ability to carry forward financial surpluses and being more accountable to the local population. In order to be granted Foundation status, the hospital has to demonstrate a sound financial position and to prove it has achieved high standards of patient care.

The policy of granting Foundation status has been rejected in Wales. We fully support that decision and agree the arrangement is not appropriate in Wales.

The Minister did not elaborate on her problems with Foundation Hospitals. We would point out that all the hospitals providing specialist tertiary services to patients in North Wales have either been granted Foundation status or are in the process of applying. All are very happy to continue to treat Welsh patients. It would be helpful if the Minister could clarify why Foundation status appears to be a bar to treating patients from Wales.

CONCLUSION

From actions and statements by the Minister there appears to have been a shift in policy about referral of patients to hospitals in England. This creates concern and confusion. We recommend:

a. The Minister makes an unequivocal statement that the existing pattern of referral for patients from North Wales to tertiary hospitals in North West England will continue

b. If this is not the case, then there should be a detailed consultative document issued by the Welsh Assembly setting out reasons for change, and for there to be an open debate on the issues. It is not acceptable to rely on cryptic remarks made by the Minister.

c. We would reiterate that our view is that where it is safe and economically viable, acute services should be developed at hospitals or one hospital in North Wales. With advances in medical techniques the scope for this increases [e.g. invasive cardiology]. Where there are specialist services that require a much larger population base, these should be provided in North West England. A long term commitment should be made to these centres, and a greater involvement with these hospitals to improve services and accessibility for Welsh patients, with more outreach services and specialist community support in North Wales.

PART 3

WAITING TIMES, COMPARISONS

From our informal discussions with staff at specialist hospitals in North West England, certain issues arise:

- doctors are frustrated that there are two standards for waiting times, between patients resident in Wales, compared with those in England. They would prefer to treat all patients by the same criteria

- most specialist hospitals have the capacity to reduce the waiting times for Welsh residents to the same as those from England

- that some of the hospitals are driving down their waiting times, and achieving significantly shorter times than the English standard

- the policy in Wales appears to be that it is satisfactory as long as Welsh minimum standards are achieved

- it would appear, therefore, that the disparity between the standards is becoming greater

- it is acknowledged that the Assembly has announced improved standards for waiting times. However, there are continued improvements in England.

These issues arose relatively lately in our review, and are based on informal discussions with doctors. We have raised questions with managers of some specialist hospitals. Perhaps not surprisingly, they have been somewhat coy about providing detailed information.

There is much publicity given to individual cases where a patient from Wales is denied a drug or operation which is available for English patients. In our view a much bigger issue, and one which affects a much larger number of patients from North Wales, is the considerable and apparently growing disparity in waiting times.

We consider our assertions need testing out. There is a need to obtain detailed information and statistics to illustrate clearly the extent of the disparity, not just between official targets, but the actual situation in each specialist hospital.

This should be done by an official body that can obtain information more easily than by a group of private individuals.

The information obtained should be made public.

Whatever the facts about the actual extent of the disparity, it remains an issue that waiting time standards are better for patients from England as opposed to Wales. We consider the public in North Wales is entitled to know the facts and that the Assembly should require Health Commission Wales to produce an action plan to remedy the situation.

SUMMARY

1. Background to the proposal by the Minister to redirect elective neurosurgical patients from Walton to Morriston Hospital, Swansea.

2. A description of the services provided by The Walton Centre, including workload, staffing, medical outcomes, sub-specialization and future plans.

3. A description of services provided by Walton in North Wales, including out-patient clinics, community services and reading scans from local hospitals

4. Objections to the proposal to redirect elective neurosurgical cases from Walton to Morriston, including extra time and distance to be travelled by patients, their relatives and carers; additional stress to patients; problems with dividing emergency from elective care; the important links between neurosurgery and neurology; rehabilitation; patient choice; general practitioners; the ambulance service - extra costs and reduced cover; the impact on Morriston Hospital.

5. Possible options for the way ahead. Opposition to establishing a neurosurgery unit in North Wales or a free standing neurology centre. Support for improved rehabilitation facilities for sub-acute cases at Llandudno General Hospital.

6. Conclusion that the proposal is withdrawn, a long term commitment should be to continue with both emergency and elective neurosurgical patients admitted to Walton; and Mr Steers Review Group examine a comprehensive rehabilitation service for patients with a neurological condition.

7. Concern at the apparent shift of policy by the Welsh Assembly that all patients requiring specialist acute care would be redirected from specialist hospitals in North West England to South Wales.

8. A statement of the background, together with the reasoning for the present pattern of referrals.

9. Analysis of recent statements by the Minister about neurosurgery, spinal injuries and foundation trusts that appear to confirm the change of policy.

10. Conclusion that the Minister should confirm the existing pattern of referrals to North West England or if not, there should be a full public debate. Recommend that acute services continue to be developed in North Wales and a long term commitment made for specialist services to continue to be provided in North West England.

11. A statement about the disparity between waiting times for Welsh patients compared with English patients at hospitals in England, and the need for a comprehensive study of the issue, and an action plan to address the situation.

20 March 2008