A HOSPITALS’ STRATEGY FOR GLASGOW SOUTH

 

 

 

 

 

 

“KEEPING THE SCOTTISH NHS LOCAL”

 

 

 

 

 

 

 

 

 

 

 

 

HEALTH SERVICE FORUM SOUTH EAST

JANUARY 2005

CONTENTS

 

 

1    INTRODUCTION

2    EXECUTIVE SUMMARY

3    KEEPING THE SCOTTISH NHS LOCAL:  A NEW DIRECTION OF TRAVEL

4    GLASGOW'S SOUTH-SIDE NEEDS TWO ACUTE HOSPITALS

5    IMPLEMENTATION BY NHSGG OF THE ACUTE SERVICES REVIEW 2002-2004

6    FUTURE TRENDS

7    RECOMMENDATIONS

APPENDICES

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1        INTRODUCTION

 

The Health Service Forum South East was constituted in 1992. It exists to promote the understanding and discussion of all aspects of the NHS in Glasgow, and to encourage high standards and quality of provision of healthcare. Its purpose is to inform the residents of south Glasgow of the changes in the NHS which relate specifically to their area, covering the hospitals, GPs, community care and the NHS overall, to the best of its ability. All of its members are users of the NHS in Glasgow. They bring a wide range of expertise from backgrounds in healthcare professions, civic representatives, skilled trades, architecture, university teaching and research, but most importantly, personal experience of the service. The membership operates through subcommittees each with professional expertise. The Forum has also commissioned reports by independent authorities and organisations. These can be found on our web site:  www.healthforumglasgow.org

 

Electoral and political pressures have culminated in a new political determination throughout the country to reverse the historical decline in the NHS. This is reinforced by government determination to back this with a budget for healthcare provision which will increase in real terms and which will close the gap in provision between the UK and its European neighbours. It is of major importance to the healthcare of Glasgow and Scotland as a whole that this opportunity is acted upon and not squandered by blindly pursuing out-dated directions of provision.

 

After over five years of NHS Greater Glasgow (NHSGG) planning and consultation processes, no quantitative parameters for a new system, such as the number of beds, estimates of environmental impact or costings have yet emerged. As at December 2004 the actual number of A&E departments is awaited.

 

Evidence of the deterioration of the current system accumulates almost daily. Serious damage to Glasgow's healthcare infrastructure will result unless this planning stasis can be broken.

 

In bringing forward a Strategic Plan once again, we do so with a determination to demonstrate that a high standard of health provision for Greater Glasgow can be achieved in a cost-effective and evolutionary manner.

 

 

2        EXECUTIVE SUMMARY

 

This document sets out a plan for healthcare in the 21^st century that takes account of existing best practice, state-of-the-art technology, and the clearly expressed views of the people of Glasgow.

 

Since the modification to the Acute Services Review was announced in December 2003, it has become clear that severe capacity shortages within the city’s hospitals have rendered it unworkable.  The present ASR cannot provide the quality of acute hospital care, which the city expects and requires, for its own population and for a significant proportion of the population of the West of Scotland.

 

Principal Components of the Plan

 

The goal is state-of-the-art acute hospital services for South Glasgow.

 

The key elements are:

 

 

The key challenges and opportunities facing healthcare in the UK and in Glasgow in particular in the 21st Century are:

 

 

3        KEEPING THE SCOTTISH NHS LOCAL:  A NEW DIRECTION OF TRAVEL

 

Following the election of Dr Richard Taylor to the Wyre Forest Constituency in the 2001 General Election, with the largest majority of any English constituency, the Health Secretary, Alan Milburn, initiated a detailed review of the policy of closing and removing services from smaller hospitals.  The prospective closure of Kidderminster Hospital and the transfer of all services to a new PFI-funded hospital in Worcester had prompted Dr Taylor’s election. 

 

This resulted in demands from many Labour MPs in marginal constituencies that there “should be no more Kidderminsters” at the next general election.  In February 2003, a consultation paper was produced entitled “Keeping the NHS Local – a New Direction of Travel” which suggested a number of options for delivering acute inpatient and day case services from smaller hospitals without resort to closure.  This was followed by a series of definitive papers in July 2004, setting out these options in more detail, with examples of their implementation in smaller hospitals.  In two documents (The Configuring Hospitals Evidence File: Parts One and Two), the Department of Health sets out detailed peer-reviewed evidence, which confirms that there is no relationship between case-volume and clinical outcomes for the majority of common medical and surgical conditions managed in NHS, European and North American hospitals.  This evidence validates the case that bigger is not necessarily better. The Evidence File commends the use of Managed Clinical Networks with telemedicine and video links to ensure close communication between smaller and larger hospitals, with flexible rotation between hospitals and modified multidisciplinary on-call rotas to facilitate compliance with the European Working Time Directive (EWTD).  This evidence underpins the Department of Health’s policy that has, for the most part, stopped hospital closures and withdrawal of services from smaller English NHS hospitals since the last general election. 

 

The current centralisation agenda being pursued by Scottish health boards, with the support of the Scottish Executive Health Department, runs contrary to the policy of the Department of Health, which rests on a well-researched evidence base.  The contrast with the Scottish Executive’s uncoordinated centralisation agenda, which has resulted in the present political crisis for the devolved Parliament, could hardly be greater.

References:

1.           Keeping the NHS local – biggest does not necessarily mean best. Department of Health, London: February 2003; Press Release.

2.           Keeping the NHS local: A New Direction of Travel. Department of Health, London: February 2003; Full document.

3.           Keeping the NHS local: A New Direction of Travel.  Department of Health, London: July 2004; Summary of Consultation responses.

4.           The Configuring Hospitals Evidence File: Part One. Department of Health, London: July 2004.

5.           The Configuring Hospitals Evidence File: Part Two.  Department of Health, London: July 2004.

Sources: -       Web site: www.doh.gov.uk; search “Keeping the NHS local”

                        Publications:   Department of Health Publications

                                                PO Box 777, London, SE1 6XH

                                                Tel: 08701 555455; Fax: 01623 724524

                                                E-mail: doh@prolog.uk.com

4        GLASGOW'S SOUTH-SIDE NEEDS TWO ACUTE HOSPITALS

 

4.1       Introduction

NHS Greater Glasgow (NHSGG’s) Acute Services Strategy remains mired in confusion. The infrastructure of Glasgow's hospitals continues to deteriorate, morale among staff is low and resources are insufficient to meet demand. While these problems are common to the NHS as a whole, there is increasing evidence of dysfunctional management in Glasgow's hospitals while the planning process lacks numeracy, clarity and direction.

The number of adult staffed acute beds in Glasgow's hospitals fell by 33% from 4264 beds in 1990-91 to 3026 beds in 2001 [1]. Despite growing evidence of bed shortages, salami slicing of acute bed numbers has continued. Since 1994-95, length of stay has ceased falling in surgical specialties in Scottish hospitals and slowed markedly in acute medical specialties because of the exhaustion of efficiency improvements [2]. With an ageing population, Glasgow needs more, not fewer, acute and post-acute beds. Despite this evidence, NHSGG currently projects fewer acute surgical beds in its new hospitals than at present [3]. NHSGG intends to concentrate its acute services in three large hospitals, which will replace the city's present five acute hospitals [4]. This involves the construction of a large south-side hospital to serve the 350,000 catchment population of the area together with substantial cross-boundary flows of patients from Lanarkshire, Renfrewshire and the west of Scotland to the secondary and tertiary specialties currently provided in the Victoria Infirmary and the Southern General Hospital.

4.2       How large will a new south-side hospital be?

NHSGG’s intention is to construct one large new hospital on the present site of the Southern General Hospital. An Ambulatory Care and Diagnostic Centre (ACAD) will replace inpatient services at the Victoria Infirmary for outpatients and day surgery.

At 2000-2001 staffed bed and inpatient admission levels [5], the first phase of the new south-side hospital for adult specialties would contain 1434 staffed beds and admit about 66,000 inpatients annually. A hospital of this size would be the biggest in Britain. The largest hospital in Scotland, Aberdeen Royal Infirmary, has just over 1000 beds. Only five English hospitals have more than 1000 acute beds. The largest, St. James Hospital in Leeds, had 1157 beds in 2000 [6]. 

Glasgow's other two acute hospitals will also have over 1000 beds. The enlarged Gartnavel site will have 1020 beds at 2000-2001 staffed bed levels [5]. The enlarged Royal Infirmary site will have 1354 beds if Stobhill's acute and geriatric assessment beds transfer following the projected closure of inpatient services [5]. Glasgow will then have the largest and second largest acute hospitals in Britain.

4.3       From mega hospital to mammoth hospital.

There are currently proposals to triple locate maternity, paediatric and adult acute services on one site which will see the closure of the Queen Mother’s and Yorkhill Hospitals.  Although this programme may be undertaken as a National project, it is highly probable that the site selected for this new development will be at the Southern General.  At 2000-2001 staffed bed levels, the new south-side hospital will then have approximately 1800 staffed beds and can expect 81,700 admissions yearly [5]. The enlarged hospital will be 55% larger than Britain's current largest hospital [6 see above]. At current ratios of inpatient admissions to day cases, outpatients and accident and emergency attendances in Scottish acute specialties, the hospital can expect about 46,000 day cases, 100,000 attendances at A&E, and 450,000 outpatients annually

4.4       Large hospitals reduce patient accessibility

The removal of inpatient facilities from the Victoria Infirmary and their relocation to the Southern General site will reduce the accessibility of acute hospital facilities for the population of south-east Glasgow. This comprises the greater part of the south-side catchment population. Public transport across the south-side is poor since most bus and rail links run to the city centre. The south-side, like the city generally, has many areas of high deprivation, and levels of car ownership are low, particularly among older people who will comprise the majority of the hospital's patients. The prospect of losing an accessible acute hospital is opposed by the overwhelming majority of the population of south-east Glasgow.

4.5       Large hospitals make communication between the hospitals and the primary and community care sectors more difficult

Ease of communication between hospital and community staff is much easier in a hospital of moderate size. These communications deteriorate as the size of the hospital increases, to the detriment of patients' overall management in the primary, community, and hospital care sectors.

4.6       There is no relationship between hospital size and clinical outcomes in NHS hospitals in Britain

The evidence relating hospital size to clinical outcomes has been reviewed previously [8]. The Centre for Health Economics in the University of York carried out the most comprehensive study of the relationship of hospital size to clinical outcomes [9]. The initial paragraph of the Conclusion to this study states: -  

"The result of this work suggests that there is no compelling reason to believe that further concentration of hospital services will result in improved efficiency through exploiting economies of scale, or to automatic improvements in the quality of clinical outcomes. In assessing the potential negative effects of increased concentration on access and utilisation, the implications for disadvantaged groups in particular should not be overlooked. Even where specific effects on cost, outcome or utilisation can be demonstrated in the literature, the process by which such effects are generated is poorly understood." The report concludes: -

"The burden of proof must be with those who propose change to quantify the expected costs and benefits, to demonstrate the process by which benefits will be realised in practice, and to explain the way in which efficiency gains will be assured and monitored."

The clinical outcome indicators published by the Scottish NHS Executive's Clinical Resource and Audit Group found no relationship between hospital size and outcomes for a range of common conditions managed in Scottish hospitals [10]. Professor Sir Brian Jarman and his colleagues found no relationship between hospital size and mortality rates in all English acute hospitals [11]. Clinical outcomes have much more to do with the skills and organisational capacities of individual groups of clinicians within an efficiently run hospital than with the size of the hospital. There is no evidence that large NHS hospitals are automatically safer than small NHS hospitals. Harefield NHS hospital, a world-class centre for heart transplantation, had 113 staffed beds in 1998!

 

4.7       Large hospitals do not provide economies of scale

While there is a close relationship between the size of acute Scottish hospitals and revenue expenditure, larger hospitals are not cheaper to run per patient treated. International comparisons show reasonable evidence of a U-shaped curve between hospital size and unit costs per 1000 episodes of care. Very large hospitals are usually less efficient because they impose severe organisational challenges on their managements. As a result, there is an almost total absence of efficient large hospitals [12]. Optimum efficiency appears to be achieved at between 20,000 and 50,000 episodes of care per annum.        

4.8       Closing acute hospitals to meet short-term staffing problems is unreasonable

A primary reason given by NHSGG for closing Stobhill Hospital and the Victoria Infirmary is that changes in doctors' hours dictated by the European Working Time Directive make it difficult to staff surgical and anaesthetic teams to cover five hospitals [13]. Staffing issues may lead to the closure of two viable hospitals. In the case of the Victoria Infirmary, removal of orthopaedic and surgical services on staffing grounds may lead to the transfer of a much larger number of medical and geriatric assessment admissions which accounted for 63% (17,479) of all admissions to the hospital in 2000-2001 [5]. The physicians and geriatricians dealing with the majority of admissions to the Victoria infirmary do not wish to move to a large south-side hospital in which total medical admissions of about 27,000 annually will impose a huge organisational burden on the Medical Division. These will deal with an average of 74 admissions daily, rising in winter to about 100 admissions daily. It is irrational that short-term surgical and anaesthetic staffing issues should close a hospital. Given the present Government's commitment to injecting more money into the NHS, the solution to the staffing problem is to provide more consultant surgeons, anaesthetists and junior staff to bring staffing levels closer to average European levels.

4.9       A rational alternative to very large hospitals: managed clinical networks

Despite NHSGG’s intention to create the largest hospitals in Britain, the enthusiasm of NHS managers and the medical profession for building very large NHS hospitals serving catchment populations of 300,000 to 500,000 is waning. The realisation that organisational networks, which integrate clinical services across a range of hospitals, can combine a wide range of specialist expertise with local accessibility is driving this reappraisal. The Scottish Hospitals Acute Services Review, chaired by the former Chief Medical Officer, Sir David Carter, introduced the concept of managed clinical networks as a way of coordinating a wide range of expertise in clinical specialties from small district general hospitals to highly specialised care in teaching hospitals [14]. The conclusion to chapter 6 of the review states: -

"The Acute Services Review has not approached its remit from the premise that concentration of services in large centres and the closure of smaller hospitals are necessary or indeed appropriate ways forward for acute services in Scotland."

The review concludes that: -

"(1) The critical mass needed to achieve the benefits which might flow from increased volume of activity can come through managed clinical networks rather than the centralisation or concentration of services. Concentration of some services may still be necessary but this must take place within an integrated regional service, the exact nature of which will vary from specialty to specialty.

(2) Managed clinical networks are based on appropriately trained and skilled individuals working in partnership in a hierarchy of appropriately established and managed facilities. Thus the benefits of any economy of scale can be achieved without having to incur the penalties of diseconomy of scale."

The Acute Hospitals Review Group for Northern Ireland concurs with the view expressed in the Scottish document [15]. The review embraces the concept of managed clinical networks for nine acute hospitals in the province. No hospital will have more than 800 beds and the smallest hospital will have just over 200 beds. There are no plans for large mega hospitals on the Glasgow model.

The Royal College of Physicians and the NHS Confederation are rethinking delivery of acute emergency services in NHS hospitals [7]. This envisages linking small local hospitals to larger hospitals with more integrated services and staff, combining the advantages of a larger specialist skill base within a managed care network without the disadvantages of inaccessibility and the poor communications, which inevitably accompany concentration of resources in very large hospitals. Political pressures against hospital closures are playing a part in this re-evaluation. Communities do not welcome the closure of their accessible local hospital and will increasingly express their displeasure through the ballot box.[16]

Conclusion

NHSGG plans to build three very large hospitals in the city, including the largest hospital in Britain on the Southern General Hospital site. If fulfilled, these plans will saddle the south-side with a costly, inefficient hospital against the wishes of the electorate of south-east Glasgow. All community councils in south Glasgow and adjacent parts of East Renfrewshire in the Victoria Infirmary’s catchment area have repeatedly expressed such opposition in public petitions, meetings and demonstrations. Informed expert opinion is moving away from the grandiose concept of very large hospitals in favour of dispersed "virtual" hospitals with close organisational links.

Plans for a very large south-side hospital should be replaced by planning for two south-side hospitals of moderate size to serve south-east and south-west Glasgow, linked by a common management, combining the benefits of scale with accessibility to their catchment areas. The last seven years have been a time of increasing uncertainty, confusion, and demoralisation for staff working in Glasgow's hospital services. Reversing this process with a more rational approach to forward planning and the provision of sufficient capital to replace the city's run down infrastructure is the most important task facing the Scottish NHS Executive and NHSGG’s Chief Executive.

REFERENCES

1. Information and Statistics Division. The N.H.S. in Scotland: 1990-91 to 2000-01.

2. Dunnigan M G. The downsized hospital hypothesis: value for money. N.H.S. Consultants Association. 2001.

3. The future of Glasgow's hospital services. Leaflet 11: The number of beds we propose to provide. Greater Glasgow Health Board. 2000.

4. The future of Glasgow's hospital services. Greater Glasgow Health Board. 2000.

5. Information Services. Greater Glasgow Health Board. 2000-2001.

6. Binley's Directory of NHS Management. NHS Confederation. Spring 2001 Edition.

7. Smith R. How best to appraise acute hospital services? BMJ 2001; 323: 245-6

8. Dunnigan M G. Greater Glasgow Health Board's Acute Services Strategy 1999-2004. Reorganisation, not reconstruction. 1999

9. Ferguson B et al. Concentration and choice in the provision of hospital services: summary report: CRD report 8. University of York. 1997

10. Clinical outcome indicators. Clinical Outcomes Working Group. Clinical Resource and Audit Group. Scottish Executive Health Department. 1992-2000.

11. Jarman B. Personal communication. 29th. July 1999.

12. Greene AFC. Principal: Booz, Allen and Hamilton International (UK) Ltd. Personal communication. 25th. July 1994. 

13. The future of Glasgow's hospital services. Leaflet 10: Impact of regulations on doctors' working hours. GGHB 2000.

14. Acute Services Review Report. The Scottish Office DoH, 1998. 

15. Acute Hospitals Review Group. Northern Ireland DoH, Social Services and Public Safety. 2001.

16. Keeping the NHS Local - A New Direction of Travel. DoH, February 2003

 

5        IMPLEMENTATION BY NHSGG OF THE ACUTE SERVICES REVIEW 2002-2004

 

In January 2002, NHSGG Board approved its Acute Services Review (ASR).  As noted, this involves the closure of three acute hospitals to inpatient services, concentration of Accident and Emergency Services on two sites and the replacement of the Victoria Infirmary and Stobhill Hospital by stand-alone Ambulatory Care and Diagnostic Units (ACADS).  These proposals have attracted considerable opposition from community and professional groups concerned by the withdrawal of accessible inpatient hospital services, including Accident and Emergency facilities, reductions in acute inpatient bed capacity, and the wisdom of placing large ACADS at a distance from the acute resuscitation facilities available in a fully equipped acute hospital.

 

The Scottish Health Executive approved the ASR in September 2002.  NHSGG projected the start of work on the two ACADS in 2004, with both fully operational in early 2007.  Work on the construction of enlarged inpatient facilities in the Southern General and Gartnavel Hospitals is due to commence in 2006 with operational completion on both sites by 2011.  Details of planned hospital bed numbers are stated to be “unlikely to change by more than five per cent”.

 

There has been considerable slippage in the implementation of the first phase of the timetable since its approval almost three years ago.  This has been mainly due to the Outline Business Case (OBC) attracting only a single bid (from Balfour Beattie Construction), removing any element of competition from the ASR.  As a result, financial closure of the Full Business Case (FBC), if approved by the Scottish Executive Health Department and Audit Scotland, is unlikely before Summer 2005.  Construction of the ACADS cannot therefore begin until late 2005 or early 2006. 

 

There are increasing concerns about the ability of present and projected acute bed capacity to cope with demand in Glasgow’s acute hospitals.  NHSGG assumes that further shifts of inpatient care to day case and outpatient settings will permit further reductions in acute bed capacity in surgical specialties.  Additional provision of long-stay capacity in private sector residential and nursing home accommodation and the provision of supported home care is also projected to reduce “blocked beds” in acute specialties.  On the other hand, emergency admissions continue to increase, compounded by an ageing population, rising public demand for rapid access to expert medical care and investigation, and emerging pressures on acute hospitals created by the ending of the obligation on general practitioners to provide 24 hour medical cover.

 

Since January 2002, pressures on Glasgow’s acute bed capacity have increased.  The city’s acute hospitals lost 29% of their adult acute beds between 1990-91 and 2000-01(4264 to 3026 beds).  Despite repeated winter bed crises, with postponements and delays in elective admissions, leading to rising waiting lists, NHSGG has pursued a policy of further reductions in acute beds towards its provisional 2001 target of 2708 acute beds.  In August 2004, NHSGG had 2757 available staffed beds in acute specialities, a 9% reduction (269 beds) from the 2001 bed complement and a 35% reduction since 1990-91.  Bed reductions were spread across most acute specialties with the greatest reductions over this period occurring in

Ear, Nose and Throat (-41%), ophthalmology (-20%), orthopaedics (-20%) and general surgery (-11%). Bed managers now struggle to cope at all times of the year.  Acute hospitals have been closed to emergency admissions frequently, with patients being moved to hospitals outwith their catchment areas, and emergency medical patients boarded inappropriately in surgical wards, leading to cancelled elective admissions and long trolley waits for admission from overcrowded Accident and Emergency departments.

 

A report from the National Audit Office in December 2004 showed that Glasgow Royal Infirmary, the Southern General Hospital and the Western Infirmary had respectively the second, fourth and fifth longest A&E waiting times in the UK (Edinburgh Royal Infirmary had the longest waiting time).

 

Greater Glasgow Health Council has repeatedly recorded problems resulting from insufficient acute beds in its Casualty Watch Surveys during 2003 and has raised concerns about insufficient acute bed capacity with NHSGG Board on each occasion.  A NHSGG-commissioned review of pressures on acute bed capacity in Glasgow’s acute hospitals by Secta Consulting in 2003 concluded,  “the present model of acute care delivery is not deliverable for much longer”.  On 3^rd February 2004, bypassing NHSGG, the Chair (Dr B A K West) and Vice-Chair (Mr Tim Parkes) of NHSGG’s Area Medical Committee, wrote directly to Mr Trevor Jones, Chief Executive of NHS Scotland, to protest about “a serious and sustained lack of availability of beds for emergency admission.  This has resulted in large numbers of patients waiting for long periods in inappropriate areas for a bed, and, for the first time in Glasgow, a significant number of patients sleeping overnight in the A & E departments”.  They concluded “Failure to act will lead to further deterioration in standards of patient care, clinical safety and staff morale”. 

 

Despite these severe capacity problems, at its 16^th December 2003 Board meeting, NHSGG set out modifications to the 2002 Acute Services Review which planned acceleration of the consolidation of acute services on three sites.  Medical Director, Dr Brian Cowan, stated that the main drivers for change were staffing and financial pressures, particularly following the introduction of the European Working Time Directive for medical staff.    Accelerated change involved the reorganisation of the emergency and elective workload between GRI and Stobhill, Gartnavel and the Western Infirmary, and the Victoria and Southern General hospitals.  All emergency admissions would be admitted to Glasgow Royal Infirmary, Gartnavel General Hospital and the Southern General Hospital; the remaining three acute hospitals would deal only with elective admissions.  Accreditation of the Admissions Unit in Stobhill hospital would be withdrawn by Summer 2005.

 

Since the modification to the ASR was announced, it has become clear that severe capacity shortages within the city’s hospitals have rendered it unworkable.  Limitations on acute bed capacity in the Royal Infirmary and Southern General Hospital make the concentration of emergency receiving on these sites impractical.  In consequence, closure of the Stobhill Admissions Unit has been deferred to 2006, at least.  The 966 acute beds, (including geriatric assessment beds) available on the Victoria Infirmary and Stobhill sites in August 2004 cannot be dispensed with until, and unless, major expansion of acute capacity is provided in the Royal Infirmary, Southern General and Gartnavel General Hospitals. This cannot happen until 2011 at the earliest.

 

At present, a combination of financial pressures, capacity constraints related to inadequate acute bed capacity, medical and nursing staff shortages (leading to ward closures), and limitations on theatre capacity raise serious concerns about the competence and planning assumptions underpinning the ASR.  The recent announcement that 10,000 patients are awaiting orthopaedic treatment in North Glasgow is only the latest manifestation of these multiple problems.  In a letter to the Health Board in October 2004, Mr Tony Reece, a senior orthopaedic surgeon in the Western Infirmary stated, “many of my colleagues are seriously concerned that the orthopaedic service in Glasgow is about to collapse due to lack of planning, poor morale and inadequate support”. 

 

The major difficulties in implementing the Acute Services Review outlined above indicate the need for substantial revisions to both the assumptions underlying the provision of capacity and the future configuration of Glasgow’s hospitals.  The present Acute Services Review cannot provide the quality of acute hospital care, which the city expects and requires, for its own population and for a significant proportion of the population of the West of Scotland.

6        FUTURE TRENDS

 

Some trends are clear.

The plan must make provision for a major increase in elderly population.

In the UK as a whole, the number of people aged 75+ is expected to increase from 4.3m to 7m by 2036. This is the sector of the population, which is by far the heaviest user of the acute hospital services.  [Reference: Candace Imison, Presentation at Cambridge Conference, 27^th June 2001] 

The plan must provide more staffed acute inpatient beds.

Between 1990-91 and 2004 Glasgow hospitals have lost 35% (1507) of all their staffed acute beds. The result has been increasingly severe difficulties in gaining admission for a rising number of emergency admissions and rising waiting lists for elective admissions who require inpatient beds. Day case accommodation cannot compensate for the severe bed shortages in the city’s acute hospitals. The current bed model proposed by NHSGG does not acknowledge these increasing problems and instead proposes further unrealistic reductions to 2708 staffed acute beds by 2004-05 (see section 5).

Improvements in Information Technology will revolutionise the management, form and delivery of healthcare. Clinical Networking, not Hospital Centralisation, is the cost-effective way towards better healthcare.

The continuing trend in all branches of information technology is that the price approximately halves every 2 years. The NHS must take account of this major trend extrapolated over the lifetime of the hospital systems now under consideration. For example costs for equivalent technology in 2010 will be reduced to only approximately 3% of 2000 prices.  The new technology is key to the re-organisation of healthcare by the establishment of Clinical Care Networks for managing patient care.

Clinical networks are seen as a key tool for improving quality of services in many countries.

The practical effects of this are the re-organisation of healthcare away from the basis of centralised individual hospitals, and to the establishment of clinical care networks for managing patient care.

The treatment of the patient is the responsibility of the network team. There is a better co-ordination and collaboration between Primary Care and the hospital service.

Clinical Networks are a key component of both Scottish and Welsh plans:

The emphasis in clinical networking is on connection and partnership rather than isolation and self sufficiency, on distribution of resources rather than centralisation, and on maximising benefits for all patients rather than a few.

Network-based models of working are already being developed in England in a wide spectrum of specialties:

·       Nationwide for Cancer, Critical Care & CHD.

·       In some areas for Paediatrics, Ear, Nose and Throat, Orthopaedics, Urology, Ophthalmology, Dermatology, Diabetes, Vascular Surgery, Renal services.

Network based approaches are developing in America, Canada, Australia, Denmark & Sweden.

Networks Permit Concentration of Surgical Specialties WITHOUT disproportionate centralisation

The Proposal is for a greater clustering of surgical specialties without at the same time requiring a disproportionate and disadvantageous centralisation of hospitals. It provides excellent utilisation of existing recent investments in Glasgow's hospitals. Construction carried out expeditiously with a stable and practical means of bridging services from their current facilities to the new buildings, which will become available as a result of this plan.

References

1. 'Introduction of Managed Clinical Networks within the NHS in Scotland' Scottish Office DH 9/2/99

2. 'Access & Excellence - Acute Health Services in Wales' DoH July 2000

3. 'Securing our Future Health: Taking a Long-Term View', Interim Report, Derek Wanless, November 2001. Published by The Public Enquiry Unit, HM Treasury, Parliament Street, London SW1P 3AG

4. 'International Critique of Integrated Clinical Services', John Clark, University Birmingham, March 2000

5. Keeping the NHS Local – A New Direction of Travel, Consultation Paper, February 2003,  DoH

6. Keeping the NHS Local – A New Direction of Travel, Summary of Consultation Responses, July 2004, DoH

7. The Configuring Hospitals Evidence File:  Parts one and two, July 2004, DoH

7         RECOMMENDATIONS

 

7.1       The number of acute beds required must be established.

As a primary measure of requirement and of cost this is a basic initial step.

It is clear that:

·       Historical data and trends are one important indicator.

·       The demographic model, particularly the increasing numbers in the population aged 75+ must be addressed.

·       A resource allocation model in which surgical beds are treated as an emergency reserve for medical emergencies is seriously flawed and must be abandoned. It leads directly to abysmal productivity for the expensive and highly trained surgical teams. This in turn leads to large waiting lists, and ultimately to patients' conditions deteriorating to reach emergency status, thus further aggravating the situation.

·       Attempts to plan hospitals on the basis of very high bed utilisation must be abandoned. These inevitably lead to long waiting times and poor productivity by the surgical departments.

7.2       Two acute hospitals are required in south Glasgow.

·       With two sites in operation both are well within the range of medium to large hospitals in the U.K. This size is found best by all other health authorities.

·       The traffic impact of the two hospital strategy is approximately half that of a single hospital of equivalent capacity on the site of the present Southern General Hospital.

·       Small surgical specialties must be re-organised using the clinical networking concepts so that each department is of appropriate size to enable 'out of hours' cover.

·       The two-site strategy permits the full development of specialist day surgery units adjacent to ITU facilities, and hence within the safety guidelines enforced elsewhere (as in USA). The two-site strategy enables utilisation of the modern facilities built at the Southern General Hospital.

7.3       During the phase of building reconstruction, capacity must be retained so that hospital operation can continue and disruption to patients kept to a minimum.

Any new construction would most efficiently be carried out on a green or brown field site. Building on a site separate from existing facilities is much cheaper and faster. Extra expense of modifying an existing hospital arises from various sources:

·       It is more costly to have to build-to-fit than to build from scratch.

·       Maintaining existing services during construction is a difficult, time-consuming and expensive process.

·       A separate construction site leads to a shorter construction phase.

This produces savings because:

·       A new facility has to be paid for from the start of construction, a longer construction period is less cost/effective.

·       The new facility can be put into use sooner, and thus its benefits in quality and reduced cost can be experienced sooner.

Go to APPENDICES