Policy responses and statements

Name of organisation:

Guy's and St Thomas' NHS Foundation Trust

Name of policy document:

Consultation on the Future Options for the Guy's and St Thomas' Poisons Information Service

Deadline for response:

7 December 2007

Background: The Guy's and St Thomas' Poisons Unit (GTPU) is part of the Guy's and St Thomas' NHS Foundation Trust and provides a 24 hour poisons information service to a range of professionals throughout the country.

The GPTU was established over 40 years ago originally as the 'Guy's Poisons Unit'. However, for the past couple of years the GTPU has been separate from the National Poisons Information Service which is commissioned by the Health Protection Agency on behalf of the Department of Health.

Following an internal review, Guy's and St Thomas' NHS Foundation Trust has concluded that the current arrangements are not likely to be sustainable in the long term. The Trust has therefore begun a process of consultation on the options for the future.

This College was identified as one of the stakeholders which could be interested in contributing to this consultation process.

The options paper provides more information on the history and background of the GPTU and the scope of the current service, and sought views on the 4 future options which have been identified.

COMMENTS ON
GUY'S AND ST THOMAS' NHS FOUNDATION TRUST
CONSULTATION ON THE FUTURE OPTIONS FOR THE GUY'S AND ST THOMAS' POISONS INFORMATION SERVICE

The Royal College of Physicians of Edinburgh is pleased to respond to the GTPU consultation and has taken advice from Fellows working in other poisons units around the UK.  This consultation offers an opportunity for external advice to the decisions takers at the Trust.  The College notes that the other poisons centres across the UK are not on the list of stakeholders for consultation, and suggests their direct input would be valuable.  In line with our normal practice for consultation responses, we will be publishing this on our website.

The College understands that the host Foundation Trust is considering the future viability and direction of the GTPU. The Trust has provided a summary of their position by way of background information that has been factually challenged in some respects by our respondents.  The College therefore advises that our comments are based on the following understanding about recent developments in the poisons information services.

A: BACKGROUND INFORMATION

The UK National Poisons Information Service (NPIS) was established as a loose federation in the 1960s.  Units in Scotland and Wales were funded, in part, directly from the local health authorities and in Scotland by the Scottish Home and Health Department.  As the service grew, units became established in a variety of different cities including Birmingham, Cardiff, Edinburgh, Belfast, Leeds, Newcastle and London.  In some of these cities, poisons information services were linked to clinical units, a policy which had been endorsed by government review in the 1960s.  In other units, dedicated clinical beds were not associated directly with the poisons service.  In contrast to most other parts of the world, the UK did not decide to adopt a public access poisons information service, and the service was constructed to promote their services to health professionals.

As the poisons information units expanded their workload, funding issues became important. Collaboration between units was conducted through regular meetings, but there was no formal management structure.  In the 1980s, the Scottish unit in Edinburgh developed its own computer database, TOXBASE, with the support of the then Scottish Home and Health Department.  The principal reason behind this was the introduction of new technology into the NHS, and the recognition that poisons information was one area where information held electronically might be a cost-effective way of delivering advice to clinicians managing patients.

NPIS funding became critical in the mid-1990s, when the then London unit of the NPIS put in a significant bid for additional funding to the Department of Health.  This prompted an external review by management consultants, the results of which were adopted by the Departments of Health in both England and Scotland and used to promote a new working structure for the NPIS.  This was based on using TOXBASE as the first line of poisons information for clinicians managing patients, supported by telephone answering centres and local consultant clinical toxicology support for more difficult medical referrals.

TOXBASE was placed on the Internet in 1999, which caused an increase in usage with a corresponding and expected reduction in telephone enquiries to NPIS.  Telephone enquiries which had peaked at around 300,000 at the end of the 1990s have reduced gradually to the present level of approximately 60,000 a year.  In parallel, TOXBASE use has more than quadrupled, indicating a significant overall increase in contacts between health professionals and the NPIS.

The introduction of NHS 24 in Scotland, and NHS Direct in England, meant that the public now had a point of access for health advice, including advice on poisoning.  TOXBASE provided an easy tool for NHS 24 and NHS Direct and was provided to their staff by the NPIS to support their activities.  This has also reduced the need for direct contact with the NPIS by telephone.

With the introduction of the Health Protection Agency (HPA) in England as an arm’s length body, it was decided that the NPIS should be included in the HPA portfolio as part of the then Chemical Hazards and Poisons Division.  NPIS funds were transferred to the HPA, and the then Scottish Executive Health Department negotiated with the HPA in order that the NPIS unit in Edinburgh could remain linked into the UK overall strategy, particularly since it was (and remains) the host unit for TOXBASE.

The HPA instituted its own review of the NPIS which endorsed the direction of travel set out in the late 1990s.  It was also faced with a number of other problems, including a limited budget and, more importantly, significant pressures from the host Trusts in which NPIS units were placed to resolve issues around consultant contracts and the European Working Time Directive.  The NPIS units traditionally had one or two consultant staff, and these staff had, for many years, supported an on-call rota with very frequent commitments.  This was no longer sustainable and, to address this issue for clinical governance purposes and in view of the overall funding levels available, HPA developed three strategies.  These were supported by the Health departments in all 4 administrations.  These strategies were:

1. To further promote a national, single telephone number for the NPIS which would be the only point of telephone access.  This was in order that call loads could be managed and switched from busy units to quieter ones at times of peak load.  This was welcomed by the majority of NPIS units, who felt that the appropriate sharing of call load would improve the public perception of the service, and reduce unnecessary waiting times which occurred in some units at peak hours.

2. The introduction of a single UK NHS NPIS clinical toxicology consultant rota for out-of-hours advice on cases of severe poisoning.  It was thought approximately 12 consultant toxicologists across the UK would be available to the rota and, since most of these staff had local NHS contracts requiring on call, their contracts would then comply with EU directives for working time, allow appropriate job planning, and ensure appropriate levels of clinical governance.

3. To examine the working practices of the then 5 NPIS units (Birmingham, Cardiff, Edinburgh, London and Newcastle).  Belfast had effectively withdrawn from providing a local service and was using TOXBASE for the Northern Ireland calls, and Leeds had been closed by the Department of Health in England in the mid-1990s for local reasons.

Following a series of meetings between UK NPIS Directors and HPA, it was agreed that a national NPIS consultant rota would start 1 April 2005 and that this would be followed by a national call switching arrangement for all units.

The College understands that the consultant staff in the NPIS unit in London declined to participate in the NPIS consultant rota, citing clinical governance concerns.  Under pressure from the funding agencies, it was agreed that the national consultant rota would start without the involvement of the London team, in the hope that they would join later.  In the event, the rota worked well and the NPIS moved to a 24-hour telephone switching service as planned.

The College also understands that, at this point, GTPU established their own UK-wide telephone service for poisons information.  This appears to have caused some difficulties with the HPA and, as a result, their contract with the HPA was revoked in November 2005.  There followed some difficult discussions at a high level, which resulted in the agreement to undertake an independent review of the clinical governance arrangements of the NPIS.  This independent review, conducted by Dr Chris Evans, found no deficiency in the governance arrangements for the 4 NPIS units covered.  The College understands that the GTPU itself was not included within this independent review.

Since this time, the NPIS units have absorbed much of the workload generated from London and the South East, and the networked service appears to be working well with additional benefits of consistent advice to users, improved CPD for information staff and consultants, and common operating procedures and clinical governance mechanisms.  In addition, shared software for recording details of poisons enquiries is now used by all NPIS units, allowing consistent recording of information and sharing of clinical data between poisons units in real time, supporting audit and research.

B: SPECIFIC COMMENTS ON THE CONSULTATION PAPER

Section 1: Background

Paras 1.4.1.-1.4.4

The Trust is seeking feedback on a range of opportunities for the GTPU beyond mainstream poisons advice to the NHS. These include:

• Veterinary Poisons Information Service (VPIS)
• Clinical Trials Emergency Response Services
• Medical Information Services for marketed products
• Emergency Response Service for Industry

In relation to all of the above, the College understands that these could be provided from other existing facilities, and therefore recommends that the Trust looks carefully at the unique aspects of their own unit and the commercial potential of these areas as none are directly related to the mainstream NHS services, which might be expected to form the core of a poisons unit staffed by clinical toxicologists and within a hospital.

Para 1.4.5

There is a need for poisons information support by telephone to CHaPD in London, but this could be provided from more distant existing units.  However, the College accepts that London in particular may have a requirement for a specialised local service given the heightened terrorist risk in the capital.  Clinical toxicology expertise in London is required to provide hands-on training and support and to help with planning for, and response to, major incidents.  The College believes this should be a higher priority for a London based unit than supporting what might be perceived as a parallel poisons information service.

Para 1.4.6

The provision of antidotes is an important function but not necessarily an NPIS role.  While poisons units may advise on the appropriate use of antidotes, is not necessary for a poisons information unit to provide antidotes.  As happens in other parts of the UK, such provision could be arranged through the pharmacy service and ensuring appropriate governance in the stocking, storage and dispensing of medicines.  Again, the College suggests that the Trust looks carefully at whether this niche service is appropriate for their poisons unit. 

Para 1.4.7

The Chinese Medicines Advisory Service (CMAS) is an interesting and potentially useful service but does not need to be provided in the context of a 24-hour poisons information unit. The College understands that the NPIS has a link with the poisons centre in Hong Kong for specialist advice on toxicity related to traditional Chinese medicines.  If a more local service is justified, then an alternate form of provision would be for the CMAS to be housed within a broader Medicines Information Unit.

Paras 1 .4.8 and 1.4.9

The College acknowledges the importance of education and training and collaborative work and research, and clearly the GTPU would have a role.  However, this is not unique to a London based unit.

Section 3: Current Situation

The College notes the acknowledgement by the Trust that the HPA contract was withdrawn  but, in the absence of any detailed information about why the Trust chose to continue a local poisons information service, finds it difficult to comment on this decision.  Also, the consultation document is rather vague on the question of the Trust’s position regarding the (now completed) governance review.  The College understands that the current telephone enquiry workload for GTPU could be incorporated into the existing NPIS networked service and therefore the sustainability (both financially and clinically) of a stand-alone information unit has to be questioned.

Section 4: Options

Option 1: Status Quo

The College understands that the jointly commissioned clinical governance review did not include the operations of the GTPU, and therefore the statement in paragraph 4.1.1 could be misleading unless there is other evidence that confirms the robustness of the current operation.

The College agrees with the concerns of the Trust regarding confusion for users of continuing a parallel information service.  This risks:

• damaging the quality and consistency of clinical advice provided nationally
• isolating staff within GTPU from national educational and networking opportunities
• failing to provide 24-hour cover within a stand-alone unit
• introducing a potential source of confusion and impaired lines of communication which could be catastrophic in the event of a major incident
• duplicating services unnecessarily
• adding to costs (double funding) by seeking contracts from other NHS users who are entitled to access existing services through NPIS

Continuing to operate a parallel toxicology information service to that offered through NPIS is neither ideal nor sustainable.

Option 2: Renegotiate the Contract with HPA to be part of NPIS

The College accepts the Trust’s reservations about the level of funding that might be available via a new contract with HPA but considers that this option should be explored, assuming HPA have the need of additional capacity.  Equally, the College understands that core funding for less than 24/7 cover will influence the viability of other related services which may have formed part of future plans for the unit.

For the network to function effectively and safely, it is essential that all participating units accept the NPIS governance arrangements and operational practices.  If a new HPA contract is feasible, GPTU would have to resolve their previous differences with the NPIS network.

Option 3: Merge the Poison Services with The Regional Information Service

The College understands that there is room for some variability between the existing units, e.g. the NPIS unit in Newcastle has been integrally linked to the Northern and Yorkshire Regional Medicine Information services for many years.  Such a model avoids some of the confusion for users of operating two separate support mechanisms.  The Edinburgh unit does not provide 24-hour first line telephone support since the (former) Scottish Executive felt this was unnecessary in view of its TOXBASE function.  However, the Edinburgh unit does contribute consultant cover to the UK NPIS consultant clinical toxicology rota.  There may be some scope for retaining local toxicological support via this option.

Option 4: Closure of GTPU

The College considers it would be a great pity to completely close a poisons unit with such a rich history.  Also, clinical toxicology is a small sub-specialty, and the loss of any members of the community threatens its critical mass in the UK.  If closure is the final outcome, the College would hope that the NHS would be able to retain the expertise of most staff. 

The College also accepts that the Trust requires financial viability.  Equally important is that the HPA itself focuses on the most cost-effective poisons information services for clinicians across the UK.  It is unclear at present whether the NPIS requires additional capacity and would be in a position to contract with GTPU.

GTPU is the only service of its kind based in the London area, but the provision of poisons information is not location dependent, being delivered now largely over the internet and by telephone.  Indeed, because of the increased terrorist threat in London it may be a more resilient arrangement if London is covered by poisons information services located away from the capital. 

Nevertheless, there is an important role for clinical toxicology expertise in London to provide hands-on training and support and to help with planning for, and response to, major incidents in London.  This is an area where GTPU may have a unique opportunity if the staffing of the service can be sustained through the development of other related services or contributing to NPIS.  The critical question, therefore, may be whether HPA requires additional capacity within the NPIS.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939

[7 December 2007]