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Policy responses and statements
- Name of organisation:
- NHS Greater Glasgow and Clyde
- Name of policy document:
- Vision for the Vale of Leven Hospital
- Deadline for response:
- 30 January 2009
Background: This consultation document outlines a Vision for the Vale of Leven Hospital and the wider Hospital site. It describes the full range of services that the Board proposes will be delivered from the Vale, explains how they will be delivered and highlights what this will mean for patients and staff. The Board believes that the Vision described in this document represents the best possible balance between providing local access to high quality services and a requirement to travel for more specialist or intensive care on the occasions when it is required. The Vision is closely informed by the work undertaken on the Lomond Integrated Care Model at the Hospital and also by the views expressed by the two groups of independent experts who have reviewed services at the Vale of Leven over the past 18 months.
COMMENTS ON
NHS GREATER GLASGOW AND CLYDE
VISION FOR THE VALE OF LEVEN HOSPITAL
The Royal College of Physicians of Edinburgh is pleased to respond to NHS Greater Glasgow and Clyde on its consultation on the Vision for the Vale of Leven Hospital.
Key Points
- The College recognises the need for and welcomes the development of a vision for the Vale of Leven Hospital.
- The College believes that the “Independent External Clinical Review of Anaesthetic Services at the Vale of Leven Hospital” exceeded its remit by commenting on acute medical services. This review group had expertise in anaesthetics and accident and emergency, but not in acute medicine.
- The College does not believe that the current proposals for acute medical services at Vale of Leven Hospital are safe.
- The College would not sanction the placement of trainees in medicine in the Vale of Leven Hospital under the proposed model.
- The College believes that further constructive reviews of the acute medical services should be commissioned, for which the expert opinions of Fellows and Members of the Royal Colleges of Physicians should be sought.
Introduction
This response reflects the views of Fellows who are acute and general physicians (including care of the elderly physicians) and supports the response of the Paisley physicians who are most affected by the proposed changes. The College commends the detailed response submitted by our physician colleagues at the Royal Alexandria Hospital, Paisley.
In providing these comments, the College has concentrated on a review of unscheduled medical services and diagnostics. It is for others to comment on the mental health, maternity and planned care services provision.
General Comments
Firstly, a report of this nature, which is essentially about the re-design and re-provision of services for a local population, must address issues of optimising quality of care, patient outcomes and access. In this respect, the report tends to use rather odd and perhaps defensive language which does not state that delivering high quality care is the main aim or goal. This is reiterated in para 6 of the Executive Summary where it states that this proposal “… does not expose patients to unacceptable levels of risk”.
Generally, however, the development of a VISION for the future of Vale of Leven Hospital is to be welcomed. This was a recommendation of the Independent Scrutiny Panel (ISP) in 2007, but the proposals outlined in this document are much more positive than the original Greater Glasgow and Clyde NHS Health Board plan as published in June 2007.
We feel that the proposal for Unscheduled Medical Admissions is not an options appraisal but offers only one solution – a fact highlighted by the continuous use of “will” rather than “would” and implies that minds have been made up.
It should be noted in this regard that the Vale of Leven Hospital does not fulfil the criteria for “Remote Rural”. In the Remote and Rural setting it is recognized that quality of acute care may be compromised, and that a major involvement by GPs is desirable and inevitable. On the contrary, this hospital lies on the edge of a large conurbation and some 19 miles and 20-30 minutes by ambulance from established Acute Medicine services. Thus the population served by the Vale of Leven should have access to the same quality of care as patients in the centre of Glasgow.
It is also noted that there have been two reviews with disparate recommendations. The ISP (Nov 2007) did not regard continuance of acute medical cases at Vale of Leven Hospital as acceptable and based this view on recent expert reports from major bodies (RCPLond, Academy of Royal Colleges, College of Emergency Medicine, Kerr Report etc). The issues surrounding this were discussed and the critical event highlighted, namely the removal of all other acute services (including A&E and full anaesthetic cover) by the Argyll & Clyde Health Board several years previously. That decision was not open to review.
The College believes that the Anaesthetic Services Report (ASR Aug 2008), upon which the current proposals draw heavily for their case, went beyond its remit. That was to assess the sustainability of anaesthetic cover (in which it agreed with ISP and the Glasgow anaesthetists). This report, however, also suggested the perceived best options for Unscheduled Medical Admissions, despite the fact that there were no physicians on the review group, nor is there evidence of discussions with physicians external to the Vale of Leven Hospital. We believe this to be unacceptable, as it has failed to take into account developments in the provision of acute medical services. Furthermore, we believe that the use of the predictive models, upon which the proposal stands, need to be examined by experts in the field of acute medicine and may well be open to challenge. With regard to this, it is noted that the consultation document misquotes the ISP views which did not recommend continued use of the medical model proposed. What it did suggest, however, was that there might be a case for a continued ‘trial’ with certain important provisos – including retention of anaesthetic cover, a national level endorsement, and resources and expert help from, for example, the Health Services Research Unit in Aberdeen.
Other Specific Concerns
Para. 5, Executive Summary - the external report gives a very broad range for the number of patients who could be safely managed at the Vale of Leven (36 – 83%). In contrast, the ‘in-house’ estimates suggest that 70-80% of the current workload could continue to be managed at the Vale of Leven. It is therefore not clear where this data originates from to allow comparison.
Para. 7, Executive Summary proposes a 25% reduction in in-patient beds but no modelling data or outline data is provided to support this reduction. To support a reduction in beds, provide high quality care and high throughput, it is essential that there are adequate laboratory and imaging diagnostic services including near-site testing. Whilst this is alluded to in later sections of the report, there is no detail about the necessary level of support required to deliver a service in this manner. More detail is required about the provision and nature of diagnostic services to adequately interpret this report.
Para. 12, Executive Summary. The projected medical admission figures give a broad range of attendees varying between approximately 12-15 patients per day. Although medical emergencies are largely predictable, this means that any provision will need to manage peaks of least 20 patients per day to accommodate the normal variation by day of the week and time of year. More detail is required in the modelling to show that this could be adequately provided within the bed base and within the proposed staffing arrangements.
Section 2.3.4. The report proposes this will be a consultant supported, GP-led acute unit with general practitioner doctors skilled and trained to deliver appropriate acute care, at present 24 hours per day, seven days per week, with more doctors available during busy periods. The report does not give any details about how the GP rotas would be constructed. In simplistic terms, to provide a EWTD compliant single tier rota 7 x 24 will require a minimum of 10 general practitioners. To achieve any form of continuity in consistent working practice even for this simple single tier model, it would be recommended that these are drawn from the same pool of GPs – is this the case? Clarification to ensure these rotas will be both viable and cost effective must be made available. In reality, to accommodate evenings and in particular peaks of activity, more doctors than this will be required. Indeed, suggestions of over 30 participating GPs have been circulating, and numbers of this magnitude would result in insufficient experience to maintain acute medical skills. No costing figures are given for the staffing arrangements to support this process.
Section 2.3.3, Unscheduled Medical Care activity. The level of detail given in this section is not sufficient to draw adequate conclusions about bed configuration. The protocols proposed would mean that it is likely that many of the patients who will be managed at the Vale of Leven will be complex, elderly patients. This implies that there should be adequate monitoring facilities present within their acute medical model which comply with the minimum level 1 facilities, as outlined in the recent Royal College of Physicians of London acute medicine task report. Equally, to maintain a high throughput to optimise patient experience, it is vital to have appropriate support from the allied health professionals present in an acute medical unit. As such, a full operational policy for the area as described would be required for a full assessment to be undertaken. It is important that these patients are not provided with, in effect, a second rate service.
Section 2.3.2, Patient perspective. This section focuses on patient flow rather than perspective. The data analysis provided using the in-house scoring system is useful, but is a relatively small sample of the proposed population. In the UK, no scoring system has been validated in the out of hospital environment, and thus the safety of patients in an unvalidated system has to be of concern. It is of interest that the reporting group feels that the majority of patients with chest pain (who do not score) should initially present to the Vale of Leven Hospital. Chest pain presentation requires particular attention, as it is one where scores are often low, but this does not relate to the illness acuity. In this group, time to intervention, whether thrombolysis or primary angioplasty, is absolutely critical to patient outcome. It would appear that this group has not been adequately modelled - further work is required to model high volume groups to assess how the Vale of Leven model would meet current acceptable time parameters.
Medical and Non-medical staff training. There is little mention of the training proposed for non-medical staffing to support the proposed unscheduled care services. To provide a high quality service it will be essential that a highly trained nursing work force is available. Clarification of how this would be provided is essential. In relation to the training of general practitioners, this group of doctors will be working effectively at the same level as a newly qualified consultant or a final year trainee in acute medicine who would have at least 4 years of clinical experience in training in Acute Medicine. As such, any training programme must be aligned to the current Acute Medicine curriculum. The College does not regard the training of GPs by 12 meetings and 38 on-line modules as in any way sufficient to provide safe patient care for acute medical admissions. Indeed, there are several notable omissions from the proposed training programme, for example, the management of chronic obstructive pulmonary disease, a common reason for hospital admission and re-admission associated with high mortality. Not only is this not mentioned in the local curriculum, but no protocols are suggested for this group of patients. Similarly, many of the patients presenting acutely will have multiple related medical problems, in other words, complex needs, and will require a combination of diagnosis and treatment to ensure appropriate management. As such, this must necessarily be included in the training requirements. In addition, the College would not sanction the placement of trainees in medicine in the Vale of Leven under the proposed model.
Conclusion
In conclusion, the College feels that it is difficult to review this report and say with any confidence that this will provide a safe service for the local population, and therefore the College could not support the recommendations in this report. To consider this proposal further would require far greater detail with internal and external validation of key areas including staffing levels, competency, operational policies and patient flows. The College does not believe that the proposal should be implemented but, if it were, it must be subject to a prospective high level evaluation to ensure high quality services are provided, and a system must be put in place to terminate the trial when, and if, evidence of impaired outcome becomes clear.
The College is disappointed that neither the acute physicians from the nearest acute hospital in Paisley nor from the national arena have been fully consulted earlier than this. The majority of the patients who require admission would present to physicians with these acute skills. There is an urgent need for the voices of these groups and individuals to be heard and to review the recommendations, as the College has significant concerns that they are incompatible with a high quality, safe service.
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
[30 January 2009]
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