NHS National Waiting Times Centre Board. Local Delivery Plan

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1 NHS National Waiting Times Centre Board Local Delivery Plan

2 Index Page Background.. 4 NHS National Waiting Times Centre Board and HEAT targets 4 The Local Delivery Plan and Financial Challenges 4 Local and relevant national HEAT targets Improving access as a national resource for NHSScotland....5 The Beardmore Hotel and Conference Centre 11 Board 2020 Strategy.. 14 The Beardmore Centre for Health Science.. 24 NHSScotland Objective 1 Health Improvement 27 Early Cancer Detection Lung Cancer NHSScotland Objective 2 Efficiency and Governance Improvements.. 29 Reduce Carbon Emissions Reduce Energy Consumption NHSScotland Objective 3 Access to Services Delayed Discharge NHSScotland Objective 4 Treatment Appropriate to Individuals 33 MRSA/MSSA Bacteraemia: Clostridium Difficile infections 2

3 The local and relevant national HEAT targets agreed for this Local Delivery Plan (LDP) are as follows: Local targets and priorities L1 Improving access as a National Resource L2 The Beardmore Hotel and Conference Centre L3 Board 2020 Strategy L4 The Beardmore Centre for Health Science 1. Health Improvement 1.1 Early Cancer Detection Lung Cancer 2. Efficiency and Governance Improvements continually improve the efficiency and effectiveness of the NHS 2.1 Reduce carbon emissions/ Reduce energy consumption 3. Access to Services recognising patients need for quicker and easier use of NHS services 3.1 Delayed Discharge 4. Treatment Appropriate to Individuals - ensure patients receive high quality services that meet their needs 4.1 MRSA/MSSA Bacteraemia/ Clostridium difficile infections 3

4 NHS National Waiting Times Centre Board Background The National Waiting Times Centre Board (NWTCB) is an NHS National Board. In 2012/13, we planned to carry out a total of 22,581 inpatient, day case and diagnostic imaging examinations. It is expected that this total will be achieved. The range of services includes: orthopaedic, general, ophthalmic and plastic surgery, bariatric and spinal surgery, minor procedures, endoscopy and diagnostic imaging. This number excludes the heart and lung activity, which is measured through our performance management process. The Board also manages the Scottish National Advanced Heart Failure Service (SNAHFS), the Scottish Adult Congenital Cardiac Service (SACCS) and the Scottish Pulmonary Vascular Unit (SPVU) which are commissioned by the NHS National Services Division (NSD). Patients can be referred to the hospital for cardiothoracic surgery, diagnostic and interventional cardiology, orthopaedic surgery, diagnostic procedures (X-ray, MRI, ultrasound etc.), plastic surgery, eye surgery, endoscopy procedures and other general surgery. During 2012/13, the Golden Jubilee National Hospital (GJNH) celebrated ten years as a national resource and it has responded to national demand for its key specialties and increased its activity by 900% over the last 10 years. GJNH, which started off delivering 3,000 procedures a year, is now on track to complete its 300,000 th procedure by the end of 2012/13. We are also the only NHS Board in the UK to have a hotel on site. The Beardmore Hotel and Conference Centre is a four-star facility specialising in conferences, meetings and training courses at special rates for the public sector. NWTCB and HEAT targets As a national board GJNH receives referrals from all Scottish NHS Boards to enable patients to be treated within the timescales set by the Scottish Government. The Board is also responsible for a range of regional and national heart and lung services. The NWTCB, in discussion with the Scottish Government Performance Division, has agreed a specific number of Health, Efficiency, Access and Treatment (HEAT) targets, to reflect where it has no direct control to influence that target. It is acknowledged that this situation is under continuous review. The NWTCB is committed to reviewing the relevance of all HEAT targets together with Government colleagues for subsequent Local Delivery Plans (LDPs). The Local Delivery Plan and Financial Challenges Delivery of the Local Delivery Plan and the three year financial plan is based on the planned achievement of all three key financial targets. This is very challenging but working in partnership, management and staff side have identified a number of efficiency schemes affecting the workforce. Through partnership working, the Board has been able to deliver these efficiency schemes. This work will continue each year with partnership colleagues committed to identifying and delivering new workforce efficiency schemes. 4

5 L1 Improving access as a national resource for NHSScotland NWTCB strategic lead: June Rogers, Director of Operations The projected activity target for 2013/14 includes capacity for: orthopaedic joints, orthopaedic other (intermediate and minor procedures), general surgery, plastic surgery, spinal surgery, bariatric surgery, ophthalmology, endoscopy and diagnostic imaging. In order to maximise the most cost effective and efficient use of capacity at GJNH and to maximise sustainable activity flows, a new funding model has recently been agreed with SGHD and presented to referring Boards. It is planned that Boards will commit to sending patients to GJNH for treatment on the basis of a three year rolling average. The main benefits of changing to this model include: Maximising the use of capacity throughout the year; Delivering greater efficiency in use of resources and public funding; Planning and retention of the GJNH workforce in a more productive and efficient way to meet the needs of NHS Boards; Improving forward planning to address the long term demands of NHSScotland; and Supporting the development of see and treat programmes. We will be working towards a total of 23,408 procedures (8,613 inpatient/day case and 14,795 diagnostic imaging procedures). These projections exclude activity associated with the Heart and Lung programme which will be managed under waiting list management arrangements and monitored through the Board s Performance and Planning Committee. L1.1 Orthopaedic surgery Orthopaedic expansion Orthopaedic surgery was again in high demand throughout 2012/13, particularly influenced by the impact of the Patients Rights (Scotland) Act 2011 which came into effect in September We increased our orthopaedic capacity at GJNH again in 2012/13 to deliver an additional 210 joint replacements in response to the numerous demands that were being made on the service. The full year effect of this increase will amount to 300 joint replacements in 2013/14. Taking into account the expansion above, the 2013/14 target for orthopaedic joint replacements is based on 2,964 primary joints. This number was calculated on the basis of one patient to one theatre slot. Each session equals two theatre slots. However, the case mix we have received over the past three years included approximately 8% revisions procedures or complex referrals. To ensure appropriate use of theatre capacity, provision will be made for this activity in 2013/14. Over a number of years, NHS Dumfries & Galloway has taken advantage of the GJNH see and treat orthopaedic service. This opportunity was offered to all Boards for their 2013/14 activity. This option was taken up by four Boards (Ayrshire & Arran, Dumfries & Galloway, Lanarkshire and Lothian) with a total number of 4,300 patients now being referred to the orthopaedic service at GJNH on a see and treat basis. While there are significant administrative and operational risks around managing this growing service, such as streamlining referral processes and managing waiting times and data flows between Boards, this process provides benefits to patients, referring consultants and GJNH consultants. 5

6 The benefits of the see and treat model of care include: High levels of patient satisfaction; Reduced waiting times in both Outpatients and Inpatients; Single pathway of care; Reduction in duplication of clinical time; and Reduction in duplication in administrative processes. Our expectation is that this level of activity will continue to be delivered on a see and treat basis in 2013/14 and beyond. Orthopaedic telehealth clinics We currently provide Orthopaedic telehealth follow-up clinics for patients from NHS Orkney. This is now the preferred follow- up model for both patients and clinicians. It is expected that in 2013/14 this model will be rolled out to other Boards whose patients experience similar travelling challenges. L1.2 General surgery The availability of a general surgeon 24 hours a day, seven days a week is a prerequisite to support the cardiothoracic programme. It is important, therefore, that general surgery continues to be part of the plan for the GJNH. Currently this service is provided by visiting consultants; the rota is fairly complex and when compounded by the fluctuation we experience in referral flows, this can be a very challenging service. This challenge would be alleviated if the GJNH could attract an appropriate surgical programme which required the presence of general surgeons on site on a continuous basis. This would allow us to provide support to boards on a routine basis and also to support the cardiothoracic programme. L1.3 Ophthalmology The GJNH have a full time Ophthalmic Surgeon who has the capacity to deliver 1200 procedures per year. This number is based on the assumption that all referrals will be for cataract surgery. During 2012/13 the GJNH Ophthalmic Surgeon provided an outreach service approximately four times per annum to supplement the service NHS Orkney receives from NHS Highland. During these visits, our surgeon remains on the island for several days to carry out outpatient clinics and theatre lists. This arrangement will continue throughout 2013/14. During the time our Ophthalmic Surgeon is operating in Orkney, he is back filled at the GJNH by a number of visiting consultants. At the beginning of 2012/13, requests were received for 1400 ophthalmology procedures to be carried out at the GJNH. As we progressed through the year, we experienced an increasing demand for both outpatient and surgical capacity. Meeting this demand has presented many operational and workforce challenges, however, by the year end we expect to have exceeded 1400 procedures. Early indications for next year are that Boards are likely to request access to significantly more capacity than GJNH currently has available. In anticipation of these requests, a paper outlining a proposed expansion of the current ophthalmology service has been presented to Scottish Government Health and Social Care Directorate (SGHSCD) for consideration. This proposal suggests that the service will double in size in 2013/14. Our expectation is that if this service is expanded, Boards will be required to commit to this capacity for a three year period to enable all workforce requirements to be addressed. 6

7 L1.4 Plastic surgery We have theatre and ward capacity to deliver 600 inpatient plastic surgery procedures and up to 1000 local anaesthetic day cases per year. Surgeon availability has presented fewer challenges in 2013/14, however referral rates have been disappointing. We have proposed to referring Boards that we will focus on carrying out more complex procedures in future as our experience is that patients are less likely to travel for minor procedures. Further capacity can be created if referring Boards give longer term commitments to activity. L1.5 Endoscopy As with all other procedures, Board requirements for endoscopy in 2013/14 are not yet clear. There is the potential to increase this service significantly if Boards are prepared to commit to referrals on a long term basis. At the beginning of 2012/13 we received requests to provide only 720 procedures. However, by the end of March 2013 we expect to have received and treated approximately 50% more patients than expected at the beginning of the year. We will continue to respond to our referring Boards pressures, however, a more predictable and long term workflow would demonstrate a more efficient and effective use of the GJNH capacity and would subsequently demonstrate more benefits to referring Boards. L1.6 Spinal surgery Spinal services were identified nationally as representing a risk to the delivery and maintenance of waiting times targets. A spinal review group was formed to develop a national pathway for low back pain and make recommendations for service reconfiguration. The West of Scotland Spinal Services Group first met in December 2011 to understand the current demand, determine future surgical capacity to deliver a service for the West of Scotland and to discuss service options and agree a surgical service model. The GJNH declared available capacity and the required infrastructure to offer a sustainable service model and we stated that our preferred option would involve partnership working within a regional service. The expectation is that non complex lumbar spinal work could be carried out at the GJNH while complex procedures continue to be carried out within NHS Greater Glasgow and Clyde. To date, while options have been considered, there is currently no agreed decision on the way forward. The GJNH will continue to have representation on the group. L1.7 Outreach Cardiology Service to NHS Western Isles In response to a request for support from NHS Western Isles, the GJNH has set up an outreach cardiology service involving provision of consultant advice by telephone and a fortnightly ECHO clinic covered by cardiac physiologists from the GJNH. This service has been set up as an interim shirt-term solution but there is the potential for delivery of an outreach service to be a longer-term requirement. L1.8 Future capacity at the GJNH There is still significant physical capacity to further develop existing services or to create new services at the GJNH. Some examples of opportunities are outlined below: There is the capacity to take on the delivery of a new national service at the GJNH. In addition, operating space in the laminar flow theatres remains available and presents an opportunity to further develop the orthopaedic programme. An expansion of this service could encompass: increasing the lower limb arthroplasty programme further, introducing a spinal service or introducing another subspecialty such as upper limb surgery. Endoscopy could be moved from the main theatre suite and relocated to another part of the hospital where a larger service could be developed. This service could interact with 7

8 the national screening programme to support service demand arising from this service on territorial boards. Capacity can be made available to either relocate or develop a general or plastic surgery service at the GJNH. These specialties are currently delivered by visiting or locum consultants. More robust services with a substantive workforce would add value to NHSScotland. Each year, Boards request magnetic resonance imaging (MRI) activity that exceeds our capacity. Our MRI capacity could be expanded by either extending the working day on the machines or by building a facility to house another unit. L1.9 Management Delivery and Improvement Capacity requests have not been received. Inability to meet projected activity targets. Boards may not accept the proposed three year rolling average commitment. Boards may not require all the capacity we can offer here. The three year commitment presents significant operational challenges including: Managing waiting times Managing unforeseen infrastructure Managing unforeseen staffing issues Managing services that we have offered on a flexible basis (e.g. Letters have been sent to Boards requesting that they complete and return a template detailing their requirements for 2013/16. This will be followed up on a weekly basis until requests have been received and capacity allocated. Any unused capacity will be allocated to Boards in conjunction with Scottish Government to alleviate use of the private sector. Face to face meetings have been held with most Scottish Boards with the exception of those who do not currently refer to the GJNH and Island Boards to discuss the merits of the new proposal. To date, these discussions have been positive. Further discussion and intervention from SGHSCD may be required if boards refuse to commit. Face to face discussions between the GJNH and Boards have been held at which time requirements for the capacity at the GJNH were discussed. We require a long term commitment to orthopaedic surgery and ophthalmology as both services have associated substantive workforces. However, a certain amount of flexibility can be offered for other services provided all capacity is used. In order to maximise the effective use of NHS resources, it is important that NHS Boards initiate early dialogue with the GJNH if they are experiencing delivery demands. The GJNH should be considered as the default provider of additional capacity prior to any consideration of using private sector capacity. The Board will build on its experience with an expanding see and treat workload, and has put in place arrangements to meet the demands of the Patients Rights (Scotland) Act The Board has adjusted its administrative and managerial infrastructure to meet the needs of the changed activity flow arrangements. 8

9 endoscopy, plastic surgery, general surgery) The Board will develop its existing workforce and operational planning mechanisms to ensure effective service delivery. In the event of any significant pressures, a solution will be agreed in partnership with the Scottish Government. The expansion of the expanding orthopaedic see and treat service will present operational and administrative challenges such as ensuring waiting times are met and referral and data transfer processes are effective with a rage of referring Boards. A significant amount of work has been done to date to streamline these administration processes internally. In addition, pilot projects are underway with some referring Health Boards to share patient data, pathways and outcomes. Workforce Availability of visiting surgeons to provide the service that is being offered to the Boards. Our dependency for plastic surgery, general surgery (including appropriate sub-specialty consultants) and endoscopy depends on the availability of visiting surgeons. The lack of long term sustainability of referrals prevents us from recruiting full time specialists in these areas subsequently the dependency on visiting consultants continues. Availability of radiologists to support the service at the GJNH due to the impact of SLA reassessment at host Board. Concerns attached to the provision of appropriate anaesthetic cover due to insufficient staff. General surgery and endoscopy carried out at the GJNH is currently provided by a consortium of visiting general surgeons and gastroenterologists. The plastic surgery service is provided by a locum consultant and visiting plastic surgeons. Permanent appointments cannot be made due to the short term nature of activity requests. Given that there may be increasing pressures at the home Boards of these consultants their continued availability may be a risk. Close and regular communication with the consultants and their Board is important in managing this risk. In addition the new funding flows model should begin to alleviate these risks. Process in place to recruit substantive Radiologists, although to date this has not been successful. In the short term, re-evaluate elements of the current service e.g. governance arrangements and training programmes. Core general/plastics anaesthetic sessions will be provided through existing job plans, with additional activity resourced through wait list initiative or locum cover. Clinical strategy will give long term view of specialties to be delivered enabling substantive appointments to be made. Recruit Specialty Doctors. 9

10 Finance Implementation of the new funding flows model guarantees income sustainability for the three year period, however the ownership of service delivery rests with NWTCB. Tighter scheduling and capacity planning processes need to be maintained. Ongoing scrutiny of scheduling and capacity utilisation will take place within the Board committees. Recovery plans will be put in place immediately. Ongoing contingency planning will be in place to support delivery of the activity. Equalities No risks identified N/A L1.10 Key Performance Targets Target Date December 2012 January- February 2013 April March 2014 April 2013 onwards Milestone Meetings with NHS Boards to discuss capacity requirements to allow delivery of waiting times for 2013/14. Longer term requirements for the use of capacity at the GJNH will form part of these discussions. Submit capacity levels for forthcoming year to National Waiting Times Unit (NWTU). Planning and review of activity by specialty for each Board for each quarter. Monitor performance against target activity by specialty on monthly basis to NWTCB. 10

11 L2 The Beardmore Hotel and Conference Centre delivering value to the public sector NWTCB strategic lead: Jill Young, Chief Executive L2.1 Delivery and Improvement The Beardmore Hotel and Conference Centre has established itself as the leading conference centre of excellence in Scotland. The Beardmore continues to play a vital and supportive role as part of NHSScotland and, since its establishment as the national NHS and public sector conference centre, around 50% of Beardmore business annually comes from the NHS, public and third sector. In the 10 years since the Beardmore has been part of NHSScotland, over 250,000 delegates have attended conferences and events in the Hotel and Conference Centre. Primary Market Usage of Beardmore - NHS/ Public Sector 2005/6 2006/7 2007/8 2008/9 2009/ / / /13 11% 21% 36% 41% 43% 53% 50% 52% The ongoing economic environment continues to present a challenge for the Beardmore. The use of improved management information technology has supported the introduction of defined processes for marketing campaigns and other developments. In depth work to analyse and enhance the customer experience through a reputation management process has enabled the Beardmore to meet expectations. A refreshed strategy for the year 2013/14 building on the 2010/13 strategy will be completed in March and work will commence on a new strategy 2014/17 early in the new financial year. The strategy will seek to consolidate the Beardmore s position as a conference centre of excellence and increase its role with the NHS National Waiting Times Centre with an increased focus on attracting medical related conferences. The current and future strategies will seek to build and maintain the NHS, public sector and not for profit sector at a minimum of 45% reflecting the challenging and unpredictable economic landscape. The Beardmore continues to support the adjoining GJNH by providing dedicated sleep room provision for clinical staff and accommodation for patients and patient relatives, to facilitate improved patient access to treatment and reduce waiting times. Part of the Beardmore Strategy is to continue to develop medical related business from the commercial sector working closely with the Beardmore Centre for Health Science combined with the expertise and specialities of the GJNH. The audio-visual links to the Cardiac Catheterisation Laboratories (Cath Lab) and theatres, and the conference and bedroom facilities in the hotel together provide a unique package for the medical and healthcare market and usage by this market as increased to meet the 2012/13 target of 8%. The Beardmore has continued to develop and invest in both the infrastructure and in the level of service required to maintain its position as a conference centre of excellence and to meet the needs of the NHS and public sector, as well as not for profit, commercial and leisure customers. The Beardmore continues to explore opportunities to increase bedroom occupancy and a continuous sustained increase has been achieved since the original Beardmore Strategy was developed in This has been attributed to smarter working particularly using online intermediaries and an increase across most sectors including patient self pays and leisure 11

12 promotions. Increased bedroom usage has a positive impact on associated spend in restaurants and other leisure activities and this has been important in meeting financial targets. The Board have approved a business case supporting the creation of a central plaza in the current reception area of the Beardmore. This will bring a number of benefits including the creation of a central area for networking, exhibiting and catering for all conferences taking place in the adjacent meeting rooms. This will also provide the opportunity to provide more effective deployment of staff in reception, front office and conference and will also enhance the patient, guest and delegate experience. A five year plan to remodel and upgrade the Beardmore bedroom stock will be developed during L2.2 Financial implications The financial plan within the approved Beardmore Strategy is based on delivery of a breakeven position year-on-year in addition to making a contribution to the Board s efficiency target. These efficiencies are contained within the Board s efficiency plans for and beyond. The Beardmore has continued to increase its income year on year at 2% growth despite the economic downturn. Increased pressure on costs particularly related to payroll and NHS Agenda for Change rates of pay continue to give concern. L2.3 Workforce planning The Front Office team is being redesigned to provide a more effective service in conjunction with the programme of works underway to create a central plaza in the main Beardmore reception area. The ongoing cost of staff, particularly in our Food and Beverage Department, and the requirement to have an affordable and flexible workforce to meet business demands will continue to be a challenge in 2013/14. In addition to the permanent workforce, the Beardmore deploys a flexible workforce model to meet the peaks and troughs of business and to run the business efficiently. These affordable arrangements work well and are essential to the viability of the Beardmore. Any significant change to arrangements in relation to the flexible workforce model would initiate a major cost pressure and threaten the viability of the Beardmore. The Beardmore management continue to work in partnership to deliver service redesign in the hotel. L2.4 Management A detailed risk plan forms part of the strategy and identifies areas of commercial risk and the process in place for mitigating these risks. Workforce Failure to meet financial targets due to impact of costs of NHS terms and conditions, including unsocial hours payments and potential changes to the arrangements regarding Casual and Agency workers. Management processes, monitoring and review of rota management. Beardmore Redesign process providing framework for sustainability. Appropriate utilisation of a flexible workforce to meet additional business needs. Meetings in partnership to develop an appropriate flexible workforce model based on a framework of fairness, affordability and business sustainability. 12

13 Finance Failure to meet financial targets due to decrease in public sector spending and impact of agents in public sector procurement. Close monitoring and tracking. Increased flexibility and ability to react. Diversification into new markets particularly medical, pharmaceuticals, energy. Increased account management. Relationship development with Agents. Failure to deliver a wider workforce model to manage the service peaks and troughs. The service model for the Beardmore, as for every other hotel and hospitality venue, requires the use of a flexible workforce model. If this resource were not available, the hotel would need to consider its financial viability and review alternative service options. The Board approved the continuous use of this flexible business model. Equalities No risks identified. N/A 13

14 L3 NWTCB Board 2020 Strategy NWTCB strategic lead: Jill Young, Chief Executive L3.1 Development of the NWTC Board 2020 Strategy L3.1.1 Background The Board consulted on and developed a programme to define the clinical strategy for the NWTC in This clinical strategy defined the current and future clinical services that it was anticipated would be delivered and developed during the period Many significant clinical developments have emerged during this time and there are a range of other drivers which have led to the need to define an overarching Board 2020 Strategy. Key drivers (this list is not exhaustive): The delivery of the Health and Social Care Quality Strategy The Scottish Government 2020 Vision Health and Social Care Integration Ongoing economic challenges Public health and health inequalities The further development of GJNH as a national resource Defining the ongoing Strategy for the Beardmore Hotel and Conference Centre and the Beardmore Centre for Health Science L3.1.2 Current service developments and innovation The Orthopaedic Service at the GJNH continues to expand and has developed significant expertise and innovation across a range of fields such as: The Enhanced Recovery programme for patients undergoing hip and/or knee replacements, allowing them to be mobile on the same day as their surgery. The first virtual 3D surgical programme to train doctors and medical students on knee anatomy and regional anaesthesia. One of our Consultant Surgeons is recognised as an international authority in Computer Aided Orthopaedic Surgery (CAOS). Within our Heart and Lung Surgery services, ongoing clinical developments are delivering real benefits for our patients and include: Implantation of ventricular assist devices into patients with advanced heart failure. These artificial hearts have a valuable role to play and can buy patients the time they need until their own heart recovers or a transplant becomes available. Creation of the Heart and Lung Institute a research collaboration with the University of Glasgow. Recently awarded 3.9m for a study into how to prevent the failure of heart bypass grafts making a total of 9m in cardiology grants over a two-year period. L3.1.3 Activities to date Two Board workshops have now taken place to shape the focus of the 2020 Strategy and identify and prioritise the strategic service opportunities. In order to facilitate the development of the 2020 strategy, a framework was utilised to bring together and integrate key components and pieces of work to define and deliver this Strategy. These are summarised in the graphic below: 14

15 L3.1.4 The Framework Approach Our existing plans and priorities Our defining principles against which we shape the The basis for building our future state The Board has undertaken a high-level scoping exercise for each of the strategic opportunities and used a prioritisation process including the following criteria: The degree of strategic fit The extent of synergies to our current services How deliverable the service opportunity was What is the degree of urgency to develop this service Through a detailed decision support analysis, the Board assessed the relative opportunity of a range of service developments and identified the prioritisation and phasing of the strategy delivery. At this stage, the Board Strategy developments have been outlined as a set of options, which will be further discussed with stakeholders and developed alongside existing relevant local and national strategies. A phased approach will be used for implementation and will consider the following options for prioritisation: L3.1.5 Sports medicine The opportunity to develop a Sports Medicine service at the GJNH would deliver a number of benefits in terms of prevention, treatment, health promotion and research. Currently, NHS patients requiring Orthopaedic Surgical opinion/treatment have to access this through territorial NHS Board trauma and elective services. Access to NHS physiotherapy services is variable and waiting times are challenging. Access to MSK Allied Health Professions is a developmental HEAT target area for 2013/14. There are good synergies with the GJNH elective orthopaedic service, clinical nutrition department, radiology service (plain XR, CT and MRI), and rehabilitation services (physiotherapy and occupational therapy). Sub-specialisation to include full range of lower and upper limb surgery would be required. There is the potential for there to be a mixed model of Consultant/Extended Scope Practitioner (Physiotherapist/Radiographer) service delivery. L3.1.6 Interventional cardiology In recent years there has been a convergence of approaches to the treatment of cardiovascular disease with combined cardiology, radiology and surgical multidisciplinary team based management. This is particularly true with the advent of transcatheter (transfemoral and transapical) aortic valve replacement as well as the new combined open and endovascular 15

16 approaches to thoraco-abdominal aneurysms, including single stage combined coronary artery bypass grafting and abdominal aortic endovascular aneurysm repair (EVAR). Combining percutaneous coronary intervention with surgical coronary revascularisation and surgical valve repair or replacement in appropriate patients has led to the development of new operating environments in the form of so-called hybrid theatres allowing single stage, hybrid endovascular and open intervention for a range of morbidities in children and adults. An appropriate hybrid facility that brings Interventional Radiology, Cardiology and Surgery together would support a direction of travel that would lead to us being able to provide higher quality modern services and be placed ready for any service developments requested of us, for example in the Interventional/Vascular Radiology field. L3.1.7 Research Strategy The focus of the revised Board Research Strategy is to contribute to the improvement of patient care, and services, both nationally and within the NWTCB, by supporting and managing research and development activity thereby creating a leading international centre of clinical research. The attributes of such a centre should be: An institutional track-record of senior or first author publications in high impact journals Programme-level or international investigator-initiated grants Principal/Chief Investigator on multicentre international industry sponsored-clinical trials Core laboratory analyses which contribute to the primary dataset of multicentre clinical trials Clinicians with lead roles in international professional organisations, e.g. guideline writing groups, speciality working group membership University academics employed or affiliated to institutions which are highly rated L3.1.8 Lung transplantation service Lung transplantation is carried out in situations where a disease or condition has caused the lungs to become so unhealthy that either one or both must be transplanted. These conditions include (but are not limited to): End-stage lung disease Bronchopulmonary dysplasia or chronic lung disease Pulmonary hypertension Heart disease or heart defects affecting the lungs Pulmonary fibrosis Alpha-1-antitrypsin deficiency There are several types of transplant that can be carried out: Single lung transplant Double lung transplant Heart-lung transplant Living donor lobar transplantation this is rarely carried out due to potential risks to the living donors Lung transplantation has the potential both to lengthen life expectancy and substantially improve quality of life. It is impossible to predict how long the recipient may survive after transplantation. The most critical period for survival is the first year after transplantation, when surgical complications, rejection, and infection are the greatest risk. NHSScotland patients requiring lung transplant are currently treated in England. The GJNH is home to the Heart Transplant Service for NHSScotland and is the only heart transplant unit in the UK which does not carry out lung transplant procedures. It is expected that the UK Review 16

17 Report will recommend all Transplant centres should carry our heart and lung transplants. We will fully explore the options available in conjunction with Scottish Government, NSD and key stakeholders and within the context of the wider UK review of transplant service provision. L3.1.9 Expansion of Endoscopy Service GJNH is home to the West of Scotland Thoracic Surgery Service and carries out a range of diagnostic and therapeutic endoscopy procedures. NHS Boards have demonstrated an ongoing demand for endoscopy services and in particular following the commencement of the Scottish Bowel Screening programme. We will explore the option to develop a larger endoscopy unit within the GJNH. L Spinal surgery NHSScotland has seen an increase in referrals to both Neurosurgery and Orthopaedics, many of which were for spinal problems; which in turn has produced an increase in the number of spinal procedures carried out nationally (26.7% increase between 2007 and 2009). Concerns exist Nationally and Regionally around this upward trend. The Treatment Time Guarantee (Patients Rights Bill) will apply to these patients on 1st October 2013 which means that patients must be treated within 12 weeks from decision to treat, following a one year stay of execution which had been negotiated to allow time for further discussions to take place around service provision in future. At the end of October 2010, the GJNH established additional capacity on a short-term basis via visiting consultants from the Royal Orthopaedic Hospital in Birmingham to see and treat a variety of patients. To date, the GJNH have received 109 referrals up to December An initial review of demand highlights by far the highest numbers of procedures are lumbar spine decompression, which have already been carried out at the GJNH. L Bariatric surgery The NHSScotland National Planning Forum and Board Chief Executives have approved the following recommendations: There should be a planned development of Regional centres with expertise in bariatric surgery with a minimum of two surgeons carrying out a minimum of 20 cases per annum each. Clinical pathways and indicators should be developed. Patients with recent onset type 2 diabetes, BMI of and aged under 45 should be offered surgery if suitable. In addition, there should be additional capacity for patients who fall outwith these criteria but may, in the opinion of local clinicians, benefit from surgery. NHSScotland should phase in over 3-5 years, additional capacity to reach a rate of 9 operations per 100,000 population. The GJNH is currently actively contributing to the regional debate and provides gastric band surgery procedures and short-term post-op follow up with the potential to provide the full range of surgical procedures. The Board provides a range of general surgery procedures delivered through a group of surgeons working on a sessional basis at the GJNH. High Dependency care is available for high-risk post-operative patient care. 17

18 L Service Change Transformation Model The Board will develop a service change transformational framework which builds on the model outlined above and brings together the key building blocks to enable successful development and delivery of the emerging 2020 Strategy. L Delivery of the Strategy The proposed programme management arrangements will be based on the Board approach to Project Management as follows: establish a Programme Board (Steering Group); appoint an Executive Lead and agree programme management; ensure full Board and wider stakeholder involvement. A structured method for programme management will deliver the following benefits: a consistent approach to the development and delivery of the Strategy; a common understanding of project team roles and responsibilities; and a robust means of project control and monitoring. L3.2 NWTCB Clinical Strategy Lead: Mike Higgins, Medical Director Significant progress has been made in a number of areas across the existing Board Clinical Strategy. This section of the LDP will focus on key strategic developments as follows: The Scottish National Advanced Heart Failure Service The Scottish Adult Congenital Cardiac Service Extracorporeal Membrane Oxygenation (ECMO) Provision Transcatheter Aortic Valve Implantation (TAVI) The Scottish Pulmonary Vascular Unit The development of the Board 2020 Strategy 18

19 L3.3 Advanced Heart Failure Service Strategy Update The Scottish National Advanced Heart Failure Service (SNAHFS) was agreed with the Scottish Government Health Directorate (SGHD) and approved by the Cabinet Secretary for Health and Wellbeing in December This Strategy describes an integrated approach which will ensure that patients with heart failure throughout Scotland have equal access to a high quality service that provides a full range of appropriate therapeutic options, including heart transplantation, and both long and short term Ventricular Assist Devices (VADs) as a bridge to transplant. It is critically important to recognise that heart transplantation procedures should not be considered in isolation but as one of several options now available for patients with severe heart failure. Extracorporeal life support (ECLS) In line with national practice, venoarterial (V-A) extracorporeal membrane oxygenation (ECMO) has become an intervention in acute circulatory failure as a bridge to recovery or other clinical interventions. Peripheral V-A ECMO may also provide emergency organ support to allow time for assessment without the need for sternotomy. Central V-A ECMO is the intervention of choice in primary graft failure after cardiac transplantation. GJNH has developed the capacity to support ECMO including training for intensive care nurses and physicians. ECMO is one of a selection of interventions such as intraaortic balloon pump, ECMO, and short and long term VADs in the management of advanced circulatory failure. Peripheral ECMO has the capacity to support patients in cardiogenic shock prior to and during transfer to the GJNH for definitive treatment. During 2012, a small number of patients who would have died without intervention were treated with V-A ECMO and addition, GJNH has three years of experience with ECLS in the form of VADS (both short term and long term). These early results are encouraging and the place of ECMO in the management of patients is continuing to evolve. L3.4 Respiratory Extracorporeal Membrane Oxygenation (ECMO) Access to Adult Respiratory ECMO for NHSScotland is through the designated adult ECMO centres in England, with Glenfield Hospital in Leicester continuing as the first point of contact. The benefits of ECMO treatment for Acute Respiratory Distress Syndrome (ARDS), especially in the management of younger adult patients with acute respiratory failure secondary to influenza, continue to be demonstrated on an international basis. While recognising the importance of the residents of Scotland having access to high quality, safe and effective services the decision has been taken that Adult Respiratory ECMO is best provided by specialist centres which treat sufficient patient numbers in order to deliver a high quality and safe service. Based on the Scottish experience in the last two winters, it was considered unlikely that a service based in Scotland would receive the minimum number of patients in any one year. However, the existing ECMO team in Aberdeen has been invited to maintain skills and capability to deliver respiratory ECMO but will not accept clinical referrals from other intensive care units in Scotland. The GJNH continues to be in a position to provide respiratory ECMO if required. L3.5 United Kingdom (UK) Transplant Review Heart and lung transplantation was established in the UK in the 1980s and marked a significant milestone in modern medicine. After a period of steady activity in the 1990s, heart transplant rates fell sharply from over 300 in 1997/98 to under 100 in 2010/11. An additional issue over this period was maintaining recruitment of new consultant surgeons to the service. In 2011, Professor Sir Bruce Keogh (NHS Medical Director) requested that the National Specialised Commissioning Team examine in depth the issues facing heart and lung transplant 19

20 centres in England. The Scottish Government agreed that the heart transplant centre in Scotland be included in this process. The Examination of Issues in Adult Cardiothoracic Organ Retrieval and Transplantation asked the existing centres to present plans for improvement. A panel of experts was convened, supported by specialist advisors in cardiothoracic transplantation, to explore the evidence and assess the plans for improvement. The final report is yet to be concluded and is expected to contain four specific sections The Findings and Recommendations of the Expert Panel, UKwide heart and lung retrieval, UK-wide heart and lung transplantation, and the individual centre issues. The final report will be given to Scottish Government, our Board and NHS Commissioners. The Findings and Recommendations of the Expert Panel will give a complete overview of the process undertaken, the observations of the expert panel and 15 recommendations for consideration. The three supporting papers each provide more detailed information on heart and lung retrieval, transplantation, and strengths of each transplant centre. The Scottish Government have sought assurance, through the Examination of Issues (EoI) programme, that the quality and outcomes achieved by the Scottish heart transplant service were equivalent to those achieved throughout the UK. However, the responsibility for transplantation in Scotland is with Scottish Government and the Cabinet Secretary and therefore, it was not thought appropriate for the EoI to make recommendations for the future of the Scottish heart transplant units. Following a full review of the final report it will be taken to our Board with a proposed action plan and then fully discussed in the first instance with the Scottish Government and NSD. L3.6 Scottish Adult Congenital Cardiac Service (SACCS) Strategy The Scottish Adult Congenital Cardiac Service based at the GJNH is a nationally commissioned service. The service has considered its way forward in the future delivery of this critical national resource. The service model described in the strategy review document provides a clinical network that builds on the expertise from the national centre and provides support to the existing regional services. Under the revised national guidance those patients assessed as having simple and moderately complex congenital cardiac conditions would no longer be cared for solely by the national service. Simple cases will be referred back to local NHS Boards and managed appropriately via local shared care arrangements (i.e. local cardiologist/primary care) or be discharged from the service. Moderate complex cases would be managed through shared care arrangements between a local/regional services with the national service. Severely complex cases will continue to be managed predominantly by SACCS. Regionally, the transfer of simple complex cases back to the host NHS Board of residence has, in the main, already been implemented. The focus is now on planning and improving the management of moderately complex cases. The Scottish Adult Congenital Cardiac Service has developed considerably since designation as a national service. The unit has been successful in achieving recognition as the national centre for treatment of adult congenital heart disease in Scotland. SACCS is acknowledged as one of the specialist Adult Congenital Heart Disease centres in the UK. Supporting Regional Service Delivery It is acknowledged that the transfer of services from NHS Greater Glasgow and Clyde to GJNH has led to a degree of deskilling of clinical staff in their ability to manage patients with recognised moderately complex congenital cardiac conditions. In order to re-establish clinical competency it has been recommended that initially it would be beneficial for those providing a regional service to attend the National Service and participate in the outpatient clinics and the weekly Multidisciplinary Team Meeting. It is also recommended 20

21 that those providing the regional service that an agreed proportion of their clinical time should be dedicated to patients with congenital cardiac disease. The West of Scotland Regional Planning Group has been presented with a proposal from the Cardiac Regional Planning Group to establish a resourced regional service co-located beside the National Service at GJNH. While it is recognised that establishing a regional service remote from large acute sites could lead to de-skilling of accident and emergency and obstetric staff, it is supported as an interim solution, which will be re-assessed. It is planned that this service delivery model will enable appropriate management of patients from the West of Scotland and ensure better equity of access to the National Service for appropriate patients from the North, South and East of Scotland. L3.7 Transcatheter Aortic Valve Implantation (TAVI) Aortic Stenosis (AS) is the most common form of acquired valvular heart disease. When patients become symptomatic they require urgent aortic valve replacement. Without surgery the two-year mortality is around 50%. Until recently the only method of replacing the aortic valve was open heart surgery which requires general anaesthesia, cardiopulmonary bypass, post-operative recovery in the intensive care unit, and a 7-10 day ward stay before discharge. The incidence of AS increases with advancing age and frequently occurs in association with other major medical conditions such as coronary artery disease, cerebrovascular disease, respiratory disease, and renal failure. As a result, there is a substantial cohort of patients in whom the risk of Surgical Aortic Valve Replacement (SAVR) is very high. Transcatheter Aortic Valve Implantation (TAVI) is a minimally invasive technique for replacing the aortic valve. It was first performed in 2002 and, since then, has been refined to the point where it can be performed in the catheter lab, percutaneously, under local anaesthesia with a procedural success rate of 98% and an in-hospital mortality rate of 6-7% compared to the predicted mortality of 15-20% if these patients underwent SAVR. In addition, the mean intensive care unit length of stay is 0-1 days versus 6-7 days for conventional surgery and the overall hospital length of stay is 4-5 days versus days. In September 2012, the Scottish Government announced the result of its review of TAVI provision in Scotland, which set up a single centre at Edinburgh Royal Infirmary commissioned to provide 50 cases per year, commencing from October 2012 to be reviewed after six months to consider numbers and need for a second centre. In December 2012, the English NHS Commissioning Board published a clinical commissioning policy for TAVI for aortic stenosis. This policy recommends providing TAVI at a rate of 25 cases per million of population (1250 cases across England). The TAVI service in Scotland is commissioned to provide approximately 10 cases per million of population. If the Scottish Government accepts the findings of the NHS England Clinical Reference Group policy, Scotland will require provision of 130 TAVI cases per year, which would involve expansion to a second TAVI centre for Scotland. There continues to be trend of increased patient referrals for TAVI within the West of Scotland with our centre receiving approximately 80 per annum although it is believed this is an underestimate. NWTCB has always been prepared to provide TAVI for NHSScotland patients and currently meets all requirements of the national standards for a TAVI centre, in particular we have: three trained and highly skilled Cardiologists who have extensive personal experience of TAVI having recently undertaken interventional fellowships of at least one year s duration in major TAVI centres in London, England, Vancouver, Toronto, and New York. a multi-disciplinary on-site clinical team who can undertake this procedure. This expertise is already supporting the pre-assessment of these patients within Scotland and performs other complex interventional procedures on a daily basis. 21