NORTH OF SCOTLAND PLANNING GROUP

NORTH OF SCOTLAND INTEGRATED PLANNING GROUP Minute of virtual meeting held on Thursday 18 th March 2009 at 14:00. NORTH OF SCOTLAND PLANNING GROUP Approved Dundee: Aberdeen: Inverness: Dr Annie Ingram, Director of Regional Planning and Workforce Development, NoSPG (Chair) Miss Sandra Hay, Corporate Services Manager, NoSPG Mr Brian Kelly, Strategy & Regional Planning Projects Manager, NHS Tayside Mr Bill Boyes, Finance, NHS Grampian (for Mr Alan Gall) Mrs Jillian Evans, Head of Health Intelligence, NHS Grampian (from item 16/10) Mrs Pip Farman, Coordinator, NoSPHN Mr Malcolm Iredale, Director of Finance, NHS Highland (from item 16/10) Ms Roseanne Urquhart, Head of Healthcare Strategy, NHS Highland 13/10 Apologies Apologies were received from: Mr Dave Carson, Financial Controller Service Development, NHS Tayside; Mrs Emelin Collier, Head of Planning, NHS Western Isles; Mrs Pip Farman, Co ordinator, NoSPHN; Mrs Betty Flynn, Regional Workforce Programme Manager, NoSPG; Mrs Marion Fordham, Director of Finance, NHS Western Isles; Mr Alan Gall, Director of Finance, NHS Grampian; Mrs Lorraine Hall, Director of HR, NHS Shetland; Mr Malcolm Iredale, Director of Finance, NHS Highland; Mr Nick Kenton, Director of Finance, NHS Shetland; Mr Ian McDonald, Director of Finance, NHS Tayside; Mr Gerry O Brien, Director of Finance, NHS Orkney; Dr Sarah Taylor, Director of Public Health and Planning, NHS Shetland; Mr Milne Weir, Acting Chief Operating Officer, NHS Orkney; and Dr Peter Williamson, Director of Health Strategy, NHS Tayside. 14/10 Minute of the meeting held on 19 th January 2010 The minute was accepted as an accurate record of the meeting. 15/10 Matters arising i) NoSPG/SAS Group Miss Hay advised that the first meeting of the group had been scheduled for 9 th April 2010 and that good representation had been achieved. ii) Meetings regarding Costing Models Miss Hay advised that Mr Gall had agreed to chair the discussion and that a date in May looked likely. iii) Quarriers Epilepsy Surgery Dr Ingram reminded members that some responses had been received, although NHS Grampian had submitted this to their Asset Investment Group for further discussion and no formal feedback had yet been received. Mr Boyes confirmed that further work had been requested regarding capital and daily charges and the decision would be communicated in due course. BB

iv) Interventional Neuroradiology Dr Ingram reminded members that she and Mr Carson had agreed to present at the national Directors of Finance Group. This had now been scheduled for the May meeting. Dr Ingram also advised that this would be discussed at the NEOPG meeting for technical advice and guidance. Mr Boyes commented that NEOPG had no formal standing for NHS Grampian who did not attend the group and suggested that they could respond remotely or be asked to attend for this item. Dr Ingram confirmed that the group was chaired by Mr Carson and saw no problem in Miss Beattie being invited to attend. AKI v) Bariatric Surgery & Obesity Management Ms Urquhart advised that the first meeting of the newly established sub group had taken place on 3 rd March 2010 and had been well attended and some progress had been made. The group aimed to explore a weight management service across the North and develop a Regional Delivery Plan for submission to NoSPG at its September meeting. Ms Urquhart outlined several areas of work that would be undertaken including: i) development of care pathways in Grampian, Highland and Tayside which would be sent to Louise Ballantyne, NHS Grampian for her to produce an integrated care pathway for the North of Scotland. ii) quantify demand for the service, specifically for severe and complex obesity management. Mrs Farman reported that a small group, which included Public Health colleagues, had been established to look at the needs of data and what was already collected at national level. Ms Urquhart commented that a particular problem area identified was the availability of information regarding weight within primary care. iii) criteria for surgery Duff Bruce, Consultant Surgeon, NHS Grampian was developing a menu of options and number of patients expected, taking cognisance of the new SIGN guidelines. iv) post operative care need to be clear what support required. Dr Utkarsh Kulkarni, Specialist Registrar with NHS Grampian was preparing a literature review. Dr Ingram commented that the SIGN guideline included body contouring surgery and that bariatric surgery was not the end of the pathway for all patients. Ms Urquhart confirmed that SIGN recommended plastic surgery intervention when weight had been lost and sustained for a period of time. Ms Urquhart advised that the next meeting of the group was scheduled for 23 rd April 2010 at 14:30 in Aberdeen. She added that the original timescale was tight and that there was concern about meeting it however this would be kept under review. Dr Ingram asked that a progress report be submitted to keep NoSPG informed of progress. RU Mr Kelly confirmed that NHS Tayside had an involvement in the work.

Dr Ingram advised that at a meeting of the Chairs and Chief Executives the previous day, they had confirmed that the whole pathway be developed, not only bariatric surgery which was one small part. It was agreed that this item be kept on the agenda. AKI 16/10 NSAG i) Process for review Mrs Farman reminded members that NSAG annually ask Regional Planning Groups to review bids that have been submitted for consideration for national designation. As part of the process, NoSPHN review the bids to support discussion at both IPG and NoSPG and decision. Mrs Farman advised that the process had not changed from the previous year and that the timescales were tight, with feedback to NSD being sought by 10 th June 2010 for consideration at the Board Chief Executives meeting on 23 rd June 2010. ii) Review of individual bids Mrs Farman advised that seven bids had been received although two must be assessed together and one was for information only. a. MCN Adult & Paediatric Haemoglobinopathy + Transcranial Doppler Service (must be assessed together) The term Haemoglobinopathy covers a range of conditions in which haemoglobin (the oxygen carrying protein in red blood cells) is either abnormal or absent. The two main disease groups are Sickle Cell Disease (SCD) and Thalassaemia. These are life long genetic disorders which often result in complex medical problems. One of the major deficiencies in clinical services is in the availability of Transcranial Doppler Scanning (TCD), an intervention enabling identification of those children with sickle cell disease at high risk of stroke, thus allowing intervention to prevent this complication. Currently patients outside of Glasgow have to travel to England for a scan or are not scanned at all. The proposed service will be based at the Royal Hospital for Sick Children at Yorkhill, Glasgow and the Network will be based in the Yorkhill Network Office. NSAG: suggested that this did meet the criteria and should be supported. NoSPHN: TCD looks cost effective and should be supported, however, this could be looked at on a case by case basis, through the out of area referrals. The case was not well made for the MCN and a number of queries had been highlighted by the review, therefore this should not be prioritised. Discussion: concern was expressed regarding further top slicing of funds, however, members agreed that purchase on a cost per case basis could be considered and questioned whether there were service sustainability issues to be addressed, if the proposal was taken forward on that basis. The impact on individual boards was also questioned and if relatively small, questioned whether this should be designated at all as a national service. TCD was confirmed as a highly specialist service. The network was thought to be disproportionate for the small number of cases. Members agreed that TCD should be supported in principle subject to the

queries identified, and that the case for the MCN had not been made. Members questioned whether the one bid could be supported in isolation from the other and it was agreed that Mrs Farman should clarify this. b. Primary Ciliary Dyskinesia (PCD) Primary Ciliary Dyskinesia (PCD) is a rare inherited medical condition that occurs in at least one in every 15,000 babies born in the UK. Due to the need for examination very quickly after biopsy, samples are taken from patients in the centre where this diagnostic testing will subsequently be carried out. Highly specialised skills are required to carry out the diagnostic procedures referred to and the multidisciplinary team, infrastructure and equipment required to support this expertise must also be highly specialised. With low referral numbers due to rarity and the need to maintain skill and sustain service, these centres are often regionally or nationally designated to ensure effectiveness of cost and quality. This proposal seeks the formal designation of the pathology department at Yorkhill as the 4 th National UK referral centre for the diagnosis of PCD in Scotland (only centre in Scotland). The service is based at the Royal Hospital for Sick Children at Yorkhill in Glasgow. NSAG: recommended that this bid be supported on the basis that numbers are small, service is cost effective and convenient for patients and families. NoSPHN: there is no alternative for service provision in Scotland, however, the review highlighted that staffing numbers are high given the small number of tests projected. Discussion: members agreed that NSD should seek economies within the range of services funded through national designation at Yorkhill. Costs should be contained within the cost of current services. c. LDL Apheresis Service The proposed service is designed to treat a small cohort of patients with familial hypercholesterolemia (FH) who have continuing very high blood cholesterol levels despite appropriate treatment with diet and lipid lowering drugs. The service will be led by lipid clinicians (including clinical scientists) employed by NHS Lothian. Initial assessment and review clinics will be undertaken at the Royal Infirmary of Edinburgh. The technical intervention (LDL Apheresis) will be undertaken within the SNBTS Clinical Apheresis Unit for SE Scotland sited at the Royal Infirmary of Edinburgh. NSAG: The LDL Apheresis service appears to meet the criteria for small numbers of patients and clinical complexity. In light of no other alternative to this being available members are invited to SUPPORT this application. NoSPHN: the current available evidence does not support endorsement of the bid at the current time. Discussion: Members agreed that the case had not been made and questioned why NICE would support this without relevant evidence. Links to bid 6 were questioned. The bid was not supported. d. Paediatric Epilepsy Surgery

It was noted that the application was still being considered by the Neurosurgical MSN and at this time was for information only, but it had been agreed that given the tightness timescale that Regional Directors has asked for opportunity to develop a view. The bid provides a case for substitution of a service provided primarily by Great Ormond Street Hospital (GOSH) with a Scottish service provided by RHSC, Edinburgh, as part of the existing Scottish Paediatric epilepsy Network (SPEN). The proposed costs are higher than the current cost of sending patients to GOSH. It is argued that a Scottish service is more likely to provide a high quality service, reducing familial stress. NoSPHN: more costly to access service in Scotland than current service in England. No cost effectiveness or best value statement available. Discussion: members noted the issue of critical mass, workforce and patient numbers. The issue of clinical outcomes and patient safety required to be evaluated prior to any recommendation and the bid was not therefore supported. e. Histocompatibility & Immunogenetics Network (resubmission) This proposal is a revised version of an application considered last year, with reduced costs being sought ( 85k reduced to 30k). The proposal is for the development of a network across the 5 H&I laboratory services in Scotland. Histocompatibility & Immunogenetics [H&I, Tissue Typing, HLA typing, HLA specific antibody screening] is a specialised laboratory discipline which supports clinical organ, tissue and cell transplantation, transfusion medicine and disease susceptibility diagnosis. NSAG: views are invited with particular reference to whether the funding sought to support a managed diagnostic network should be prioritised. NoSPHN: the questions highlighted last year remain outstanding. Discussion: members suggested that NHS Blood and Tissue should fund this network if they wished but and agreed that the case had not been made. The bid was not supported. f. Extracorporeal Photopheresis (ECP) Programme In extracorporeal photopheresis blood is removed from the patient, then the white blood cells are separated from the whole blood, treated with ultraviolet light and re infused into the patient. The proposal is to provide an ECP service for all of NHS Scotland for the nine core patient groups for whom the treatment is indicated. ECP will be undertaken within the SNBTS Clinical Apheresis Unit sited within the Beatson Cancer Centre. Clinical teams who refer patients for this specialist intervention will provide ongoing support throughout, however, the administration of ECP is complex and highly specialised and requires dedicated time from the clinical team within SNBTS. Up to 80 patients per annum (rounded) will be eligible for one of the 9 core indications. This reflects a substantial increase in activity for the unit which is currently managing a limited number of patients funded on a cost per case basis. NSAG: The Extracorporeal Photopheresis service appears to meet the criteria for small numbers of patients and significant clinical complexity. Whilst this

treatment might in future be offered more locally the patients who are likely to benefit will already be attending specialist centres close to the service provider. In light of limited existing capacity within Scotland and evidence of significant geographical inequity of use; set against evidence of clinical and cost benefits members are invited to SUPPORT this application. NoSPHN: there is an existing service, funded through Scottish Government, which has focused on patients attending the Glasgow Bone Marrow Transplant Unit (6 new cases per year). The proposal presents a case for more equitable provision of service to patients across Scotland in the 9 core groups indicated. There may be some costs offset by reductions in drug costs. NICE currently approves ECP for two of the 9 groups only (predicted 39 patients). Discussion: members questioned the inequity of the current service for all Scottish patients and whether there was unmet need which required to be addressed. It was suggested that the current service should be equitable and acceptable within the available resource. It was agreed that there may be a case to support in principle, for the NICE approved groups, however there is more work to do to understand what the service will look like in the future. Dr Ingram asked for the views of each territorial Board as to whether in principle, any services should be supported for national designation, which in effect meant more top slicing of resources, given the current financial situation. Tayside: Mr Kelly confirmed that any developments should be funded from efficiencies within current resources and did not support an further top slicing at this stage. Highland: Ms Urquhart expressed serious reservations around further top slicing in the current climate and said that a very strong case would be required, which had not been seen in the bids considered above. Mr Iredale added that locally, no developments were being considered that were not contained within current funding or achieved through efficiency savings or disinvestment. Grampian: Mr Boyes agreed with these comments, saying that it was extremely difficult to support as a priority for investment. Mrs Evans suggested that each case should be evaluated on its own merits and should not be discounted completely as some included risk sharing or were cost effective. Members agreed that any new applications for nationally designated services should highlight the financial case and the impact for Boards to ensure transparency and ease of evaluation. Dr Ingram summarised that the presentation to NoSPG should highlight that in the financially tight environment, recognition be given to cost or clinically effective services which provided better outcomes for patients. Bids 2 5 were not supported, bid 1 may be supported on a cost per case basis and bid 6 may be supported with additional detail provided. It was agreed that NoSPHN should seek answers to the questions highlighted above prior to presentation at NoSPG. 17/10 NoSPG workplan i) Board Leads Miss Hay advised that there was still a disparity between project manager and Board responses and that she would contact Boards individually to clarify. SH

ii) 2009/10 Progress Report Dr Ingram reported that the January 2010 update had been presented to NoSPG and Chairs/Chief Executives groups and was supplemented by the Annual Report and Compendium of Events report. iii) 2010/11 Draft Workplan Dr Ingram advised that the draft workplan had been presented to the Chairs/Chief Executives group the previous day and had been approved subject to the removal of Stroke from the workplan. Dr Ingram reported on the remaining workstreams: Oral: funding had not been approved by all boards for the continuation of the project. NoSPG had asked for a review of the outstanding objectives and a letter had been sent to Chief Executives requesting a response by 24 th March. This would remain on the workplan and the project manager in place until a final decision had been made. Eating Disorders: the clinical lead was due to retire and a discussion regarding replacement had been scheduled. Cardiac: a successful event had taken place on 24 th February 2010 and had resulted in a clear idea of what was required for the development of the Regional Delivery Plan, building on the previous plan. The plan would be presented to NoSPG in June although a discussion on cardiac surgery would be added to the NoSPG agenda for 14 th April 2010. Cancer: an updated workplan and progress report had been received for 2009/10. Children s Services: it was noted that the CHCP needed to detail its objectives and identify real deliverables therefore a scrutiny role was suggested for IPG to hold the group to account and provide a governance structure. Discussion with the CHCP to be scheduled into IPG agenda over the next year. CAMHS: it was noted that timescales had slipped and a substantive discussion would take place with NoSPG in September 2010. The Government had asked for a Gateway Review and it was hoped that this could be undertaken just before OBC stage. Bariatric Surgery: see discussion above. Stroke: it was noted that the Chairs and Chief Executives group had agreed that this should not be added to the workplan. Remote & Rural: it was noted that the project would formally end at 30 th June 2010 and an exit strategy was being discussed. Children s Cancer: this is a national project which is led by Dr Ingram. Medical Directors Group: this has been added to the workplan formally this year although the group was established in 2007. Workforce Planning & Development Group: this group had now been formally established, co chaired by Mr Sinclair, Director of HR, NHS Grampian and Mrs A Gent, Director of HR, NHS Highland. A remit and draft workplan would be presented to NoSPG at its April meeting.

It had been agreed by the Medical Directors that Neurology should be removed from the workplan and confirmed by the Chairs and Chief Executives Group. iv) NoSPG Annual Report Dr Ingram advised that the Annual Report and Events Report would be presented to Boards along with the draft workplan. v) NoSPG Event Report See iv) above. 18/10 Scottish Health Technologies Group Ms Urquhart reported that the last meeting of the group had taken place on 23 rd February and highlighted the main areas of discussion: TAVI: it was noted that there were significant health benefits for patients who were not eligible for surgery, although costs were high. Due to the small number of patients, it was suggested that if TAVI be introduced in Scotland, it should be in one national unit. As there was limited discussion at the meeting, a further discussion regarding roll out would take place on 29 th April 2010. Ms Urquhart advised that there was a proposal for a proper trial in England and that it would make sense for Scottish patients to access this. Computer navigated total knee arthroplasty: significant cost and no added value regarding clinical outcomes. Ms Urquhart was not clear why this service was being used or by whom, if any, in the North. SIGN update: new guidelines regarding weight management were issued on 24 th February and would be launched on 11 th May in Dundee. The existing guideline on Diabetes had been updated and would be launched at the national diabetes conference on 23 rd March 2010. Disinvestment: A national conference entitled Disinvestment Challenge would be held on 6 th May 2010 at NHS QIS, Edinburgh. Ms Urquhart planned to attend and agreed to share the details with colleagues. RU 19/10 Financial Challenges Mr Iredale commented that the current financial challenges were being debated in many fora and he questioned what could be added on a regional basis. It was agreed that a discussion would be scheduled at the next meeting and this made a standing item on the agenda. MI/AKI 20/10 Any Other Competent Business No further issues were raised. 21/10 Date of Next Meeting The next meeting will be held on Thursday 20 th May 2010 at 10:00. Subsequent meetings have been scheduled for: 10 th August; 21 st October; and 21 st December 2010. All meetings will commence at 10:00 and will be virtual. Please notify the NoSPG team (nospg.admin@nhs.net) of the relevant v/c details in order to book the bridge.