NHS Lanarkshire Radiology Review August 2011
Review of Radiology Services 1. Background NHS Lanarkshire has been undertaking a review of acute and community radiology services over the past 18 months. The aim of this review was to ensure the provision of a high quality radiology service across Lanarkshire that is in line with the three quality ambitions - person centred; safe; and clinically effective - as identified in the Quality Strategy. The review focused on the role of community facilities which provide plain film x-rays. These facilities are in Coatbridge, Cumbernauld and Kilsyth Health Centres with another x-ray unit at Stonehouse Hospital. The community plain film x-ray equipment is all at, or beyond, the recommended age for continued use (in accordance with the Royal College of Radiologists Guidelines). In the case of the equipment at Cumbernauld, Kilsyth and Coatbridge, this was being maintained by the manufacturers on a best endeavours basis, meaning that it is subject to the availability of parts in the event of a breakdown. The review was therefore timely in terms of establishing whether there were alternative ways the service could be provided which would achieve an overall improvement in the service patients were receiving and at the same time improve efficiency. Throughout the course of the review public engagement was undertaken and views were sought on options for the future delivery of the service. The options identified and discussed included: 1) Retain all community facilities 2) Retain a community facility in Cumbernauld 3) Move all community x-ray activity from Coatbridge, Cumbernauld, Kilsyth and Stonehouse to the mainstream radiology units in the acute hospitals. During the course of the review notification was received from the manufacturers of the equipment in Cumbernauld and Kilsyth that they would no longer maintain the equipment. As a result these units were no longer safe to use and had to close in December 2010. This document sets out the findings of the review and the recommended next steps. 2. Improving the service The outcome from the review has identified that a safer, more person-centred and more clinically effective service can be achieved and this paper sets out the case for change.
It is believed that concentrating the community plain-film x-ray activity within the mainstream radiology units in the acute hospitals will achieve an overall improvement in the service to patients. Recognition is given to the fact that some patients will require to travel further as a result and detailed in this paper is activity which will be pursued to mitigate the impact. 2.1 Safe and Effective The Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R) state that patients must not be exposed to harmful radiation for examinations that have limited or no useful clinical diagnostic benefit for the patient. The use of CT, ultrasound and MR provide a more detailed image which can lead to better diagnosis and access to appropriate treatment, and in the case of ultrasound and MR, without the harmful effects of radiation. While there has been a reduction in the use of plain films within acute settings this has not been replicated in the community facilities. There is a need to reduce the number of plain film-x-rays patients are receiving in the community as many of these are not required for diagnosis (see case study 1). Since the facilities at Cumbernauld and Kilsyth closed six months ago there has been a 20 per cent reduction in the number of patients from this area receiving chest x-rays and a 30 per cent reduction in lumbar spine x-rays. Case study 1 - Lumbar Spine X-rays GP Referrals from three Health Centres in North Lanarkshire (Cumbernauld, Coatbridge and Kilsyth) were reviewed and compared with Hairmyres Hospital (South Lanarkshire) over a six month period from Oct 2009 to March 2010. Lumbar spine imaging was chosen for the review because: There are extensive recommendations regarding the value of this examination (Royal College of Radiology: Making the Best Use of an X-ray department). There has been substantial investment from NHS Lanarkshire in alternative, patient focused and more appropriate back pain assessment e.g. direct access to Physiotherapy Back Pain Clinic with direct access to MR imaging. Significant radiation burden to both patient and environment. (Highest single radiation dose of all plain film referrals). The study showed: Health centres were 10 times more likely to refer for a lumbar spine x- ray than the hospital.
No. of Annualised Total % referral patients population rate 3 health 521 1042 101,000 1% centres Hairmyres 193 386 310,000 0.1% The study showed that only 7.5% of referrals from the health centres met current imaging criteria and that no significant pathology was demonstrated in the entire patient group.
2.2 Person-Centred 2.2.1 The Royal College of Radiologists recommend a turnaround of 3 days for the reporting of outpatient x-rays. It is impossible to guarantee that this timescale can be met within the health centres due to the process for submitting x-rays to a radiologist. As there is no electronic system, hard copy x-rays have to be sent to a radiologist based at an acute hospital. The radiologist reviews the x-ray then sends the results back to the GP. On average it will take three days before an x-ray is sent to a radiologist for reporting. Patients attending an acute hospital for a plain film x-ray will have their results sent to their GP on the same day. This allows for serious problems to be picked up immediately as patients can be referred for additional tests or admitted to hospital for treatment on the same day. Where appropriate patients can also be offered alternative imaging to plain film x-ray, such as ultrasound. GPs in other rural areas in Lanarkshire, that do not have access to community x-ray facilities, have the opportunity to receive same day results. For example, patients from Lanark are referred to Wishaw General Hospital for a plain film x-ray and can receive their result on the same day. Patients in Cumbernauld were seen at Central Health Centre and waited a minimum of three days for their result. The professional clinical view of the Clinical Director for Imaging and her senior radiologists is that patients would benefit from better clinical outcomes through having their plain film examinations at an acute site because: (a) images are immediately available for examination and reporting (b) the acute hospitals can view better images as the electronic system (PACS) can allow images to be enhanced (c) patients would have direct access to the relevant specialist at time of their examination The situation is slightly different in Stonehouse as there is an electronic system (PACS) which means plain film x-rays can be sent directly to the radiologist and the report can be sent back to the GP within 24 hours. However patients are still required to travel to an acute site for further examinations if an issue is identified. 2.2.2 For those patients who have been able to access a community radiology service, a change in the location may result in greater travel. It is recognised that patients are regularly travelling to Monklands, Hairmyres and Wishaw Hospitals from their local communities for
numerous reasons: to access services, out patient and day case appointments, etc. Since the closure of Stobhill A&E department we have also seen an increase in the number of Cumbernauld patients attending Monklands A&E (Appendix 1) The issue of transport has been raised by communities in Cumbernauld. However between 1 March 2010 and 28 February 2011 26,485 patients from Cumbernauld attended Monklands Hospital for an outpatient appointment which demonstrates that, despite transport challenges, they are able to access the hospital. Figures show that more than 80% of patients attending Monklands also travel by car or taxi to their appointments. Patients travelling to Monklands for x-ray can receive reimbursement of their expenses if they are in receipt of benefits. Some patients may also be eligible for patient transport to Monklands Hospital and this will be arranged through their GP. As the x-ray clinic is a drop-in clinic this allows flexibility as patients do not have to attend for a specific appointment time. This means visits can be timed to suit with bus times, transport arrangements or other hospital appointments. These transport arrangements will cover the vast majority of patients however if all of these options have been exhausted then every effort would be made to ensure a patient was able to attend the x-ray department. Transport to and from hospital sites is an area that is under continual review and a number of initiatives are underway to address travel/ transport issues which are regularly raised by local communities. These include: Continued dialogue with the Local Authorities, NHS Lanarkshire and Strathclyde Passenger Transport Executive regarding the provision of local transport to and from hospital sites. Development of a pan-lanarkshire car parking strategy to improve management of car parking on all sites Continuous promotion of travel plan within NHS Lanarkshire to encourage car sharing, cycling to work and use of public transport to reduce demand for parking.
Case study 2 Patient AA was referred by their GP in Cumbernauld for a plain film x-ray and was sent to Monklands Hospital. Here the radiology team take responsibility for the patient s pathway. The x-ray was viewed by a radiologist and the patient was admitted to hospital immediately and booked for a CT scan. The patient had the scan and begun treatment within 24 hours of attending for the initial plain film x-ray. Had the patient attended the local health centre for the x-ray there would have been a minimum three-day delay before the results were reported to the GP. It is then the GPs responsibility to refer for additional tests which could result in a further delay in the patient s access to treatment. Patient AA s Pathway Via Radiology 24 HOURS GP Appointment X - Ray X Ray Result Other Tests Patient Starts Treatment Patient AA s Pathway If Attending GP 24 HOURS 24 HOURS GP Appointment X -Ray 3 DAYS X Ray Results GP Refers for Tests Patient Starts Treatment
2.3 Clinically Effective 2.3.1 The number of patient attendances at each community facility over the course of 2010 is listed below. In comparison a plain film x-ray unit at an acute hospital will see around 11,000 patients per annum. Site Attendances Kilsyth Health Centre 1463 Central Health Centre 5047 Coatbridge Health Centre 3857 Stonehouse Hospital 3229 Acute hospital c11,000 per site There has been a steady decrease in the use of plain-film x-rays. The Royal College of Radiologists and SIGN have issued guidelines which have altered the way in which plain films are used. Examinations are shorter and the number of images per examination has reduced. Also the types of exams have reduced with examinations including skull exams, nasal bones, sinuses and ribs no longer carried out. As a result of the decrease in plain films all three acute sites have converted a plain film x-ray room into rooms for either ultrasound or CT with a consequent saving of 10,000 per annum in maintenance costs. According to JH Barber et al; Health Centre X-ray Unit ; British Medical Journal, 1974, 2, 423-427 an efficient community service would see a comparable number of x-rays as an acute district general hospital. When the article was written this number was estimated at 6,000. However with advances in technology and process each of Lanarkshire s acute sites see approximately 11,000 patients per annum. Currently not one of the community sites meets the 1974 recommendation and all are operating at around less than half of the current capacity of the acute sites. Following the closure of the x-ray units at Cumbernauld and Kilsyth in December 2010 there has been a significant reduction in the number of referrals for plain film x-rays. This would suggest that the previous number of attendances were not all necessarily based on clinical need. By way of comparison, there has been no reduction in the use of plain film x-rays at either Coatbridge or Stonehouse.
Plain film x-rays 2010 and 2011 Number of patients 2500 2000 1500 1000 500 Jan - May 2010 Jan-May 2011 0 Cumbernauld Kilsyth Coatbridge Patients by health Centre Stonehouse Comparison of Health Centre Patient Attendances Jan - May 2010 with Jan - May 2011 Jan - May 2010 Jan - May 2011 Cumbernauld 2242 1562 Kilsyth 616 29* Coatbridge 1616 1592 Stonehouse 1454 1638 *There has been a substantial drop in Kilsyth. While some of this will be due to a reduction in the total number of referrals, it is likely that some patients will have been referred directly to the new minor injuries service at Stobhill. Work is continuing with GPs in the area to ensure that all referrals are appropriate. Case study 3 back pain pathway NHS Lanarkshire developed a back pain pathway in 2005 and introduced an extended scope physiotherapy (ESP) service with full clinical support. One of the agreed outcomes of the introduction of the ESP service was a reduction in the requests and practice of lumbar spine x- rays. In 2006 6,522 lumbar spine x-rays were carried out in Lanarkshire. By 2009, following the roll-out of the back-pain pathway, this had dropped to 2,500. In Cumbernauld prior to the x-ray facilities closing in December 2010 only 15 patients per month were referred to the back pain service. This has now risen to an average of 35 patients per month.
We expect the number of plain film lumbar spines to fall even further as the use of lumbar spine x-rays becomes increasingly obsolete in diagnosing the cause of back pain. This is in line with IR(ME)R Regulations which state that patients must not be exposed to harmful radiation for examinations that have limited or no useful clinical diagnostic benefit for the patient. 2.3.2 The equipment within Cumbernauld and Kilsyth is already out of use and the equipment at Coatbridge and Stonehouse is beyond the recommended age for use (in accordance with the Royal Collage of Radiologists Guidelines). The equipment at Coatbridge is being maintained by the manufacturers on a best endeavours basis, meaning that it is subject to the availability of parts in the event of a breakdown. The cost of replacing all community facilities will require a capital investment of approximately 100,000 per community facility. In order to address the delay in reporting results we would also need to install a PACS system at each health centre. The PACS system is an essential part of x-ray provision an would cost an additional 150,000 per health centre. The current capital allocation to NHSL for 2011/12 is 19.454m. This includes the need to meet all costs associated with the construction of Airdrie Community Health Centre during the year. The project is due for completion in June 2012 and the expected spend on Airdrie in 2011/12 is moving towards 14m. This leaves less than 6m for investment in ehealth, backlog maintenance, Monklands Hospital, medical equipment, primary care modernisation and any other requirements which may arise unexpectedly during the year. Providing a radiology service within the acute setting that satisfies all the dimensions of the quality strategy and delivers a higher quality of service would avoid the cost of replacing the local community radiology equipment. Additionally, there would be opportunities to consider the introduction of other outpatient services for patients within the clinical space currently used for the provision of community x-ray services. Further work with patients and our primary care colleagues would be required to identify the potential use of the clinical space and taking account of the cost of alterations.
3. Engagement undertaken so far Substantial local engagement has been undertaken during the past 18 months. This has involved meeting with local GPs, Public partnership forums and community groups to identify the options that should be considered for the future provision of radiology in Lanarkshire. A stakeholder event was held in June 2010, the conclusion from which was the preferred option was to transfer the x-ray activity from all of the community facilities into the acute hospitals. The outcome of this event prompted requests for further engagement with the local communities in Cumbernauld and Kilsyth. The community groups in these areas have expressed a view on the retention of their local community radiology services. The Scottish Government has confirmed that the recommended radiology proposals from NHS Lanarkshire do not constitute major service change under the terms of CEL 4 (2010) Informing, Engaging and Consulting People in Developing Health and Community Care Services and therefore do not require formal public consultation. As a final stage in the engagement process, a review paper was shared with key stakeholders. The paper was also issued publicly to local media and was published on the NHS Lanarkshire website. Responses to the paper were also encouraged via Lanarkshire s social media sites, Facebook and Twitter. Stakeholders were given two weeks to respond with comments to be received by 16 September 2011. We have received 11 responses in writing and comments on social media. A full summary of these can be found in Appendix 2. The key theme that has been raised is travel and transport. This issue has been raised throughout the process. We recognise that public transport is an issue for many people accessing hospitals however we continually review this through our travel plan and with our partners in SPT to see where improvements are made. Solutions It is acknowledged that the majority of patients do travel by car and we are also introducing new car parking management processes to ensure parking is made is easy as possible for patients particularly at Monklands which is of concern to patients from Cumbernauld. These will be in place spring 2012.
Patients from Kilsyth have and continue to be entitled to access services in Glasgow which they may find easier to access by public transport. Flexibility of x-ray clinic the hospital based clinics are drop-in clinics which means that patients can attend at a time that suits them and their travel arrangements. 4. Recommendation The recommendation from this review is that a higher quality patient service can be achieved through the transfer of community radiology activity into the radiology departments within the acute hospitals. It is therefore proposed that all community x-ray facilities are transferred to an acute hospital. This would take place on a phased basis. A full implementation plan would be developed to support this. Phase 1 Transfer x-ray services for Coatbridge, Cumbernauld and Kilsyth patients to Monklands Hospital by 31 December 2011. Remove the obsolete x-ray equipment from Coatbridge, Cumbernauld and Kilsyth. Reduce the Stonehouse x-ray service to one-day per week. Phase 2 - Transfer x-ray services from Stonehouse to Hairmyres hospital by September 2012 when current comprehensive maintenance contract expires. We would seek Board approval to proceed with the implementation of this recommendation. Rosemary Lyness Director of Acute Services September 2011