POSITION STATEMENT ON THE FUTURE MODEL OF NEUROSCIENCES IN MID AND SOUTH WALES. Chief Executive

AGENDA ITEM 5.2 23 October 2009 POSITION STATEMENT ON THE FUTURE MODEL OF NEUROSCIENCES IN MID AND SOUTH WALES Report of Chief Executive Paper prepared by Purpose of Paper Action/Decision required Link to Health Care Standards: Link to Health Board s Strategic Direction and Corporate Objectives Acronyms and abbreviations General Manager, Medicine Service Group To update the Board on the proposed implementation of the Axford Neurosciences recommendation in including a position statement on the transfer of the unscheduled neurosurgery service from Morriston hospital, Swansea to the University Hospital of Wales. To note contents and approve recommendations Relates to all of the Health Care Standards To align with the clinical and financial 3-5 year service strategy. LHB Local Health Board UHB University Health Board ABM - Abertawe Bro Morgannwg UHW - University Hospital of Wales WAG - Welsh Assembly Government HCW Health Commission Wales Position Statement on the transfer 1/5 Board Meeting of the unscheduled neurosurgery service 23 October 2009

POSITION STATEMENT ON THE FUTURE MODEL OF NEUROSCIENCES IN MID AND SOUTH WALES Executive Summary On Friday, October 16 th 2009, the Health Minister, Edwina Hart, wrote to Assembly Members confirming that the recommendations of the Mid and South Wales and the North Wales Neurosciences Implementation Planning Groups had been referred to the Chairs of the relevant Health Boards for implementation. The report s recommendations pave the way for a more robust, comprehensive and accessible neurosciences service to be put in place, which will focus on the delivery of high quality, safe and accessible patient services. The report, attached at Appendix 1, recommends that a single neurosurgical service is established urgently, with all emergency and intra-cranial activity being undertaken at the University Hospital of Wales, and with an increase in non-complex spinal surgery at Morriston Hospital. In addition, outpatient, diagnostic services and day case neurosurgery activity will continue at both Morriston Hospital and the University Hospital of Wales. Spinal services will also be strengthened under the new model, with many West Wales patients travelling shorter distances to have their surgery, and patients with routine conditions like slipped discs getting better access to treatment. The recommendations have been backed unanimously by all neurosurgeons working in Mid and South Wales and fulfil the ambition to continue to provide a safe and sustainable neurosurgery service in Mid and South Wales for the future. The recommendations are in accordance with best practice and will maintain and sustain both centres in Wales for the benefit of patients and staff; importantly they provide the platform to develop service models that are responsive to local patient population needs. A Joint Media Statement, attached at Appendix 2, was issued on behalf of all six Health Boards in the Mid and South Wales area welcoming the report s recommendations. Position Statement on the transfer 2/5 Board Meeting of the unscheduled neurosurgery service 23 October 2009

An overarching group included the Chief Executive and Executive Directors of ABM and Cardiff & Vale Health Boards is now being established, together with an implementation group jointly led by the Directors of Planning for the respective organisations. ISSUES FOR CONSIDERATION BY THE BOARD Cardiff and Vale and ABM University Health Boards are required to establish mechanisms to deliver the recommendations of the Axford Implementation Programme Board. This means planning pathways with practical and pragmatic approaches which reflect service requirements for the future, and which must be phased over a number of years. There are, however, a number of key recommendations that will need to be implemented over the next 6 months, principally the sustainable establishment of the emergency and intra-cranial neurosurgical service at UHW, and the strengthening of the spinal surgery service at Morriston hospital. A number of related recommendations will also need to be developed in parallel, principally: Recommendation 1: Support the stroke improvement work being undertaken by LHBs and the continuation of the Stroke Services Improvement Programme, to ensure clear links through all aspects of neurosciences Recommendation 2: Establish a rehabilitation network that integrates spinal and neuro-rehabilitation and supports patients at acute sites and in the community, reaching out from the two current specialist centres in Cardiff and Swansea, to ensure that patients are rehabilitated closer to home Recommendation 3: Establish a Mid and South Wales 24/7 acute spinal service Recommendation 4: Establish 24/7 Neuroradiology on call advice system should be established enabled by high definition teleradiology. This will require appropriate 24/7 scanning service at major acute hospitals. Position Statement on the transfer 3/5 Board Meeting of the unscheduled neurosurgery service 23 October 2009

Recommendation 5: LHBs must work together to ensure that there is a well developed trauma system between hospitals and that the major trauma centres effectively support emergency departments in district general hospitals. Recommendation 6: LHBs should work with critical care networks to align future needs for critical care services Recommendation 7: LHBs must work with the Welsh Ambulance Service to ensure appropriate and efficient transport services for patients Recommendation 8: LHBs must work with the post-graduate Dean to ensure training for junior medical staff is of the highest quality Recommendation 9: LHBs should plan and implement effective engagement with all stakeholders, communities, patients and the public to ensure that the opportunities for excellent neurosciences services proposed in this report are fully understood. In supporting the delivery of these ambitious recommendations the Board is encouraged to support recommendation 16: the establishment of a project team across Mid and South Wales to ensure that the proposed service models are fully implemented. Further, the UHB is advised to consider: ISSUES 1. the development of a local project team to support the necessary capital development 2. engage the support of an external facilitator to establish a sustainable integrated service model on the 2 acute sites. Cardiff and Vale UHB is mindful that the work to date has focussed on a safe interim emergency neurosurgery service transfer. In formalising this arrangement the UHB is asked to recognise the following issues: The consequences of full implementation on case mix, capacity (theatres, critical care, neurosurgical and neuro-rehabilitation) and skill-mix requirements. Position Statement on the transfer 4/5 Board Meeting of the unscheduled neurosurgery service 23 October 2009

The required timeframe in which to deliver the detailed clinical model across both centres and other affected services. The need to manage financial consequences across the 2 centres and HCW to ensure an effective and timely implementation of the new service model. Effective and inclusive communications strategy to support the changing clinical model across the 2 centres. CONCLUSIONS The Axford Implementation Programme Board provides an exciting opportunity to secure a successful and sustainable neurosciences service model across Mid and South Wales for the future. Following from the Minister s recent announcement the UHB needs now to work with colleague Health Boards to implement the recommendations of the Axford work. RECOMMENDATIONS The UHB is requested to:- ACCEPT the recommendations of the Axford Implementation Programme Board CONSIDER the specific actions necessary to establish the emergency and intra-cranial work at the University Hospital of Wales urgently ESTABLISH an implementation group supported by a project manager, to deliver the recommendations of the report CONFIRM that the temporary transfer of emergency neurosurgery is maintained at UHW until the permanent solution is in place. Position Statement on the transfer 5/5 Board Meeting of the unscheduled neurosurgery service 23 October 2009

Mid and South Wales Neurosciences Implementation Programme POSITION STATEMENT AND RECOMMENDATIONS FOR EARLY IMPLEMENTATION 1 Overview This report reflects the conclusions of the Mid and South Wales Neurosciences Implementation Programme Board (the Implementation Board) and sets out clear recommendations for service models for robust, high quality neurosciences services. It has been produced by clinical experts in neurosciences from Mid and South Wales. The Implementation Board believes that these recommended service models provide a unique opportunity to ensure that neurosciences in Wales can achieve a world class reputation for their quality, outcomes for patients, research and training excellence. The proposed services represent a significant service improvement. They ensure improved local access for patients supported by excellent specialist centres. The Implementation Board s remit was to provide clinically led advice on the way forward to support the delivery of safe, sustainable and high quality neuroscience services in Mid and South Wales following the publication of the review led by James Steers. Through clinically led working groups, the Implementation Board has made significant progress such that recommendations for implementation have been agreed, specifically: 1. appoint 2 additional neurologists, 1 in Cwm Taf and 1 in Hywel Dda LHBs, to enable the establishment of effective local services working as part of an integrated clinical network; 2. support the integration of the current neurophysiology services to work to common protocols and guidelines 3. support the stroke improvement work being undertaken by LHBs and the Stroke Services Improvement Programme needs to continue to ensure clear links through all aspects of neurosciences 4. establish a rehabilitation network which integrates spinal and neurorehabilitation that supports patients at acute sites and in the community, reaching out from the two current specialist centres in Cardiff and Swansea, to ensure that patients are rehabilitated closer to home 5. strengthen supportive and palliative care for people with neurological conditions to be delivered by multi-disciplinary teams with a specialist interest in neurological conditions 6. urgently establish a single neurosurgical service, with all emergency and intra-cranial activity being undertaken at the University Hospital of Wales, with non-complex spinal surgery and outpatient, diagnostic services and day case neurosurgery activity continuing at both Morriston Hospital and the University Hospital of Wales Neurosciences Implementation Programme 1/15 Position Statement & Recommendations September 2009

7. strengthen and expand spinal surgical capacity at Morriston Hospital to provide improved local access for patients in Mid and West Wales 8. co-locate complex spinal surgery and intra cranial neurosurgery within an expanded unit on the University Hospital of Wales site 9. establish a Mid and South Wales 24/7 acute spinal service 10.establish 24/7 neuroradiology on call advice systems enabled by high definition teleradiology. This will require appropriate 24/7 scanning service at major acute hospitals. 11.LHBs must work together to ensure that there is a well-developed trauma system between hospitals and that the major trauma centres effectively support emergency departments in district general hospitals 12.LHBs should work with critical care networks to align future needs for critical care services 13.LHBs must work with the Welsh Ambulance Service to ensure appropriate and efficient transport services for patients 14.LHBs must work with the post-graduate Dean to ensure training for junior medical staff is of the highest quality 15.LHBs should work with the two universities in Swansea and Cardiff to capitalise on academic and research opportunities 16.LHBs should establish a project team across Mid and South Wales to ensure that these service models are fully implemented 17.LHBs should plan and implement effective engagement with all stakeholders, communities, patients and the public to ensure that the opportunities for excellent neurosciences services proposed in this report are fully understood. 18.in endorsing the service models in this report the Minister may wish to ensure that new models are continually evaluated, taking into consideration views of patients and that this is formally reported to her at regular intervals 19.the Implementation Board should continue to have a role in the on-going planning of neurosciences for Mid and South Wales To ensure the sustainability of core services the Implementation Board is clear that there are a number of key decisions that must now be made, and that rapid implementation should follow retaining strong clinical involvement and leadership through this process. This is of particular relevance to the sustainability of safe, high quality neurosurgical services in South Wales. Neurosciences Implementation Programme 2/15 Position Statement & Recommendations September 2009

2 Background In September 2008 the Expert Group commissioned by the Minister for Health and Social Care, led by James Steers, presented a series of recommendations (see below) for the delivery of a neurosciences service across Mid and South Wales. Overarching Recommendations from Steers Report A managed Clinical Network for neurosciences for Mid and South Wales should be established Four medical neurology services, with in-patient capability, should be established in Cardiff, Newport, Swansea and Carmarthen. Complex care will take place in Cardiff and Swansea. Acute stroke Thrombolysis services should be run by the four medical neurology services until it can be established in the other acute admitting hospitals, where stroke units should be being developed in keeping with the UK guidelines. Two in-patient Neurorehabilitation services should be developed and the spinal rehabilitation service should be close to the Neurosurgical service. This will require an additional WTE consultant at each site. A single Neurosurgical service for South and West Wales, co-located with the complex spinal and spinal deformity surgical service, the Neurocritical care service, the spinal injury unit and principal Neurorehabilitation service should be urgently developed. Non-complex spinal surgery should be available in Cardiff and Swansea and could be provided by either orthopaedic or neurological surgeons. In response to the review, the Minister asked Dr Alan Axford to chair a group to consider how these recommendations could be implemented taking into consideration previous reviews and future pressures and opportunities impacting upon neurosciences services. The Neurosciences Implementation Programme Board held its first meeting in February 2009 and established 5 workstreams to support the detailed work required to inform the implementation programme. The Implementation Board did not attempt to re-work any of the previous reviews but it considered the reviews, in particular the recommendations of the Steers report, and has provided a clinical opinion on how theses recommendations could best be implemented. The membership of the Implementation Board and the nominated workstreams is set out at appendix 1. The Implementation Board believe that the service models recommended in this report will ensure that neurosciences, across all of its disciplines, are of the highest quality, accessible across Mid and South Wales and will provide optimal care for patients. Neurosciences Implementation Programme 3/15 Position Statement & Recommendations September 2009

Benefits of the Proposed New Service Models for Neurosciences Increased access to consultant neurologists in local hospitals Telemedicine links to specialist centres to save patients travelling Improved rehabilitation immediately post surgery or injury and better rehabilitation in the community to enable patients to go home faster Enhanced rehabilitation and supportive care for patients with neurological conditions High quality, sustainable intra-cranial surgery in a department that has a reputation for excellence and where surgeons have the opportunity for subspecialisation Increased access to spinal surgery in Morriston Hospital Joint working with the two universities to increase research opportunities Excellent training opportunities The Implementation Board also recognised that there are a number of immediate and urgent issues that required consideration to enable clear direction to be given to sustain services in Wales. In particular the Implementation Board was aware of the expressed concerns about the sustainability of neurosurgery (which are summarised in the box below) and with this in mind the Implementation Board recommend that a quick and clear decision is made about the future service model. It also recognised that any solutions to the issues associated with neurosurgical services needed to be based in the context of a wider neurosciences service model. Sustainability of Neurosurgical Services The Implementation Board acknowledged the following issues: Clinicians working within neurosciences had expressed their concerns over a number of years associated with the sustainability of the current service The European Working Time Directive had brought these issues to the fore The Deanery had expressed concern about the ability to sustain training status in 2 centres in South Wales and on July 15 th, training status was removed from the Morriston centre The need to support a temporary shift of emergency and complex intra cranial work from Morriston to University Hospital Wales from July 2009 The unequivocal view set out by Neurosurgeons in South Wales that the only way to deliver a safe, sustainable, high quality in-patient intra cranial service was for this to be delivered on one site That to ensure a sustainable and viable service decisions must be made rapidly on the proposed service models but in particular the emergency and intra cranial service Neurosciences Implementation Programme 4/15 Position Statement & Recommendations September 2009

2.1 Structure of the Implementation Board and Working Groups The Implementation Board was specifically established to provide clinically led and clinically owned advice and direction to enable models of care to be developed that would address the issues and recommendations arising from the Steers Review. Membership of the Implementation Board, chaired by Dr Alan Axford included Medical Directors from all the NHS Trusts in Mid and South Wales, the Chairs of each of the workstreams, representation from the Federation of Community Health Councils in Wales, the Wales Neurological Alliance, the National Public Health Service and Health Commission Wales. The Chair of the Stroke Service Improvement Programme (SSIP) was also invited to join the group, recognising the role of the SSIP in supporting the NHS to deliver an excellence in stroke care and the requirement for LHBs to include the recommendations from the neurosciences programme in stroke action plans. The Implementation Board established five workstreams, each chaired by senior clinicians, with strong clinical membership ensuring comprehensive representation both in terms of disciplines and geography. The Wales Neurological Alliance (WNA) has been an integral part of the implementation board and the work streams and their insight into the needs of patients has been invaluable in developing the service models. 3 Service Models and Recommendations Through the five workstreams, service models have been developed which support the delivery of high quality neurosciences services to meet the needs of the local population. The Implementation Board are unanimous in their belief that these models will deliver a high quality, accessible service across Mid and South Wales to the benefit of all patients and importantly make certain the provision of a network of neuroscience services that will have the flexibility to respond to future needs. The new models of care will: Increase access to neurology services particularly in areas where services are scarce Enhance supportive and palliative care for people with neurological conditions delivered by multi-professional teams with a specialist interest in neurological conditions Ensure access to specialist advice 24/7 from neurologists and neuroradiologists to support the diagnosis and management of acute stroke patients, neurosurgery, spinal services etc Establish a single, integrated neurosurgery service across Mid and South Wales Ensure sustainable neurosurgical services with all intra cranial neurosurgical services provided at the University Hospital of Wales co-located with complex spinal and paediatric neurosurgery services Enhanced non-complex spinal service delivered in Morriston Hospital Neurosciences Implementation Programme 5/15 Position Statement & Recommendations September 2009

Increase access to specialist rehabilitation both in the acute hospital phase and in the community with the two specialist centres working together and specialists out-reaching from these centres. Ensure neurosciences services are able to meet all legislative requirements and provide enhanced opportunity for training, research and subspecialisation Confirm the commitment to develop a true partnership with the third (voluntary) sector Improve research opportunities Ensure excellence in professional training 4 Resources In developing new models of care, the Implementation Board has been mindful of the resource framework in which improvements in neurosciences services must be considered. However, the Implementation Board regards this as an opportunity to re-design neuroscience services for the benefit of patients. It is acknowledged that services will need to be modernised within available resources however, the Implementation Board is also of the view that a modest investment into the service would make a real difference in allowing these much needed developments to take place and would enable re-design to be achieved more quickly. The new Health Boards will need to work together to implement these new models of care and in doing so to ensure that services are provided efficiently and revenue requirements are minimised. Phasing of the implementation will be required but some aspects of the programme require early implementation if services are to be sustained and financial risks managed. In particular this applies to the proposed neurosurgical model. 5 Service Models The following section gives an overview of the models of care developed and the key issues and recommendations emerging. 5.1 Neurology The proposed model of care ensures that core neurological services are available at a local level. The Implementation Board has recognised these services are insufficient particularly in West Wales, Powys and in the Cwm Taf areas. The service model proposed requires each Health Board to take ownership of local neurology services to ensure strengthened neurology services are available in each Health Board area. The priorities identified include: The appointment of two consultant neurologists 1in Hywel Dda and 1in Cwm Taf Health Boards, working in a network with the tertiary neurology centres. Through an expanded consultant workforce, to enable subspecialisation with particular reference to stroke care services To focus on developing Morriston Hospital and the University Hospital of Wales as tertiary centres for complex neurology, with local neurology services Neurosciences Implementation Programme 6/15 Position Statement & Recommendations September 2009

supporting and working alongside acute neurology admissions including stroke services Supporting the role of specialist nurses and increasing the access to neurological input for existing nurse specialists To develop supportive and palliative care delivered by a team of multiprofessionals with a special interest in neurological conditions that can access specialist services quickly. The use of telemedicine to support the delivery of neurology services to more rural areas It has been recognised that Powys currently has no local service provision by a Consultant Neurologist and that patients resident in Powys receive their services from a number of hospitals, some outside of Wales. It is anticipated that the proposed increase in neurologists would support the delivery of an improved and accessible consultant led service particularly for those people living in South Powys or who access services in Bronglais hospital. Further consideration for those patients from other parts of Powys is covered in the North Wales report. The expected benefits for patients of this service model include: improved access to a neurology specialist services closer to home especially with the use of telemedicine access to physicians with increased expertise with the benefits of subspecialisation and increased focus on complex neurology in tertiary centres access to specialist nurses who are well supported access to specialist nurses and therapists in the palliation phase 5.2 Neurophysiology The proposed model would result in the two neurophysiology services currently operating across Mid and South Wales working together as a fully networked service. This would ensure that existing resources are used effectively and are equitably distributed to meet the needs of patients. Priorities identified include: The development and agreement of common protocols and referral guidelines to ensure access to service is optimal. Addressing capacity issues particularly in the Hywel Dda area Utilising all of the current neurophysiology resource particularly where clinicians are dually qualified Strengthening and supporting the development of sub specialist expertise which will be enabled by the focusing of complex spinal surgery in Cardiff and brachial plexus injuries in Morriston. The expected benefits for patients include: Reduced waiting times Service close to home Access to clinicians with expertise in the less common procedures Improved intra-operative monitoring Neurosciences Implementation Programme 7/15 Position Statement & Recommendations September 2009

5.3 Stroke The Implementation Board have recognised that the planning for stroke care improvement across Wales is being supported by the Stroke Services Improvement Programme (SSIP). However, a number of issues have been identified in the context of neuroscience services as being of importance in supporting excellence in the diagnosis and management of acute stroke: A recognition of the need to ensure appropriate neurology advice and support is available to stroke physicians and other members of the stroke multi-disciplinary team as required The need to recognise the key role of neuroradiology in the interpretation of scans and diagnosis to support thrombolysis The opportunities to progress the co-location of neurology in-patient facilities with stroke units The key role of neurorehabilitation in aspects of stroke care It is noted that LHBs are required to produce revised stroke action plans by the end of November 2009 and that the SSIP is undertaking a series of visits in October to support this process. The detailed report from this aspect of the programme will therefore be available in these timescales. The key priorities supported by Welsh Association of Stroke Physicians are: Dedicated stroke physicians in each health board area Supported medical training grade doctors across Wales The expected benefits for patients include: Access to a neurological opinion as required Scanning and interpretation of scans locally 5.4 Neurorehabilitation, Spinal Injury and Supportive Care The key objective highlighted by the clinicians and patient representatives through the work of the Implementation Board was ensuring early access to specialist rehabilitation. The model proposed will ensure that neurological and spinal injury rehabilitation teams are able to provide expert treatment and advice to patients in the acute phase to maximise the rehabilitation potential of any individual and inform treatment options. The service model will establish a managed network of experts supporting acute care, community based care and supportive care in local settings. It will: Reduce the length of time patients will require in the specialist centres by providing rehabilitation closer to home post surgery. Ensure a network between the two specialist rehabilitation centres in Cardiff and Swansea and the existing community teams. Support patients on the basis of needs, to include stroke services, people who require long term ventilation and muscle service and people with other complex conditions such as severe chronic fatigue Neurosciences Implementation Programme 8/15 Position Statement & Recommendations September 2009

Ensure on-going rehabilitation of patients with neurological conditions and support them in their own homes It is recognised that the acute rehabilitation teams will need to be of a size that allows increased support when the number or complexity of patients dictates. This approach ensures flow of patients through the acute neuroscience units and the earliest repatriation to the locality. It is envisaged that there will be flow of staff around this comprehensive network ensuring education and adequate experience of the expert. The expected benefits for patients include: Increased access to specialist rehabilitation in the acute phase which will maximise rehabilitation potential Support to allow patients to move to a local hospital or home and continue to receive specialist rehabilitation Improved rehabilitation at home for patients with long-term conditions 5.5 Neurosurgery and Critical Care The Implementation Board confirmed the shared commitment to providing a single neurosurgical service in South Wales which has a reputation for excellence, is able to attract, retain and train high calibre clinicians and is at the forefront of service innovation, research and development. The Implementation Board concluded there is an urgent need to establish a single neurosurgical service, with all emergency and intra-cranial activity being undertaken at the University Hospital of Wales only with non-complex spinal surgery and outpatient, diagnostic services and day case neurosurgery activity continuing at both Morriston Hospital and the University Hospital of Wales. This view has been confirmed unanimously by all the neurosurgeons working in Mid and South Wales who place great emphasis on the retention of service excellence. The Implementation Board established that the current configuration of inpatient intra cranial services is unsustainable and cannot continue to deliver a high quality service. Patient numbers are not sufficient to build up two larger departments that could potentially deliver the required rotas as surgeons would only be undertaking small numbers of procedures. The current service model has struggled to recruit middle grade doctors and had difficulty complying with training requirements. In common with a number of smaller departments in the UK compliance with the requirements of the European Working Times Directive has been particularly difficult. The Implementation Board gave detailed consideration to the potential options for the location of the intra-cranial work. This reconfirmed the findings of the work undertaken through the Steers review. In that Emergency neurosurgery and intra cranial surgery has to be co-located with paediatric neurosurgery, paediatric intensive care and should be co-located with complex spinal surgery. The only hospital in Mid and South Wales where all of these facilities and services are currently located is on the University Hospital of Wales site. The Implementation Board considered how the service components and facilities above could be created on the Morriston Hospital Neurosciences Implementation Programme 9/15 Position Statement & Recommendations September 2009

site and concluded that replicating or moving these services onto the Morriston Hospital site is not feasible, practical or desirable. This is consistent with previous reviews and recommendations and the Implementation Board has not been provided with any evidence that would lead to a different conclusion. In particular: Paediatric neurosurgery cannot stand alone from adult neurosurgery and it would not be possible nor desirable to move paediatric services particularly given the development of the children s hospital on the University Hospital of Wales site. The co-location of adult neurosurgery will support the sustainability of paediatric neurosurgery The recommended service model relies on the development of increased supportive services such as neuroradiology including interventional radiology and neuropathology. These services are better developed in the University Hospital of Wales and would not easily be re-located (and if moved would destabilise other services). The neuropathology service by its nature is not a large service but in Cardiff attracts the support from the University and additional work from the Home Office. This element of the work could not be re-located and therefore disaggregating this service would lead to a disparate and inefficient service. Additionally the capital costs of developing this service on the University Hospital of Wales site are considerably less than those on the Morriston site The recommended model therefore proposes that all neurosurgeons work together across Mid and South Wales so that: Out-patient and diagnostic services will be provided at the University Hospital of Wales and Morriston Hospital, with increased sub-specialist working where appropriate. (Out-patient clinics will also be held in other major hospitals across Mid and South Wales, using telemedicine opportunities where appropriate). Day case work will be undertaken at both the University Hospital of Wales and Morriston Hospital All emergency neurosurgery and intra-cranial surgery will be carried out at the University Hospital of Wales within a dedicated facility to include access to critical care capacity. Non-complex spinal neurosurgery will continue to be undertaken at both Morriston Hospital and the University Hospital of Wales with increased numbers of patients treated in Morriston Hospital Morriston hospital will continue as a major trauma centre and further work should be undertaken between LHBs to ensure trauma systems are well developed and that the major trauma units effectively support emergency departments in district general hospitals. Access to a CT scanner within the A&E department at Morriston Hospital will be required to support this model This new model of care will ensure increased access to a high quality service for all patients across Mid and South Wales which is sustainable and will secure both adult and paediatric neurosurgery together with complex spinal surgery in Wales. Neurosciences Implementation Programme 10/15 Position Statement & Recommendations September 2009

The Implementation Board considered in detail the implications for Morriston Hospital and concluded that, with strong network arrangements, the proposed model would not have a detrimental impact on local services (see below) Impact on Service Provided in Morriston Hospital Morriston Hospital will continue as a major trauma centre. The Implementation Board work has confirmed that the vast majority of the procedures, about 700 operations per year, currently undertaken in the neurosurgical department in Morriston are non-complex spinal operations and this activity would continue. Only about 250 operations per year would need to be transferred. It has also confirmed that there is scope to increase the amount of patients treated in Morriston through the repatriation of appropriate activity from Cardiff to provide improved local access for the population of West Wales. This would mean around 400 operations per year in Swansea. Over time, it is expected that this activity would be undertaken by appropriately trained orthopaedic surgeons. Neurosurgery out-patient and diagnostic services would be expanded in Morriston through the network arrangements and provide the opportunity to develop sub specialist services. Strengthened specialist neurorehabilitation services working across Cardiff and Swansea will be developed enabling early transfer of patients to Morriston, together with increased support in the community to get patients home in a more timely manner. Concurrent with the work of the Implementation Board work, due to clinical governance concerns arising from medical staffing issues in Morriston Hospital, an interim transfer of emergency and complex intra cranial neurosurgical services to the University Hospital of Wales took place during July 2009, overseen by the ABM and Cardiff and Vale Transition Directors. While recognising that, due to the commitment of all involved, this emergency interim transfer has been managed successfully in terms of patient safety, the Implementation Board is clear that the position is not sustainable both for neurosurgery and services that support it. There is an urgent need to agree a clear service model for intra cranial work that gives confidence to clinicians, patients and external regulatory bodies and that has all of the components for a high quality service, meets the legislative requirements and supports training and research. The expected benefits for patients of this service model include: High quality service that attracts high calibre doctors Out-patient and diagnostic services close to home Access to consultants who have developed a sub-specialty expertise Surgery in a fully resourced department Emergency access to a team of surgeons Neurosciences Implementation Programme 11/15 Position Statement & Recommendations September 2009

5.6 Neuroradiology The Implementation Board has endorsed the view that a 24/7 neuroradiology on call advice capability should be developed across the Mid and South Wales area using high definition teleradiology capabilities. This would ensure that local teams have access to expert advice to support the appropriate management of patients. This capability will have far reaching benefits, including the management of hyper acute stroke services in more local settings. The provision of 24/7 access to neuroradiology advice will, however, be dependent upon local availability of 24/7 appropriate scanning to diagnose patients with spinal and cranial conditions. The Implementation Board has not been able to develop detailed costings involved in achieving this at the present time and this will need to be addressed by the new Health Boards. Access will also be required to a CT scanner within the A&E department at Morriston Hospital. Additionally interventional neuroradiology will need to be strengthened at the University Hospital of Wales The expected benefits for patients include: Increased access to a specialist neuroradiologist Improved reporting of scans Local scanning and so reducing the need to transfer patients 5.7 Neuropathology The forensic pathology service for South and West Wales includes neuropathology and is centred in and organised from the University Hospital of Wales. The Implementation Board do not believe that this could be provided on two sites and should continue to be centred in the University Hospital of Wales. The neuropathologists play an essential role in other all-wales neuroscience services including muscle disease and genetics, and provide the CJD (Creutzfeldt-Jacob Disease) service for Liverpool and the whole of Wales. The expected benefits for patients include: Access to a service that is noted for its expertise and has a renowned research reputation that attracts high calibre clinicians 5.8 Neuro-oncology The Implementation Board has acknowledged that the Minister has requested the establishment of a project to explore the options for a future model for cancer services This programme will need to work closely with that project. In the area of neurosciences cooperation between the services in Velindre Hospital and Singleton Cancer Centre is already increasing although it is recognised that both centres have capacity pressures. The proposed service model advocates that patients from the mid and west Wales will continue to be treated in Singleton Cancer Centre. However robust multi-disciplinary team meetings will need to be further developed. The expected benefits for patients include: Improved care as a result of further joint working between the centres Continuation of non surgical oncology delivery from the two cancer centres Neurosciences Implementation Programme 12/15 Position Statement & Recommendations September 2009

Paediatric neurosurgery is and will continue to be provided at the University Hospital of Wales, at the Children s Hospital for Wales. The Implementation Board have confirmed that paediatric neurosurgery would not be sustainable if separated from adult neurosurgery and this also depends heavily on paediatric oncology for which the Children s Hospital for Wales will remain the primary centre. The expected benefits for patients include: Continuation of high quality paediatric neuro-oncology services in Wales 5.9 Spinal Surgery Current services for patients with spinal conditions in Mid and South Wales are inequitably distributed and inefficient. The Implementation Board support the view that complex orthopaedic spinal surgery should continue to be undertaken by specialists in Cardiff and Vale. A single site neurosurgery service for Mid and South Wales co-located with the current orthopaedic delivered spinal services in Cardiff should be urgently developed on the University Hospital of Wales site. This would facilitate a sustainable emergency spinal rota and a sustainable emergency intra cranial rota. The integration would improve care for spinal emergencies for all patients from Mid and South Wales and improve training in spinal surgery. Guidelines for diagnosis and management of acute cauda equine and spinal cord compression have been developed by the spinal surgery workstream. Access to emergency MRI in each LHB will facilitate efficient transfer to University Hospital of Wales for emergency spinal surgery. A scheduled, non-complex spinal surgery service needs to be further developed in Morriston Hospital for the patients from the ABM and Hywel Dda Health Board areas. This service will have a greater emphasis on scheduled work for spinal pain, offering more instrumental fusion surgery as well as continuing the decompression surgery for non-emergency spinal cord and nerve root compression. This service will reduce the number of patients who currently have to go to Cardiff for this type of service. Collaboration with well developed musculo-skeletal assessment and pain services will create a modern, comprehensive and efficient service. To this end each LHB that does not have a musculo-skeletal assessment service to triage referrals to spinal surgery must develop one urgently. Additionally LHBs will need to fully implement the chronic pain commissioning directive issued by the Welsh Assembly Government. The expected benefits for patients include: Access to high quality sustainable adult and paediatric complex spinal surgery in a dedicated department Improved access in an emergency Local management for conditions not requiring transfer to the tertiary centre by joint clinical decision from the spinal centre and the local hospital Increased access for surgery at Morriston Hospital for a range of non-complex spinal procedures meaning that patients from west Wales do not have to travel to Cardiff. Reduced waiting times Access to a range of services as an option to surgery for certain conditions Neurosciences Implementation Programme 13/15 Position Statement & Recommendations September 2009

7 Conclusion and Recommendations The Implementation Board has worked to develop clinically owned and supported models of care which address and respond to the needs and issues of patients and their carers, as well as the organisational and operational pressures and constraints that have been articulated through the various reviews. There is a consensus amongst Board members for these recommendations and it is important that the board has an on-going future in the planning and development of neurosciences. There are a number of immediate priorities where early decisions are essential to ensure that strong, high quality, safe and sustainable neuroscience services are maintained and developed to meet the needs of the population of Mid and South Wales. A number of these priorities fall directly within the remit of the individual Health Boards in their work to meet the needs of their local populations. In relation to neurosurgical services, the issues which have been subject to a previous public consultation led by Health Commission Wales, require an urgent and purposeful decision as a matter of urgency. It is suggested that the work of the Implementation Board has enabled and supported clinicians in working together to develop the solutions proposed. It has enabled and encouraged the essential network arrangements to emerge and these are reflected in the models of care developed. The Implementation Board endorses the following recommendations and recommends urgent implementation of the neurosurgical service model; Recommendation 1: Appoint 2 additional neurologists should be appointed 1 in Cwm Taf and 1 in Hywel Dda to enable the establishment of effective local services working as part of an integrated clinical network; Recommendation 2: Support current neurophysiology services to work to common protocols and guidelines Recommendation 3: Support the stroke improvement work being undertaken by LHBs and the Stroke Services Improvement Programme needs to continue to ensure clear links through all aspects of neurosciences Recommendation 4: Establish a rehabilitation network that integrates spinal and neurorehabilitation and supports patients at acute sites and in the community, reaching out from the two current specialist centres in Cardiff and Swansea, to ensure that patients are rehabilitated closer to home Recommendation 5: Strengthen supportive and palliative care for people with neurological conditions to be delivered by multi-disciplinary teams with a specialist interest in neurological conditions Recommendation 6; Urgently establish a single Neurosurgical service with all emergency and intra-cranial activity be undertaken at the University Hospital of Wales, with non-complex spinal surgery and outpatient, diagnostic services and day case neurosurgery continuing at Morriston Hospital and the University Hospital of Wales Neurosciences Implementation Programme 14/15 Position Statement & Recommendations September 2009

Recommendation 7: Strengthen and expand spinal surgical capacity at Morriston Hospital to provide improved local access for patients in Mid and West Wales Recommendation 8: Co-locate complex spinal surgery and intra cranial neurosurgery within an expanded unit on the University Hospital of Wales site. Recommendation 9: Establish a Mid and South Wales 24/7 acute spinal service Recommendation 10: Establish 24/7 Neuroradiology on call advice system should be established enabled by high definition teleradiology This will require appropriate 24/7 scanning service at major acute hospitals. Recommendation 11: LHBs must work together to ensure that there is a welldeveloped trauma system between hospitals and that the major trauma centres effectively support emergency departments in district general hospitals. Recommendation 12; LHBs should work with critical care networks to align future needs for critical care services Recommendation 13: LHBs must work with the Welsh Ambulance Service to ensure appropriate and efficient transport services for patients Recommendation 14: LHBs must work with the post-graduate Dean to ensure training for junior medical staff is of the highest quality Recommendation 15: LHBs should work with the two universities in Swansea and Cardiff to capitalise on academic and research opportunities Recommendation 16: LHBs should establish a project team across Mid and South Wales to ensure that these service models are fully implemented Recommendation 17: LHBs should plan and implement effective engagement with all stakeholders, communities, patients and the public to ensure that the opportunities for excellent neurosciences services proposed in this report are fully understood. Recommendation 18: In endorsing the service models in this report the Minister may wish to ensure that new models are continually evaluated, taking into consideration views of patients and that this is formally reported to her at regular intervals Recommendation 19 The Implementation Board should continue to have a role in the on-going planning of neurosciences for Mid and South Wales Neurosciences Implementation Programme 15/15 Position Statement & Recommendations September 2009

REPORTS OUTLINE IMPROVEMENTS TO ADULT NEUROSCIENCE SERVICES Friday, 16 October, 2009 W09907-Hlt Two reports published today [Friday, 16 October] outline how adult neuroscience services can be improved for Welsh patients using the existing specialist centres in South Wales and England. The plans, which have been backed by neuroscience clinicians, will also enhance services available at major local hospitals across Wales. The plans will deliver safe, sustainable services for the benefit for patients and staff. Health Minister Edwina Hart said: I have received copies of the reports from the North Wales and Mid and South Wales Neuroscience Implementation Groups. I want to thank Dr Alan Axford and Elwyn Price-Morris for leading this work and am pleased with the extensive clinical engagement and support for the implementation plans. I have now sent the reports to the Chairs of the Health Boards in Wales to implement the recommendations for the benefit of patients and staff. NHS Wales Chief Executive Paul Williams said: The aim of the review and the follow-up implementation reports was to look at the current provision of neuroscience services, including spinal and stroke services, and to build on the current services available and to deliver future services which are robust, safe, sustainable and high-quality. The reports have tackled the key issue of how best to use the skills of the staff, and provide opportunities for new recruits to get the necessary experience to deliver safe services. The reports outline how this can be achieved utilising the current specialist centres in South Wales and England, and enhancing services at existing hospitals. Patients in North Wales will continue to receive neurosurgery at the Walton Centre in Liverpool but receive more neurological care, support and rehabilitation at local hospitals in Wales, reducing the need for travel. In addition, a neurology service will be developed in North Wales with enhanced services at Ysbyty Glan Clwyd, Bodelwyddan, Ysbyty Gwynedd, Bangor and Wrexham-Maelor Hospital. This will provide an enhanced medical neurology service with improved neurological input into stroke management, neurorehabilitation and neurophysiology.

This will improve greatly access to care for people with Parkinson s Disease, muscular dystrophy, multiple sclerosis and stroke Again, in South Wales, the Report, which demonstrates a strong clinical consensus and has been backed unanimously by all neurosurgeons working in Mid and South Wales, will maintain the neuroscience centres at Morriston Hospital and the University Hospital of Wales. Wales, like the rest of the UK, has had difficulty in recruiting middle-grade doctors, particularly in specialist fields, such as neurosciences, where there are relatively few doctors available. This has had an impact on complying with requirements to trained specialists of the future. Surgeons at both centres have been working closely since July and this will be maintained. Complex intra-cranial neurosurgery will continue at the University Hospital of Wales but any pre and post-operative care will be carried out at Morriston Hospital. However, more patients from Mid and West Wales who require spinal surgery will go to Morriston instead of travelling to UHW as at present. The plans will allow surgeons to sub-specialise, increasing their expertise and services, which will improve outcomes for patients. On top of this, additional neurologists will be recruited to provide more services locally for patients across Mid and South Wales. The strengthened neurology service will be able to provide neurological input into stroke management. Rehabilitation for people with neurological and spinal conditions will also be considerably strengthened, to ensure patients are rehabilitated closer to home. While there will be an integration and movement of services between the two sites, we will maintain and sustain both centres for the benefits of patients and staff. The improvements are in line with best practice and have the backing of the neuroscience clinicians across Mid and South Wales. This is an excellent example of how the new NHS is working in partnership for the benefit of patients. Notes Glossary of terms: Neurology is the medical specialty concerned with the diagnosis and treatment of diseases or disorders of the nervous system, including the brain and spinal cord, as well as related nerves, muscles, and their blood supplies. Conditions treated include seizures, migraines, Alzheimer's disease, and Parkinson's disease, among others.

Neurosurgery is the surgical specialty concerned with the treatment of disorders of the nervous system, including brain (intra-cranial), spinal cord, and peripheral nerves. Neurorehabilitation is a complex medical process which aims to aid recovery from a nervous system injury, and to minimize and/or compensate for any functional alterations resulting from it. Neuroradiology is a subspecialty of radiology focusing on the diagnosis and characterization of abnormalities of the central and peripheral nervous system, spine, and head and neck. Neuropathology is a specialty of pathology involved with the study of disease of nervous system tissue. Neurophysiology is the study of nervous system function.

Appendix 2 Date: 16 th October, 2009 MID AND SOUTH WALES NEUROSCIENCES SERVICE A joint statement from Cardiff and Vale University Health Board; Abertawe Bro Morgannwg University Health Board; Hywel Dda Health Board; Powys Teaching Health Board, Cwm Taf Health Board and Aneurin Bevan Health Board. All six Mid and South Wales Health Boards today welcome the recommendations set out in the Mid and South Wales Neurosciences Implementation Programme report. Cardiff and Vale University Health Board; Abertawe Bro Morgannwg University Health Board; Hywel Dda Health Board; Powys Teaching Health Board, Cwm Taf Health Board and Aneurin Bevan Health Board agree that the report paves the way for a more robust, comprehensive and accessible neurosciences service to be put in place, which will focus on the delivery of high quality, safe and accessible patient services. The report recommends that we urgently establish a single neurosurgical service, with all emergency and intra-cranial activity being undertaken at the University Hospital of Wales, with noncomplex spinal surgery and outpatient, diagnostic services and day case neurosurgery activity continuing at both Morriston Hospital and the University Hospital of Wales. Spinal services will also be strengthened under the new model, with many West Wales patients travelling shorter distances to have their surgery, and patients with routine conditions like slipped discs getting better access to treatment. The report s recommendations reflect international best practice and expert clinical advice. NHS Trust Medical Directors, Neuroscience Consultants, patient representatives and expert advisers were represented on the Implementation Board, ensuring recommendations were based on the views of professionals and the interests of patients. At an early stage the Board concluded that certain aspects of the current Neurosciences Service are unsustainable. This reflects a range of workforce pressures. They also clarified scope to drive up Page 1 of 3

Appendix 2 quality and outcomes if new, best practice service models are introduced. We agree with the conclusions. The Health Boards welcome the renewed focus on the development of a more comprehensive neurosciences service, which will encompasse a wide range of services to improve access to diagnosis and treatment of a large number of illnesses and conditions affecting the brain, spine and nervous system, including stroke. This will ultimately improve care for thousands of patients in Mid and South Wales. The new service model also enhances rehabilitation services for people who have suffered a brain or spinal injury, or who have a neurological condition, to enable them to recover and regain as much independence as possible. The proposal will allow surgeons to be supported to sub-specialise, increasing their expertise and the service they offer to patients, including improving patient outcomes. We will also be able to cope better with staffing issues and consolidate the training of new neurosurgeons. Importantly, the proposal provides the opportunity to maintain a safe and sustainable service in Mid and South Wales. The University Hospital of Wales and Morriston Hospital already work closely together and this relationship has been consolidated and strengthened in recent months, following the transfer of complex and emergency neurosurgery from Morriston to Cardiff in July, which was necessary because of doctor shortages. We now have an excellent platform from which to embark on the development of the new single neurosurgery service model outlined in the report, a recommendation which has the unanimous support of our neurosurgeons. We will be setting up a joint Implementation Committee to take these recommendations forward as soon as practicable. Chair of the Mid and South Wales Neurosciences Implementation Programme Board, Dr Alan Axford, said: I am confident that the recommendations in our report represent the best way forward to strengthen and improve neurosciences in the region. Developing the service in this way will offer many benefits to a large number of patients, Page 2 of 3

Appendix 2 improving safety, patient outcome and ensuring we have a sustainable service in the future. Morriston Hospital-based Consultant Neurosurgeon John Martin said: We very much welcome this report and look forward to working together with our Cardiff colleagues to develop safer and even higher quality services for our patients. University Hospital of Wales Consultant Neurosurgeon Brian Simpson added: Patient safety and best possible outcomes for patients are our top priorities. We are delighted to have this great opportunity to develop the clinical neurosciences into the superb regional service we all want. Ends Page 3 of 3

Neurosciences Frequently Asked Questions What effect will the report s recommendations have on patient flows at Morriston Hospital in future? The flow of neurosurgery patients into Morriston Hospital is expected to be greater than the flow away, under the new neurosciences plan for Mid and South Wales. More than 1,500 patients are expected to be treated at Morriston Hospital in future, an overall increase of 50-100 cases a year. In addition, neurosurgery outpatient clinics will continue in Morriston Hospital and other major hospitals across the region. How can the majority of cases still be treated at Morriston Hospital, if neurosurgery is based at the University Hospital of Wales? It largely comes down to managing the mix of spinal surgery and brain surgery casework in the region. Under the new plans, figures sourced by the report show that about 300 patients a year needing complex or emergency surgery will go to Cardiff instead of Morriston. However, more than 70 per cent of planned spinal procedures and daycase surgery will continue as before in Morriston just over 700 a year. In addition, 450 or so emergency spinal cases will still be seen at Morriston if they are not complex. And, it isn t a one-way flow East. Approximately 350-400 patients from Mid and West Wales, who for a variety of reasons currently travel to UHW for spinal treatment, will instead come to Morriston. This means that the overall number of patients into Morriston Hospital in future is expected to increase annually by 50-100 cases. 1