LLANDUDNO HOSPITAL PROJECT CYCLE ONE REPORT FOR REHABILITATION PROJECT TEAM: ASSESSMENT OF POTENTIAL SOLUTIONS FOR DEVELOPING SERVICES MARCH 2010

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1 LLANDUDNO HOSPITAL PROJECT CYCLE ONE REPORT FOR REHABILITATION PROJECT TEAM: ASSESSMENT OF POTENTIAL SOLUTIONS FOR DEVELOPING SERVICES MARCH 2010 SITUATION The Rehabilitation Project Team has been established under the Project Board. It has been tasked to base its work on the relevant recommendations of the Conwy LHB review (June 2009) and will develop a services plan for its respective service area, including consideration of all resource, staffing and infrastructure requirements. The project team will produce a services plan and consider the resource implications, including estates, for developing services at Llandudno hospital in its given service area. The overall project is divided into three cycles. This report forms part of the first cycle. The objective of the report associated with this cycle is to assess the range of potential solutions for developing services based upon the recommendations of the Conwy LHB review. In accordance with that Conwy LHB review, this report builds upon the recommendations of that report, provides an update of the expected need, determines the expected capacity required and assesses the clinical viability, sustainability and resource requirement of each solution. This report also identifies a short list of solutions for further investigation, demonstrating the evidence in support of the short list. This report will then form the basis of the next cycle within the project, which ultimately identifies the preferred solution. 1 of 18

2 BACKGROUND A review regarding the future of Llandudno General Hospital was undertaken by Frank Burns between May and December 2007 which made 50 recommendations of a clinical and non-clinical nature. The review identified a range of service enhancements that the hospital could develop, given its geographical location, to meet both the needs of the local community and a broader population. The Report recommends that Llandudno Hospital becomes a diagnostic, treatment and rehabilitation centre for both the immediate Llandudno area and, for certain services, the four counties of central and western North Wales. The hospital would deliver a wide range of health care that supports local primary and community services, as well as the acute hospital sites at Bangor and Glan Clwyd. Through this it would be able to play its full part as one of the network of hospitals across North Wales. Specifically, support was made for the development of a post acute specialist rehabilitation centre for the intensive rehabilitation of stroke, other neurological, orthopaedic and cardiac patients, with rehabilitation of elderly medically frail patients and those with a comorbidity including delirium being identified. The Burns review states that the key purpose of developing a geographical centre of excellence in rehabilitation include: Increasing critical mass for the clinical teams in order to facilitate subspecialisation Creating an environment in which specialist or consultant therapists can evolve Improving liaison and collaboration in the design of care pathways between related specialities Increasing critical mass for the more economic use of specialist facilities or staff Maximising the flexible deployment of specialist rehabilitation staff Creating a reputation for excellence of services and facilities that aids recruitment and retention of the best staff Creating a multi disciplinary, integrated approach to rehabilitation that generates opportunities for academic involvement, research and publications further improving recruitment and retention prospects Development of patient (and carer) empowerment services 2 of 18

3 including patient/care involvement processes, education facilities, information services, expert patient programmes etc. In light of the recommendations of the workgroups, the following actions were agreed by the Conwy LHB Project Board: Specialist stroke rehabilitation services for the two local acute stroke units are developed for the defined conditions. Routine stroke rehabilitation is continued for Llandudno Hospital catchment residents. Support for considering the Hospital as the location for the establishment of an inpatient ABI facility, as it would have synergy with other pre existing services on site and enhance the development of further services, such as a hydrotherapy pool. The current Assessment and Treatment Unit would have freed space to provide a base for the provision of rehabilitation services if the proposed therapy unit adjacent to the Endoscopy unit is developed. The establishment of an education centre at the hospital. A facility is developed on site for the diagnosis and treatment of delirium. NOTE: the recommendation of developing a delirium service was not a recommendation of the Frank Burns review and report. In developing this report, several sources of recommendations and standards have been considered and referenced, some of which are Nationally recognised. These are as follows: 1) Long Terms Conditions (Neurological) NSF: England 2) Older Person s NSF 3) All Wales Neurosciences Review recommendations 4) North Wales Neurosciences Review recommendations 5) The Frank Burns Review 6) The Conwy LHB Review 7) Supporting evidence, best practice and other review documents: a. North Wales Stroke Local Delivery Plan March b. The 10-year Brain Injury Strategy for North Wales c. Designed for North Wales by Dr. Christopher D.V. Jones CBE 3 of 18

4 d. The Association of British Neurologists (ABN) Response to the NSF for Long Term Conditions This literature review concludes with the below diagram that helpfully outlines the context of this paper as part of the wider core services provided at Llandudno hospital. Evidence from the above publications are referenced in the following sections as supporting evidence for the proposed solutions. 4 of 18

5 Service Relationships between Rehabilitation and core hospital services Rapid Access Chest Pain General Outpatients Surgery Breast Surgery (+? Reconstruction) Day Cases MIU Selected Admissions as per protocol Elective Semi-acute Rehabilitation Orthopaedics Maxillo-facial? Ophthalmology?Other Specialities Gastroenterology (sub regional diagnostic elective) Transferred back to LLGH after stabilisation Monitor Beds Facility Bone Services Proposed Neurosciences Facility Movement orders (Outpatient & inpatient) ABI (Inpatient Services) Core Rehab Services Physiotherapy Speech & Language Occupational Therapy Psychology, Dietetics Proposed Therapy Unit Rheumatology Community Services Care of the Elderly Specialised Stroke Rehabilitation (young patients, Cognitive, basal Ganglia, neglect EMH/Delirium Unit (inpatient and Outpatient specialised Clinic) Proposed Hydrotherapy Pool Current Assessment & Treatment unit Routine Rehabilitation Cardiac Rehabilitation Pulmonary Rehabilitation Local Stroke Rehabilitation New Service or Facility Existing service or facility some change Existing Service or Facility no change 5 of 18

6 ASSESSMENT Both the Burns and Conwy LHB review clearly identify five areas for development: 1) Inpatient Rehabilitation 2) Acquired Brain Injury 3) Outpatient based Rehabilitation 4) Therapy Services 5) Education Centre The Conwy LHB review goes one step further to introduce the concept of providing: 6) Delirium Services Using the literature review and the recommendations of the relevant reviews and reports, this report identifies the following options for these developments. 1) Inpatient Rehabilitation Both the Burns review and the Conwy LHB review acknowledged the need to establish a footprint of rehabilitation services that will make Llandudno a leading centre in specialist rehabilitation. This will include rehabilitation for: Stroke Orthopaedics Cardiac Pulmonary It was suggested in the Burns review that Llandudno could become a dedicated specialist stroke rehabilitation centre. The Conwy LHB review supported this recommendation and indicated that specialist stroke rehabilitation should include: Younger People Cognitive Impairment Basal ganglia Vision Sensory Neglect Other neuromuscular diseases requiring rehabilitation Consideration for those young people aged (i.e. transitional) moving up from paediatric services The Conwy LHB review also makes recommendations to examine the extent to which the organisations and services would benefit 6 of 18

7 of such a centre if it could be maximised for a wider range of specialties and services including: Rheumatology Neurological Rehabilitation Pain management services Movement disorders (e.g. Parkinson disease, dystonia, treatment of spasticity linked to stroke) Other chronic neurological disorders Balance problems Falls prevention services Audiology service Vascular and cardio- respiratory rehabilitation specialties Amputees Cardiac rehabilitation (for acute and Chronic disease) Pulmonary Rehabilitation Llandudno hospital could continue to provide stroke rehabilitation to patients resident within its catchment area, and provide a (second stage) specialist service for patients from a wider catchment area (i.e., those served by YG and YGC acute hospitals). This could be operationalised as an in-reach service whereby referrals are made to Llandudno hospital from the acute hospitals for the rehabilitation team to assess the patients individual needs and look at transferring the patient to Llandudno hospital to receive their specialist rehabilitation service. Currently, Llandudno hospital provides rehabilitation services from two dedicated wards, equalling 45 beds. The current average number of referrals received per month to the unit is 40. The majority of referrals into these beds are from within Llandudno hospital, from the two acute hospitals (YG and YGC) and also from Abergele hospital for orthopaedic related rehabilitation. There are also a small number of referrals from the community based Parkinson Team. Some referrals are also made on a step-down basis from specialist rehabilitation sites such as Walton, and also from other hospitals where local residents were admitted. The majority of patients are over 65-years old, but there have been specific cases where the rehabilitation potential for several under 65-year olds has been attained at Llandudno hospital (for 7 of 18

8 example, younger strokes and head injuries). 58% of rehabilitation patients are currently discharged back into their own homes, with a further 25% being discharged back into a nursing or residential home setting. Less than 10% of patients are actually transferred to other units or wards at either Llandudno hospital or neighbouring acute sites. The Conwy LHB review has indicated that there is potential for existing wards at Llandudno hospital to be freed up as a result of other Project Teams, therefore there is a requirement for close joint working with the Unscheduled Care Team to ensure their plans are consistent and complement ours. The report that has been generated for the Unscheduled Care Team indicates that an Assessment and Therapy Unit could provide a comprehensive, multi-disciplinary assessment, treatment and rehabilitation for people with chronic diseases and frail / elderly population. The Chronic Conditions programme would focus on care for the patient groups who are associated with high admission rates. The Assessment and Therapy Unit would also improve access to active rehabilitation. All pathways for patient flows and services should be documented within Integrated care pathways, which need to be inclusive of Primary, Secondary and Tertiary care, and be recognisant of the support potentially on offer from the Voluntary Sector. Although the North Wales Stroke Local Delivery Plan does not specifically detail any proposed developments at Llandudno hospital, there is a recognition that there needs to be an identified clinical pathway for Stroke and TIA, and as such it is recommended that the development of a specialist stroke rehabilitation service of Llandudno hospital be included in this. This development would be supported by the NICE guidance on Stroke (July 2008) and more specifically the NSF for Older People (March 2006). The NSF for Long Term Conditions (England) specifies that as a principle, specialist rehabilitation referrals should be made to a specialist with appropriate neurological training who will usually be a consultant neurologist. The appointment of a Consultant in Rehabilitation Medicine to Llandudno hospital at the early stage of developments would aid its implementation and therefore should be considered. However, for this option to be pursued, 8 of 18

9 BCUHB would need to identify a revenue neutral funding stream. This was however supported by the North Wales Neurosciences review group, where the appointment of a consultant in rehabilitation medicine could be supported by bringing together existing therapy resources from the Community Brain Injury Team at Colwyn Bay. Normally, investigations associated with a specialist rehabilitation unit would include: MRI scanning CT scanning EEG and EMG and Nerve Conduction Studies Video telemetry CSF examination As such, there is a need for close working with the Elective Treatment and Diagnostics project team to ensure these investigations are available. Access for discussion of the results of these investigations in a multidisciplinary meeting is essential. Patients receiving any form of rehabilitation at Llandudno hospital should also be assessed for receiving step-down community based rehabilitation services. They should also be able to access community based services and information on a step-up basis to prevent unnecessary hospital admissions. By providing a comprehensive range of community services (complemented by accessible advice to support their continuing and changing needs) patients will become empowered to maintain their own independence and autonomy. The provision of information should be extended to providing support for the patients family and carers. Again, it should be noted that the whole Llandudno Project needs to be revenue neutral when considering the establishment of Intermediate Care services for this purpose. Upon discharge of the patient, it is essential that all equipment and accommodation needs are catered for. The North Wales Neurosciences Review considered several options for the enhancement of services for North Wales residents. The list of supported options included to locate a new 9 of 18

10 inpatient Neuro-rehabilitation unit at Llandudno hospital. Locating the unit at Llandudno would mean disinvesting in the services currently provided by Clatterbridge NRU. All North Wales patients would benefit from inpatient neuro-rehabilitation flow to Llandudno hospital. This option was recommended by the Steers Review of Neurosciences as a suitable location for a specialist neurorehabilitation unit. This work would need to be done in conjunction with the managed clinical network that is to be established. There is also a requirement to link in with hospices to ensure that clients within their setting receive an appropriate level of care in a coordinated manner. Page 5 of this report shows the relationships between proposed / strengthened rehabilitation services and the core services of Llandudno hospital. 2) Acquired Brain Injury It was suggested in the Burns review that Llandudno could develop an inpatient facility for a North Wales acquired brain injury service. The Conwy LHB review supported this recommendation. This was also considered as part of the All Wales and North Wales Neurosciences Project Groups; the North Wales Group reporting their findings in July The Conwy LHB review stressed that the establishment of such a unit would complement other Neurosciences based services that already exist (or are proposed) in Llandudno hospital: Current movement disorder clinics Proposed specialised stroke rehabilitation Proposed EMH/Delirium Unit Strengthen the case for a Hydrotherapy Pool Strengthen the case for CT scanning on site. The All-Wales review for Neurosciences identified that rehabilitation services for acquired brain injury needed to be improved. It was also reported that the on-going rehabilitation for these patients should reduce re-admissions and reduce demands on respite care. Specifically, the North Wales review group recommended that an Inpatient Neurological Rehabilitation Centre should be developed 10 of 18

11 in North Wales as part of the Managed Clinical Network and based on a resourced facility at Llandudno hospital. This would cater for traumatic acquired brain injury, stroke and other neurological conditions requiring rehabilitation. The view is that a specialist Acquired Brain Injury Unit would need to be developed as a self-contained sub-acute rehab unit that is co-located / adjacent to the specialist / general rehabilitation unit. The staff of the unit would need to be part of the integrated North Wales Brain injury Service providing both inpatient and community based rehabilitation. Currently, referrals for Brain Injury Services are made to the North Wales Brain Injury Service, and this arrangement could be continued for the Inpatient element of the service too. Patients with acquired brain injury should have access to the team and to neuropsychology services. As a principle, the review stated that patients who are repatriated there from the Walton Centre should be referred into the rehabilitation centre and assessed for rehabilitation potential and should not be returned to orthopaedic or general surgical wards. The unit should be medically led with multi-disciplinary input from other professionals. The review continues to state that by working together the acquired brain injury team and the rehabilitation teams, both Llandudno hospital based and community bases could maximise their effectiveness for patients. The voluntary sector also needs to be considered for service provision. There must be a provision at Llandudno hospital to provide the required diagnostic care for patients, namely CT scanning. For patients requiring Thrombolysis this must be performed within one hour of the patient s admission within a DGH setting. It is key to note that the community developments around Brain Injury services in North Wales was the first phase in developing a total rehabilitation service. A Consultant Report and Recommendations for the development of Rehabilitation for Acquired Brain Injury was developed in The development of 11 of 18

12 the inpatient facility is seen as the first stage of rehabilitation needs, followed by the need to have intermediate rehabilitation services and long term residential care. Reports demonstrate that back in 2002 there was a specific need for the inpatient development to cater for between 35 and 45 patient per year, each with a length of stay ranging from 6-week through to 3-months. Based on this assumption there is a requirement for 7 inpatient beds dedicated to Acquired Brain Injury. 3) Outpatient based Rehabilitation The NSF for Long Term Conditions (England) states that patients who would benefit from rehabilitation are to receive timely, ongoing, high quality rehabilitation services in hospital or other specialist settings to meet their continuing and changing needs. When ready, they are to receive the help they need to return home for ongoing community rehabilitation and support. The NSF also states that people with long term conditions living at home are to have ongoing access to a comprehensive range of rehabilitation, advice and support to meet their continuing needs, increase their independence and autonomy and help them live as they wish. As part of this Llandudno Project, there is a specific Project Team established to look at Outpatient Services (as part of the Elective Treatment and Diagnosis project team). However, this report highlights that there are elements of Rehabilitation Services that are delivered in an Outpatient setting, thus there is a need for both Project Teams to be cognisant of each others development plans. The range of Rehabilitation services that are run in an Outpatient setting includes: Cardiac Respiratory Falls / balance Pain Management Rheumatology These can often be run in a Multi Disciplinary Team setting. 12 of 18

13 The Burns review and the Conwy LHB review recognises the importance for the local community to preserve these specialist outpatient clinics. The Unscheduled Care Project Team have identified that the development of a Rapid Access Chest Pain Clinic, supported by staff at the Coronary Care Unit, would also facilitate patient rehabilitation, with the Coronary Care Unit providing the inpatient based treatment / monitoring. Patient flows to and from these coronary care services would have to be explored further. The Elective Treatment and Diagnosis project team will ensure that the facilities are present for these developments identified by the working group, with the working group making the necessary recommendations as to how the teams are structured and supported by the intermediate care teams. Currently, the Outpatient facility at Llandudno hospital is used by Consultants from both YG and YGC. 4) Therapy Services It is recognised that no rehabilitation service can be delivered without the appropriate therapy support. The Burns review states that the concentration of rehabilitation services on one site will allow a more focused deployment of physical therapy skills and allow for the more convenient and consistent input to the care of these patients of other very scare clinical skills. The Burns review not only talks about the actual delivery of the services but also of the management of these; this being recognised too in the Conwy LHB review. Establishing a centre of excellence will also help maximise flexibility in deployment of staff and continuity of service (and as an aid to recruitment by offering a greater range of career development choice). As seen within the Acquired Brain Injury section of this report, developing one would strengthen the case for a Hydrotherapy Pool. Not only would this benefit ABI patients but the facility could be utilised for other rehabilitation purposes. 13 of 18

14 There is a need to consider the provision of therapy support outside of an Inpatient, Day Care or Outpatient setting - providing rehabilitation and support in the community with a range of therapies (e.g., physiotherapy, occupational therapy, speech and language therapy and clinical psychology). Providers of community rehabilitation and support services can train those providing day to day support (e.g., healthcare staff, personal care staff or carers), to make sure that rehabilitation (e.g., wearing splints to manage spasticity) becomes part of everyday life and helps to maintain the person s health and wellbeing and prevent their condition deteriorating. 5) Education Centre The Burns review makes reference to: o Development of patient (and carer) empowerment services including patient/care involvement processes, education facilities, information services, expert patient programmes etc. whereas the Conwy LHB review identifies: o the development of an Education Centre for clinical and non-clinical staff, consolidating the limited resources currently on site and providing an academic and training focus for staff working in the hospital, and those being rotated through as part of their development. The Burns review does however state that the scope of that report does not allow for a detailed assessment of the extent to which education facilities should be developed at Llandudno hospital. However, the report does propose that a centre of excellence for rehabilitation at Llandudno hospital will emerge de facto if the recommendation to base a sub regional stroke facility and a regional Acquired Brain Injury facility at the hospital is implemented, thus requiring the development of all round patient, carer and staff development. The Education Centre should be a dedicated suite of rooms with the necessary facilities, such as I.T., Video Conferencing and teaching facilities. 6) Delirium Services The Conwy LHB report specifies that Llandudno hospital should be developed as a post acute specialist rehabilitation centre for the intensive rehabilitation of stroke, other neurological, 14 of 18

15 orthopaedic and cardiac patients, with rehabilitation of elderly medically frail patients and those with a co-morbidity including delirium. The inclusion of Delirium was requested by the Conwy LHB project team due the loss of facilities at Llandudno i.e., the transfer of services form the Bodnant Unit to Bryn Hesketh Unit in Colwyn Bay. People with a dementing illness, but only in the early stages of cognitive decline, can suffer from episodes of acute delirium due to a multitude of medical conditions. These medical conditions can be resolved successfully to allow the patient to return to full independence. This can take weeks, and can require rehabilitation services. As part of the Conwy LHB project a workgroup was tasked with looking at this development to decide on services to be provided and the pathways that patient should follow. They looked at the establishment of a specialist delirium facility as part of the portfolio of services for dementia and delirium. They reported that the facility will have the following attributes: It would be a separately provided inpatient facility It would act as a safe place for people with delirium to be admitted Their acute condition would be identified and treated This treatment will be multi disciplinary in its nature, with input from Care of the Elderly specialists, psychiatrists, rehabilitation and others as appropriate. Early discussions suggest that inpatients suffering with delirium should not be moved from one site to another as this can cause further confusions. As such, an expert outreach / support service should be developed, based at Llandudno hospital. RECOMMENDATION This report recommends a range of options that needs to be analysed further. It is recommended that the Rehabilitation Project Team develops these into a list of preferred options through the establishment of specific working groups. Discussions at the Project Team meeting has resulted in the suggestion 15 of 18

16 that for Cycle 2, three working groups are established: ABI, Specialist Rehabilitation and Neuro Rehabilitation General Rehabilitation Musculoskeletal These three working groups will consider both Inpatient and Outpatient services under their areas, together with any assessment services required. All three working groups will have an identified lead. It was also recommended that the Therapy Hub working group and the Education Centre working group be established at Cycle 3 stage because they will be dependent on the cycle 2 work from the above working groups. The Education Centre working group will be seen as a cross cutting theme. Additionally, a small group will be established to discuss the scope of developing a Delirium service. Taken from the above report, the following will be recommended to each of the established working groups: 1) ABI, Specialist Rehabilitation and Neuro Rehabilitation As identified in the report, this working group will consider the development of an ABI unit alongside a dedicated specialist stroke rehabilitation centre which should include: Younger People Cognitive Impairment Basal ganglia Vision Sensory Neglect Other neuromuscular diseases requiring rehabilitation Consideration for those young people aged (i.e. transitional) moving up from paediatric services It is recommended that when the working group is established looking at the work stream for Acquired Brain Injury service they scope the size and location of the dedicated unit, identifying patient flows and numbers (including potential repatriation of patients who historically received services from England), plus identifies the required range of supporting / diagnostic services required to support the unit. 16 of 18

17 It is recommended that the working group considers the specific range of services to be provided, identifying a service model and access criteria / process that could be implemented. The working group should also consider potential facilities that may be freedup from the development of other projects on the site. The working group should also consider how patient pathways be developed and documented. The working group is also recommended to consider the appointment of a Consultant in Rehabilitation Medicine, as it is suggested that this Consultant would heavily lead on the implementation of the agreed model. This working group will also have to consider the linking with Hospices, especially for the treatment of motor-neuron conditions. 2) General Rehabilitation The working group for general rehabilitation needs to consider the range of services to be provided, together with access criteria and facilities required. The working group will also need to consider what outpatient facilities are required, plus any specific therapy and Intermediate Care / Community services required to deliver optimum services for clients. Finally, the working group will be requested to consider the range of community / intermediate care services that can provide clients with step-up and step-down services, avoiding unnecessary admissions and facilitating timely discharges. 3) Musculoskeletal Specifically within this working group there needs to be consideration of the existing Bone Densitometry and Rheumatology service services which are currently provided at present from within Llandudno hospital. It should be noted that there are already Rheumatology plans being implemented at present, focusing on the development and centralisation of the service at Llandudno hospital. It should also be noted that any plans affecting the services currently provided at Abergele hospital will also have to be factored in this work stream, albeit at present discussions are at a 17 of 18

18 very early stage. 4) Therapy Services There will not be a working group established for cycle 2 for the Therapy Hub, as this work will be dependent on the findings from the cycle 2 working groups. However, there will be therapy input into the cycle 2 working groups. 5) Education Centre There will not be a working group for the Education Centre work stream at this point, as it seen as a cross cutting theme and will be brought together during cycle 3. 6) Delirium Services It is recommended that a small group reviews the recommendations from the Conwy LHB working group and propose a service model that can help support this client group. There are however caveats that need to be considered in considering these. These include having to implement the final plan on a revenue neutral basis, and another being to develop the total site within an indicated capital envelope. The caveat of the project being revenue neutral includes the repatriation of work currently being conducted within and outside of North Wales. For example, it may be possible to repatriate stroke services from both YG and YGC acute wards, but it may not be possible to totally repatriate the revenue costs of those beds unless a whole ward and associated services can be moved. Likewise, it may not be clinically appropriate to repatriate patients from English providers at certain stages of their acute episode. The next report will identify the preferred solutions, based upon ability to meet the defined need, clinical viability, sustainability and affordability, and determine a) the necessary estate and infrastructure requirements to support delivery of the preferred model of care; and b) the necessary staffing configuration to support delivery of the preferred service model. This report is required by the 7 th May of 18