Freedom of Information Act Request Rookwood Hospital With regard to the planned move of the spinal injuries unit at Rookwood to University Hospital Llandough please provide the following information: Question 1 For spinal injuries how many beds are currently at Rookwood Hospital and what has been the number of beds over the last 10 years; Response - The information provided below relates only to The Spinal Injuries Unit and bed numbers. Please be aware that there are other beds in Rookwood Hospital for Neuro-Rehabilitation and other specialities. Previously within the past 10 years there were a total of 37 beds for spinal rehabilitation. However in 2010 there was a reconfiguration of service provision within specialist rehabilitation and as a result of this reconfiguration the number of beds required was reduced to 26 beds. Question 2 What is the current level of service at Rookwood in relation to access to allied health professions AHP (speech therapy, occupational therapy and physiotherapy) and reablement provision and has the level of service has changed during the last ten years. Response Over the last 10 years the only change in physiotherapy establishment was in 2004 when the staffing was uplifted by an additional 1.5WTE to its current level of 5.57WTE Further supporting information is contained within the attached report.
Mid & South Neurosciences Programme Second Phase Implementation Final Report to the Project Board October 2011
Contents 1. Introduction 3 2. Project Structure 4 3. What has the Project Delivered? 6 3.1 Headline achievements 6 3.2 Delivery of Axford Recommendations 7 3.3 Work in Progress and Delivery Objectives 11 4. Workstream Reports 13 4.1 Spinal Surgery 13 4.2 Adult Rehabilitation and Supportive Care 16 4.3 Neurology 23 4.4 Diagnostics and Transport 28 5 Conclusions 32 6 Recommendations 33 7 List of Appendices 37 2
1. Introduction In 2008, the Welsh Assembly Government commissioned James Steers to undertake a review of neurosciences in Wales. Following the publication of the Steers Review, Dr Alan Axford was asked by the Minister for Health and Social Services to make specific recommendations for implementing the Steers findings for Mid & South Wales. Dr Axford made 19 key recommendations which were taken forward through the Mid & South Neurosciences Implementation Programme. The 1 st phase of this programme focused on the transfer of neurosurgery to a single site at the University Hospital of Wales, Cardiff. This was achieved between 2009 and 2010. The 2 nd phase of the implementation programme commenced in December 2010 with the aim of implementing the wider Axford recommendations for spinal surgery, neurology, rehabilitation and diagnostics, by September 2011. This report describes the achievements of the 2 nd phase of the Mid & South Neurosciences Programme. Section 2 outlines the structure for delivery of the neurosciences implementation programme. Section 3 summarises what has been achieved, providing an assessment of progress against each of the specific Axford recommendations. Section 4 contains summary reports of the work undertaken by each workstream (full workstream reports are attached as appendices to this main report). The recommendations to the Project Board are set out in Section 6. 3
2. Project Structure 2.1 Project Board The All Wales Chief Executives Peer Group provides the Project Board for the Mid & South Neurosciences Implementation Programme. 2.2 Project Team The Project Team was established to provide direction and coordination for the Mid & South Neurosciences Implementation Programme. Following the conclusion of the 1 st phase of the Programme, the Project Team was re-established with revised terms of reference to ensure it remained fit for purpose. Mark Dickinson, Director of Planning, Public Health Wales, became the Chair of the Project Team. Membership of the Project Team included Directors of Planning from the 6 Health Boards and WAST, representation from Directors of Therapy and Health Sciences and the Wales Neurological Alliance (full membership listed in appendix 1). Project management support to the Project Team was provided by the planner for neurosciences, WHSSC. The Project team established 4 workstreams (table 1), each led by an LHB Executive Director. The Axford recommendations were allocated across the workstreams for implementation. 4
Table 1: Mid & South Neurosciences Implementation Programme Workstreams Workstream Lead Workstream 1. Spinal Surgery Workstream 2. Adult Rehabilitation and Supportive Care Workstream 3. Neurology Paul Stauber Fiona Jenkins Tony Chambers Director of Planning, Abertawe Bro Morgannwg UHB Director of Therapies and Health Science, Cardiff and Vale UHB Director of Planning, Hywel Dda LHB Workstream 4. Diagnostics and Transport Chris White Director of Therapies and Health Science, Cwm Taf LHB 5
3. What has the Project Delivered? 3.1 Headline Achievements Spinal Surgery Spinal surgery capacity at Morriston Hospital has been strengthened through the appointment of 2 additional spinal surgeons (commenced in their posts in January 2011) Arrangements for the 24/7 provision of acute spinal surgery across Mid & South Wales have been formalised and implemented. Adult Rehabilitation and Supportive Care Detailed proposals have been developed for a service model and network to provide community based rehabilitation support for patients with acquired neurological and spinal injuries across Mid & South Wales. Adult rehabilitation services for spinal cord and acquired brain injury have been mapped across all Mid and South Wales NHS organisations. An option appraisal for the delivery of Functional Electrical Stimulation (FES) treatment across Mid & South Wales has been produced. Neurology Agreement achieved across the 6 HBs to appoint two additional consultant neurologists for Mid & South Wales. Job descriptions and job plans are being developed by the Health Boards. Full appointments expected within 6 months (with locum appointments in the meantime). Needs assessment completed by Public Health Wales. A model for neurology services and network across Mid & South Wales developed Diagnostics and Transport Sustainable neuroradiology service across Mid & South Wales secured through closer working between neuroradiology services in ABM UHB and C&V UHB. Established on-call neuroradiology advice systems in place (separately for East and West): work in progress to provide a single on-call rota across South Wales. Protocol for ambulance transfer to neuroscience centre implemented. 6
3.2 Delivery of Axford Recommendations This section highlights what the Neurosciences Programme has delivered against each of the Axford recommendations for spinal surgery, neurology, rehabilitation and diagnostics. These achievements are summarised in table 2 below. A simple traffic light system has been adopted: Where the Project Team believes the Axford recommendation (or the commitment set out in the project initiation document, if different) has been delivered in full, this is marked as achieved (green). Where further work is required to fully deliver the recommendation (or the commitment set out in the project initiation document, if different), this is marked in progress (amber). Where no progress has been made towards delivering an objective, this is marked as no progress (red) 7
Table 2: Summary of achievements to September 2011 against the objectives set by the Project Team to deliver the Axford recommendations Axford Recommendation Achieved? Comments Spinal Surgery Strengthen and expand spinal surgical capacity at Morriston Hospital Establish a Mid and South Wales 24/7 acute spinal service Project Team Commitment (PID) To deliver full Axford recommendation To deliver full Axford recommendation Adult Rehabilitation and Supportive Care Establish a rehabilitation To develop community network which integrates spinal and neuro rehabilitation that model to recommend to the Project Board supports patients at acute sites and in the community Yes Effective spinal service fully operational comprising 4 Consultant Surgeons Yes Cardiff & Vale Health Board has devised a protocol and this has been circulated to Health Boards. Cardiff and Vale provide an out of hours spinal service across Mid & South Wales. Within hours, initial referral will be to the local spinal service with onward referral to Cardiff if required. Yes Service mapping work for adult neuro-rehabilitation services has been completed. The Service Specification and Community Models sub-group has produced 8
Strengthen supportive and palliative care for people with neurological conditions to be delivered by multi-disciplinary teams with a specialist interest in neurological conditions. To develop community model to recommend to the Project Board Yes (included within the Community Model) recommendations for the development of a service model for community rehabilitation services. Palliative care representatives have been fully engaged in the process. Neurology Appoint 2 additional neurologists, 1 in Cwm Taf LHB and 1 in Hywel Dda LHB, to enable the establishment of effective local services working as part of an integrated clinical network Diagnostics and Transport Establish 24/7 neuroradiology on call advice systems enabled by high definition teleradiology. To deliver Axford recommendation to increase capacity. To develop service model to recommend to the Project Board To deliver full Axford recommendation In Progress Yes Yes Health Boards have agreed to fund 2 wte consultant neurologist posts on a regional basis. Recruitment process underway (job descriptions developed). Needs/service assessment undertaken by workstream to identify sub-specialty expertise required from new appointments. Service model for neurology developed for recommendation to the Project Board. On-call system in place with advice currently provided by separate rotas at Morriston and UHW. Formalisation of closer working agreed between ABM and 9
LHBs must work with the Welsh Ambulance Service to ensure appropriate and efficient transport services for patients. LHBs must work together to ensure that there is a welldeveloped trauma system between hospitals. To deliver full Axford recommendation In Progress C&V to secure a sustainable neuroradiology service. Working towards a single integrated oncall rota. Delivery of this recommendation was defined in terms of implementing a clinical protocol for transfer of patients with head injury to the appropriate service, including direct transfer to the neurosciences centre. Appendix 8 shows current pathway. Work is still in progress to develop this protocol further. This recommendation is being taken forward via the South Wales Plan. Support the integration of the current neurophysiology services to work to common protocols and guideline To deliver full Axford recommendation In Progress Assessment undertaken to map the distribution of neurophysiology services and resources, and identify strategic issues to be addressed via collaborative working across the services. 10
3.3 Work in Progress and Delivery Objectives Table 3 highlights on-going work required, with time-scales where possible, to deliver the all the Axford recommendations in full. It is recognised that fully meeting some of the recommendations, particularly implementing new models in neurology and neurological and spinal rehabilitation, requires a complex process of service change and development. Timescales for these developments will be defined as part of specific implementation planning following consideration of the recommendations of this report by the Project Board. Table 3: Summary of actions and timescales to implement Axford recommendations in full Axford Progress Recommendation and Delivery Objectives Neurology Appoint 2 additional neurologists, 1 in Cwm Taf LHB and 1 in Hywel Dda LHB, to enable the establishment of effective local services working as part of an integrated clinical network Adult Rehabilitation and Supportive Care Establish a rehabilitation network which integrates spinal and neuro rehabilitation that supports patients Recruitment process in progress. Appointments anticipated within 6 months. If the model for neurology proposed in this report is supported by the Neurosciences Programme Project Board, work will commence to implement the model. Long term programme of service change and re-design. If the model for rehabilitation proposed in this report is supported by the Neurosciences Programme Project Board, work will 11
at acute sites and in the community commence to implement the model. Long term programme of service change and re-design. Diagnostics and Transport Establish 24/7 neuroradiology on call advice systems enabled by high definition teleradiology. Support the integration of the current neurophysiology services to work to common protocols and guidelines LHBs must work with the Welsh Ambulance Service Trust to ensure appropriate and efficient transport services for patients. Sustainability of service secured through closer working between ABM UHB and C&V UHB neuroradiology services. Move to develop single rota in progress. Target: to complete by December 2012. Assessment of the distribution of resources for neurophysiology undertaken. Issues identified requiring joint solutions. Implementation process required to put in place joint solutions. Timescale to be identified Overall pathway defined and implemented Further work on-going to develop protocol further, particularly to ensure the right ambulance is requested for the right journey. 12
4. Workstream Summary Reports This section includes summary reports of the work undertaken by each of the 4 workstreams. Where full reports have been developed by the workstreams to support their recommendations, these are referenced in the summary reports below and attached within the appendices. 4.1 Spinal Surgery 4.1.1 Purpose The aim of the workstream was to implement the Axford recommendations for spinal surgery. These were to: Strengthen and expand spinal surgical capacity at Morriston Hospital to provide improved local access for patients in Mid and West Wales Establish a Mid and South Wales 24/7 acute spinal service 4.1.2 Structure The spinal surgery workstream was led by Paul Stauber, Director of planning, Abertawe Bro Morgannwg UHB. The workstream involved orthopaedic spinal clinical leads, Medical Directors from Cardiff & Vale and ABM Health Boards, and managerial staff with responsibility for spinal services, from the 3 orthopaedic surgery provider Health Boards in South Wales (Cardiff & Vale, Abertawe Bro Morgannwg and Aneurin Bevan Health Boards). Full membership of the working group is outlined in appendix 2. 13
4.1.3 Achievements Key Achievements The key achievements are:- Delivery of the Axford recommendation to strengthen and expand surgical capacity at Morriston Hospital Delivery of the Axford recommendation for a 24/7 acute spinal service Expanded surgical capacity at Morriston Capacity was increased through the appointment of 2 additional spinal surgeons to take the consultant team to 4 surgeons. Protocol for provision of 24/7 acute spinal surgery Out of hours spinal surgery for Mid & South Wales is provided by the spinal service at Cardiff and Vale University Health Board. The full protocol for accessing the specialist spinal service at Cardiff and Vale University Health Board, both within the working week and out of hours, is attached in appendix 3. The protocol sets out the process for referral to the specialist spinal service for each Health Board. This protocol has been circulated to Health Boards and implemented. 4.1.4 Work in progress There is a historical referral pathway for patients from Mid and West Wales to spinal surgery at Cardiff & Vale HB. With the increased capacity at Morriston Hospital, this activity will decline, enabling the spinal service at Cardiff & Vale to focus on the South East and Mid Wales population. All new referrals to spinal surgery for patients from West Wales are now directed through local referral management arrangements. Onward referral to the spinal service at Cardiff & Vale will only be made where patients require the expertise of the specialist spinal service. 14
4.1.5 Conclusion The spinal workstream has delivered the Axford recommendations for spinal surgery. This has resulted in the provision of increased capacity for spinal surgery closer to patients homes. 15
4.2 Adult Rehabilitation and Supportive Care The section provides a summary of the work undertaken by the Adult Rehabilitation and Supportive Care workstream. The full workstream report is attached in the appendix. 4.2.1 Purpose The aim of the workstream was to implement the Axford recommendations for rehabilitation and supportive care. These were to: Establish a rehabilitation network which integrates spinal and neuro rehabilitation 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. Strengthen supportive and palliative care for people with neurological conditions to be delivered by multi-disciplinary teams with a specialist interest in neurological conditions. The workstream identified the following specific objectives: Map current local adult neuro-rehabilitation services by LHB Develop service specifications for the neurological and spinal rehabilitation specialist services (including access criteria, bed requirements, in-reach and out-reach provision) Work with each LHB to identify pragmatic models for providing community based rehabilitation to patients with neurological and spinal injuries to facilitate timely discharge to the community, with on-going input and support from the specialist centres, making recommendations for the model to LHB Directors of Planning Identify within the service specification how the specialist neurorehabilitation service contributes to supportive and palliative care for people with neurological conditions, including through the provision of out-reach support to community teams. In addition, to delivering the Axford recommendations, the rehabilitation workstream included within its remit the objective to explore need and provision of Functional Electrical Stimulation (FES) across Mid & South Wales. 16
4.2.2 Structure The rehabilitation workstream was led by Fiona Jenkins, Director of Therapies and Health Science, Cardiff and Vale UHB. Figure 1 below outlines the workstream structure and lines of accountability. The workstream structure consisted of an overarching group and 3 sub-groups. The overarching group was chaired by Fiona Jenkins. Membership was drawn from across the 6 Health Boards (see appendix 2 for full membership). The overarching group met on a bi-monthly basis, with regular updates from sub-group leads to the Adult Rehabilitation and Supportive Care Workstream Chair. Three sub-groups were established: i) Service mapping (led by Sian Harrop-Griffiths) ii) Service specification and community models (led by Jakko Brouwers, lead physiotherapist and service development manager, C&VUHB) iii) Functional Electrical Stimulation (led by Dr David Abankwa, Consultant in Rehabilitation Medicine, ABM UHB). Figure 1: Project Board Project Team Spinal Surgery Adult Rehabilitation Neurology Diagnostics and Transport Neuromuscular Services Service Mapping Service Specification and Community Models Functional Electrical Stimulation 17
Neuromuscular Services The Adult Rehabilitation and Supportive Care workstream maintained close links to the work of the Neuromuscular Services working group, Chaired by Jan Williams, Chief Executive Cardiff and Vale University Health Board (represented in Figure 4.2a via a dotted line). Whilst the Adult Rehabilitation and Supportive Care workstream did not have direct accountability for this work, it was important that the links were established to ensure that development work was complimentary for both areas of work. An update briefing on neuromuscular services is provided in Appendix 6. 4.2.3 Achievements Key Achievements The key achievements of the Adult Rehabilitation and Supportive Care workstream are:- Adult rehabilitation services for spinal cord and acquired brain injury have been mapped across all Mid & South Wales NHS organisations Detailed proposals have been developed for a network of services to provide community based rehabilitation support for patients with acquired neurological and spinal injuries across Mid & South Wales. An option appraisal for the delivery of Functional Electrical Stimulation (FES) treatment across Mid & South Wales has been produced. The key elements of the proposed model for the provision of community based neurological and spinal rehabilitation are outlined below. Full details of the methods, demand analysis, best practice guidance, care pathways and the proposed model are set out in full workstream report in appendix 6. 18
Service Mapping The service mapping is contained in the workstream report in appendix 6. Service Model The proposed model is focused on delivering seamless care defined through 3 linked rehabilitation care pathways: 1) Community Integration pathway This describes the patient pathway from immediately postacute injury through an inpatient rehabilitation period (if appropriate) into the community. 2) Community Support pathway This describes the on-going monitoring of Acquired Brain Injury (ABI) and Spinal Cord Injury (SCI) patients 3) Escalation pathway This describes the process of rapid (re-)provision of a service to the patient whose needs have changed, deteriorated or otherwise been identified as needing further support. It aims to provide this at the lowest appropriate level of service and as close to home as possible. Key elements of the service model Figure 2 below depicts the service model and linkages across the different levels of the service. 19
Fig 2: Service model and linkages for community rehabilitation for Acquired Brain Injury and Spinal Cord Injury The role of each component is summarised below: i. Specialised Inpatient Rehabilitation Service Role: - In-reach to acute setting - Provision of in-patient specialised rehabilitation - Out-reach to provide Specialised Community and Outreach Service ii. Specialised Community and Outreach Service (for Acquired Brain Injury and Spinal Cord Injury). Role: - Outreach from inpatient specialised service - Specialist assessment and management plans - Maintain complex patients in the community -Work with local community rehabilitation services 20
iii. Local community rehabilitation services Role: - In-reach to the specialised inpatient service - Maintaining patients in the community - Monitoring of patients - Escalating patients to specialist community and outreach team - Provision of case manager/coordinator role Implementation of this model will provide flexible neurological and spinal rehabilitation services responsive to patient needs. The model aims to reduce length of stay by providing community integration closer to patients homes. The model recognises the importance of closely monitoring patients to ensure early detection of change with rapid intervention to maximise independence, maintaining patients within the community, preventing deterioration and reducing risks of admission to hospital. Key Developments Required to Implement the Model The following key components would need to be developed to implement the model: the Specialised Community and Outreach Teams robust community based neuro rehabilitation or Disability Resource Teams or other specialist teams who work in a MDT model in the community in each of the LHBs hubs of local rehabilitation services in each of the LHBs to provide general rehabilitation facilities for a range of conditions and age groups Resource Implications The Adult Rehabilitation and Supportive Care workstream have made 17 recommendations (listed in appendix 6). It is anticipated that many of these recommendations, including establishing the key component services described above, could in principle be achieved through service re-design. Other recommendations (such as recommendation 6 to increase capacity in neuro-psychology) require investment. Further specific work is required to quantify the net cost implications of implementing the full proposals. 21
Functional Electrical Stimulation The FES report is contained in appendix 6. 4.2.4 Work in Progress Given agreement of the model by the Project Board, detailed work would commence to implement the changes required to deliver the vision for the service. 4.2.5 Conclusion The workstream has achieved its objectives as stated in the Project Initiation Document. The key recommendations for Adult Rehabilitation and Supportive Care are set out in the Recommendations of this report. Further detailed recommendations for implementation of the community rehabilitation model are contained in the full workstream report (appendix 6). 22
4.3 Neurology 4.3.1 Purpose The aim of the workstream was to implement the Axford recommendation for neurology. This was to: Appoint 2 additional neurologists, 1 in Cwm Taf LHB and 1 in Hywel Dda LHB, to enable the establishment of effective local services working as part of an integrated clinical network To deliver this recommendation the workstream developed the following specific objectives: Map current demand for neurology services both scheduled and unscheduled Develop a service and resource model for meeting this demand in line with the above principles, key target delivery and appropriate adjacencies with key services eg neuromuscular conditions. Develop a workforce plan to deliver the preferred service model including consultant expansion in line with the Axford report and specialist nursing roles to support CDM and RTT delivery. Agree approach for bridging any knowledge and skills gaps in line with Health Education providers and LHB Organisational Development plans. The approach agreed by the workstream was to focus on developing a network to optimise sub-specialisation (rather than pursue a model which assigns neurologists to serve geographical areas) and to develop the service model to deliver care in the right location, at the right time and to ensure equal access to the networked services for the whole population. 4.3.2 Workstream structure The workstream was led by Tony Chambers, Director of Planning, Hywel Dda Health Board. The work was taken forward through an overarching working group and sub-groups to shape the needs assessment and develop the service model. The work was coordinated by Karen Preece, Planning Manager, Hywel Dda HB. 23
The membership of the overarching group included representation from across the 6 Health Boards and was comprised of consultant neurologists from the 3 provider Health Boards, service managers, and patient representatives from the Wales Neurological Alliance (see appendix 2 for full membership). 4.3.3 Achievements Main Achievements The main achievements to September 2011 in delivering the Axford recommendation for neurology are as follows: Agreement secured across Health Boards to increase capacity through funding 2 additional consultant neurologist posts for Mid & South Wales (pending agreement of apportionment costs) Needs assessment undertaken by Public Health Wales to establish prevalence and incidence of neurological conditions in Mid & South Wales Overarching model for the shape of neurology service developed Assessment and identification of the sub-specialty expertise required from the new consultant appointments to meet the needs of the local population Recruitment process in progress, job descriptions are being developed and posts will be in place as soon as possible, pending agreement to the apportionment of costs by CEOs Needs Assessment The workstream engaged Public Health Wales to undertake a needs assessment to inform the development of the service model and networked approach to providing neurology services, and to identify any gaps in skill-mix to inform the investment in additional capacity. The needs assessment is attached in appendix 5. The needs assessment reinforced the Axford recommendation (and the Steers report prior to this) that additional neurology capacity is required across South Wales. 24
Increased Capacity The appointment of two additional consultants starts to address the gap in neurology services across South Wales. However, the needs assessment indicates that compared to other parts of the UK and other European countries, neurology services will still remain stretched. Implementation of this model including development of community based services and alternative workforce models will start to address a more robust service, delivered closer to patients homes. A network approach will also assist in developing subspecialty expertise across South Wales. Model for Neurology Services This section provides a brief overview of the proposed service model (the model is set out in more detail in appendix 4). All neurology services should be planned and delivered via a network to ensure appropriate sub-specialisation and expertise across South Wales. The model proposes 3 levels of service (Fig 3 below): Fig 3: Structure for delivery of neurology services for Mid & South Wales 25
Neurosciences Centre UHW Neurology Centre Morriston Neurology Centre UHW Neurology Centre Royal Gwent DGH & Community Services PPH, WGH, GGH BGH PoW, NPT Singleton DGH & Community Services Royal Glam PCH Llandough DGH & Community Services Nevill Hall Ysbyty Ystrad Fawr i) DGH/ Community Services: - local out-patient services - diagnostics ii) 3 Neurology Centres at Morriston Hospital, University Hospital of Wales, Royal Gwent Hospital Services: - specialist clinics - beds for elective and acute in-patient neurology - diagnostics iii) Tertiary/Specialist Centre Services: - beds for elective and acute in-patient neurology - specialist diagnostics - support to Neurology Centres Implementation of this model will re-shape the existing patterns of provision. It will imply changes to where care is delivered to ensure 26
it is delivered in the appropriate location, as close to patients homes as possible. It will re-shape referral pathways and ways of working to take account of the distribution of skills and subspecialty interests across the network. 4.3.4 Work in progress Given agreement of the model by the Project Board, detailed work would commence to implement the changes required to deliver the vision for the service. This would include: All consultants working in a network to ensure on-going planning for neurology services and development of sub-specialty expertise across South Wales Detail of distribution of clinics and consultant job plans Detail of network arrangements Pathways Structure for implementing change: The Group should consider its on-going membership and develop into a formal Network to plan and implement neurology services, including the development of sub-specialty expertise. The recruitment of the two additional consultants has commenced in that job descriptions and job plans are being developed. Substantive appointments should be in place in six months (once CEOs have given final approval, locum appointments could be considered). Health Boards will need to continue to develop community services. 4.3.5 Conclusion The neurology workstream has undertaken a needs assessment and developed a model for neurology services across Mid & South Wales. This has informed the development of job descriptions for the recruitment of 2 additional consultant neurologists for Mid & South Wales. This recruitment will deliver the increase in neurology capacity recommended by the Axford report. 27
4.4 Diagnostics and Transport 4.4.1 Purpose The purpose of the workstream was to implement the recommendations for neuroradiology, neurophysiology and links with the ambulance service contained within the Axford Report. These recommendations were: To 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. 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. LHBs must work with the Welsh Ambulance Service to ensure appropriate and efficient transport services for patients. Support the integration of the current neurophysiology services to work to common protocols and guidelines 4.4.2 Workstream structure The workstream was led by Chris White, Director of Therapies and Health Sciences, Cwm Taf Health Board. Membership of the workstream included clinical directors for neuroradiology, lead neuroradiologists, lead neurophysiologists and representation from the Wales Ambulance Trust (full membership is listed in appendix 2). A specific sub-group was established for Neuroradiology, chaired by Brian Sullivan, Clinical Director for Radiology, Aneurin Bevan HB. To take forward transport issues identified by the workstream, the Wales Ambulance Trust led the development of a clinical protocol for transfer to the neurosciences centre. This work will report to the All Wales Medical Directors peer group for sign-off of the protocol. A specific meeting, chaired by the workstream lead, was held to discuss the way forward for neurophysiology. The actions from this meeting were coordinated by Regional Services, ABMUHB and reported to the overarching workstream group. 28
4.4.3 Achievements Key Achievements The key achievements to September 2011 in delivering the Axford recommendation for diagnostics and transport are:- Formal arrangements agreed for consultant sessions at UHW for neuroradiologists from ABM to ensure sustainability of the provision of neuroradiology in Mid & South Wales Distribution and configuration of neurophysiology services mapped, and key issues for development of the neurophysiology service identified Protocol for ambulance transfer to neuroscience centre in process of development Neuroradiology Access to neuroradiology opinion and advice out of hours is currently available through the established separate on-call rotas delivered from Morriston Hospital and UHW. The Axford recommendion suggests moving towards a single rota facilitated by the use of teleradiology. Since December 2010, the neuroradiology services at ABM UHB and C&V UHB have been working more closely together through, for example, providing cross cover. The neuroradiology working group agreed that their primary objective was to ensure the sustainability of neuroradiology in Mid & South Wales through formalising closer working across the 2 services. It was agreed this should be achieved in 2 phases: Phase 1) formalisation of sessions in Cardiff for ABM neuroradiologists within hours; Phase 2) establish integration of the out of hours service to provide a single on call rota across Mid & South Wales. Cardiff & Vale and Abertawe Bro Morgannwg UHBs have agreed arrangements for 3 days per week in UHW for the neuroradiologists 29
from ABM. This is shared across 3 neuroradiologists undertaking 1 day per week each. Neurophysiology To support the development of neurophysiology, the working group mapped the distribution of neurophysiology services and resources, and undertook an assessment of strategic issues facing the service (full report is attached in appendix 7). A number of key issues were identified:- Risks to service sustainability due to: - there are currently no Higher Education providers offering Modernising Scientific Careers compliant training schemes - age structure of current Neurophysiology Physiologist workforce (a number of retirements are imminent) Variance in ways of working across services (leading to variance in productivity) How the spoke units within Cwm Taf and Aneurin Bevan Health Boards are developed to allow efficient service delivery and address variance in waiting times across Health Boards Creating links to Health Boards clinical information systems (Clinical portal/ Clinical Workstation etc.) so that Neurophysiology results are available across all hospitals where Neurophysiology services are provided; Electronic links between Health Boards so that EEGs can be read remotely. An on-going project is required to implement joint solutions to these issues, in particular, collaboration to secure the long term sustainability of the service. Transport The workstream identified that the development and implementation of a clinical transfer protocol for patients with neurological injury, would support the efficiency of the system for ensuring timely transfer to the appropriate setting (including direct transfer to the neurosciences centre). The Welsh Ambulance Services NHS Trust are leading the development of this protocol which will be signed off via the Medical Directors peer group. 30
The attached flowchart (appendix 8) is a framework for the care pathway that reflects current practice but which requires further development, in particular around ensuring the right type of ambulance is requested for the right journey. 4.4.4 Work in progress Further work has been identified by the workstream as required in order to deliver the Axford recommendations in full. Neuroradiology Establishing a single on-call rota across South Wales. The next phase of integration of neuroradiology services will focus on moving to a single on-call rota, facilitated by teleradiology where required. Neuroradiologists in ABM already have access to and utilise teleradiology systems that would facilitate a single rota. Neurophysiology On-going work is required between Health Boards to work towards joint solutions to common issues faced by neurophysiology services. Transport As noted above, the Wales Ambulance Services NHS Trust is leading on-going development of a clinical transfer protocol. 4.4.5 Conclusion The diagnostics workstream has achieved closer working across the neuroradiology services at ABM and C&V Health Boards. This has helped to secure a sustainable neuroradiology service for Mid & South Wales. Further work is required to move to a single rota for on-call neuroradiology cover. The workstream has undertaken work to map in detail the distribution of neurophysiology services across Mid & South Wales and has identified issues that require joint solutions. 31
The A clinical protocol is under further development to ensure appropriate and timely transfer for patients with neurological injury to the neurosciences centre. 32
5. Conclusions This report has outlined the outputs from the 2 nd phase implementation of the specific recommendations for neurosciences in Mid & South Wales set out by Dr Alan Axford. These include the recommendations for neurology, rehabilitation for acquired brain injury and spinal injury, rehabilitation input in supportive care, spinal surgery, diagnostics and transport. This report has summarised the key achievements to September 2011 and assessed the extent to which the objectives of this phase of implementation have been delivered. Significant progress has been made by the project towards meeting the Axford recommendations. The recommendations for spinal surgery have been delivered in full, and the recommendation to increase capacity in neurology is close to completion with a process underway for recruitment. Substantial and detailed work has been undertaken to develop models for neurology and rehabilitation services and networks. Closer working across neuroradiology services has been formalised, with further integration planned, to ensure the sustainability of diagnostic neuroradiology. However, as is made clear in the report, further work is required to meet the full recommendations in order to provide the neurosciences services of the highest quality for the population of Mid & South Wales. The recommendations to the Project Board from this phase of implementation are set out in Section 6 below. 33
6. Recommendations to Project Board The Project Board is asked to consider the recommendations set out in table 4 below. Table 4: Recommendations to the Project Board Recommendation Status Resource/Other Implications Spinal Surgery R1. The Project Board notes that the Axford recommendations for spinal surgery have been delivered. For Noting There are no further resource implications. Action No further action required. Adult Rehabilitation and Supportive Care R2. The Project Board supports in principle the proposed model for the provision of neurological and spinal rehabilitation in the community. Specifically, the Project Board is asked to endorse the following key recommendations to be implemented within each of the Health Boards: For Support The resource implications of implementing the proposed model need to be explored and quantified (see R3). Health Boards continue to work through the rehabilitation workstream/network towards implementation of the new model. 1) To establish specialised 34
community outreach teams for acquired brain injury and spinal injury 2) To develop robust community based neuro rehabilitation or Disability Resource Teams or other specialist teams who work in a MDT model in the community. 3) To establish hubs of local rehabilitation services to provide general rehabilitation facilities for a range of conditions and age groups R3. The Project Board notes that, as part of on-going work, further analysis is required to explore and quantify the resource implications at individual Health Board level of implementing the full workstream proposals. For Noting Health Boards continue to work through the rehabilitation workstream/network towards implementation of the new model. 35
Neurology R4. The Project Board agrees the method of apportionment for the investment in additional neurology capacity. For Decision Health Boards have previously agreed to fund 2 additional neurologists to meet the Axford recommendation. An agreement on apportionment is now required to enable recruitment to proceed. Project Board to agree apportionment. Health Boards to complete recruitment process. Investment required to recruit 2 additional consultants: 593,502 (see front sheet, appendix 4). R5. The Project Board supports the proposed model as the direction of travel for the provision of neurology services across Mid & South Wales. R6. A network is formed to plan and deliver neurology services For Support For Support Options: Equal shares (this means that all six health boards would have to contribute 98,917) Shares based on HCHS allocation To be achieved largely through service re-design. It is recognised some elements may require investment. Delivered from within existing resources. Clinical and managerial staff time Health Boards implement new model through South Wales Neurology Network (see R6). Health Boards to establish neurology network. 36
Diagnostics and Transport R7. The Project Board notes the integration of neuroradiology services within hours and the ongoing work to integrate out of hours provision. R8. The Project Board notes the identification of key issues for collaborative working in neurophysiology across the services at ABM and C&V UHBs. R9. Transport system: The Project Board notes the work in progress to further develop the clinical protocol for transfer of patients with a head injury to the appropriate setting, including direct transfer to the neurosciences centre. allocated to establish network. For Noting None. Cardiff and Vale and Abertawe Bro Morgannwg Health Boards to continue to work to integrate out of hours provision. For Noting None. Health Boards establish neurophysiology implementation group under a DoTH to take forward collaborative working to address key challenges. For Noting None. Wales Ambulance Trust to continue development of protocol. 37
List of appendices A1. Membership of Project Team A2. Membership of Workstreams A3. Protocol for Accessing the Specialist Spinal Surgery Service at Cardiff and Vale University Health Board A4. Neurology Workstream Report A5. Neurology Needs Assessment A6. Adult Rehabilitation and Supportive Care Workstream Report A7. Neurophysiology Report A8. Flowchart for Neurological Transport Model 38