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| Acute Services Review Report |
| Chapter 4: Prediction of need and the organisation of services 65. This Chapter discusses ways in which need can be predicted and services developed accordingly. It considers two diseases for which various treatment options are available, using them as templates for discussion and as potential models to be exploited in other areas of the acute sector. The work of the Renal Sub-Group is used to illustrate how service needs can be defined when there is a national database, and the work of the Cardiac Sub-Group is used to demonstrate some of the problems facing a priority service where overwhelming demand is coupled with a need for rational development and a more coherent database. 66. Without renal replacement therapy (dialysis or transplantation), all patients with end stage renal disease (ESRD) will die. Dialysis may take the form of haemodialysis undertaken in hospital (the commonest option) or at home, or chronic ambulatory peritoneal dialysis (CAPD). Renal transplantation can dramatically improve the patient's quality of life by removing the need for fluid/dietary restriction, dialysis, and vascular or peritoneal access. Haemodialysis is the most expensive option (circa £19 000 a year), transplantation the cheapest in that each operation will save some £30 000 over 20 years. Rational discussion of the services needed for patients with ESRD has been greatly facilitated by data drawn from the Scottish Renal Registry and the UK Transplant Support Services Authority (UKTSSA). 67. ESRD develops each year in 80-100 people per million population (pmp) who are medically suitable for renal replacement therapy. At the close of 1997, 856 patients in Scotland were receiving hospital haemodialysis. With current acceptance criteria, the number of patients suitable for renal replacement therapy (RRT) is predicted to rise to a plateau by 2010, by which time some 720 patients pmp will have been transplanted or on dialysis. The need for hospital haemodialysis will depend mainly on the rates of transplantation, graft survival and patient survival. Assuming that:
68. When considering increased rates of transplantation, it should be borne in mind that this rate is unlikely to exceed 40 pmp per year in the next decade (see below) and that allowance always has to be made for regrafting in the event of graft failure. Table 4.1 shows the predicted rise in the number of patients who will require hospital haemodialysis if there are changes in the numbers receiving alternative forms of dialysis and transplantation. An increase in the transplant rate to 35 pmp would save an estimated £27m on haemodialysis by 2010, the figure rising to £57m with a rate of 40 pmp. There would of course be additional costs for the transplant patients but these are not as great; it should be noted that the need for haemodialysis does not fall in any of the models.
Table 4.1
Current provision in Scotland 69. Currently, haemodialysis for adults is provided by 11 renal units (four of which also serve as renal centres) and a network of satellite units, staffed by nurses or artificial kidney assistants, and providing a limited dialysis service. Data from the Scottish Renal Registry show no difference between the various centres and units in patient survival rates. Costs vary, but not as a function of volume of service provision. At present there is no central organisation of services and individual Health Boards are principally responsible. 70. Renal transplantation is currently undertaken in 4 centres (Aberdeen, Dundee, Edinburgh and Glasgow). Data from the Scottish Renal Registry show no differences in patient and graft survival rates and the Review accepts that kidney donation rates may be greater in population centres where transplantation is undertaken. However, it has concerns about the continued viability of Scotland's 4 centres given the present difficulty in recruitment of transplant surgeons and endorses the Sub-Group's list of attributes needed by a Centre undertaking kidney implantation. All hospitals undertaking dialysis require surgical support to establish vascular access for haemodialysis and insert/remove CAPD catheters.
Table 4.2
Resource issues if the need for haemodialysis were to increase 71. Current funding levels could not sustain the present acceptance rate for dialysis if transplantation rates remain unchanged; indeed the acceptance rate might have to fall to 60 new patients pmp if additional resources could not be made available. Provision of more dialysis facilities would incur significant costs in buildings, equipment and staff, particularly if it was thought necessary to improve patient access by dispersing services in satellite units. 72. With regard to workforce concerns, the supply of renal physicians would probably be sufficient to cope with additional demands related to dialysis, but there would be a pressing need to increase the number of renal nurses and ensure the availability of resources (surgical, anaesthetic and nursing staff; theatre sessions) to provide vascular access or peritoneal catheter insertion. The current difficulties in the recruitment of transplant surgeons is a deeply perturbing trend which needs to be addressed urgently if Scotland is to retain 4 renal transplant units. Increased rates of renal transplantation 73. The number of new patients suitable for renal transplantation each year currently exceeds the number of operations being performed, and waiting lists are increasing (Table 4.2). Shortage of organs is the major factor, the number of kidney donations having declined as death rates from road traffic accidents and intracranial haemorrhage have fallen (Table 4.3). Multi-organ donors currently provide around 70% of the kidneys transplanted in Scotland, while transplantation from living-related donors is relatively uncommon.
Table 4.3
The need for transplantation could be accommodated more readily if kidney donation rates in all Scottish regions equalled those of the best. It is the view of the Renal Sub-Group that an annual target of 40 transplants pmp is a realistic goal. 74. Currently, three separate retrieval teams (heart/lung, liver, kidney) may travel to a hospital maintaining a multi-organ donor. The kidneys are generally retrieved by a team from the nearest renal transplant centre. The local hospital provides a staffed operating theatre and an Intensive Care Unit (ICU) to sustain the donor until the retrieval operation begins. A single Scottish organ retrieval team would benefit the staff of transplant units and hospitals where retrieval takes place, through reduced disruption; it would require no increase in resources and could well produce savings by reducing the number of staff on call. 75. Ways to increase organ donation rate include the following:
76, Xenotransplantation is not included in this list given uncertainties about its future. Similarly, legislative changes to alter donation arrangements ('opt out' versus 'opt in') or increase the number of potential donors ('elective ventilation') lie outwith the scope of this Review. 77. It is clear that a sound database is the key to modelling and defining services to contend with increasing numbers of patients with ESRD. Similar modelling for other regional and national services (e.g. cardiac services and neurosurgery) is hampered by a lack of comprehensive quantitative data, and in some areas there is also a paucity of evidence-based clinical information. The need for such databases is addressed in greater detail in Chapter 9. The Review recommends that the Management Executive continue to work with the Scottish transplant community to develop service modelling, monitor the viability of renal transplant centres, introduce a single multiorgan retrieval team, enhance organ donation rates and develop a lead centre for living-related kidney donation. It recognises that such programmes will have potential benefits for all forms of organ transplantation. 78. Scotland has the second highest mortality rate from coronary heart disease (CHD) in Western Europe and all agree that it must remain a priority area for the NHS. An estimated half a million Scots have CHD, of whom 180 000 are being treated for symptomatic disease. Patients with stable angina pectoris have a 4-6% risk of death or non-fatal myocardial infarction each year and 30% of those with recent onset angina will have a significant cardiac event (death, non-fatal infarct or coronary revascularisation) within 2 years. CHD accounts for more than a quarter of all deaths in Scotland (over 15 000 deaths in 1996), and although age-adjusted mortality has declined by approximately 30-40% from its peak in the early 1970s, the overall prevalence of the disease continues to rise. The burden of disease and expenditure on it is not evenly distributed. Incidence is linked to deprivation, and in general, mortality rates are higher in the West of Scotland and are highest in Lanarkshire. 79. Outpatient workloads in cardiology and cardiothoracic surgery rose by 77% and 57% respectively between 1991 and 1996, and admission rates for acute myocardial infarction have risen while continuous inpatient stay times have fallen. Revascularisation of the heart in patients with CHD can be undertaken by percutaneous transluminal coronary angioplasty (PCTA) with/without stenting or by coronary artery bypass grafting (CABG). In respect of PCTA, the UK undertook 359 procedures per million in 1996, the figure in Holland, Germany and Belgium being around 900 per million. 80. In respect of CABG, Scotland undertakes around 470 operations per million of the population annually compared to a rate of 800 per million in Sweden. The British Cardiac Society have recommended a target rate of 600 per million for the UK, although this might be regarded as equivalent to 750 per million given the magnitude of Scotland's problem. The Scottish Cardiac Surgery Programme costs around £20 million annually (of which 70% is the cost of CABG), although this must be set against the indirect costs of death and disability (estimated at around £435 million annually). 81. PCTA has the advantage that it avoids surgery under general anaesthesia and the risks associated with cardiopulmonary bypass, and while the approach may be preferred to CABG in defined circumstances, CABG offers better long-term outcomes and value for money in other groups of patients. The definitive role of stenting remains uncertain and there should be caution in increasing the use of stents in patients undergoing angioplasty. Stenting should not be seen as an alternative to surgery but in certain situations can prevent emergency surgery. PCTA costs about £2000 including an overnight hospital stay but excluding the cost of the stent (currently £800). Overall costs at 5 years appear similar for CABG and angioplasty/stenting. 82. The Review accepts the view of its Sub-Group that outcomes may be better in higher volume centres (Chapter 6 and Annex 4) and that trained operators should undertake 1-2 PCTA per week (>60 per year) and work in a centre with at least 2 operators and a workload of more than 200 procedures a year. It agrees that stenting should not be undertaken where on-site cardiac surgical back-up is not available. It accepts that angioplasty is being undertaken in units such as Hairmyres Hospital and the Western General Hospital, Edinburgh on the basis that cardiac surgical cover is available within 30 miles and cardiopulmonary bypass can be established within 90 minutes of the decision to undertake emergency CABG. However, the Review would much prefer to see interventional cardiology being undertaken on sites providing cardiac surgery and this issue will be considered further below. 83. It is against this background that the NHS in Scotland needs to consider its provision of specialist services for patients with CHD. The Review accepts that the main priorities are to establish a national database (which remains capable of local ownership) and develop a mechanism to take a strategic overview of provision of services for patients with CHD. It is essential to define the number of coronary revascularisation procedures that should be undertaken annually and reduce unacceptable delay and variation in waiting times for referral and treatment. The SIGN Guidelines which are about to issue on Coronary Revascularisation in the Management of Stable Angina Pectoris should assist this process. Reliance on the private sector for coronary revascularisation is inappropriate. 84. If additional interventional capacity (coronary angioplasty and/or CABG) is deemed necessary, an assessment would then have to be made of whether it could be found by expanding existing units or whether new provision would be needed. There are indications that at least 2 of the 4 existing cardiac surgery units could increase their throughput with relatively modest additional resource. However, in this debate it must be borne in mind that the benefits of angioplasty and stenting are denied in locations such as Dundee where there is no cardiac surgery and anxieties have already been expressed about interventional cardiology in sites lacking surgical back-up. Evidence presented to the Review gives no grounds for believing that patients are being referred inappropriately for CABG who would be better managed medically or by angioplasty; over 80% of patients being operated on have either stenosis of the left main coronary artery or 3 vessel disease. The number of deaths of patients on cardiac waiting lists currently exceeds operative mortality rates and it is difficult to escape the conclusion that the NHS in Scotland should be treating less advanced disease and minimising delays that are leading to avoidable morbidity and mortality. 85. In this debate, due regard will need to be given to ensuring service quality, providing more equitable access and provision, ensuring local access and patient choice wherever feasible, and optimal cost effectiveness. Given the present inequity and maldistribution of resources, some redistribution of resources and workloads may well be necessary. 86. The Review is persuaded that the magnitude of the problem posed by CHD merits a special national mechanism to drive forward work in this area. The Management Executive is encouraged to build on its current CHD/Stroke Priority Action Team to create a CHD Task Force to develop the clinical network of cardiac services. The Group's remit would include maintaining a national database to monitor referral and outcomes, addressing waiting list issues (risk stratification, management of myocardial infarction, selection criteria for revascularisation, prioritisation and national waiting list co-ordination), implementation of SIGN (and other appropriate) guidelines, audit, quality assurance, evaluation of resource distribution (including provision for interventional cardiology) and rehabilitation. It would assess the case for increasing the capacity for revascularisation and would determine the need for, feasibility, cost-benefits and location of any new cardiac surgical facility. The work of the Cardiac Sub-Group is viewed as a useful platform for these deliberations. The Task Force could also consider the provision of heart valve surgery in Scotland (currently amounting to 640 operations per year). The Review sees attractions in defining National Cardiac Resource Centres in Edinburgh and Glasgow which would underpin specialist services in the East and West of the country respectively, link to managed clinical networks through regional 'lead centres', and provide a strong basis for research and development. The case for such Resource Centres could also be considered by the Task Force.
Chapter 5: Organisational Issues Designed to Care 87. Designed to Care affirmed the Government's vision for the Health Service in Scotland: a modern, 'designed' health service which puts patients first. Patients are likely to benefit from the best balance between local access and access to specialist care if clinicians work together in networks to provide integrated clinical services. The concept of managed clinical networks which has emerged strongly from the Review presents a number of conceptual and organisational challenges to Health Boards and the Trusts which are now forming. However, it is the not the detailed organisation of Trusts but the key principles underlying the service functions which are essential to the Acute Services Review, and they are briefly restated here. Replacement of the Internal Market 88. The White Paper retains the benefits of devolved management by defining distinctive roles for Health Boards and Trusts. The longer-term perspective and strategic role of Health Boards is strengthened, while the service role of Trusts is reconfirmed and extended. In most Health Board areas, the majority of health services will be delivered by two complementary organisations: one Primary Care Trust and one Acute Hospital Trust. Key themes include the need for co-operation, the breaking down of organisational barriers, and improved communications. Improving clinical links across the interfaces between primary, secondary and tertiary care is vital. In refining the roles of Boards and Trusts, Designed to Care described the organisational framework which forms the backdrop to the Review. 89. The lead role of Health Boards in protecting and improving the health of their population is retained in the White Paper, with Health Improvement Programmes (HIP) being seen as the main vehicle through which these responsibilities will be discharged. Development of HIPs must be a genuinely co-operative process if Boards are to provide responsive leadership to Trusts and to other organisations with an interest in health, most importantly local authorities, voluntary organisations and the wider community. Boards have the responsibility to ensure that Trusts implement these Programmes through Trust Implementation Plans (TIP). 90. All of the Review's Sub-Groups have highlighted the need for national and regional structures to take forward the development of clinical services. The size of the population served by many of Scotland's 15 Health Boards is seen as too small to allow optimal strategic planning and delivery of many services. Details of the suggested regional configurations have varied, with two-, three- or four-regional models being presented (variations on West, East and North). One of the Review's working assumptions was that it should not be constrained by Health Board boundaries; indeed the Review is persuaded that the existing boundaries between Health Boards can be positively unhelpful when planning the organisation of some managed clinical networks. 91. However, the Review appreciates that the strategic planning of clinical specialities or sub-specialties may be quite different from, and may even conflict with, the strategic planning of the comprehensive health needs of a population. High level specialty-specific planning cannot be undertaken in a vacuum and the relationship of such services to the NHS as a whole needs to be borne constantly in mind. 92. The Management Executive (ME) has the national lead responsibility for health services planning and by definition their remit straddles existing Health Board boundaries. It is not appropriate for the ME to lead the strategic planning and oversee the delivery of individual specialty services and much will depend upon developing regional planning through consortia of Health Boards. Discussions about the development of services across networks will require careful orchestration, including the imperative to involve colleagues in Local Authority, voluntary and other relevant agencies such as Health Councils. These regional strategic planning and management agendas are consonant with the broader responsibilities of Boards for the health of their populations. 93. Health care services are delivered across a spectrum of primary, secondary, tertiary and community care. The Review has recognised from the outset that it was quite inappropriate to regard acute services as the exclusive concern of secondary or tertiary hospital services. Significantly, the Review was not constrained by existing boundaries between primary, secondary and tertiary care and was encouraged to develop models of care through which to achieve the vision outlined in Designed to Care. 94. The creation of Primary Care Trusts will give strong focus to the range of primary care services within any Health Board area. They will typically comprise General Practitioners (largely organised in voluntary Local Health Care Co-operatives), community hospitals/services and mental health services, but their precise organisational form is currently a matter for consultation. The possible inclusion within the Primary Care Trust framework of services traditionally associated with secondary care (e.g. services for children and maternity services) has exciting potential with regard to cohesiveness and seamlessness of services. It is clear that Primary Care Trusts will have horizons which extend beyond those of services provided by general practitioners alone; they will be concerned with the collective contribution of a wide range of professionals. 95. Designed to Care encourages primary care and secondary care clinicians to work together on the design and delivery of clinical services by requiring each Health Board to establish a Joint Investment Fund (JIF). The size of the JIF will be for local determination by Health Boards and Trusts, with Primary Care Trusts taking the lead role in discussions regarding the fund's application. The specific objectives will vary but considerable emphasis could be placed on 'clinical networking' with blurring of the boundaries between primary and secondary care, promotion of seamless care, and improved access to services. 96. The pressures faced by Acute Hospital Trusts in the delivery of services is recognised in the very establishment of the Acute Services Review. Concurrently it was concluded that there were too many acute trusts, and that mergers would be needed to foster functional unity. The definitive configuration of Acute Hospital Trusts will shortly be determined and the activities of the new Trusts will be crucial to the optimal delivery of acute services. The work of the Review has consistently identified the need for 'networks' with the objective of making expertise available throughout a region and at points where it can provide the greatest benefit to patients who need specialist care. Throughout, the aim is to balance local access with the need to provide high quality and cost effective services which make the best use of scarce specialist skills and resources. National Professional Advisory Structures 97. There has been growing recognition during the Review of the need for a national mechanism to advise on and take forward emerging issues. The method of conducting the Review has highlighted shortcomings in the present structure and operation of the National Professional Advisory Committees which form part of the advisory structure of The Scottish Office Department of Health. The six Committees in their present form date from 1994. They are the direct descendants of the 34 committees constituted under the National Health Service (Scotland) Act 1972 to introduce strategic planning into the NHS, foster the development of seamless care, and avoid duplication of effort. 98. The Committees were originally established as a resource for both the Department and the professions. In the case of the National Paramedical Advisory Committee, the Committee is the only source of contact at national level. The Committees have a remit to provide advice on the formulation of national policy, provide good practice statements, provide informed comment on consultative documents produced by the Department (or other bodies), act as an early warning mechanism for new developments in health care and serve as a forum in which to discuss issues which require resolution at national level. 99. While they have produced much valuable work on specific subjects, there is a general view that the National Professional Advisory Committees are not achieving their full potential, and lack a clear focus as to their remit and role. Nor have they the power to monitor the implementation of recommendations originating from their reports. It seems likely that some of their activities (and in particular the 'New Developments in Health Care' exercise undertaken by the National Medical Advisory Committee) will be largely subsumed by the new Scottish Health Technology Assessment Centre. 100. There are also specific issues in relation to the somewhat artificial configuration of the Committee structure. For example, the interests of clinicians working in diagnostic services are fragmented across two Committees (National Medical Advisory Committee, NMAC; and National Paramedical Advisory Committee, NPAC) and share common threads of interest with a third Committee (National Advisory Committee on Scientific Services, NACSS). The interests and expertise of some health care professionals (for example, clinical psychologists) do not fall within the compass of any of the existing Committees. 101. One of the most striking features of the Review was the way in which it has encouraged professional groupings to meet, often for the first time, to discuss issues related to the provision of services. This is reflected in the call by each of the Sub-Groups for a national forum for their particular area of interest. The Review supports those calls, and encourages each specialty or area of interest to develop its own forum, emphasising the value of multidisciplinarity wherever possible. If that suggestion is adopted, those bodies would assume one of the main roles currently discharged by the National Professional Advisory Committees. 102. After due deliberation, the Review proposes that the National Professional Advisory Committees should be retained, although it recommends merger of NMAC and NACSS. It can see advantage in retaining a multidisciplinary Acute Services Group to assist the Management Executive and the Service in carrying forward the work of the Acute Services Review. This Group would draw on expertise and advice from the appropriate National Professional Advisory Committees and fora as appropriate. The subject of advisory mechanisms and Review implementation will be considered in further detail in Section 3 of this Report.
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