North Wales Neurosciences Review

NORTH WALES NEUROSCIENCES REVIEW

Head Injury, Spinal Surgery, Critical Care and Radiology Workstream

PHASE 2

FIRST PHASE REPORT

As detailed in the workstream methodology the Phase 2 meeting was held on the 17th April to develop options for consideration based on the knowledge gained in Phase 1.

RADIOLOGY WORKSTREAM

As identified at the phase 1 meeting the Radiology Imaging group did not require to meet again until the final phase.

HEAD INJURY AND CRITICAL CARE WORKSTREAM

The meeting was well attended with representatives from across North Wales:

Crispin Wigfield, Walton Centre for Neurology and Neurosurgery

David Cartlidge, Consultant, A & E, Ysbyty Glan Clwyd

Karen Smith, Case Manager, Community HDT, North West Wales NHS Trust

Lyn Roberts, Senior Nurse, A & E, Ysbyty Gwynedd

Stephen Jones, Head of Speech and Language Therapy, North West Wales NHS Trust

Pauline Cutting, Consultant A & E, North West Wales NHS Trust

Glynne Andrew, Consultant Orthopaedic Surgeon, North West Wales NHS Trust

Georgina Mudge, Physiotherapist, North West Wales NHS Trust

Ian Langfield, Health Commission Wales

Ed Farley Hills, Consultant Anaesthetist, North West Wales NHS Trust

Jeff Pye, Head of I M & T, North West Wales NHS Trust

Aeneas O’Kelly, Consultant Orthopaedic Surgeon, Conwy and Denbighshire NHS Trust

Apologies

Jacqui Lockett, Finance

Chris Whitehead, Walton Centre for Neurology and Neurosurgery

Head Injury & Critical Care Options for Discussion

Prior to the meeting members were asked for a list of options for consideration. However it was felt that it was difficult to generate a formal options list as most recommendations are either do or not do.

Neurosurgery

Plans in place to expand the critical care capacity of the Walton Centre- monitor effect- consider need for further capacity at Walton- consider neurocritical care in North Wales.

Develop clear and unequivocal guidelines across North Wales for the management of
The Management of Acute Head Injury- Completed.
The management of Spontaneous Subarachnoid Haemorrhage- pathway in progress.
The management of an acute Neurovascular event- pathway in progress.
The management of Acute Spinal Injury and Cauda Equina Compression- Being progressed by the Walton Centre with Crispin Wigfield.
The management of metastatic spinal cord compression (NICE)- NICE guidance available. Walton Centre are developing pathways in response to these.
The management of brain and other CNS tumours (NICE)- NICE guidance available. Walton Centre are developing pathways in response to these. It was agreed to Radiotherapy Centre Lead to offer them the opportunity to participate in the pathway development.

Recommendation

A videoconference link to the Walton Centre should be established both to facilitate the above and to improve consultation on individual patients.

Neurotrauma

Agree number and location of receiving units and ensure clearly designate person is responsible for the inpatient clinical care of non-neurosurgical head injuries and ensure that clinicians have the appropriate training and that a governance system is in place- Achieved.

Develop local facilities for overnight monitoring of patients that do not require transfer- Achieved but model of care and senior input inconsistent.

Recommendation

The model for immediate care of patients who do not require transfer should be standardized across North Wales as part of the Unscheduled Care Project. Action Workstream Chair.

Expand the critical care capacity of the Walton Centre

The Walton centre is in process of increasing number of critical care beds by 8. These will not be exclusively for use by N. Wales patients. Will improve access but will almost certainly not accommodate all patients who might benefit from neurocritical care. (Source Document recommends a minimum capacity of 8 neurocritical care beds at the Walton Centre for the population of North Wales)

Ongoing negotiations on funding between HCW and Walton – flagged as a legacy issue for BCULHB

The SBNS (Society of British Neurological Surgeons) and TARN guidelines be adopted- Achieved

Recommendation

The robustness of data collection systems to monitor application varies across the 3 main sites and with time. A robust system of data collection to monitor outcomes should be developed.

Monitor effect of increased critical care capacity at Walton.( Critical Care Network) Based on above plan to further increase neurocritical care capacity

Investigate feasibility of providing some neurocritical care capacity in N. Wales

Development of improved transport to address delays e.g. use of air ambulance – Work in progress- Air ambulance Service.

Develop local 24/7 MRI services and supporting diagnostic tests- Radiology workstream.

Comply with national audits(TARN) mandatory across North Wales- See SBNS commentary.

Neurocritical Care

Expand the critical care capacity of the Walton Centre to meet the unmet need in a single tertiary centre- See under neurosurgery.

Develop regional Neuroscience critical care capacity- See under neurosurgery.

Develop a local service integrating critical care beds into a general critical care facility- See under neurosurgery.

Develop Accident and Emergency Departments in North Wales to ensure necessary resources to assess, image and stabilise patients with acute neurological conditions and as part of multiple trauma or multi system failure, is available- Is in place. Will be reviewed as part of the Unscheduled Care project.

Develop appropriate facilities locally to allow the transfer/repatriation of patients to in a timely manner- Complete. North Wales Critical Care Pathway for severely head injured patients in place.

Critical Care Outreach/Rehabilitation

Develop a dedicated neuro rehab service to allow early assessment of head injured patients, adequate neuro rehab facilities and methods to place patients with server long term disability- Will be addressed by the Rehabilitation workstream.

Develop local outreach provision- Will be addressed by the Rehabilitation Workstream.

Develop the concept of critical care outreach services to neuroscience patients in ward areas in the neuroscience unit- To be addressed by the Walton Centre.

Develop support service for patients returning into the community setting- To be addressed by the Rehabilitation Workstream.

Long term ventilation

Development of a ‘step-down’ facility for the management of patients who require long term ventilatory support with 24/7 medical cover and located on an acute hospital site/sites- This forms part of a separate project addressing the need for long term ventilation across Wales. (Paper available on request)

SPINAL SURGERY WORKSTREAM

The meeting was well attended with representatives from North Wales and tertiary providers:

Crispin Wigfield, Walton Centre

Karen Smith, Case Manager, Community HDT, North West Wales NHS Trust

Lyn Roberts, Senior Nurse, A & E, Ysbyty Gwynedd

Stephen Jones, Head of Speech and Language Therapy, North West Wales NHS Trust

Glynne Andrew, Consultant Orthopaedic Surgeon, North West Wales NHS Trust

Georgina Mudge, Physiotherapist, North West Wales NHS Trust

Ian Langfield, Health Commission Wales

Ed Farley Hills, Consultant Anaesthetist, North West Wales NHS Trust

Jeff Pye, Head of I M & T, North West Wales NHS Trust

Wendy Farrington Chad, Chief Executive, Robert Jones and Agnes Hunt Hospital

Apologies

Jacqui Lockett, Finance

Chris Whitehead, WCNN

Options

Prior to the meeting a range of options and questions were developed which were discussed and actions agreed:

Do Nothing

Refer all patients to a single tertiary provider

Refer to a mix of tertiary providers

Develop a local service for non-complex spinal surgery with remaining patients referred to tertiary providers

Commission a local service from tertiary provider(s).

Develop a service referring patients to the Countess of Chester for non-complex spinal surgery and all other patients being referred to tertiary providers.

Questions

Are there sufficient patients for a local service?

All patients with back problems benefit from triage and appropriate referral. Triage services in North Wales are at different stages of development. For the majority of patients there is no surgical input to decision making.

Requirements to develop a service

Surgery for lower back pain alone- evidence of benefit is equivocal. Surgery for patients with lower back pain and sciatica appears to shorten the period of disability allowing early return to functionality.

Services for patients with back pain require leadership and again there are different models across North Wales.

Both main tertiary providers indicated that they can provide and support a range of services in North Wales, but not local surgery.

Would such a service be viable?

The numbers of patients undergoing spinal surgery in North Wales shows a significant increase over time. In 2007/08 there were 147 patients identified as undergoing non complex spinal surgical procedures for lower back problems. This is probably sufficient to sustain 2 Spinal Surgeons. Concerns raised regarding a service based around a small number of individuals.

CONCLUSION/ACTION

To develop a detailed model identifying the requirements to set up a local service in North Wales for non complex spinal surgery- Mr Andrew and Ms Mudge.

Next Stage

As detailed in the Option Appraisal Guide the workstream will develop a shortlist of options and:

Confirm the evidence base of each objective
Confirm the benefits associated with the objective
Verify the choice of options against the objectives and benefits and that there is an evidence base
Ensure no tenable options have been eliminated.

Following this a benefits appraisal will be undertaken.