Review of General Surgical Services in Carmarthenshire Dr. Michael Thomas Consultant in Public Health Medicine
Statement of the Problem Need to reconfigure services in Carmarthenshire identified in previous reports: • Report on the Future Provision of Elective/Emergency General Surgery at the Carmarthenshire N.H.S. Trust by the Royal College of Surgeons, 2005. • Recovery Planning Report by Teamwork Management Services, 2004. • Joint Committee on Higher Surgical Training (J.C.H.S.T.) Specialist Advisory Committee (S.A.C.) in General Surgery Regional Visit Report to West Wales General Hospital, 2004. • The findings of the Mid and West Wales Acute Services Review will need to be considered.
The Task • Surgical Services Working Group established to advise Carmarthenshire L.H.B. on future organisation of surgical services. • Surgical Services Working Group is multi-disciplinary. • Integrated working of key stakeholders resulted in recommendations for future delivery of surgical services. • Literature review and health care needs assessment. • Information on activity obtained using epidemiological and comparative needs assessment approaches. • Information on treatment and care gained using corporate and comparative approaches. • Identification of problems that need to be addressed and provide information for planning service improvement.
Background • Trust Organisation – Two District General Hospitals, Prince Philip Hospital in Llanelli, and West Wales General Hospital in Carmarthen. – Main providers of surgical services for Carmarthenshire. – Carmarthenshire N.H.S. Trust also provides a service for some residents of Ceredigion, Pembrokeshire, Powys and West Glamorgan. – Some Carmarthenshire residents access surgical services at Swansea N.H.S. Trust. • Primary Care Organisation – 26 General Practices providing primary care services for the population.
Background • Surgical Services – Current arrangement for surgical services in Carmarthenshire involves both emergency and elective surgery at West Wales General Hospital and at Prince Philip Hospital. – No general surgery emergency admissions to Prince Philip Hospital between 5 pm and 9 am during the week or at weekends. – Emergency admissions during these times transferred to West Wales General Hospital. – Elective surgical work is performed at both hospitals.
Aims and Objectives • Aims – To review the existing organisation and delivery of surgical services for Carmarthenshire residents and develop recommendations in order to drive improvement. • Objectives – To conduct a critical literature review to identify evidence of best practice. – To conduct a health care needs assessment for surgical services, drawing on epidemiological, corporate and comparative information. – To use the information to identify problems and produce a strategy for surgical services aimed at delivering change. – To act as a source of advice to current local planning.
Literature Review • Aim of Literature Review – Identify evidence of best practice in the delivery of surgical services. • Methods for Literature Review – Search Strategy involved searching multiple databases in order to capture all relevant information. • Literature Appraisal – Literature appraised giving consideration to the hierarchy of evidence.
Literature Review • Audit Commission, 2003. Waiting for Elective Admission: Review of the National Findings. London: Audit Commission. • Audit Commission, 1998. Audit Commission Update. Day Surgery Follow-up: Progress against indicators from a shortcut to better services. London: Audit Commission. • Senate of Surgery of Great Britain and Ireland, 2003. Reconfiguration of Surgical, Accident and Emergency Services in the UK. Glasgow: Senate of Surgery Secretariat. • The Royal College of Surgeons of England, 2000. The Provision of Elective Surgical Services. London: The Royal College of Surgeons of England. • The Royal College of Surgeons of England, 2005. Developing a Modern Surgical Workforce. London: The Royal College of Surgeons of England. • Audit Commission, 2003. Operating Theatres: Review of National Findings. London: Audit Commission. • Audit Commission, 2003. Acute Hospital Portfolio Reviews, 2003. London: Audit Commission. • Department of Health, 2004. Day Surgery: Operational Guide. Waiting, Booking and Choice. London: Department of Health.
Key Findings of Literature Review • The Royal College of Surgeons of England and the specialist associations exist to set and improve standards of surgical care to patients. • Modern surgical care must be delivered by Consultant Surgeons within a multi-professional team. • There must be a sufficient number of Consultants to meet the increasing need for service, education, training and professional development of surgeons. • Consultant Surgeons must be grouped in clinical networks of sufficient size to provide safe emergency and elective care, and appropriate local services. • Consultant Surgeons must be employed under conditions that will attract the widest range of doctors to the permanent surgical workforce. • Academic Surgeons have a key role to play in enhancing scientific standards and research, but at present the recruitment and resources are deficient.
Key Findings of Literature Review • Staff and associate specialists are, at present, essential to maintain a service and require an appropriate career structure. • The productivity of surgical teams can be improved by extending the roles of other professionals within the team. • Surgeons in training should not undertake unsupervised service work to the detriment of their training opportunities. They should not be relied upon to support surgical rotas, particularly at night. • There must be a recognition of the time commitment required of Consultant Surgeons to provide increased workplace training and subsequent effects on service delivery. • Improved facilities and better methods of working will be required to provide an efficient and cost effective service to patients. • The surgical profession must engage with Government and the Department of Health to develop new ways of training and service provision. The rapid development of surgical knowledge and technology requires a more responsive and versatile training process. A whole systems approach to training is needed in order that the talents of all members of the surgical team are effectively deployed.
Healthcare Needs Assessment • Epidemiological Needs Assessment – Epidemiological approaches required to develop more accurate estimate of burden on surgical services in Carmarthenshire and to provide more information about surgical services. – P.E.D.W. provides information on individuals who require admission to hospital to access surgical services.
Surgical Services Information from Carmarthenshire N.H.S. Trust
West Wales General Hospital General surgery admissions to West Wales General Hospital by method of admission and year of admission Data source: Admitted Patient Care dataset, Health Solutions Wales 2600 Number of general surgery admissions 2400 Elective inpatients 2200 2000 1800 Day cases 1600 1400 Emergency 1200 1000 Other 800 600 400 200 0 2000/1 2001/2 2002/3 2003/4 2004/5 Date of admission (financial year)
Prince Philip Hospital General surgery admissions to Prince Philip Hospital by method of admission and year of admission Data source: Admitted Patient Care dataset, Health Solutions Wales 2600 Number of general surgery admissions 2400 2200 Elective inpatients 2000 1800 Day cases 1600 1400 Emergency 1200 1000 Other 800 600 400 200 0 2000/1 2001/2 2002/3 2003/4 2004/5 Date of admission (financial year)
West Wales General Hospital Emergency general surgery admissions to West Wales General Hospital by area of residence and year of admission Data source: Admitted Patient Care dataset, Health Solutions Wales 2000 Number of emergency general surgery 1800 1600 Carmarthenshire 1400 admissions 1200 Ceredigion 1000 Pembrokeshire 800 600 All other areas 400 200 0 2000/1 2001/2 2002/3 2003/4 2004/5 Date of admission (financial year)
Prince Philip Hospital Emergency general surgery admissions to Prince Philip Hospital by area of residence and year of admission Data source: Admitted Patient Care dataset, Health Solutions Wales 2000 Number of emergency general surgery 1800 1600 Carmarthenshire 1400 admissions Swansea 1200 1000 Neath Port Talbot 800 600 All other areas 400 200 0 2000/1 2001/2 2002/3 2003/4 2004/5 Date of admission (financial year)
Emergency Surgery Admissions for Carmarthenshire Residents Emergency general surgery admissions for Carmarthenshire residents by hospital site: 2004/5 Data source: Admitted Patient Care dataset, Health Solutions Wales Number of emergency general surgery admissions 2000 1800 1,841 1600 1400 1200 1000 800 773 600 400 200 82 45 127 0 West Wales Prince Philip Morriston Hospital Singleton Hospital Other hospitals General Hospital Hospital
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