The Division of Surgery Currently Delivers Acute and Elective Inpatient, Day Case and Outpatient

Service Change Data Sheet Acute and Elective Surgery National Context (Outcome & Quality) Key changes have occurred nationally that have seen a change to the way both elective and non-elective surgery is delivered. These are summarised as follows:  Greater surgical sub specialisation.  Greater reliance on rapid access diagnostics.  Greater amount of surgery undertaken as day case.  Enhanced recovery programmes have had a significant impact in reducing elective and non-elective Lengths of Stay.  National shortages of training grade Doctors and a smaller pool of Non- Consultant Career Grade Doctors (NCCG’s).  Development of new staffing models in light of reduced Doctor numbers, e.g. Advanced Nurse Practitioner.  More complex operations performed on an increasingly elderly population. Development of minimally invasive procedures and procedures which can be performed under sedation (requiring less time in hospital). Local Challenges Following the commissioning of the new Hospitals at Pinderfields and Pontefract it has been increasingly difficult to provide the current range of acute and elective surgery across the Trust. Until recently utilisation of the theatre unit at Pontefract was poor, with Pinderfields and the Trust as a whole seeing capacity problems in both acute and elective surgery. Recent developments have had some success with demonstrable performance improvements against 18 week targets and a decreased reliance on the Independent Sector to meet SLA’s. However; these improvements are not thought to be sustainable going forward and changes to the provision of surgical services at MYHT is proposed. Changes to guidance on clinical safety and best practice, along with workforce supply and demand issues will give the Trust significant challenges to the provision of surgical services in the future. High demand for acute services on the Pinderfields site has been to the detriment of elective services; historically there has been a high elective cancellation rate. This has led to a drive to separate acute and elective to improve performance and clinical outcome. Current Configuration The Division of Surgery currently delivers acute and elective inpatient, day case and outpatient care in the following specialities:  ENT  Ophthalmology  Oral and Maxillo Facial and Community Dentistry

2013.03.14 Surgery Department Data Sheet v.2  Trauma and Orthopaedics  Plastic and Burns  Urology  Gynaecology  Vascular Surgery  Breast Surgery  Colorectal Surgery  General Surgery Day case and outpatient sessions in all these specialities are currently offered at Dewsbury, Pontefract and Pinderfields Hospitals. All acute inpatient surgery with the exception of Gynaecology, General and Colorectal Surgery are centralised at Pinderfields. There is currently some short stay elective surgery at Pontefract. Dewsbury provides inpatient elective care in Bariatric, Colorectal, General and Orthopaedic Surgery. Service changes have recently been agreed that will create an elective orthopaedic inpatient facility and a specialist adult ophthalmology services at Pontefract and at Dewsbury. The 2011/12 baseline data used in the capacity modelling showed that there was a total of 54,379 non-elective, elective inpatient and elective day case spells at MYHT. The following breaks down the spells by site: 1 Dewsbury: 2 2858 Non-Elective 3 1793 Elective Inpatient 4 6806 Day Case 5 Pinderfields: 6 12,813 Non-Elective 7 5688 Elective Inpatient 8 11,185 Day Case 9 Pontefract: 10 127 Non-Elective 11 863 Elective Inpatient 12 9885 Day Case 13 Independent Sector: 14 0 Non-Elective 15 1059 Elective Inpatient

2013.03.14 Surgery Department Data Sheet v.2 16 1302 Day Case

The Case for Change National Guidance Future provision of surgical services will be affected by a number of factors, including clinical safety, best practice and clinical guidelines. Others include:  NCAT Report on the Trust’s Clinical Services Strategy proposals in 2010, which recommends the following: “Consideration will also need to be given to how sustainable emergency general surgical services can be provided across the Pinderfields and Dewsbury sites”.  Royal College Guidelines suggest that surgical teams should be consolidated on one site.  Royal College of Surgeons/DH ‘The Higher Risk General Surgical Patient’: Recommends that all high risk surgical patients should have access to prompt senior review, CT scan, critical care beds and Emergency theatre. These drive consolidation of Emergency Surgery onto one site.  Centralisation of specialist services due to Specialist Commissioning specifications for example vascular surgery. Workforce There are two issues relating to workforce supply that will affect the future provision of surgical services:  Reduction in doctor training numbers (Foundation Year 2’s), currently the Yorkshire School of Surgery is reducing the number of surgical trainees throughout the Yorkshire region.  GI cover from a colorectal surgeon is required when a breast surgeon is on call at Pinderfields (at an additional cost). National Cancer guidance also suggests that all acute colorectal cancer cases should be treated by a colorectal surgeon. Emergency / Elective Surgery Split  Performance - the increasing numbers of emergency admissions and bed constraints has an effect on the Trust's ability to deliver elective surgery. The Trust met the 18 week referral to treatment target for patients requiring admission in August 2012 across all specialties, but performance is not consistent and will not be sustainable without changing the way that services are delivered.  Best practice - the current configuration of services prevents the Trust from separating emergency from elective work. This is identified nationally as best practice, reducing the risk of infection and improving the overall effectiveness and efficiency of the services by reducing cancelled operations.  Patient Experience - by keeping elective and emergency care separate, patients can be confident that their planned operations will take place as arranged and they will not experience the frustration, inconvenience

2013.03.14 Surgery Department Data Sheet v.2 and distress of a sudden cancellation.  Management of infectious diseases - increasingly, patients coming into hospital for planned care are tested for MRSA and other highly infectious diseases, Patients who test positive are treated before they receive their surgery, thus reducing the risk of infection. However, this cannot be done for patients who need emergency treatment. Mixing planned and emergency care in the same hospital or unit increases the risk of spreading infection to a larger number of patients.

Future Configuration All General and Colorectal acute inpatient surgery would centralise in Pinderfields.. Pinderfields would move towards a “complex” site providing all acute surgical procedures and surgery for the most complex elective surgery and higher risk patients. This would include general and colorectal inpatient surgery. Less ‘’complex” surgery will be undertaken at Pontefract and Dewsbury. Critical Care would no longer be required on the Dewsbury site. Clinical cover for surgery at Pontefract and Dewsbury will be provided by 24/7 advanced nurse practitioner cover (ANP) and resident anaesthetists. It is expected that closer working between surgical teams will allow specialist cover during core working hours, with Consultants reviewing all patients, regardless of whether they did the operation. The split of acute work from elective would provide a protected elective bed base, reduce cancellations due to unavailability of beds, improve theatre utilisation, and create inpatient bed capacity at Pinderfields for increased acute workload. Work is ongoing to develop the elective model of care at Dewsbury to maximise local surgery; however the capacity modelling assumes that circa 60% of all elective activity on the Pinderfields site could be undertaken on the Dewsbury site. This is estimated to be around 3500 spells based on this year’s activity. Pre-operative assessment and post operative follow up would be offered on all three hospital sites. Key Facts and Figures National Outcome Data Dr Foster’s hospital guide 2012 ‘Fit for the Future’ suggests:

 Being admitted to hospital to have an operation that is then cancelled wastes NHS resources and the patient’s time. While the rate at which operations have been cancelled after admission has been falling in recent years, it still happened to more than 200,000 patients last year.

 Evidence that certain operations such as tonsillectomies or knee wash operations are of little or no benefit to patients has been available for some time. There have been calls to reduce the number of these procedures, which has resulted in a fall of 15% over the past four years. However, more than 175,000 such operations took place in the NHS last year.

 Dr Foster has looked at operations where it is estimated that more than 90% could be done as day cases. The actual rate nationally varies between 78% and 96%. Common elective procedures done at weekends varies between 16% and 0% of activity.

2013.03.14 Surgery Department Data Sheet v.2 Local Outcome Data (Source: KMS) 2011/12:  Admitted performance 2011/12 – 78.7% (min: 90%)  Non-Admitted performance 2011/12 – 94.5% (min: 95%)  Elective Activity: - Pinderfields – 76% Day Case, 24% Inpatient - Pontefract – 96% Day Case, 4% Inpatient - Dewsbury – 83% Day Case, 17% Inpatient 2012/13: (Year to Date)  Admitted performance 2011/12 – 91% (min: 90%)  Non-Admitted performance 2011/12 – 96% (min: 95%)  Elective Activity: - Pinderfields – 82% Day Case, 18% Inpatient - Pontefract – 99% Day Case, 1% Inpatient - Dewsbury – 89% Day Case, 11% Inpatient Local Activity/Trends Market Share: NHS Wakefield – the Trust has seen a reduction in Market share in 2011/12 to 2010/11:  Elective Daycase – 83.1% compared to 82.7%  Elective Inpatient – 63.3% compared to 60.7% NHS Kirklees – the Trust has seen a modest increase in Elective Daycase market share from 2011/12 to 2010/11; however there has been a decrease in Elective Inpatient share:  Elective Daycase – 78.4% compared to 78.5%  Elective Inpatient – 61.8% compared to 61.1% Key Benefits The key benefits to the proposed changes are as follows:  Rapid access for urgent surgery.  More senior & specialist care for sickest patients.  Acute/elective split improves outcomes and experience .  Increases available specialties at Dewsbury .

2013.03.14 Surgery Department Data Sheet v.2  Local treatment and choice for non-complex planned surgery .  Less risk of cancellation and better patient experience.  More efficient use of elective surgical lists and theatre capacity through improved scheduling.  Reduced length of hospital stay.  Less risk of infection.  Less variation & better weekend care. Assumptions used in the service model The preferred option relies on the following assumptions to deliver the service model:  Critical Care will be centralised at Pinderfields.

 60% of all elective inpatient activity at Pinderfields and Dewsbury will be undertaken on the Dewsbury site; excluding the Wakefield elective orthopaedic take which will be done on the Pontefract site.  The Dewsbury and Pontefract sites will be supported by Advanced Nurse Practitioner and Resident Anaesthetist staffing models twenty four hours a day, seven days a week.  Day surgery will be provided on all three hospital sites, providing local access to this service.

 New and improved models of care will be developed to meet surgical demands moving forwards. Supporting Information/links Key References:  NCAT report – 2010.  Lord Darzi - Healthcare for London report – 2009.  Royal College Guidance – minimum medical staffing levels.  Productive Series, NHS Institute for Innovation and Improvement.  NHS Outcome Framework, 2013/14.  British Association of Daycase Surgery.  The Higher Risk General Surgical Patient: Towards improved care for a forgotten group’ The Royal College of Surgeons of England and Department of Health. Report on the peri-operative care of the higher risk general surgical patient 2011.

2013.03.14 Surgery Department Data Sheet v.2