Bariatric Surgery / Obesity Management

Transcription

1 Meeting: NoSPG Date: 3 rd February 2010 Item: 05/10 NORTH OF SCOTLAND PLANNING GROUP Bariatric Surgery / Obesity Management Purpose of the Report To advise NOSPG members of the progress made in reviewing the provision of bariatric surgery and obesity management across the North of Scotland and make recommendations regarding future action. Background Five of the North of Scotland Boards (Grampian, Highland, Shetland, Orkney and Western Isles) agreed an SLA for the provision of bariatric surgery service in 2007, based on the surgical service provided in. NHS Tayside re established a surgical service in Dundee for Tayside patients and did not participate in the agreement. The planned activity was for 40 procedures per year and the fixed and variable costs were shared by the five participating Boards. It was acknowledged early in 2009 that the capacity within the service is insufficient to cope with demand both in the North and across Scotland as a whole. Indeed the recently established National Planning Forum discussed bariatric surgery on the 22 July 2009 emphasising that any national work should be underpinned by regional experience, views and input. NOSPG members had already agreed at the meeting of 10 June 2009 to establish a short life working group to review the position across all six NHS Boards in the North, develop proposals for the future and influence the national discussion. Proposal A NoS workshop to discuss bariatric surgery in the context of wider obesity management strategies was held on 15 December The workshop was attended by 28 representatives from 4 of the 6 NoS Boards (Tayside, Highland, Grampian and Shetland). An action note of the workshop is attached at appendix 1. The outcome can be broadly summarised as follows: There was an overwhelming desire from the 4 Boards represented to work together to provide a bariatric surgery service as part of integrated obesity management services across the North. Discussion focused on surgical services delivered in two centres, Aberdeen and Dundee as part of a Regional Managed Clinical Network. The establishment of a formal bariatric surgery/obesity management sub group of NOSPG was proposed in order to plan and implement the regional network and manage the interface with any national initiative. The need for a structure and processes for regional delivery of these services irrespective of any national initiatives or network was stressed. 1

2 The sub group would establish the scope and terms of reference for the regional network particularly the extent to which the network would focus on surgical interventions and wider obesity management pathways and strategy. The sub group would commission a more robust and detailed analysis of demand and capacity. The sub group would develop a single, surgical pathway and ensure that this is fully integrated with wider obesity management pathways. The sub group would agree the criteria for access to surgical interventions in the NOS. The sub group would develop a workplan for the network. The sub group would lead the NOS input to any national discussions. The sub group should be chaired by a member of the NOSPG pending development of a network and establishment of the usual leadership arrangements. The sub group would produce a first draft regional delivery plan by July 2010 following the model developed by NOS Cardiac Sub Group/Network, including activity projections and resource implications. The existing SLA should remain in place pending production of the Regional Delivery Plan which should include proposals to clear the significant backlog. Lead managers from each Board have been asked to nominate representatives for the sub group, Recommendations NOSPG members are asked to support and approve the above proposal and in particular to: Identify a member of NOSPG to chair the sub group; and The intention to produce a draft delivery plan by July 2010 for presentation to NOSPG. Mr D.A. Sullivan Director of Planning 22 December

3 North of Scotland Planning Group Bariatric / Obesity Management Event Notes Tuesday 15 Dec 2009 AECC Appendix 1 Scene setting Agreed current situation: 40 procedures per year: 26 Grampian, 11 Highland, 1 Western Isles, 1 Orkney, and 1 Shetland. 1/4m fixed costs + variable costs = total of around 1/2m for regional service. National Planning Forum sponsored by NHS board chief executive and Scottish Government. Although National Planning Forum exists, still encouraged to have discussions at a regional level. Regional or National Board? 6 NOS boards. Duff Bruce s presentation Morbidly obese have increased risk of; diabetes, asthma, arthritis, high blood pressure and cancer. Main reason for wanting surgery is social and psychological reasons rather than worry of lowered life expectancy. 171m per year costs to Scotland of co morbidities. Scotland performs 3 bariatric procedures per 100,000 of population. 100,000 patients in Scotland would benefit from surgery. Currently a 3 year backlog. Government not supportive of closing the door to the service. Currently 4 per month referred in. 40 procedures per year manageable. Health Intelligence Presentation 189 patients had a bariatric procedure between Sharp rise in 2007 reflective of limit of 40 patients set. Length of stay average 13.7 days days Bariatric surgery patient numbers increased by 350% whilst bed days only increased by 35%. (Duff Bruce explained this was due to diabetic assessment?). 81% patients female however proportion of males increasing. 34 male patients between Majority years old (30 39 female, male). 3

4 Whilst the proportion of and years is going up, there has been a decrease in the proportion of year olds when comparing with Local data: 67% return questionnaire and receive an appointment for a first assessment. PAS activity: : 1028 attendances, 70 = first appointments and 19% = DNA (new and return) : 494 attendances, 116 = first appointments and 23% = DNA (new and return). Legacy list: 7 patients ready to go for surgery; a further 22 patients waiting for surgical assessment having completed psychological, dietetic and medical assessments; and an additional 35 patients under dietetic and medical assessment. Group Discussion Key issues Regional Considerations 1. National Planning Forum should link in with the Multi Disciplinary Teams to make joint decisions. 1a. What should be done locally, regionally and nationally? 1b. Differing visions between boards at present. 1c. Is it possible to develop a single regional pathway and how does it fit with local pathways? 1d. Regional managed network who is in/out? How does this fit nationally? Boards asked to express a view. 1e. Can agree a pathway but may not be realised for 2 years until backlog cleared. 1f. Equity of access to surgical assessment/bariatric service needed. Should be a single patient queue for North of Scotland. 1g. Focus on obesity management or bariatric surgery? Need a structure for resolving at some level. 1h. There is a responsibility to join together at a regional level, at least for governance alone. 1i. Is service cost effective to the service as a whole? Only cost effective to a number of patients. Need to identify best use of current resource and offer support from other regions. 1j. Possible virtual clinic of excellence suggested. 1k. Need a business case to establish a network. Needs and resources vary between regions but still a need to develop a network. Operational Considerations 4

5 2. Immense pre/post op issues. Local services for pre/post op care cannot currently be met. Question asked whether we should refer patients to Grampian at all if we cannot provide a comprehensive service. 2a. Agreed referral routes should be transparent. 2b. Access to surgery should be fair and consistent so as it can be explained to patients who are not eligible. 2c. 40 surgical procedures carried out in Grampian covering Highland, Orkney, Shetland and Western Isles/<10 surgical procedures in Tayside on a named patient basis. 2d. MDT and assessment. 2e. Morbid obesity needs acknowledged as a lifelong condition. Possibility of rapid access for lifesaving procedure and others managed within primary care. GPs should have electronic access to advice and option to refer for specialist assessment. 2f. Communication (cash limited threshold) Summary Good to have policy guidance from a national level, but issues still need dealt with regionally. Willingness identified from 3 boards (Grampian, Tayside and Highland) to look at equity of access, pathways and how they might fit together There is an absence of an agreed wider strategy. Regional structure to look at scope of work aspirations and objectives need drafted. Discussion to look at criteria and issues of access needs to take place. Possibility to influence national agenda. May need additional support to do this. 5

6 Appendix 2 Attendees 1. Joyce Thompson Public Health and Nutrition, NHST 2. Audrey Warden General Manager, NHST 3. David Exon Consultant Surgeon, NHST 4. Roseanne Urquhart Head of Health Care Strategy, NHSH 5. Fiona Clarke NHSHI, NHSH 6. Margaret Moss Professional Head of Service, NHSH 7. David Sullivan Director of Planning, NHSG 8. Vince Shields Divisional General Manager, NHSG 9. Duff Bruce Consultant Surgeon, NHSG 10. George King Unit Operational Manager, NHSG 11. Derek Walker Finance Manager, NHSG 12. Judith Hendry Head Dietician, NHSG 13. Sheila Riddoch Dietician, NHSG 14. Jillian Evans Head of Health Intelligence, NHSG 15. Helen Strachan Regional Manager, NSPG 16. Nicola Beech Health Intelligence, NHSG 17. Kathleen MacKinnon Medical Secretary, NHSG 18. Elaine Brown Medical Secretary, NHSG 19. Fiona Sim Senior Dietician, NHSG 20. Paul Nairn Service Planning Manager, NHSH 21. Sheelagh Rodgers Area Clinical Psychologist, NHSH 22. Mairi Wotherspoon Senior Dietician, NHSH 23. Utkarsh Kulkarni Specialist Registrar, NHSG 24. Jamie Hogg Better Care Without Delay Team 25. Sally Jones Dietician, NHSS 26. Maria McQuigg Counterweight Specialist Dietician, NHSS 27. Hannah Findlay Better Care Without Delay Team 28. Louise Ballantyne Better Care Without Delay Team 6

7 Appendix 3 North of Scotland Planning Group Bariatric/Obesity Management Feedback Tuesday 15 Dec 2009 AECC Identified Good Practice At Individual Boards Restructured their Nutrition Clinic to better meet the needs of Patients requiring weight management and assessment. Developed an Integrated Care Pathway with gives options in weight management and also Counter Weight support. Improving the transparency of their service. NHS Tayside Developed both adult and child obesity management pathways. NHS Tayside Re designed to make their service more centralised. NHS Highland Developed a Healthy Weight Strategy. NHS Highland Introduced a Counter Weight Programme. NHS Shetland Developed a Counter Weight Programme which currently approximately 25% of their patients are on. Barriers Experienced At Individual Boards Referral routes are not currently centralised and are able to be bi passed. Good models of care exist but are not formalised. Lack of awareness at local services available, for example Highland s Binge Eating Service. NHS Tayside Too many variations around their existing pathway. NHS Tayside Prevention Services for obesity do not currently exist. NHS Tayside Huge demand and capacity mismatch 548 referrals received in the last 6 months. NHS Tayside Named patient basis that exists does not work well. NHS Tayside Insufficient psychological provision, currently 1 year wait to be seen. NHS Highland Lack of primary care support in some areas leads to access inequality. NHS Highland Too many side door routes into the service. NHS Highland General lack of resources to manage obesity. NHS Highland No weight management programme currently exists. NHS Shetland Has had no dietician for the last year and as a result have a long waiting list. NHS Shetland Lacking a strategic plan of how to manage this service in the future. Does the GP contract influence referral into the service? Possible Opportunities And Individual Boards Improve referral routes Formalise existing models of care. Raise awareness of local services available. NHS Tayside Pathway criteria development and agreement. NHS Tayside Introduce prevention management services. NHS Tayside Priority criteria to be developed for surgical treatment. NHS Tayside Increase psychological assessment/support provisions. NHS Highland Improve primary care involvement and support of obese Patients. NHS Highland Ensure equality of access, develop access criteria. NHS Highland Undertake capacity and demand analysis to ensure adequate resources are available to manage obesity. NHS Highland Develop or adopt a weight management strategy. 7

8 NHS Shetland Undertake capacity and demand analysis to ensure adequate resources are available to manage obesity. NHS Shetland Develop a strategic plan for managing this service in the future. Explore the GP contract. Key Issues Identified For All Boards Lack of clear, agreed vision for the future of Obesity Management and Bariatric Surgery. No clear group or network exists to support and guide this service. Lack of equity for access to this service. No clear queue for fair and transparent access. Varied referral criteria and medical complexity of individual cases can cause inequity in accessing surgical treatment. Lack of local support for patients pre and post operatively when referred to Aberdeen for surgical treatment. Lack of clarity exists in the service decision points, decision makers, demand, capacity, activity and queues. Large back log needs to be managed. Proposed Actions For All Boards Develop a 5 year plan for Obesity Management. Explore the Regional Cardiac Service Delivery Plan as a possible model to be used. Senior representatives from all boards to decide who from their area will be members of the Regional Planning Sub Group that will be formed. Ensure Primary Care representation and in put to the Sub Group. Adopt, adapt or develop an Integrated Care Pathway to be used regionally. Identify the corporate resources that will be needed to support this work. Explore options for clearing the backlog. Individual Boards to get clarity on their service around: Referral sources and routes. Vetting criteria and processes. Admin processes, patient visibility and pathway measurement points. Decision points and decision makers. Professionals in their Multi Disciplinary Team. Prevention, assessment and support services available to them. Demand, capacity, activity and queue analysis. 8

9 Appendix 4 North of Scotland Planning Group Bariatric Surgery/Obesity Management Sub Group Terms of Reference Purpose To agree the scope and terms of reference for a Regional Network, in particular, the extent to which a network would focus on surgical intervention and/or wider obesity management strategy and action. To commission a robust and detailed analysis of demand and capacity for surgery taking into account the actual and potential impact of other interventions. To develop a single surgical pathway across the NOS, with agreed criteria for access and integration with wider obesity management pathways. To produce a first draft Regional Strategy/Delivery Plan by July To provide advice to NOSPG and represent the views of the NOS Boards in any national planning discussions. Membership Member of NOSPG Vincent Shields Duff Bruce Audrey Warden David Exon Roseanne Urquhart Chair NHS Tayside NHS Tayside NHS Tayside NHS Tayside NHS Highland NHS Highland NHS Highland NHS Shetland NHS Orkney NHS Western Isles 9