Working with you to transform general surgery – Considering our options

1 Purpose

The purpose of this paper and the consultation document Working with you to transform general surgery is to set out our shared understanding of what is driving change and why we need to transform our general surgery service. This paper describes in detail the options we have considered and our assessment of the best way forward.

While the paper sets out a preferred option, it does not represent a final commitment to any particular course of action. Its aim is to support a conversation and to gather feedback on the preferred option that we have identified.

2 About us

The Northern Health and Social Care Trust provides a range of health and social care services to a population of approximately 480,000 people across a geographical area of 1,733 square miles (2,773 square km) making it the largest geographical Trust in Northern Ireland.

The Trust’s vision is ‘to provide compassionate care with our community in our community.’

3 Introduction and background

The Northern Health and Social Care Trust provides both inpatient emergency and complex elective surgery on two acute sites: Causeway Hospital and Antrim Area Hospital. We are currently the only Trust in Northern Ireland to split our surgical service in this way. Many other parts of the United Kingdom and Ireland have changed the delivery of emergency general surgery so that it is provided in bigger hospitals with elective surgery taking place in dedicated elective sites, often located in smaller hospitals.

3.1 General Surgery Reform

The Reform North Programme comprises an ambitious programme of reform and transformation for the Trust organised into a range of workstreams and associated projects.

The work to consider the reform of general surgery services sits as one of the four distinct workstreams under the formal structure of Reform of acute services.

Acute services in the Northern Trust are delivered from two sites: Antrim Area Hospital and Causeway Hospital. Both hospitals play an essential role in our service delivery and the Trust is committed to maintaining acute services on both sites.

3.2 Working with you to transform general surgery

Our consultation document Working with you to transform general surgery sets out our case for change and describes how we have engaged our staff and other stakeholders as part of the process. It also summarises our options and appraisal process, which are described in more detail in this document.

Our public consultation will enable us to have a conversation with our service users, staff and other stakeholders, to help us make an informed decision about the future direction of our general surgery service.

4 Considering our options

4.1 Initial scoping

In November 2023 a workshop was held with the surgical consultants and senior Trust management to discuss significant concerns regarding pressures on the surgical team, and the sustainability of the current service configuration. As a result a Project Board was established to oversee the process of detailed planning, engagement and options development for the service including, if required, a public consultation.

The Project Board was chaired by the Director of Surgical and Clinical Services and included senior clinical representation from surgery and medicine, from both the Antrim and Causeway sites. The Board established a multidisciplinary group with broad clinical and managerial representation to oversee the development and appraisal of options, as set out below.

4.2 Long list of options

An initial list of seven options was developed by the service which considered a range of scenarios for the future provision of general surgery in the Northern Trust. The seven options were:

1. Do nothing. Maintain inpatient emergency, major colorectal and high volume elective activity in Antrim Area and Causeway hospitals
2. Uplift Antrim Area hospital. Maintain inpatient emergency, major colorectal and high volume elective activity on both Antrim and Causeway sites, investing in an additional three consultant surgeon posts and associated staffing in Antrim Area Hospital.
3. Uplift Antrim Area and Causeway hospital. Maintain inpatient emergency, major colorectal and high volume elective activity on both Antrim and Causeway sites, investing in an additional three consultant surgeon posts and associated staffing in both Antrim Area and Causeway Hospitals.
4. Centralise emergency general surgery on the Causeway Hospital site. Both sites continue to provide major colorectal and high volume elective activity.
5. Centralise emergency general surgery and major colorectal in Causeway Hospital, and high volume elective activity in Antrim Area Hospital.
6. Centralise emergency general surgery on the Antrim Area Hospital site. Both sites continue to provide major colorectal and high volume elective activity.
7. Centralise emergency general surgery and major colorectal in Antrim Area Hospital, and high volume elective activity in Causeway Hospital.

4.3 Evaluation criteria

The evaluation criteria below were developed to test each option.

1. Affordability: This option is affordable within the current budget
2. Workforce capacity: This option maximises the available workforce to equitably address demand for emergency general surgery and complex elective surgery
3. Sustainability (surgery): This option maximises our ability to recruit and retain consultant surgeons
4. Sustainability (other services): This option minimises the risk of destabilising other services such as emergency departments (ED), medicine and intensive care units (ICU)
5. Strategic alignment: This option achieves the optimum delivery of emergency and elective general surgery
6. Patient care (elective): This option creates the conditions for high volume elective surgery to be carried out
7. Patient care (emergency): This option achieves compliance with the General Surgery Review Standards, specifically:
   1. 24/7 access to an NCEPOD theatre
   2. Access to MRI scanning
   3. Access to interventional radiology
   4. Access to a bleeding rota
8. Access: This option ensures that all patients who require emergency general surgery regardless of where they present are able to access it in a timely way
9. Capacity: The option can be managed within our current bed and theatre configuration

4.4 Agreed methodology

A two-stage approach was used to produce a shortlist of options.

The first (pass/fail) stage was based on criterion 1 (affordability). Given the pressure on finances across the Health and Social Care (HSC), if an option was not considered affordable it was rejected at this stage and not considered for further appraisal.

Stage 2 of the appraisal involved using a weighting and scoring methodology on all options which passed Stage 1. Weighting and scoring was agreed by the multidisciplinary group established by the Project Board and including senior clinical and managerial representatives from surgery, medicine and strategic planning.

4.5 Stage 1

Options 2 and 3 require the addition of three and six consultant surgeons respectively, along with the theatre and other staff required to deliver their associated activity. As these options would require significant financial investment they were considered not to pass the affordability criterion and did not proceed to Stage 2 as set out in Table 1.

Table 1: Stage 1 options appraisal

Option	Criterion 1 Pass / Fail	Proceed to Stage 2?
1	Pass	Yes
2	Fail	No
3	Fail	No
4	Pass	Yes
5	Pass	Yes
6	Pass	Yes
7	Pass	Yes

 

4.6 Stage 2 weighting

The multidisciplinary appraisal team considered each of the remaining criteria and agreed that three should be given a higher weight than the others. These were:

• Criterion 2 – workforce capacity. The current imbalance in capacity and demand is one of the key drivers of the need for change and as such is given a higher weighting.
• Criterion 4 – sustainability (other services). This recognises the potential impact of changes in surgery on other services and the risk of destabilisation.
• Criterion 6 – patient care (elective). This recognises the impact of the current configuration on the efficiency of our elective care service, and the very long waiting lists that have arisen as a result.

The appraisal criteria were therefore weighted as shown in table 2 below:

Table 2: Stage 2 weighting

Criterion	Description	Weighting
2	Workforce capacity	12
3	Sustainability (surgery)	8
4	Sustainability (other services)	12
5	Strategic alignment	8
6	Patient care (elective)	12
7a	NCEPOD theatre	8
7b	MRI	8
7c	Interventional radiology	8
7d	Bleeding rota	8
8	Access	8
9	Capacity	8
Total		100

4.7 Stage 2 scoring

The multidisciplinary appraisal team scored each shortlisted option against the evaluation criteria using the following score methodology outlined in table 3.

Table 3: Stage 2 scoring methodology

Score	Description
0	Fails to meet criterion
1-4	Somewhat meets criterion (up to 40%)
5-9	Mostly meets criterion (up to 90%)
10	Fully meets or exceeds criterion (100%)

Table 4 below shows the outcome of this scoring exercise.

Table 4: Stage 2 scoring

Criterion	Description	Option
		1	4	5	6	7
2	Workforce capacity	4	8	10	8	10
3	Sustainability (surgery)	4	6	9	6	9
4	Sustainability (other services)	10	5	5	4	4
5	Strategic alignment	4	6	9	6	9
6	Patient care (elective)	5	7	10	7	10
7a	NCEPOD theatre	7	7	7	9	9
7b	MRI	9	9	9	9	9
7c	Interventional radiology	6	7	7	7	7
7d	Bleeding rota	5	5	5	5	5
8	Access	10	6	6	8	8
9	Capacity	9	6	4	7	5

• Workforce capacity. Options which centralise emergency and major colorectal surgery on a single site score highly on this criterion as they concentrate patients with high clinical risk on one site thereby enabling a concentration of workforce, particularly out of hours.
• Sustainability (surgery). A single-site model for emergency and major colorectal surgery is more likely to prove attractive to current and future consultant surgeons.
• Sustainability (other services). This criterion recognises that some disruption to other services will be inevitable if inpatient emergency surgery is no longer provided on one of our two acute sites. The Causeway Hospital options (4 and 5) score slightly higher than the Antrim Area Hospital ones (6 and 7) due to the relative fragility of some other specialties on the Causeway site.
• Strategic alignment. Options with emergency and major colorectal surgery on one site and high volume elective on the other are most in line with recognised best practice, regionally and nationally.
• Patient care (elective). Options with high volume elective surgery on a single site separated from emergency and major colorectal surgery will provide the best environment for an efficient high volume elective unit to address waiting lists.
• NCEPOD theatre. Antrim Area Hospital has a funded NCEPOD (24/7) emergency theatre, whereas Causeway Hospital does not. In any of the options Antrim Area Hospital will need to retain its NCEPOD theatre for other specialties, with the result that Causeway Hospital will be providing emergency surgery without the recommended theatre availability in Options 1, 4 and 5.
• MRI. We anticipate an MRI scanner to be operational on the Causeway site during 2025, so this criterion scores the same across all options.
• Interventional radiology. The Trust’s interventional radiology service can be delivered on whatever site emergency general surgery service is delivered, so this criterion scores the same across all options with a single-site emergency model.
• Bleeding rota. The Trust does not have a GI bleeding rota on either site but does have mitigations in place to manage compliance with this standard. The options under consideration do not change this situation, so this criterion has been scored equally across all options.
• Access. This criterion recognises that some patients will have to travel further to access inpatient emergency surgery. The Antrim Area Hospital based options (6 and 7) will impact fewer people than if the service were to be centralised in Causeway Hospital, so those options have been given a higher score.
• Capacity. This criterion recognises that a site with a centralised emergency general and/or colorectal service will experience increased pressure on its beds and theatre infrastructure. The impact of this additional activity would be proportionally greater on the Causeway site so that options 6 and 7 have scored slightly higher than options 4 and 5 respectively.

When combined with the weighting set out above, the final outcome of the options appraisal is shown as follows at table 5:

Table 5: Stage 2 weighted scores

Criterion	Description	Weight	Option
			1	4	5	6	7
2	Workforce capacity	12	48	96	120	96	120
3	Sustainability (surgery)	8	32	48	72	48	72
4	Sustainability (other services)	12	120	60	60	48	48
5	Strategic alignment	8	32	48	72	48	72
6	Patient care (elective)	12	60	84	120	84	120
7a	NCEPOD theatre	8	56	56	56	72	72
7b	MRI	8	72	72	72	72	72
7c	Interventional radiology	8	48	56	56	56	56
7d	Bleeding rota	8	40	40	40	40	40
8	Access	8	80	48	48	64	64
9	Capacity	8	72	48	32	56	40
	Total		660	656	748	684	776
	Rank		4	5	2	3	1

4.8 Options being brought forward for public consultation

The two options which centralise emergency and major colorectal surgery on one site and high volume elective surgery on the other have obtained the highest scores. Of these, the option which scores the highest is Option 7: Centralise emergency general surgery and major colorectal in Antrim Area Hospital, and high volume elective activity in Causeway Hospital.

Based on the overall options appraisal, it is the recommendation of the Project Board for approval at Trust Board that a public consultation is held to consider the two highest scoring ‘do something’ options. In line with usual practice the ‘do nothing’ option is also retained for comparison. The shortlisted options are therefore:

• Option 1: Do nothing. Maintain inpatient emergency, major colorectal and high volume elective activity on both Antrim and Causeway sites.
• Option 5: Centralise emergency general surgery and major colorectal in Causeway Hospital, and high volume elective activity in Antrim Area Hospital.
• Option 7: Centralise emergency general surgery and major colorectal in Antrim Area Hospital, and high volume elective activity in Causeway Hospital.

Based on the options appraisal set out above, the Trust’s preferred option is Option 7.

5 Involvement of stakeholders in developing our options

We have engaged inclusively and constructively with our internal stakeholders to consider the options we would like to consult on for the future of general surgery services. Our staff were involved in a range of meetings, briefing and workshops. The staff who work within general surgery, including our surgeons and specialist doctors, have helped to develop the options. Staff, particularly those in close contact with service users, are in a great position to know what is and is not working and to suggest better ways of doing things.

We also held a number of meetings with external stakeholders including other Trusts and the Northern Ireland Ambulance Service. The review process was also discussed with our Engagement Advisory Board (an advisory body made up of service users and carers who support the Trust to engage in a meaningful way). On 8 March we held an engagement event to look at our future priorities which gave us the opportunity to discuss general surgery with a range of service users, carers and representative organisations.

6 Equality Impact Assessment

We have completed an Equality Impact Assessment (EQIA). The EQIA looks at the potential impacts of the options on those classed as having protected characteristics as laid down in Section 75 of the Northern Ireland Act 1998. The Trust will consult on its EQIA during the consultation period in order to assess the views of those who will be affected by decisions. Our initial assessment of impact in our EQIA has shown the following.

Impact on service users and carers

Older people are more likely to require planned elective care and therefore are more likely to be impacted by the proposed shift in elective care provision to Antrim Area Hospital under option 5 or to Causeway Hospital under option 7. For both men and women the rate of disability increases with age. For those aged 75 and above, the prevalence of disability increases to over 68%.

The impact of the proposal on people with dependents is anticipated to be on family carers. Many of the people who receive surgical services are visited by friends and family and the Trust is aware of the importance of regular contact between patients and their family and friends.

For ethnically diverse services users, our initial feedback shows there may be an impact in terms of further travel distances and journey times for those who do not have access to a form of transport. The Trust is committed to ensuring that its services are accessible to everyone and provides an interpreting service for those whose first language is not English.

The Trust has considered mitigations including

• considering local access for as many appointments as possible,
• the use of telephone and virtual clinics,
• arranging appropriate appointment times to allow for travel time,
• promoting eligibility for the use of non-emergency patient transport services and the Hospital Travel Costs Scheme.

Impact on staff

The proposed service reconfiguration may impact on staff in terms of relocation to a new work site and /or redeployment to a different post and a new role. The Trust will ensure that its engagement arrangements adhere to best practice principles governing consultation and are meaningful and inclusive of all staff affected and trade unions in line with the Trust’s Management of Change Human Resource Framework. There are systems in place to support staff through the changes such as providing timely information, the availability of retraining opportunities, consideration of redeployment options, accessing occupational health support and eligibility for excess travel allowance payments. The Trust is committed to monitoring for any adverse impact.

7 Rural Needs Impact Assessment (RNIA)

We have completed a Rural Needs Impact Assessment (RNIA).  A Rural Needs Impact Assessment helps the Trust to understand the impact the options are likely to have on people living in rural areas.

For this proposed service change the Northern Trust has defined rural areas based on drive time from a town centre or a settlement with a population of 10,000 or more (a large service centre). There are two areas that fall outside the 30 minute drive-time boundary to a town centre or large settlement exceeding 10,000 people; this is the north east coast boundary of the Trust and associated hinterlands covering settlements such as Ballycastle, Cushendall, Cushendun and the Glens area and the second area is to the west of Ballymena covering settlements to the east of the Sperrin Mountains such as Draperstown, and Upperlands.

The Trust has analysed the travel times and distances, to both Causeway and Antrim Area Hospital sites, from settlements where more than 1,000 people reside within Northern Trust geographical area. Analysis of travel distances and time for all settlements in NHSCT area with 1,000 or more residents indicates that 15 locations with resident numbers totalling 83,642 (26%) are in excess of 30 minutes travel time to Antrim Area Hospital. There are 30 locations with resident numbers totalling 258,427 (80%) in excess of 30 minutes travel time to Causeway Hospital.

Patients accessing emergency surgery who present at their nearest emergency department will be transferred by ambulance to the most appropriate hospital to meet their surgical needs.

Those living in rural locations who do not have access to private transport may require more effort, time, and resources to travel to planned elective surgery than those in an urban area due to limited availability of public and community transport. We are also mindful that the following issues require to be considered,

• additional travel time for those who live rurally who wish to visit a patient,
• connectivity for virtual appointments and for virtual visiting,
• eligibility for the Hospital Travel Costs Scheme,
• home care availability in rural areas to ensure appropriate support for people being discharged from hospital,

The impact on redeployed staff will be managed through the Human Resources Management of Change Framework and appropriate consultation.

Listening events during the consultation process will provide rural communities with the opportunity to learn more about the rationale for the change to general surgery services, the steps taken to keep all patients safe, and for people to give feedback.

8 Proposed Consultation Process

The Trust is committed to a transparent, best practice approach to consultation based on the following key principles.

We will:

• Engage with local people and describe our journey and the purpose of our review
• Incorporate the findings from our Equality Impact Assessment and Rural Needs Impact Assessment, which have helped us identify the groups and communities we should target during the consultation process
• Involve stakeholders through a variety of activities including attending pre-existing engagement opportunities
• Acknowledge the importance our communities place on health and social care services and commit to considering all available feedback and insight to further inform our proposals
• Share the information we have considered in developing our options
• Ensure that we engage with all groups and partners with an interest in our plans including our partners in local Councils, local Councillors, MPs and Members of the Local Assembly
• Be clear about our strategic goals to deliver high quality care for local people, whilst also being transparent about the challenges we face
• Be transparent about the benefits and risks of our options.

8.1 Outline of the consultation process

The consultation process will run for a period of 14 weeks from 23 August 2024 until 29 November 2024 to allow us to gather stakeholder feedback that will enable it to make an informed decision on the options in the best interests of local people.

During the consultation process, there will be many opportunities for service users, carers, local communities and staff to make their views known. During the consultation period we will hold three in-person listening events and one online event.

• 30 September 2024, 7:00pm -8.30pm, Glenavon Hotel, Cookstown
• 1 October 2024, 7:00pm -8.30pm, Online meeting
• 7 October 2024, 7:00pm -8.30pm, Lodge Hotel, Coleraine
• 9 October 2024, 7:00pm -8.30pm, Dunsilly Hotel, Antrim

We are happy to engage further on request. These events provide the opportunity to ask further questions and give feedback.

For our online public meeting, please contact involvingyou@notherntrust.hscni.net for registration and joining instructions.

We will also be writing to local groups and organisations, to ask if they would like us to attend their meetings to talk about the consultation. We will also be making sure that we contact particular communities of interest in the Trust area to seek their views.

The responses to the consultation process will be analysed and we will publish a report outlining how we have considered the feedback in coming to our decision. We will promote the consultation process through social media and other established channels including dissemination to our Consultee Database, our Involvement Network, local stakeholder groups and existing forums.

An easy read and signed version of the Consultation Document are available on our website and to ensure accessible communication other versions are available on request (including Braille, disk and audio cassette, and in minority languages to meet the needs of those who are not fluent in English).

8.2 Process for decision-making following close of the consultation

Following the close of the formal consultation, the Trust’s Senior Management Team and Trust Board will review all the feedback and any new and relevant information received during the consultation period, and propose a final recommendation for approval by the Minister for Health.