Working with you to transform general surgery – Consultation paper

Foreword

We at Northern Trust are proud of our general surgery services and we want all of our community to benefit from safe, effective and high quality care. Our primary focus throughout our review of general surgery is the safety of our patients.  We are committed to ensuring the best outcomes for our patients and we can only achieve this by planning services carefully around the needs of our population.

We have a growing older population which brings both opportunities and challenges. While living longer is something to be celebrated and a higher proportion of older people are now able to live independent lives, they also need timely access to quality care rather than long waiting lists for planned surgery. Ignoring this demographic shift could undermine the potential benefits of living longer. We must plan our services to be able to manage increasing and changing demand within the resources that we have.

Our surgical teams working across Antrim Area and Causeway Hospitals believe that we need to change how our services are organised. We need to plan now for the long term sustainability of our services, making sure we retain the excellence of our current workforce as well as being able to attract future surgeons.

The options presented in this document have had extensive clinical engagement and we believe would better help us to provide the quality of care and outcomes we aspire to deliver for all, in line with clinical evidence and national policy, guidance and standards.  Your opinion matters to us, and we encourage everyone to provide feedback during the consultation. This feedback will allow us to work together to carefully consider next steps before making any decisions about changes to services.

Kevin McMahon

Director of Surgical and Clinical Services

About the Trust

The Northern Health and Social Care Trust provides a range of health and social care services to a population of approximately 484,000 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 income is just over £1 billion and we employ approximately 15,000 permanent, temporary and bank staff across a wide range of disciplines.

We deliver services from over 150 facilities including two acute hospitals, a mental health hospital, local community hospitals, health centres, social services, and a significant network of community services as well as provision of care in the home.

The Trust covers four local council areas – Antrim and Newtownabbey, Causeway Coast and Glens, Mid and East Antrim and Mid Ulster. The Trust has the largest population including the highest number of older people and children when compared to other Trusts in Northern Ireland.

Our vision is to provide compassionate care with our community in our community. In delivering, planning and reforming services, all staff are guided by the health and social care values: working together, excellence, openness and honesty, and compassion.

Introduction

The Northern Trust provides the following types of surgery.

General surgery is a wide-ranging surgical specialty that focuses on diseases of the alimentary (digestive) tract and abdominal cavity.

Emergency general surgery is the treatment of patients presenting with acute abdominal problems, soft tissue infections requiring treatment, bleeding and trauma, and sees the admission of some of the most unwell patients to the acute hospital setting.

Elective general surgery is surgery that is planned in advance such as surgery on the gallbladder and biliary system, hernia repair and other minor surgeries.

It is helpful to distinguish between different types of elective surgery.

Major colorectal surgery includes procedures such as bowel resections, often for the treatment of cancer. It is considered to be high risk surgery and patients often require support in an intensive care unit after their procedure.

High volume surgery includes procedures such as cholecystectomy (gall bladder removal) and hernia repair. These procedures are shorter than major colorectal ones, and are considered lower risk. In some cases however the patient may be frail or have other health conditions which increases the risk of surgery and the need for intensive care unit support.

The Northern Health and Social Care Trust provides all these types of surgery (inpatient emergency, major colorectal and high volume elective) on both of its 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.

This consultation document explains why we need to transform our general surgery service and describes some options for future services. 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 options we have identified.

Regional Context

The Bengoa Report ‘Systems, Not Structures’ and ‘Health and Wellbeing 2026: Delivering Together’ (2016) stated there is a need to change how we deliver our health and social care services in Northern Ireland. Demographic changes, particularly a growing and ageing population with more chronic health problems and complex health needs, means we have increasing demand for hospital based services.

The stark options facing the HSC system are either to resist change and see services deteriorate to the point of collapse over time, or to embrace transformation and work to create a modern, sustainable service that is properly equipped to help people stay as healthy as possible and to provide them with the right type of care when they need it.

(Systems Not Structures, p. 11)

The Department of Health’s Review of General Surgery (2022) addressed the challenges of how general surgery in Northern Ireland is currently configured. In a modern environment with increasing surgical specialisation, new technology, capacity gaps within the current structure and an increase in demand, there is a real need to take action.  We need to increase capacity, or there is a risk that we will not be able to meet the future needs of our population.

The current model for delivering general surgery in Northern Ireland is neither sustainable nor providing uniformly high-quality care. Going forward we need to ensure that the system is person centred with a focus on patient outcomes – with services structured around the needs of those who require care and treatment.

(Review of General Surgery, p19)

General Surgery in the Northern Trust

Outpatients

Most people’s first contact with the elective surgical service is through an outpatient appointment. We provide general surgery outpatient clinics in Antrim Area, Causeway, Whiteabbey and Mid-Ulster Hospitals.

The chart below shows that outpatient activity has been increasing since the dip during the pandemic. The proportion of appointments dedicated to red flag (suspect cancer) and urgent referrals has increased, from 54% in 2018/19 to over 63% in 2023/24.

Endoscopy

Many general surgery patients require an endoscopy as part of their diagnostic pathway. We provide elective endoscopy in Antrim Area, Causeway, Whiteabbey and Mid-Ulster Hospitals.

The chart below shows that endoscopy volumes have recovered to pre-pandemic levels. It also shows a shift towards red flag (suspect cancer) activity.

Day surgery

Elective day surgery is also provided in Antrim Area, Causeway, Whiteabbey and Mid-Ulster Hospitals.  The table below shows the split of activity between these hospitals in 2023/24.  The majority of day surgery is classed as routine, with smaller proportions of red flag and urgent procedures.

Inpatient elective surgery

Inpatient elective surgery includes both major colorectal surgery and general elective procedures such as gall bladder and hernia surgery. Antrim Area and Causeway Hospitals both provide inpatient elective surgery, with 2023/24 activity shown below.

Waiting lists

Waiting lists increased significantly during the pandemic. We have seen some improvements in recent years but waiting times for all types of surgery are still longer than we would want. The table below shows the average waits for new outpatients and inpatient or daycase (IPDC) treatment as of January 2024.

Emergency general surgery

Many patients require general surgical assessment, diagnosis and/or treatment in an unplanned way, often following presentation in an emergency department. This is called non-elective or emergency general surgery.

Both our acute hospitals provide inpatient beds and have access to an emergency theatre for non-elective surgical patients. We also have a same day emergency care (ambulatory) service on each site, where patients can receive rapid assessment and diagnosis from a senior surgeon.  They can often be managed appropriately without needing to be admitted to hospital overnight.

As can be seen below, approximately two-thirds of the Trust’s emergency surgical activity is managed through Antrim Area Hospital.

A message from our Surgeons

As surgeons in the Northern Trust, we care very much about the quality of service we provide to our patients. We are strongly committed to ensuring that everyone who needs the care of a surgeon can get that care, in the right place and at the right time.

Unfortunately the way our service is organised at the moment means we can’t always provide that level of care. Our waiting lists are too long, especially for less urgent procedures such as gall bladder surgery.  We are concerned that stretching our resources across two inpatient emergency units is making our service unsustainable.

That means we need to change, to ensure that we can sustain a resilient emergency service for many years to come and to begin to reduce some of our very long waiting lists.

Thank you for taking the time to read this document. I hope you will work with us to build a better, more sustainable surgical service for the population of the Northern Trust.

James Patterson

Clinical Director for General Surgery

Why our service needs to change

Sustainability

We treat around 6,600 emergency general surgery patients each year. This breaks down as around 12 per day to Antrim Area Hospital and 6 per day to Causeway Hospital. Antrim’s unscheduled surgical demand is double that of Causeway’s and this is not reflected in the surgical workforce between the two sites. Antrim has 9 funded consultant posts and Causeway has 6. It is not possible to relocate surgeons to Antrim because a minimum of 6 is required to manage the on-call demands of emergency surgery in Causeway.

This imbalance of capacity and demand exacerbates the already intense workload on the Antrim site which has the following consequences:

• Sustaining rotas across 2 sites makes the service vulnerable to being able to retain and attract staff and increases the risk of service collapse if there is any unplanned change in staffing
• The Antrim surgical team experiences high levels of stress and burnout
• The Antrim surgical team has had to reduce its elective activity to manage the emergency workload, resulting in an increase in waiting lists for patients including those with a cancer diagnosis
• Our ability to meet our targets for cancer waiting lists and red flag referrals continues to be a challenge without dedicated elective capacity and access for our patients
• Additional locum consultants are employed to support the team in Antrim, the temporary nature of which represents a further vulnerability

 Looking ahead, we would expect that around 25% of our consultant surgeons are likely to retire in the next 3-5 years. There will not be enough doctors completing general surgery training locally to fill all of the consultant vacancies that we expect to arise in the same 3-5 year period. When recruiting consultants we are in competition with the four other Trusts in the region.  Having two smaller teams means that surgeons have to be on call more often and this is less attractive than a single Trust wide rota with good cross cover for periods of leave.

The inability to recruit and retain consultant surgeons in the future is a real risk to the sustainability of our general surgery service.  We are mindful of the recent collapse of general surgery emergency services in two other Trusts. This happened because vulnerable and precarious staffing arrangements, made worse by unsuccessful recruitment into consultant posts, resulted in an inability to provide 24/7 consultant cover. It is important to plan our workforce proactively rather than waiting for and reacting to an inevitable collapse in the service.

As well as needing a sustainable workforce, our surgical service must be financially sustainable. We have noted above that the current model is increasing locum costs, and we would expect a more resilient staffing model to reduce our reliance on this kind of staff.

Given the current financial pressures on the health and social care system and the public sector as a whole, any proposed model must be deliverable within current resource. This is not to deny that more investment is needed to meet the demand of our population, it is simply a recognition that no additional resource is available at the current time and any service change that relies on increased funding is unlikely to be deliverable in the short to medium term.

Standards

In June 2021, the Minister for Health commissioned a Review of General Surgery in NI in response to challenges in the delivery of safe and sustainable services. It was recognised that there are differences in the delivery of services and waiting times across the region, as well as difficulties in maintaining 24/7 rotas for emergency general surgery across a number of sites due to staff shortages. The Report was published in June 2022 and all Trusts are guided by these standards when reviewing current services and deciding how best to provide a safe, secure and effective general surgery service.

The Report sets out 28 standards for the provision of emergency general surgery. In its current configuration the Trust does not meet four of these standards. The table below summarises the situation, and more detail on the standards is below the table.

Standard 2.2

The hospital with emergency inpatient surgery must have access to a fully staffed emergency theatre available 24/7 (National Confidential Enquiry into Patient Outcome and Death [NCEPOD]).

This is in place on the Antrim Area site. In Causeway there is a dedicated emergency theatre available out of hours. In-hours (Mon-Fri 9-5) emergency surgery can be provided, although it may be necessary to interrupt an elective (planned) list.

Standard 3.2

Radiology (interventional) – All hospitals admitting surgical emergency patients must have on-site access to simple interventional radiological procedures such as drainage, ideally 7 days per week but a minimum of 5 (Mon-Fri).

Antrim Area has 5-day interventional radiology.  On the Causeway site this is available 2-3 days per week.

Standard 3.4

The hospital admitting surgical emergency patients must have access to a gastroenterology service and an on-site ‘bleeding rota’ with the ability to undertake urgent upper and/or lower endoscopy on emergency surgery patients as required for diagnostic and therapeutic purposes.

Neither hospital has an on-site bleeding rota.

Specialisation

The DoH Review of General Surgery highlights the importance of separating as far as possible scheduled from unscheduled care. General surgery has important clinical interdependencies between emergency surgery and high risk colorectal surgery which are best managed together on the same site. For the lower risk, high volume elective procedures such as gall bladder and hernia surgery, the ideal scenario is to have separate theatres, teams and beds to ensure planned patients are not cancelled when unscheduled pressures rise.

We currently carry out emergency surgery, major colorectal surgery and elective general surgery in both Antrim and Causeway hospitals, using the same beds, teams and theatres. This leads to competition for the same resources and reduces the efficiency of both sites.

A more efficient use of our resources would be to have one site specialising in emergency and major colorectal surgery and the other focused on high volume procedures. This would help us address our very long waiting lists for procedures which present a lower clinical risk but still have a significant impact on quality of life.

Safety

Our primary focus throughout our review of general surgery is the safety of our patients. While we do not have concerns about the safety of our current surgical services, we are concerned that the sustainability issues we have highlighted could make safe services difficult to maintain in the future. We would prefer to act in a planned way to protect the safety of our services and our patients, rather than wait and respond to a crisis.

We must also give due attention to the safety of the services that sit alongside general surgery on our two acute sites, and ensure that decisions taken in one area do not have unintended consequences elsewhere. In particular, we will continue to provide 24/7 emergency departments on both Antrim Area and Causeway sites, and these must be safe for the patients who use them. We have considered the bed and operating theatre capacity to ensure that any changes we make can be accommodated within our infrastructure.

Considering the options for future general surgery services

We developed a list of seven options for the future configuration of our general surgery service, and tested them against the following criteria.

• Affordability: This option is affordable within the current financial envelope
• Workforce capacity: This option maximises the available workforce to equitably address demand for emergency general surgery and complex elective surgery
• Sustainability (surgery): This option maximises our ability to recruit and retain Consultant Surgeons
• Sustainability (other services): This option minimises the risk of destabilising other services
• Strategic alignment: This option achieves the optimum delivery of emergency and elective general surgery
• Patient care (elective): This option creates the conditions for high volume elective surgery to be carried out
• Patient care (emergency): This option achieves compliance with the General Surgery Review standards
• 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
• Capacity: The option can be managed within our current bed and theatre configuration

 Involving and listening to staff to identify and develop good practice has been important when developing and assessing our options for consultation. We have also considered the regional strategic direction and national best practice.

We have held over 30 engagement events, involving affected staff from both acute sites, as well as a range of external stakeholders including the Western Health and Social Care Trust, the Northern Ireland Ambulance Service, the Major Trauma Network and the Department of Health. This has helped shape and inform the development and assessment of our options.

Our staff have told us that they are concerned about the recruitment and retention of staff, they want to ensure that emergency department services are protected and that patient safety is the priority.

We have also engaged with service users, carers and representative groups about our service review.  There was an understanding that there may be a need to travel for specialist services. They told us that good clear communication with the public is vital. Some concerns were raised about the future of Causeway Hospital and extra travel times.

Our shortlisted options and preferred option for future general surgery services

For full details of all options considered and how they were assessed, please see our ‘Considering the Options’ paper.

After considering all of the options, we are bringing forward the following three options for public consultation, the ‘current state’ option and the two reconfiguration options with the highest score in our assessment.

• Option 1: ‘do nothing’ – continue to deliver emergency and elective general surgery in Antrim Area and Causeway Hospitals.
• Option 5: – centralise emergency general and major colorectal surgery in Causeway Hospital and high volume elective activity in Antrim Area Hospital.
• Option 7: – centralise emergency general and major colorectal surgery in Antrim Area Hospital and high volume elective activity in Causeway Hospital.

The outcome of our options appraisal is that our preferred option is Option 7: centralise emergency general and major colorectal surgery in Antrim Area Hospital and high volume elective activity in Causeway Hospital.

We believe this option provides the best configuration of emergency and elective surgery, maintains safe and effective care for our population and provides a sustainable model for the future provision of surgical services in the Northern Trust.

What does the preferred option mean in practice?

What happens to emergency surgical patients in the Causeway area?

Causeway Hospital will still be able to assess and diagnose the majority of patients with surgical issues. The surgical assessment unit will extend its opening hours to 7 days per week and senior surgical staff will be available 24/7 to respond to any patients presenting at the emergency department at Causeway Hospital.  Many patients will be managed without a hospital admission, including returning to Causeway Hospital if required for a planned surgical procedure. Only those patients who require an overnight stay or an urgent surgical intervention will be transferred to Antrim Area Hospital. A small number of patients will need to go directly to Antrim Area Hospital and a bypass protocol has been agreed with the Northern Ireland Ambulance Service.

Will I have to travel further for planned surgery?

With the separation of major colorectal and high volume elective surgery between Antrim Area and Causeway Hospitals, some patients who would previously have been treated in Antrim Area will go instead to Causeway, and vice versa. The creation of these two specialist units will improve the quality and efficiency of our elective pathways, and help to bring down waiting times for everyone.

Will Causeway keep its Emergency Department?

The Trust’s Strategic Vision for Causeway Hospital (March 2024) includes a clear commitment to maintaining a 24/7 emergency department on the Causeway site and sets out an ambitious vision for the development and enhancement of services in Causeway.

How will this reduce waiting lists?

We are currently providing high volume elective surgery on both our acute sites, alongside emergency and major colorectal activity.  This means that the more seriously ill emergency and colorectal patients take priority and it is difficult for us to secure bed and theatre capacity for less urgent procedures.

Our preferred option will result in the development of a dedicated high volume elective unit on the Causeway site, which would open at the same time as the proposed change to emergency general surgery. Because Causeway has inpatient acute services and an intensive care unit, we can operate on complex patients, older people and those with frailty or other long term health conditions. This unit will be able to deliver many more high volume procedures than we currently provide. This will help us to bring down our very long waiting lists for procedures which have a lower clinical risk but still have a significant impact on quality of life.

This is in line with the Trust’s ambition for Causeway Hospital to become an elective and diagnostic hub for the North-West, as set out in the Trust’s Strategic Vision for Causeway Hospital.

These planned changes would require some adjustment to the deployment of ambulances and discussions are well advanced with NIAS about how this could be achieved.

In the following eight scenarios we describe the patient pathway for our preferred option, that is what will happen to the patient in terms of diagnosis and treatment.

John aged 35, has been involved in a serious altercation on the north coast and has been stabbed in the abdomen resulting in serious injury.  When the ambulance arrives John is assessed by the paramedics.  On this occasion due to the severe trauma he has suffered, NIAS makes the decision to by pass Causeway ED and take him directly to Antrim Area hospital as he may require emergency surgery.  The emergency department is alerted in advance.

Susan aged 47, arrives at the Causeway emergency department with severe abdominal pain.  A scan shows that she has a perforated bowel. She is assessed by the senior surgeon on the Causeway site who determines that she will require surgery within a few hours.  Susan is stabilised and given antibiotics and a transfer is arranged to take her to Antrim Area hospital by ambulance.  When Susan arrives at Antrim Area Hospital she is admitted directly to the surgical unit without having to go through the emergency department.

Peter aged 70 is an inpatient on the medical ward at Causeway Hospital, he develops severe abdominal pain and his condition suddenly deteriorates.  Peter is now acutely unwell and is assessed by the senior surgeon on the Causeway site.  Peter requires intubation and is stabilised.  A decision is made that he requires an emergency transfer to Antrim Area Hospital by ambulance.  An anaesthetist travels with the Peter in the ambulance and he is taken straight to the surgical unit on arrival.

Kevin aged 60, a local farmer, arrives at Causeway emergency department after his tractor overturns and there is concern that he has sustained a head injury. Kevin is brought by ambulance to the Causeway emergency department as the nearest trauma receiving unit within the regional network.  He is assessed, receives a CT scan and later is discharged home from Causeway.

Kate aged 40 arrives at the Causeway emergency department with abdominal and back pain.  She is assessed and from her notes the emergency department  consultant is aware of ongoing issues with her gallbladder.  Kate is moved to the surgical ambulation ward at Causeway Hospital.  After surgical assessment, it is decided that Kate will need surgery to remove the gallbladder.  She is discharged with a treatment plan to return to the surgical unit at Causeway Hospital to have the surgery two days later.  Kate is scheduled on the surgical list and receives her surgery at Causeway Hospital.

Jack is 10 years old and has been feeling unwell during the day with right side abdominal pain and a slight temperature.  His mum has become increasingly worried as his symptoms seem to be getting worse and they arrive at Causeway emergency department at 9pm.  Jack is examined and assessed by the onsite surgeon.  Jack is diagnosed with suspected appendicitis and will require surgery.   A decision is made to transfer him to Antrim Area Hospital.  Jack is transferred directly to theatres or to the children’s ward as appropriate, without having to go to the Antrim emergency department.

Donna aged 35 has been on a surgical waiting list for 4 years for a hernia repair.  She has had her pre-operative assessment completed and a date given for her surgery in Antrim Area Hospital in March 2024.  Unfortunately due to other pressures on the site, her surgery has been cancelled. Following the transformation of general surgery and the separation of unscheduled and elective surgery, Donna receives a new date to have her surgery at Causeway Hospital.  The development of the dedicated elective unit in Causeway Hospital means that Donna’s surgery is less likely to be cancelled and Donna receives her surgery as planned

Alex aged 39 from the Glens of Antrim arrives at Causeway emergency department with severe abdominal pain.  He is given a CT scan and results show that he has an obstruction suggestive of suspected bowel cancer.  Alex’s condition requires emergency surgery.  An ambulance transfer is arranged and Alex has his surgery in Antrim Area Hospital.  Alex will require follow up as an outpatient over the next three years.  Most of his follow up care is accommodated locally in Causeway Hospital.

Impact on staff

We value and respect our staff and will keep them informed at every stage. The principles of the Trust’s Management of Change Human Resource Framework provide a robust and transparent process for proposals that impact on our staff. We have systems in place to support staff through the changes such as the availability of retraining opportunities and eligibility for excess travel allowance payments.

A communication strategy will make sure that staff are kept fully informed of any proposed action and developments. Staff will also have regular communication meetings with their managers to discuss plans, influence the planning process and air their concerns. The Trust will work in partnership with trade unions to assess the impact on staff and to put robust mitigating measures in place.

Promoting equality and considering rural needs

It is important that we understand how the changes we are proposing might affect the population we care for. To help us to do this we have completed, and are also consulting on, an equality impact assessment (EQIA) and a rural needs impact assessment (RNIA).

This has helped us to identify groups and communities in our population who might be most impacted by the changes we are proposing. We want to hear from people in these groups to help us understand how the proposal could impact them and how any negative impacts could be reduced.

We invite views on these assessments and want to make sure that everyone gets the opportunity to be involved. We are keen to be flexible in how we engage with local people so please contact us to talk about how you would like to provide feedback.

Tell us what you think

We are consulting with you on the future configuration of general surgical services in the Northern Trust area.

The feedback on this consultation will help us to provide local people with better care in the most appropriate place. Please take the time to read this document. There is additional supporting information online

We want to consult as widely as possible on our proposals and the findings of our equality impact assessment (EQIA) and our rural needs impact assessment (RNIA) commencing 23 Aug 2024.

We are committed to hearing your views and to facilitate this we have extended the consultation period to 14 weeks.

During the consultation period we will hold listening events in person and online as follows.

• 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

These events will provide the opportunity to ask further questions and give feedback. If you would like to attend please contact involvingyou@northerntrust.hscni.net or telephone 028 2766 1377.

To facilitate your feedback, a consultation proforma is available online.  To request a copy of the proforma for you to fill in at home or to arrange to complete it with a member of staff, email involvingyou@northerntrust.hscni.net or telephone 028 2766 1377. We welcome your feedback in any format by 29 November 2024.

If you have any queries or comments regarding this consultation document, EQIA or RNIA and their availability in alternative formats (including Braille, disk and audio, and in minority languages to meet the needs of those who are not fluent in English) please contact:

Equality Unit
Route Complex
8e Coleraine Road
Ballymoney
Co Antrim
BT53 6BP
Tel: 028 2766 1377
Fax: 028 2766 1209
Textphone: 028 2766 1377
E-mail: involvingyou@northerntrust.hscni.net

In compliance with the legislation, when making any final decision the Trust will take into account the feedback received from this consultation process. A consultation feedback report will be published on the Trust website.