Working with you to transform general surgery – Frequently asked questions

1. What is the reason for the change?

The Northern Health and Social Care Trust provides emergency inpatient surgery and elective surgery at two acute hospital sites: Causeway Hospital and Antrim Area Hospital. We are currently the only Trust in Northern Ireland to split our surgical service in this way. Challenges around balancing our demand and capacity have resulted in increased difficulty in maintaining the required staffing levels to support the service across two sites. Although Antrim’s emergency surgical demand is approximately double that of Causeway’s, this is not reflected in the allocation of the surgical workforce between the two sites

In 2022, the Department of Health published its review of General Surgery in Northern Ireland. The review outlined new standards for emergency and elective general surgery that cannot be fully met within the Trust’s current service configuration. Following discussions with our consultant surgical teams in Antrim Area Hospital and Causeway Hospital, towards the end of 2023 we started early engagement with staff in relation to the future provision of general surgery.

2. How have other Trusts dealt with this to date?

Currently, the Northern Trust is the only HSC Trust in the region to continue to deliver emergency inpatient surgical services across two acute hospital sites. Challenges around the recruitment and retention of general surgeons is not an issue that is unique to the Northern Trust; it is an issue affecting the entire region. The inability to recruit and retain Consultant Surgeons in the future is a real risk to the sustainability of the general surgery service. The Trust must also pay attention to the collapse of general surgery emergency services in other Trusts in recent months. In January 2024, the Department of Health approved the decision of the Southern HSC Trust to permanently move emergency general surgery to Craigavon Area Hospital. The service had previously been split across two hospital sites but a shortage of general surgeons led to the suspension of emergency surgery at Daisy Hill Hospital. The Western HSC Trust also moved to temporarily suspend its emergency surgery provision at SWAH (South Western Acute Hospital) in 2022, after it experienced similar staffing issues.

It is important to plan our workforce proactively rather than to wait for and react to an inevitable collapse of services.

3. What has accelerated the Trust’s decision to move forward now?

Our review of General Surgery services is necessary due to a number of factors.  We have outlined the challenges of balancing our demand and capacity within our current surgical model; this imbalance is not sustainable, and we need to consider how best to manage our resources to meet the needs of our population.

There is an acceptance among our surgical teams and wider staff groups that transforming how we deliver general surgery within the Trust is both urgent and necessary if we are to continue to provide a safe and sustainable service

Our workforce plan must consider how we attract and retain general surgeons in the Northern Trust. In addition to this, the Department of Health published its Review of General Surgery in Northern Ireland in 2022. The review outlined new standards for emergency and elective general surgery that cannot be fully met within our current service configuration.

4. What is the timeline for change?

The public consultation will run for a period of 14 weeks from 23 August 2024 to 29 November 2024.

Once the consultation period is over, we will consider all responses and feedback received and this will help to inform the final recommendation of the Trust. Following the consultation, an update will be brought to the Board of the Northern Trust with a preferred option recommended for approval. If the Board approves the recommendation of a preferred option, it will require the final approval of the Department of Health and the Health Minister. No planned change will come into effect without the approval of the Department of Health.

5. If the consultation process and feedback received shows that there is no support for the preferred option, will the Trust take that on board and provide a solution that is acceptable to all?

The Trust will fully engage with a wide range of stakeholders during the consultation period and will consider all feedback received. The final recommendation will take account of the views expressed and will seek to meet the objectives of providing a safe and sustainable service which will best meet the needs of our population. Final approval will be required from the Department of Health and Health Minister.

6. Is there a risk that the Department of Health will not approve the recommended option of the Trust and its Board?

We are keeping the Department of Health informed as a key stakeholder in this process to provide the necessary assurances and evidence for decision making.  In 2022, the Department of Health published its review of General Surgery in Northern Ireland. The review outlined new standards for emergency and elective general surgery that cannot be fully met within the current service configuration.

The proposals are in line with regional policy and strategy for elective care management and standards for general surgery.  Our aim is to carefully plan our changes to avoid any risk that our services would become unsustainable or unsafe, and ultimately to avoid the risk of service collapse.

7. Has the Trust already made a decision to remove emergency general surgery from Causeway Hospital?

No. The purpose of the public consultation is to outline our current position regarding general surgery provision within the Trust, and detail the case for change. We have also detailed the rationale around the options we have explored, including an explanation of why we have arrived at a preferred option, supported by evidence-based data analysis of service activity, workforce, capacity and demand, as well as the constraints of our financial environment.

8. How will the local population view this if emergency surgery is moved from Causeway Hospital, especially coming so soon after the transfer of acute maternity services to Antrim Area Hospital.  Does this put the future of Causeway Hospital and the ED at risk? Will that not result in more staff leaving Causeway Hospital?

We recognise that any change to the current service may cause concern for the local community. Causeway Hospital is and will remain an important part of our acute hospital network. We remain fully committed to maintaining a 24/7 Emergency Department and acute inpatient services at Causeway Hospital. General surgery will not be removed from the Causeway site. Causeway Hospital will still be able to assess and diagnose the majority of patients with surgical needs. 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 Causeway ED.  Only patients who require admission for emergency surgery will be transferred to the Antrim site

Our “Causeway Hospital – A Strategic Vision” document published in March 2024, clearly outlines our ambition to develop and enhance services at the site to best meet the needs of the local population.  Included in our vision is the ambition to focus on the development of our workforce, how we develop new roles and opportunities for staff and how we plan to stabilise the recruitment and retention of staff.

9. If Antrim Area Hospital is struggling to cope with current demand, how does it make sense to move all emergency surgery to Antrim?

By undertaking this review of general surgery, we are responding to the concerns raised by our clinical and surgical teams about the critical pressures on our surgery team at Antrim Area Hospital and the future sustainability of the current surgical model. A consolidated emergency surgical service will mean a more robust and sustainable service for the whole population of the Northern Trust.

We are fully aware of the pre-existing pressures on the Antrim site and have developed a plan to mitigate the impact of the additional emergency surgical patients who will be managed there in the proposed model. This includes creating more surgical bed capacity and investing in our ambulatory service.

10. Will a full rural needs analysis be conducted?

Yes. This is a legal requirement. A Rural Needs Impact Assessment has been completed and published as part of the consultation documents.

11. Have you considered the extra travel times for people in many rural areas across the Trust?

The Trust has conducted a Rural Needs Impact Assessment as part of the consultation process.

Where possible we will see and treat patients as close to their own home as possible with as short a stay in hospital as necessary.  We will minimise the need for transfers to another site by maximising diagnostics and ambulation through the use of outpatient appointments at the nearest hospital. Whilst we recognise that people may have to travel further for their planned surgery /treatment, this will be for a one-off occasion.   An added benefit will be the increased elective capacity meaning that patients can get their procedure sooner.

12. Are there any concerns about safety because of the way that general and emergency surgery is currently being provided?

Our primary focus throughout this review is on the safety of our patients. While we do not have concerns about the safety of our surgical services at present, we are concerned that the sustainability issues could make safe services difficult to maintain in the future

Given the Department of Health’s Review of General Surgery, and the concerns raised by our staff around current pressures within the service, we recognise that change to our general surgery provision is required if we are to continue to maintain a safe service. There is an acceptance among staff and senior management that the current operating model is becoming unsustainable.

13. What about the ‘golden hour’ – do patients not have just 60 minutes to get to hospital?

The ‘golden hour’, a concept dating back to the 1950s is an outdated term, which was previously associated with trauma care. It suggested that to ensure a positive outcome, a patient had only 60 minutes from time of injury to receive the appropriate hospital treatment/care. The term was only ever associated with traumatic injuries such as a road traffic collision and did not refer to emergency surgical procedures. This does not reflect the latest approach to trauma through formal trauma networks.  In Northern Ireland, a trauma network is in operation, in line with other parts of the UK. Modern trauma care regularly involves patients being transferred directly to large trauma centres, often with longer associated travel times/distance. The development of Major Trauma Networks across the UK is associated with a significant (19%) increase in the odds of survival for patients. The Royal Victoria Hospital in Belfast is the major trauma centre for Northern Ireland.

According to the latest clinical studies, travel time/distance to a hospital is not the primary determinant of a patient’s risk of death. There are many other factors to consider. It is important to point out that a patient’s care begins from the moment they are in the care of a health professional and that will include receiving treatment during any transfer to hospital. When considering the best option for general surgery provision within the Trust, our aim is to have a service model which will provide the best possible outcomes for patients and one which will support the right care, in the right place, at the right time.

14. Does the ambulance service have the capacity to deal with the extra transfers? How many transfers to you think there will be on a daily basis?

We understand that the ambulance service is very busy.  We have had engagement with the NI Ambulance Service (NIAS) and we anticipate that the number of patients transferring on a daily basis will be 2-3 per day.  We will provide additional mitigations through the use of private ambulances where appropriate.

15. When will a patient go directly to Antrim Emergency Department?

There will be occasions where patients will not be brought to Causeway Hospital by NIAS.  We have agreed protocols in place for certain pathways which we have described in our consultation document.

These pathways have been agreed by our clinical teams in Surgery, Emergency Medicine and NIAS.

16. Have you sought advice from independent expertise?

We have sought the advice of GIRFT – Getting it Right First Time, who have expertise and experience in this field.  GIRFT is a national programme designed to improve medical care within the NHS by reducing unwarranted variation.  Using data and benchmarking, identifying best practice, GIRFT helps map out what “good” looks like for standardised pathways of care ultimately for the benefit of patients who can receive treatments quicker, have more equity of access to high quality care, and have better outcomes.

17. How do I get involved?

Extensive engagement is vital to the success of the reconfiguration of general surgery. It is important that service users, carers and communities fully understand the rationale and proposals, and engage with us during the consultation to ensure that we have the best services for our population. Please see below our engagement plans.

We plan to hold four public listening events to support the consultation.

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

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