1. NORTH WALES NEUROSCIENCES REVIEW Head Injury, Spinal Surgery, Critical Care and Radiology Workstream SECOND PHASE REPORT Dr Paul Birch May 2009

2. Head Injury, Spinal Surgery, Critical Care and Radiology Workstream Workstream Aim Produce agreed plans to develop services in the following areas; neurocritical care head injury non-complex spinal surgery neuroimaging Areas excluded from remit Stroke Rehabilitation Complex and emergency spinal surgery

3. Phase 1 - Investigate present knowledge. Phase 2 - Long list of models and options Phase 3 - Develop final preferred model of implementation against the original areas of recommendation. Head Injury, Spinal Surgery, Critical Care and Radiology Workstream Methodology.

4. Head Injury, Spinal Surgery, Critical Care and Radiology Workstream The Radiology Group identified that they did not need to meet again until the final cycle. Head Injury, Critical Care and Spinal Surgery groups generated a list of options prior to discussion at the phase 2 meetings. Outcome of Phase 1 :

5. Head Injury, Spinal Surgery, Critical Care and Radiology Workstream Phase 2 meetings followed similar formats considering: List of models and options based on information/data gathered in phase1 Questions to be considered Preferred Option/s & Actions prior to next meeting Work plan and Communication

6. Spinal Surgery Members Dr Paul Birch Workstream Chair Crispin Wigfield, Walton Centre Karen Smith, Case Manager, Community HDT, North West Wales NHS Trust Lyn Roberts, Senior Nurse, A & E, Ysbyty Gwynedd Stephen Jones, Head of Speech and Language Therapy, North West Wales NHS Trust Glynne Andrew, Consultant Orthopaedic Surgeon, North West Wales NHS Trust Georgina Mudge, Physiotherapist, North West Wales NHS Trust Ian Langfield, Health Commission Wales Ed Farley Hills, Consultant Anaesthetist, North West Wales NHS Trust Jeff Pye, Head of I M & T, North West Wales NHS Trust Wendy Farrington Chad, Chief Executive, Robert Jones and Agnes Hunt Hospital

7. Spinal Surgery – Options Do Nothing Refer all patients to a single tertiary provider Refer to a mix of tertiary providers Develop a local service for non-complex spinal surgery with remaining patients referred to tertiary providers Commission a local service from tertiary provider(s) Develop a service referring patients to the Countess of Chester for non-complex spinal surgery and all other patients being referred to tertiary providers

8. Spinal Surgery - Questions Are there sufficient patients for a local service All patients with back problems benefit from triage and appropriate referral. Triage services in North Wales are at different stages of development. For the majority of patients there is no surgical input to decision making. Increase in referrals over the 2008 – 2009 period in comparison to previous years. Predominant increase in Chester and Walton. Greatest growth in unspecified spinal puncture. More information on increase expected

9. Requirements to develop a service Surgery for lower back pain alone- evidence of benefit is equivocal. Surgery for patients with lower back pain and sciatica appears to shorten the period of disability allowing early return to functionality. Services for patients with back pain require leadership- there are different models across North Wales. Both main tertiary providers indicated that they can provide and support a range of services in North Wales, but not local surgery. Spinal Surgery - Questions

10. Would such a service be viable? The numbers of patients undergoing spinal surgery in North Wales shows a significant increase over time. In 2007/08 there were 147 patients identified as undergoing non complex spinal surgical procedures for lower back problems. This is probably sufficient to sustain 2 Spinal Surgeons Spinal Surgery - Questions

11. To develop a detailed model identifying the requirements to set up a local service in North Wales for non complex spinal surgery Identify resource in current service provision Spinal Surgery - ACTIONS

12. Head Injury & Critical Care Members Dr Paul Birch, Workstream Lead Crispin Wigfield, Walton Centre for Neurology and Neurosurgery David Cartlidge, Consultant, A & E, North Wales (Central ) Karen Smith, Case Manager, Community HDT, North West Wales NHS Trust Lyn Roberts, Senior Nurse, A & E, Ysbyty Gwynedd Stephen Jones, Head of Speech and Language Therapy, North West Wales NHS Trust Pauline Cutting, Consultant A & E, North West Wales NHS Trust Glynne Andrew, Consultant Orthopaedic Surgeon, North West Wales NHS Trust Georgina Mudge, Physiotherapist, North West Wales NHS Trust Ian Langfield, Health Commission Wales Ed Farley Hills, Consultant Anaesthetist, North West Wales NHS Trust Jeff Pye, Head of I M & T, North West Wales NHS Trust Aeneas O’Kelly, Consultant Orthopaedic Surgeon, North Wales (Central)

13. Head Injury & Critical Care - Options Difficult to generate a formal options list as most recommendations are either do or not do.

14. Head Injury & Critical Care – Options Neurosurgery Plans in place to expand the critical care capacity of the Walton Centre Monitor effect consider need for further capacity at Walton consider neurocritical care in North Wales.

15. Develop clear and unequivocal guidelines across North Wales for the management of: The Management of Acute Head Injury- Achieved. The management of Spontaneous Subarachnoid Haemorrhage- Pathway development in progress. The management of an acute Neurovascular event- Pathway development in progress. The management of Acute Spinal Injury and Cauda Equina Compression- Development in progress by the Walton Centre. The management of metastatic spinal cord compression (NICE)- NICE guidance available. Walton Centre developing pathways in response to these. The management of brain and other CNS tumours (NICE)- NICE guidance available. Walton Centre developing pathways in response. Head Injury & Critical Care – Neurosurgery Guidelines

16. Head Injury & Critical Care Neurosurgery Recommendations A videoconference link to the Walton Centre should be established both to facilitate the above and to improve consultation on individual patients.

17. Head Injury & Critical Care Neurotrauma Agree number and location of receiving units and ensure clearly designate person is responsible for the inpatient clinical care of non-neurosurgical head injuries and ensure that clinicians have the appropriate training and that a governance system is in place- Achieved. Develop local facilities for overnight monitoring of patients that do not require transfer- Achieved but model of care and senior input inconsistent.

18. Head Injury & Critical Care Neurotrauma Recommendations The model for immediate care of patients who do not require transfer should be standardised across North Wales as part of the Unscheduled Care Project. Expand the critical care capacity of the Walton Centre The SBNS (Society of British Neurological Surgeons) and TARN guidelines be adopted- Achieved

19. Head Injury & Critical Care Neurotrauma Recommendations The robustness of data collection systems to monitor application varies across the 3 main sites and with time. A robust system of data collection to monitor outcome should be developed. Development of improved transport to address delays e.g. use of air ambulance – Work in progress- Air ambulance Service. Develop local 24/7 MRI services and supporting diagnostic tests- Radiology workstream.

20. Head Injury & Critical Care Neurocritical care Recommendations Many of the recommendations are being taken forward under as part of improving service for Neurosurgery Develop Accident and Emergency Departments in North Wales to ensure necessary resources to assess, image and stabilise patients with acute neurological conditions and as part of multiple trauma or multi system failure, is available- Currently in place. However will be reviewed as part of the Unscheduled Care project. Develop appropriate facilities locally to allow the transfer/repatriation of patients to in a timely manner- North Wales Critical Care Pathway for severely head injured patients in place.

21. Head Injury & Critical Care Critical care outreach/Rehabilitation Recommendations Recommendations are being taken forward via the Rehabilitation workstream and the Walton centre

22. Head Injury & Critical Care Long Term Ventilation Recommendations Development of a ‘step-down’ facility for the management of patients who require long term ventilatory support with 24/7 medical cover and located on an acute hospital site/sites. This forms part of a separate project addressing the need for long term ventilation across Wales.

23. Head Injury & Critical Care Questions Which workstream should be addressing the intermediate care for disinhibited post acute patients with head injury? Should we developing a neuropsychiatric service either locally or with outreach from Walton? Will the rehabilitation workstream be making specific recommendations around the care of patients in transition from adolescence to adulthood?

24. Confirm the evidence base of each objective Confirm the benefits associated with the objective Verify the choice of options against the objectives and benefits and that there is an evidence base Ensure no tenable options have been eliminated Head Injury, Spinal Surgery, Critical Care and Radiology Workstream Next Stage Then: Shortlist options using benefit criteria Then: Undertake Benefits Appraisal