Meeting: NoSPG Date: 19 th June 2013 Item: 16/13 (ii) Scottish Hyperbaric Medical Service Strategic Context and Overview Background & Aim of the paper The provision of hyperbaric medicine has been discussed at a number of forums recently including NOSPG and NHS National Directors of Planning. These discussions have been aimed at informing the formal process which will be taken through National Specialist Service Committee (NSSC) before formal recommendation for approval is submitted to NHS Chief Executive Group. As outlined below (see 1.4) this paper therefore aims to provide a costed option appraisal on all available options to support this decision. Strategic Context 1.1 The Hyperbaric Medicine Service was designated as a national service in 1979, and the nationally designated service has been provided by the National Hyperbaric Unit based at Aberdeen Royal Infirmary since then. 1.2 A review was undertaken in 2011 of the Hyperbaric Medicine Service which involved an expert Review Group Chaired by the Chief Executive (NHS Lanarkshire). The Review Report was presented to NSAG in June 2011 and found that because of the low and unpredictable volume of diving decompression illness; the emergency nature of the care required; the importance of time to treatment on quality of outcomes; and the nature of the Scottish geography, that there was a need for a solution that concentrated clinical skills and activity but that one facility was not a suitable option. 1.3 The Review recommended that national designation should be extended to incorporate one or more of the independent chambers as long as the cost of the service did not exceed the current cost of hyperbaric provision (including those of the independent chambers) whilst seeking to pursue efficiencies to reduce the cost of the service for NHS Scotland. 1.4 More recently the NHS Scotland Board Chief Executives have requested that all options for the provision of Hyperbaric Medicine be reviewed and that a paper is presented to the National Specialist Services Committee. As part of this process of review, the North of Scotland Planning Group was invited to present its assessment of options for the national hyperbaric service. Description of the current national designated service Aberdeen Royal Infirmary 1.5 The nationally designated hyperbaric service is provided within The National Hyperbaric Unit on the site of Aberdeen Royal Infirmary. The National Hyperbaric Unit currently provides a comprehensive specialist Hyperbaric Service to NHS Scotland delivering treatment for all severity of diving related injuries, hyperbaric emergencies and Hyperbaric elective needs. It provides a 24/7 hour consultant run diving and hyperbaric advice line to the public, the NHS, emergency providers and other chambers. It supports the private chambers in their treatment of diving injuries and takes all patients requiring category 1 level care or helium saturation treatment. 1.6 The service in Aberdeen also provides: co-ordination of the management of diving emergencies in Scotland providing a 24/7 consultant advice service for patients, HM Coastguard, SAS and other independent chambers operational support for emergency treatment for any diving related incidents across Scotland; a Scottish National Registration Service for non-nhs hyperbaric chambers; and 1
National diving medicine courses, an annual Scottish hyperbaric education meeting and training for other Scottish chamber staff. 1.7 The level of clinical knowledge and expertise for Hyperbaric Oxygen treatment for diving decompression illness is embedded within NHS Grampian, and the independent chambers continue to rely on the Aberdeen service for advice, guidance and training. 1.8 The chamber in Grampian is the only Category One Chamber in Scotland which is capable of receiving patients who may require Advanced Life Support either immediately or during hyperbaric treatment. This covers patients who may require access to ITU. Mark McEwan Modernisation Executive Team NHS Grampian 10 th June 2013 2
Other hyperbaric medicine provision independent chambers 1.9 In addition to the national designated service there are three independent hyperbaric chambers registered to treat diving decompression illness. The independent chambers only provide service at Category 2 or below, which is for patients of less severity who do not require access to advanced life support: Hyperbaric Unit, University Marine Biological Station, Millport, Isle of Cumbrae National Diving Research Centre, Scottish Association for Marine Science, Oban Orkney Hyperbaric Trust, Stromness, Orkney 1.10 There are other single patient chambers in Scotland, one of which is in Ninewells Hospital, which do not currently meet the national standards to provide treatment for diving decompression illness. 1.11 On average the independent chambers treat around, in total, 18 Scottish NHS Board residents each year (not including the 2012 activity figures) Appendix 1. 1.12 There are also, on average, 3 EU/EEA patients treated each year - the cost of which is picked up by the host NHS Board where patient is treated. Due to the fact that Scappa Flow is an internationally renowned diving site and therefore brings many EU and non-eu divers the cost of this is borne almost exclusively by NHS Orkney currently. Summary 1.13 As acknowledged by the national review group and the Board Chief Executives, there is a requirement to review alternatives to the current model for the provision of the nationally designated service. 1.14 This paper sets out our assessment of the available options and the risks and benefits of each, including our preferred solution which we believe meets the recommendation of the Review Group and the need to demonstrate best value for NHS Scotland; namely Extension of nationally designated service and clarity over national access; Retention of the clinical skills required to support the delivery of a comprehensive national Hyperbaric Medicine Service within NHS Scotland; and Cost effectiveness compared to other alternative options 3
Scottish Hyperbaric Medical Service evaluation of options Introduction 2.1 The following options as specified by NHS National Services Division have been considered and within this section we set out our evaluation of these options and preferred solution. Option 1: No Change Option 2: Extended national designation two centres Option 3: Centralisation of hyperbaric medicine in Aberdeen (no use of independent chambers) Option 4: Re-provision at national designated service in another NHS Scotland hospital Option 5: De-designation 2.2 Whilst we have not undertaken a formal scoring of each option we have formally considered whether each option meets the following criteria: Retention of diving medicine skills within NHS Scotland Access to 24/7 specialist clinical support to respond to diving incidents Access to category 1 chamber for the most severe diving incidents (within clinically appropriate timescales Access to category 2 chamber for decompression (within clinically appropriate timescales and within national designation) Reduction in current cost of service Executive summary 2.3 In terms of the options we set out below our assessment as to how each option meets the criteria above and preferred solution Retention of diving medicine skills (Scotland) Access to 24/7 emergency cover Timely access to category 1 chamber Timely access to category 2 chamber Reduction in current cost of service Option 1 x - Option 2 1 Option 3 x Option 4 x 2 Option 5 x x 2.4 Taking into consideration the above factors and our desire to preserve a comprehensive and cost effective nationally designated hyperbaric service in Scotland our preferred option is Option 2 - the two centre model (extending the existing designated service to include the private chamber at Orkney). Given the extent of coastal waters around Scotland, the significant diving activity at Scappa and the strategic importance of the oil and gas sector in the North Sea, de-designation and a loss of the specialist clinical diving medicine skills currently in Aberdeen would present challenges in terms of the safe and effective management of diving incidents. 2.5 As set out below NHS Grampian and NHS Orkney are committed to delivering the two centre model at a lower cost than the current service. In addition there would be the potential to retaining and indeed expanding access to the elective hyperbaric service. 1 If a nationally funded hyperbaric chamber could be constructed in Aberdeen there would be the potential to withdraw from the current contract with the private provider (saving of c 200k per annum) 2 However this option would require approval of business case to build an NHS chamber at a cost of c 1.5m. 4
2.6 With regard to costs the following table sets out our estimation of the costs of each option: Option 1 Option 2 Option 3 Option 4 Option 5 000 000 000 000 000 NHS Grampian and NHS Orkney 3 954 4 954 5 954 6 200 7 200 8 Independent chambers 320 0 0 0 700 Additional transport 0 20 40 80 110 NHS site provision (without NHC Ltd) 0 0 0 800 0 Total 1,274 974 994 1,080 9 1,010 2.7 Under the designation option, the costs of the independent chamber are based on those estimated by the National Specialist Services Committee. As these services are provided outwith the NHS there is risk of introducing a higher degree of variability into the costing of services than currently under the national designation. Overview of options Option 1 No Change 2.8 NHS service provision maintained as it stands for the national service with treatments still undertaken in private chambers at Orkney, Oban and Millport Benefits Provision of recompression close to dive sites with reduced transit time Continuing dilution of medical expertise and deskilling given the reduction in numbers Continued charging from the private sector chambers to Boards will mean continuing to pay twice for a national service. 3 Including the cost of the contract with the National Hyperbaric Centre Limited 4 Net of income received for treatment of patients with England / Wales residences 5 We would redesign the service to accommodate the two centre model within existing national funding 6 Under this option we would fund any increase in activity transferred from Orkney within existing capacity 7 There would need to be retention of clinical input with Scotland to assist with assessment and potential treatment, prior to transfer to alternative location 8 There would need to be retention of clinical input with Scotland to assist with assessment and potential treatment, prior to transfer to location outwith Scotland 9 Would require an approved business case for an NHS chamber c 1.5m 5
Option 2 Two Centre Model 2.9 Under this option the national designation would be extended to cover Aberdeen and Orkney, with NHS Grampian retaining the lead designation and working with NHS Orkney to manage incidents within their geographical area. In 2011 and 2012, 70% of all diving treatments were provided in Aberdeen or Orkney (Appendix 1). All diving incidents would be referred to either Aberdeen or Orkney, with no use of independent chambers at Oban and Millport. Benefits This would mean the abolition of the private chamber costs Sustain National Service with medical interest and competence in Scotland Ensure clinical governance is provided in ARI & Orkney Cost saving by stopping referrals to other private chambers Continued support for key industries (oil and gas, fishing and diving tourism) and offers a helium capability if required. Maintenance and availability of national expertise and category 1 care within Scotland. Continuation of the elective Hyperbaric service in Aberdeen There would be an increase in transfer costs from West to East coast but not a prohibitive sum nor timescale to treatment. This would be 10 divers requiring transfer from the 2012 figures. Need to engage with transport agencies / coast guard & SAS to ensure use of private chambers was to cease Option 3 Centralisation within Aberdeen 2.10 Centralisation was the preferred option of the management representatives within the Review Group as it would meet the normal criteria of providing a national service for the whole of Scotland. This would mean transferring all patients requiring recompression to Aberdeen from all over Scotland and a few of these may not require treatment following assessment. 2.11 It is however unlikely that this would be a significant number given that specialist advice is available from Consultant run diver helpline and the usual practice is to seek local assessment if appropriate. This was not the favoured option of clinicians at the time of the review. Similarly the diving community were strongly opposed to this. Benefits This would mean the abolition of the private chamber costs. It would maintain and sustain the clinical expertise in one centre with access to all the activity to sustain accreditation, clinical interest and revalidation. Aberdeen service would meet the terms of NSD contract as single provider Aberdeen would continue to support cases of severe industrial decompression illness and offers a helium capability if required. There have been 2 such cases in 2013 This option would increase the transport costs and potentially time to treatment with the cost of ambulance transport being around 600 per journey (from original review assessment) and helicopter transfer costs being around 5 to 7k per journey for a minority of cases. For the year 2012 this figure was 25 divers. The issue of availability of transport to transfer would need to be considered particularly from Orkney who provide half the activity. This figure was 15 divers last year. This would threaten the future of private chambers if they could not continue to charge residents from other Scottish boards to sustain their funding base. 6
Orkney Chamber was opened on basis of an FAI and closure will be challenged. Option 4 Re-provide service within another NHS Hospital at lower costs 2.12 In order to reduce the cost associated with the Aberdeen service through the NHC Ltd contract and service could be provided from an NHS Hospital either in Aberdeen or elsewhere in Scotland. 2.13 Whilst there is a monoplace chamber in NHS Tayside (Ninewells) it does not meet the standards for treating diving decompression illness and has not treated divers for well over a decade. Therefore any re-provision within an existing NHS hospital in Scotland will require procurement and installation of a suitable chamber with the associated capital costs. Benefits This would allow potential investment in an NHS facility and withdrawal from the NHC Limited contract The clinical knowledge and skills would not be easily transferable from Aberdeen and so there would be a requirement for investment in training and development of staff to provide service Challenge around gaining approval for capital funding Loss of clinical expertise in Aberdeen Option 5 De-designation 2.14 It would mean the closure of the Scottish national service in Aberdeen as NHS Grampian could not sustain the level of service without national funding. The result of this would be the loss of the Category One level service from Scotland, the coordinated guidance provided by the National Advice line and the chamber appraisal service. 2.15 Any patients requiring Category One chamber care, following assessment at the dive site or independent chamber, would need to be transferred further to a Category One facility in England, either in Hull or the Wirral. This would potentially lead to prolonged transfer for sicker patients, around 2 per year. 2.16 The telephone helpline provided by Aberdeen would also be lost. Therefore a more rigorous protocol for patients presenting following a diving incident would need to be followed by A&E Departments and the NHS 24 helpline or a negotiation for the helpline for the rest of the UK to take calls from Scotland. The Navy have just closed the E&W advice line and another provider has taken this on for a trial period. 2.17 There would be some uncertainty over the costs of the service being provided by the independent chambers but if NSD or other organisation were allowed to negotiate a tariff range with the independent chambers then these costs could be controlled and possibly managed through a risk share scheme - e.g if a cap on treatment was set at 20k per patient and including a couple of patients requiring to be treated in England then the costs could be contained within 700K per year (given around 30-40 patients treated each year, a significant proportion of which would not need the total cost). However, if diving activity level returns to pre economic downturn levels, then these costs may elevate sharply. This does not include the current workload of the elective service (currently around 500 patient treatments per year) as developed and supported with NSD. 7
Benefits Loss of clinical expertise from Scotland to support private chambers for divers Longer time to treatment for seriously injured divers Loss of the Hyperbaric elective service which currently provides over 500 patient treatments per year. (see Appendix 1) Loss of the quality assurance and clinical governance process for these chambers & service provided Financially the Scottish private chambers in recent years have charged boards full cost recovery. There would be reduced control over the costs charged. Potential issue for diving medicine support of Diving Industry (Oil /gas, wind farm, fish farming and scallop diving) Loss of teaching and training facilities in diving medicine in Scotland. Loss of a chamber facility on a major hospital site. 8
Appendix 1: Location of residence of patients receiving Elective HBO treatment Health Board Health Board 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 Ayrshire & Arran 4 3 3 1 Dumfries & Galloway 2 1 1 1 1 Grampian 19 20 11 14 11 17 15 14 Greater Glasgow 1 1 3 8 4 3 4 4 Highland 1 3 4 5 5 4 3 Lanarkshire 1 2 1 2 4 1 Lothian 1 Orkney 1 1 2 Shetland 1 1 1 Tayside Total patients 32 29 23 28 23 28 26 23 Total no of individual treatments 752 740 671 634 475 496 511 555 Treatment activity Divers Aberdeen Oban Millport Orkney Total Treated 2003 38 19 9 19 85 2004 12 12 11 19 54 2005 16 14 11 17 58 2006 9 18 16 20 63 2007 15 18 6 20 59 2008 14 15 11 25 65 2009 17 6 3 22 47 2010 14 13 4 16 48 2011 7 8 2 19 36 2012 4 5 4 13 26 These figures do not include the figures for patients seen and not recompressed. 9