Plans for neurology services in north wales

PLANS FOR NEUROLOGY SERVICES IN NORTH WALES


Contents

	Page
A managed clinical “network” for neurology services	2
Neuroscience nurse network	3
Welsh hospital based services	5
Provision of services in other sites	6
Time spent at the Walton Centre for Neurology and Neurosurgery	6
Proportion of neurologists’ time in Wales	7
General considerations.(see appendix A for detailed options)	7
Appendix A.: Options for enhanced N Wales consultant neurology provision	9
Appendix B: Distribution of Neurology Services in North Wales	16
Appendix C: The continued involvement of WCNN in provision of the of neurological services in Wales	18
Appendix D: Neurology day cases	20

PLANS FOR NEUROLOGY SERVICES IN NORTH WALES
Following meetings with the James Steers Neuroscience Review Group and the North Wales Neuroscience Implementation Group, the main short to medium term aim will be the establishment of a managed clinical network for neurology services, with enhanced services at each of the three main hospitals and setting up of improved neurology nursing services in the community, with full liaison and coordination between the two. Continuous professional development and clinical governance will be the responsibility of the present provider, Walton Centre for Neurology and Neurosurgery. It is recognised that all this would only be possible with considerable additional funding recurrently. The suggestion of a neurology centre at Glan Clwyd was discussed at NWNIG, and in this workstream, and it was decided that this would be best regarded as a long term plan, perhaps coordinated with re-development at YGC (Appendix B).
As well as providing an enhanced community neurology nurse network, there is also the aim to make provision for the population living large distances from the present DGHs, i.e. in south Gwynedd and Clwyd, and it has also been decided that the population of north Powys should also be included. It is thought that this population in north Powys is approximately 42,000 (1/3 of 127,000 for all of Powys in 2001 census). This is a significant addition to the 670,000 for the rest of North Wales, especially considering its relative geographic isolation.
Principles guiding neurology service provision

1. 
   A managed clinical “network” for neurology services.
   

The consensus opinion, after  initial consultation which  involved  primary, secondary, tertiary NHS personnel, and also patient and carer networks,  is that integration of services is essential, and a key priority:

1. 
   between those provided in hospitals and those in the community/primary care
   
2. 
   between those provided in the Welsh DGHs and WCNN, for both out-patients and in-patients
   
3. 
   between neurology and neurosurgery (including spinal surgery)
   
4. 
   between neurology and the specialist neuro-diagnostics (neuro-radiology, neurophysiology & neuropathology).
   
5. 
   between the neurology & neurosurgery and neuro-rehabilation
   

Of these, a., e. and to a lesser extent b. are the most apparent to the patients but the professionals recognise c. and d. also.

The Steers review recognises the need for the continued involvement of WCNN for CPD provision and for in-patient complex neurology. The continued involvement of WCNN in provision of the other aspects of neurological services may be open to debate (Appendix C), but undoubtedly this would be the most reliable and secure way to provide a sustainable comprehensive service that could progress in the future, with clinical governance assured by WCNN.
Whilst WCNN would run the operational issues of such neurology services, there would need to be a structure to ensure accountability to the commissioning body (LHB from October). Supervision of the service and advice to the LHB on strategy and planning could be the role of a “managed network” or other such group, with involvement of the commissioning body (LHB from October), secondary care, primary care, patients’ representatives (e.g. Welsh Neurological Alliance) and neurologists and clinical and general managers from WCNN.

2. 
   Neuroscience nurse network
   

It is important that the neurology service in each DGH is supported by a neurology specialist nurse who can cover the full range of neurological conditions. Such a post would be in addition to any disease-specific specialist nurses. Most significantly, these posts would be the extension of the service out into the community and primary care, and this would represent the most significant expansion of the range of the service. Whilst obviously representing an additonal initial  cost resource, the corresponding savings to GP consultations, emergency hospital admissions, and possible bed blocking  would counterbalance these costs. There is some evidence for this in pilot studies – for example an initiative in Devon that has demonstrated cost effectiveness in addition to improved patient satisfaction and wellbeing.

Such a role has been piloted by WCNN in England, and there is an intention amongst English commissioners to expand such posts to one per PCT over the coming years as part of their management of long term conditions. WCNN provides the clinical training and experience, with the academic part provided by Edge Hill University; training takes two years. The nurse is employed by WCNN, not by the PCT. This is regarded as absolutely essential:

• 
  To allow WCNN to assure clinical governance, including CPD
  
• 
  To allow for appropriate clinical and professional supervision (experience has shown the potential for major clinical difficulties without this)
  
• 
  To allow WCNN to provide employer governance
  
• 
  To ensure integration with other elements of the service: neurologists, disease-specific specialist nurses, secretarial and other clerical staff, and importantly also with the neurosurgical services (e.g. involving themselves in the care of some post-operative neurosurgical patients after discharge)
  
• 
  To ensure that the focus of such nurses remains completely on neurological (and neurosurgical) patients, so that there can be no re-direction of their efforts to other groups of patients (e.g. COPD or heart failure patients who are frequently admitted to hospital and are many times more numerous).
  

Each nurse would ideally attend one clinic each week with each neurologist working at that DGH, at least initially. In this way, some supervised follow-up consultation work may be undertaken, additional counselling offered to selected patients attending the consultant clinic, and the nurse’s clinical skills would be fully utilised and reinforced. Some time would also be spent on the wards, providing skilled nursing advice for patients with chronic neurological conditions who are in hospital for other reasons. The DGH setting is also ideal (in terms of availability of notes, test results and as a base for secretarial back-up) for the site for administration and for conducting telephone “clinics” (answering patient/carer questions, clarifying points for patients, monitoring of changing clinical status etc). The rest of the time would be spent in the community, with the possibility of

• 
  liaison with voluntary organisations (e.g. Motor Neuron Disease Association), through both formal and informal links with professionals within the voluntary sector, an often unrecognised (free at the point of delivery) resource for the provision of  an integrated service  to the individual and his/her family/carers , enhancing NHS provision, and potentially helping prevent hospital re-admission.
  
• 
  telephone clinics
  
• 
  structured clinics (e.g. held in cottage hospital setting or in GP health centres) and/or
  
• 
  home visits (though the latter are obviously lose lots of time to travelling), and
  
• 
  “signposting” to and liaison with social services
  

There would be need to be some sessional time built into the job plan of both the neurologists and the neurology nurses to allow a scheduled multi-disciplinary team meeting each week. Ideally this should occur face-to-face, but could perhaps be managed by telephone, especially with appropriate IT back-up (eg. video-link, secure e-mailing etc).

A possible initial timetable would appear as below, and this would need to flex according to local requirements, travel commitments etc, and in particular the split between hospital and community work. In each location this would be piloted and adjusted accordingly. Inevitably once the nurse’s experience grew and with everyone having increasing confidence in these new roles and system, the proportion of community based work would grow considerably with much less in the hospital services (this has been the experience on the Wirral).

Day	Time	Location	Work
Monday	Morning	DGH	Clinic with Consultant A
	Afternoon	DGH	Consultant liaison, Phone clinic, Admin, Ward work
Tuesday Alt for PCT	Morning	Community	Community clinic
	Afternoon	Community	home visits
Wednesday Alt weeks	Morning & Afternoon	DGH nursing (alt weeks)	Training, education, (of nurses) Audit & research
		WCNN (alt weeks)	CPD, neurosurgical integration, integration with WCNN generic neurology & disease-specific specialist nurses (England & Wales), research, audit etc
Thursday	Morning	DGH	Clinic with Consultant B
	Afternoon	DGH	Consultant liaison, Admin, Phone clinic, Ward work at DGH
Friday	Morning	DGH	Clinic & liaison with Consultant C
	Afternoon	Community	Community clinic +/- home visits

In North Wales, an extension of their role could be the supervision of some patients with neurosurgical problems, for which there is presently no provision. Neurosurgery has lagged behind neurology in use of specialist nurses, but there are undoubtedly some neurosurgical patients in whom expert neurological nursing input would be beneficial, in enhancing quality of life in post-operative patients and the survivors of major neurosurgical problems such as subarachnoid and other intracranial haemorrhages, brain tumours etc.

CPD could be alternated between being spent locally, and at WCNN where there would be the opportunity for them to interact with the neurosurgeons and other specialist neuroscience nurses (and to have their job managed by the appropriate leads at WCNN).
At least three nurses would be required though this number might grow according to the workload placed upon the community-based service.
There may be scope in the future to dovetail their role into the neurorehabilitation services, but these are different in some ways from the long term neurology conditions, and this would be reassessed as a second phase of consolidation of their role and development (and increase in numbers!)

3. 
   Welsh hospital based services
   

There is strong support for specialist neurology being embedded within the DGHs, in terms of their presence and involvement, and that the DGH should be the main site of their clinical work. In terms of specifics:

1. 
   There should be a neurology clinic at each DGH each day of the week, each requiring 0.5 PA administration time.
   

2. 
   Ideally there should be a ward based referral service at each DGH each day of the working week (Monday to Friday).
   

3. 
   There should be some sub-specialty clinics, e.g. in epilepsy and MS.
   

4. 
   There should be at least two neurologists in each Trust so that there are no weeks without some neurological presence.
   

5. 
   There should be the possibility of day case neurology patients for investigation (e.g. lumbar puncture) and selected treatments (e.g. some drug infusions) (see Appendix D).
   

6. 
   There should be the possibility of integration of the service with those for neurosurgical patients.
   

4. 
   Provision of services in other sites
   

Though neurology services should continue to be organised and delivered predominantly from the enhanced services at the three DGHs, there should also be some outpatient and community-based service to other locations. These include both the dispersed populations in south Gwynedd and south Clwyd, and also that population in Deeside_1_clinic_a_week_(Dr_I_Iniesta)_N_Powys_2_clinics_a_month_(WCNN_consultant_TBA)___3._Option_3'>Deeside_1_clinic_a_week_(Dr_I_Iniesta)_N_Powys_2_clinics_a_month_(WCNN_consultant_TBA)___2._Option_2'>Deeside who tend presently to attend the outpatient clinic at the Countess of Chester Hospital. This would be a significant extension of the present services, and new sites for clinics would have to be found.

Such clinics would carry undoubted benefits for patient accessibility, and allow treatment as close to home as possible. It would also encourage greater contact with local GPs/primary care.
Problems might be anticipated arising from

1. 
   Running an outpatient service divorced from other hospital services, particularly for a new patient service.
   
2. 
   Geographical problems in south Gwynedd and south Clwyd, with time lost to travelling etc
   
3. 
   Matching clinic frequency to local need (numbers of patients/”critical mass” considerations)
   
4. 
   Balancing possible conflicts between clinical requirements for an individual patient’s care and local accessibility
   

The extension of services to north Powys will cause additional but not insurmountable difficulties, since it would:

● be entirely new

● have no obvious DGH to host it

● it would be at the extreme of travelling times both for staff and patients for travelling from or to Liverpool. This situation might be eased by, for example, holding double clinics one day per month (though this has possible knock-on effects on hitting RTT targets).
Such clinics should be possible, and it is suggested that they at least be piloted to assess the practical workings.

5. 
   Time spent at the Walton Centre for Neurology and Neurosurgery
   

The Steers review clearly and explicitly outlines that sessions at WCNN are essential to

• 
  provide high-quality CPD and
  
• 
  allow WCNN to assure the clinical governance.
  

To ensure regular attendance at CPD, and regular clinical contact with WCNN clinicians (neurological, neurosurgical, neuroradiological & neurophysiological), it would be necessary for the new consultants to have a weekly clinic commitment (with some administrative time) at WCNN. This might take the form of a subspecialist clinic, which should also enhance recruitment and retention. All staff should have CPD at the Walton Centre. Complex in-patient neurology work will continue to be done at the Walton Centre, with patients being admitted under the care of neurologists who are in the Centre at least two days each week.

6. 
   Proportion of neurologists’ time in Wales
   

As a general principle, neurologists should be spending as great a proportion of their working time in Wales as possible, acknowledging that there will need to be a minimum of one day a week spent at the Walton Centre in Liverpool. Other “supporting PAs” such as those devoted to audit, teaching, research and appraisal should take place in Wales. In practice, this will mean a four to one split, four days in Wales and one day in Liverpool. However, job planning may need to be flexible to allow optimal recruitment of good candidates who may prefer to opt for three days in Wales and two in Liverpool. This may obviously be also partly dictated by the location of their main base in Wales and where they choose to reside. It is suggested that this flexibility is built into the job description and job planning process.

Supporting PAs constitute about 25% of a consultant’s commitments under standard English contracts which involve 10PA. They are expensive but not “productive” in terms of seeing patients or generating an “income”. Under the present WCNN-based neurologist model, all these SPAs take place at WCNN and the English commissioners bear the cost. In a model where the new posts in North Wales would be locally based, with non-CPD SPAs conducted in Welsh hospitals, the Welsh commissioners would need to be prepared to contribute appropriately. If the new consultants were to be appointed by, and have their contracts held by Welsh providers, the Welsh contract is different, involving 3SPAs, i.e. 30% of the time is “non-productive”. In the later detailed workings (appendix A), it is assumed that the consultants are appointed by WCNN and so have English contracts.

7. 
   General considerations.(see appendix A for detailed options)
   

a. Presently there are 25 direct clinical care PAs per week spread across the three main hospitals in North Wales: 10 clinics, 10 ward referral sessions and 10 half sessions for administration. No supporting PAs are included.

b. To provide a clinic and ward referral session in each hospital each day will require 37.5 PAs, i.e. an additional 12.5 PAs of direct clinical care.
A CPD day at Liverpool will require 2.5 PAs for each consultant.
Each locally based consultant will require half a PA within their job plan for nurse liaison time in the multi-disciplinary team clinic.
In addition to their 1 PA of CPD to be undertaken at WCNN, each locally-based consultant will require one and a half supporting PA (audit, teaching, appraisal and research). A locally-appointed consultant would need a further 0.5PA because of the different Welsh contract (see above section)
The Steers Review recommended that the North Wales neurology service required six whole time equivalents of consultant neurologist input. For a population of 670,000, this is a little under the UK recommendation of 1 per 100,000 population. If north Powys is to be included in the North Wales service, with an additional 42,000 population and considering its geographical “problems”, then a further 0.5 whole time equivalent will be required in addition to the Steers recommendations.
The present input is equivalent of 3 whole time neurologists.
It can therefore be concluded that a minimum of an additional 3 whole time equivalent neurologists need to be recruited, or 3.5 if north Powys is to be included. However:

• 
  if for recruitment reasons the balance of the jobs needed to include more time at the Walton Centre, the number of actual neurologists may need to be greater than this.
  
• 
  Also, if it were felt “necessary” for YGC to have their own locally-based neurologist, this would require a fourth new neurologist (with partial withdrawal of a WCNN-based neurologist)
  
• 
  If the neurologists were to be appointed by Welsh providers and so have Welsh contracts, a further 0.3 (or 0.4) wte would be required.
  

NB The Association of British Neurologists’ recommendation is for one consultant neurologist per 100,000 population, and so this tallies reassuringly well.

Appendix A.: Options for enhanced N Wales consultant neurology provision
1. Current situation
Ysbyty Gwynedd
3 days providing 3 clinics + 3 ward consultation sessions
Dr M Bracewell (Dept Psychology Bangor University): 1 day

Dr I Iniesta (WCNN): 2 days

Special interests covered: epilepsy, cognitive neurology/dementia

Also MS nurse clinic (Mr A Jones WCNN) x1 weekly

Ysbyty Glan Clwyd
4 days providing 4 clinics + 4 ward consultation sessions
Dr M Doran (WCNN): 2 days

Dr A Jacob (WCNN): 2 days

Special interests provided: MS, epilepsy, dementia

Also GPwSI clinics in epilepsy x2 weekly

Also Epilepsy nurse clinics x 2 per week (Sheila Lewis)
Ysbyty Maelor Wrexham
3 days providing 3 clinics + 3 ward consultation sessions
Dr M Doran (WCNN): 1 day

Dr D Smith (WCNN): 2 days

Special interests provided: epilepsy, dementia

Also GPwSI clinic in epilepsy x1 weekly

Also Epilepsy nurse clinics x 2 per week (Sheila Lewis)

WCNN consultants support local PD nurse.

Job plan for option involving new locally based WCNN neurologists (10 PAs):

• 
  Wales:
  
  • 
    2 clinics (2 PA - DCC)
    
  • 
    2 ward consultation sessions (2 PA - DCC)
    
  • 
    1 clinical administration (1 PA - DCC)
    
  • 
    Nurse liaison (0.5 PA - DCC) (0.25 at YG)
    
  • 
    Travel (0.5 PA - DCC/SPA) (0.75 at YG)
    
  • 
    Audit / appraisal / teaching (1.5 PA - SPA)
    
• 
  WCNN:
  
  • 
    1 clinic (1PA - DCC)
    
  • 
    Clinical administration (0.5 PA - DCC)
    
  • 
    CPD (1 PA - SPA)
    

Job plan for option involving new WCNN based neurologists (10.5 PA; 10.75 PA at YG)

• 
  Wales:
  
  • 
    2 clinics (2 PA - DCC)
    
  • 
    2 ward consultation sessions (2 PA - DCC)
    
  • 
    1 clinical administration (1 PA - DCC)
    
  • 
    Travel (1 PA - DCC/SPA) (1.5 at YG)
    
• 
  WCNN:
  
  • 
    1 clinic (1PA - DCC)
    
  • 
    Clinical administration (0.5 PA - DCC)
    
  • 
    CPD (1 PA - SPA)
    
  • 
    Nurse liaison remotely (0.5 PA - DCC) (0.25 at YG)
    
  • 
    Audit / appraisal / teaching (1.5 PA - SPA)
    

2. Option 1

• 
  3 new locally based WCNN neurologists (3 x 10 PAs; 4 days in Wales + 1 day at WCNN for CPD + specialist clinic)
  
  • 
    2 new neurologists at YG; 1 at YMW
    
  • 
    Dr Iniesta drops sessions (2 days, 5PAs) at YG, and substitutes sessions at YGC & Deeside
    
• 
  Deeside clinic weekly provided by existing WCNN consultant (+2 PAs)
  
• 
  N Powys clinic 2/month provided by existing WCNN consultant (+1PA)
  
• 
  3 Generic neurology nurses – 1 per DGH area (community based)
  

Ysbyty Gwynedd
9 days providing 5 clinics + 5 ward consultation sessions
Dr M Bracewell (Dept Psychology Bangor University): 1 day

New locally based post 1: 4 days

New locally based post 2: 4 days
Ysbyty Glan Clwyd
5½ days providing 6 clinics (1 MS; 1 epilepsy)) + 5 ward consultation sessions
Dr M Doran (WCNN): 2 days

Dr A Jacob (WCNN): 2 days

Dr I Iniesta (WCNN): 1½ days
Ysbyty Maelor Wrexham
7 days providing 5 clinics + 5 ward consultation sessions
Dr M Doran (WCNN): 1 day

Dr D Smith (WCNN): 2 days

New locally based post 3: 4 days
Deeside
1 clinic a week (Dr I Iniesta)
N Powys
2 clinics a month (WCNN consultant TBA)

2. Option 2

• 
  4 new locally based WCNN neurologists (4 x 10 PAs; 4 days in Wales + 1 day at WCNN for CPD + specialist clinic)
  
  • 
    2 new neurologists at YG; 1 at YGC; 1 at YMW
    
  • 
    Dr Iniesta drops sessions (2 days, 5PAs) at YG, and substitutes a session at Deeside
    
• 
  Deeside clinic weekly provided by existing WCNN consultant (+2 PAs)
  
• 
  N Powys clinic 2/month provided by existing WCNN consultant (+1PA)
  
• 
  3 Generic neurology nurses – 1 per DGH area (community based)
  

Ysbyty Gwynedd
9 days providing 5 clinics + 5 ward consultation sessions
Dr M Bracewell (Dept Psychology Bangor University): 1 day

New locally based post 1: 4 days

New locally based post 2: 4 days
Ysbyty Glan Clwyd
8 days providing 6 clinics (1 MS; 1 epilepsy) + 6 ward consultation sessions
Dr M Doran (WCNN): 2 days

Dr A Jacob (WCNN): 2 days

New locally based post 4: 4 days
Ysbyty Maelor Wrexham
7 days providing 5 clinics + 5 ward consultation sessions
Dr M Doran (WCNN): 1 day

Dr D Smith (WCNN): 2 days

New locally based post 3: 4 days
Deeside
1 clinic a week (Dr I Iniesta)
N Powys
2 clinics a month (WCNN consultant TBA)

3. Option 3

• 
  3 new WCNN based neurologists (3 x 10 PAs; 2 days in Wales + 3 days at WCNN)
  
  • 
    2 new neurologists at YG; 1 at YMW
    
  • 
    Dr Iniesta drops sessions (2 days, 5PAs) at YG, and substitutes sessions at YGC & Deeside
    
• 
  Deeside clinic weekly provided by existing WCNN consultant (+2 PAs)
  
• 
  N Powys clinic 2/month provided by existing WCNN consultant (+1PA)
  
• 
  3 Generic neurology nurses – 1 per DGH area (community based)
  

Ysbyty Gwynedd
5 days providing 5 clinics + 5 ward consultation sessions
Dr M Bracewell (Dept Psychology Bangor University): 1 day

New WCNN post 1: 2 days

New WCNN post 2: 2 days
Ysbyty Glan Clwyd
5½ days providing 6 clinics (1 MS; 1 epilepsy)) + 5 ward consultation sessions
Dr M Doran (WCNN): 2 days

Dr A Jacob (WCNN): 2 days

Dr I Iniesta (WCNN): 1½ days
Ysbyty Maelor Wrexham
5 days providing 5 clinics + 5 ward consultation sessions
Dr M Doran (WCNN): 1 day

Dr D Smith (WCNN): 2 days

New WCNN post 3: 2 days
Deeside
1 clinic a week (Dr I Iniesta)
N Powys
2 clinics a month (WCNN consultant TBA)

Costs
Option 1:
3 new locally based (10 PA) consultant neurologists = 30PA

3 generic nurses

Dr Bracewell 2.7 PA

Dr Doran 7.5 PA

Dr Jacob 5.0 PA

Dr Iniesta 5.5 PA (+1.5)

Dr Smith 5.0 PA

Powys 1.0 PA (+1.0)

26.7 PA (equivalent to 3.5 wte)
Total consultant neurology PAs = 56.7

Consultant neurologist wte’s = 6.5

Increased SLA costs for YG; YGC; YMW + new SLA costs at Deeside + Powys
Option 2:
4 locally based (10PA) consultant neurologists = 40 PA

3 Generic nurses

Dr Bracewell 2.7 PA

Dr Doran 7.5 PA

Dr Jacob 5.0 PA

Dr Iniesta 1.75 PA (-2.25)

Dr Smith 5.0 PA

Powys 1.0 PA (+1.0)

22.95 PA (equivalent to 3 wte)
Total consultant neurology PAs = 62.95

Consultant neurologist wte’s = 7.0

Increased SLA costs for YG; YGC; YMW + new SLA costs at Deeside + Powys
Option 3:
3 new WCNN based (10.5 – 10.75 PA) consultant neurologists = 31.75 PA

3 generic nurses

Dr Bracewell 2.7 PA

Dr Doran 7.5 PA

Dr Jacob 5.0 PA

Dr Iniesta 5.5 PA (+1.5)

Dr Smith 5.0 PA

Powys 1.0 PA (+1.0)

26.7 PA (equivalent to 3.5 wte)
Total consultant neurology PAs = 58.25

Consultant neurologist wte’s = 6.5

Increased SLA costs for YG; YGC; YMW + new SLA costs at Deeside + Powys


Specific comments / advantages / risks

1. 
   Locally based posts deliver more local days but same clinics and ward sessions because SPAs are located in Wales – presently all SPAs are at WCNN and only clinical (DCC) sessions are in Wales.
   

2. 
   Current provision of the ward referral service into each of the 3 North Wales DGHs is already greater than for any English DGH except Chester. This is widely misunderstood in North Wales where the WCNN neurology in-patient provision is frequently “under-estimated”.
   

3. 
   No reference is made to neurological input from Bangor University psychology department to brain injury unit in North Wales – this is unclear to WCNN but appears to have no clinical neurological implications.
   

4. 
   Locally based posts allow more days to allow for leave cover, local teaching, audit and research. Also locally based consultants may be more available for advice in person rather than by phone.
   

5. 
   Locally based consultants would have no beds at WCNN, and would require a “buddying” system with WCNN-based consultants.
   

6. 
   Locally based consultants are likely to be harder to recruit and retain on basis of past WCNN experience. Recruitment could be attempted but may fail. Retention likely to be difficult but could be attempted. Option 3 could then be default position.
   

7. 
   WCNN based new posts deliver same clinical (DCC) sessions in Wales but nurse liaison done remotely (phone, video link) and SPAs at WCNN. Travelling time greater hence higher PAs, especially at YG. May also be difficult to recruit to but arguably less so. There may be retention difficulties as with locally based posts.
   

8. 
   YGC currently has significantly greater provision than YG / YMW hence options look different especially options 1 and 3.
   

Appendix B: Distribution of Neurology Services in North Wales
There are a number of considerations in deciding the distribution of services:

• 
  The peculiar geography of North Wales, especially if North Powys is also to be included
  
• 
  The population dispersion across North Wales
  
• 
  The distribution of secondary services across North Wales
  
• 
  The requirement for an in-patient consultation element of the service at each DGH
  
• 
  The need for services throughout all weeks of the year (i.e. cover for periods of leave)
  
• 
  Accessibility for patients
  
• 
  The perceived weaknesses in present services, and in particular the integration of neurological care out into the community
  
• 
  Achievability and viability in terms of human resources issues:
  
  • 
    recruitment & retention
    
  • 
    job planning
    
• 
  Achievability and viability in terms of capital outlay requirements
  
• 
  The need for complex neurology to take place at WCNN (Steers Review)
  
• 
  The need for neurology integration with other neuroscience disciplines (especially neurosurgery) to take place at WCNN (Steers Review)
  
• 
  The need for neurology CPD to take place at WCNN (Steers Review)
  

Following meetings with the James Steers Neuroscience Review Group in Cardiff and the North Wales Neuroscience Implementation Group at which these issues were aired, it was decided that the main short to medium term aim will be the establishment of a managed clinical network for neurology services with:

1. 
   enhanced services at each of the three main hospitals and
   
2. 
   improved general neurology nursing services in the community, with
   
3. 
   full liaison and coordination between the two, and
   
4. 
   continued use of WCNN for complex neurology, CPD and integration with other neuroscience disciplines.
   

It is recognised that all this would only be possible with considerable additional funding recurrently.

The suggestion of an in-patient neurology centre at Glan Clwyd was discussed at NWNIG, and in this workstream, and it was decided that this would be best regarded as a long term plan, perhaps coordinated with re-development at YGC:

1. 
   the capital outlay would almost certainly be prohibitive at present or in the next few years
   
2. 
   the need for other supporting services (e.g. neuroradiology, neurophysiology) would add further to capital and recurrent expenditure
   
3. 
   there was no appetite within the North Wales stroke services for centralisation of their services (in conjunction with neurology) at this time
   
4. 
   the provision of middle-grade medical staff would be difficult
   
5. 
   it was felt that in practice this would seriously endanger provision of neurological in-patient and outpatient care at YG and Wrexham Maelor unless there was an (unrealistic) even greater expansion of neurologist provision
   
6. 
   this would compromise setting up a service to include north Powys
   
7. 
   in general, it was acknowledged that aiming for such a centre now would significantly lessen the chances of achieving lesser and realistic plans for a less centralised but enhanced community and DGH-based service.
   

Appendix C: The continued involvement of WCNN in provision of the of neurological services in Wales
The Steers review recognises the need for the continued involvement of WCNN for CPD provision and for in-patient complex neurology. The continued involvement of WCNN in provision of the other aspects of neurological services may be open to debate.
The need for an integration of services is agreed by everyone:

1. 
   between those provided in hospitals and those in the community/primary care
   
2. 
   between those provided in the Welsh DGHs and WCNN, for both out-patients and in-patients
   
3. 
   between neurology and neurosurgery (including spinal surgery)
   
4. 
   between neurology and the specialist neuro-diagnostics (neuro-radiology, neurophysiology & neuropathology).
   
5. 
   between the neurology & neurosurgery and neuro-rehabilation
   

Of these, a., e. and to a lesser extent b. are the most apparent to the patients but the professionals recognise c. and d. also.

The arguments for remaining with WCNN as the provider of all neurology services are briefly summarised:

1. 
   WCNN could not guarantee the clinical governance unless it was the employer and did more than provide the CPD.
   
2. 
   WCNN could not guarantee the provision of service unless it was the employer, able to direct the staff’s work practices and job plans
   
3. 
   recruitment and retention : the options outlined in this document include new neurology jobs which are locally-based 4 days a week. However it may be very difficult indeed to recruit to these, even with the name of Walton attached. That is why the 3:2 jobs have been included as alternatives, to cover this possibility (?probability). The reality is that the chances of the North Wales trusts recruiting worthwhile consultant neurologists by themselves are even worse.
   
4. 
   NHS consultant contracts in England contain a greater proportion of time dedicated to “direct clinical care” and less to “supporting programmed activities”.
   
5. 
   in the case of the present WCNN-based neurologists whose satellite commitments are in Wales, the cost of those “supporting programmed activities” are actually borne by the English commissioners, and these costs would have to be subsumed if the work was taken over by Wales in its entirety!
   
6. 
   economies of scale
   
7. 
   access to subspecialty clinics, not only from the quality point of view but also other implications (e.g. the use of "disease-modifying" agents in our sub-specialist MS clinic is a fraction of that usage found in small and non-subspecialist neurology units around the country)
   
8. 
   cross-cover that comes from a larger service, when individual neurologists are away on leave (10 weeks per year potentially).
   
9. 
   proper integration with neuro-surgery, specialist neuro-radiology and neuro-physiology.
   
10. 
    training of generic neurology specialist nurses would rely on WCNN and their subsequent integration with the whole service, including for neurosurgical patients, would be greatly facilitated by WCNN’s continued involvement.
    
11. 
    the management of services within the neurology division at WCNN is presently used as an exemplar by DH in England of good, effective and innovative management, modernising pathways to meet RTT targets. This managerial experience and expertise in neurology services would not be available to continue future developments if the service were to be run from within North Wales.
    

Continued involvement of WCNN in all neurological provision would be the most reliable and secure way to provide a sustainable comprehensive service that could progress in the future, with clinical governance assured by WCNN. WCNN would run the operational issues of such neurology services, but there would need to be a structure to ensure accountability to the commissioning body (LHB from October). Supervision of the service and advice to the LHB on strategy and planning could be the role of a “managed network” or other such group, with involvement of the commissioning body (LHB from October), secondary care, primary care, patients’ representatives (e.g. Welsh Neurological Alliance) and neurologists and clinical and general managers from WCNN.

Appendix D: Neurology day cases
There should be the possibility of day case neurology patients for

• 
  some investigation (e.g. lumbar puncture) and
  
• 
  selected treatments (e.g. some drug infusions of methylprednislone, intravenous immunoglobulin)
  

This would require

1. 
   access to day case beds/unit
   
2. 
   availability of junior medical staff
   
3. 
   agreed protocols / instruction of clinical staff to cover common complications
   
4. 
   presence within the hospital that day of a consulant neurologist
   

DRAFT Page 01/06/2017