Urology - Belfast Health and Social Care Trust

2. How are urology services currently delivered?The urology multi-disciplinary team is made up of urology surgeons, anaestheticspecialist nursing staff, and administration staff. Traditionally the field of Urology wasone of the many that was delivered by general surgery. In the past 30 years Urologyhas developed and evolved as a separate surgical specialty. Higher specialisttraining in General Surgery no longer covers Urology, which now has its own trainingprogramme.2.1 What is Urology?As a specialty, urology can be sub-divided into a number of special interest areas,most of which also comprise elements of general or ‘core’ Urology work.Core Urology involves the diagnosis, medical and surgical treatment of diseases ofthe kidney, bladder and male reproductive organs. Urologists, regardless of specialinterest area, all provide core urology services.Uro-Oncology. Around 40% of urology work is cancer related and most of thediagnostics and medical or simple surgical treatments are appropriately undertakenoutside of the regional centre. Less than 10% of urological cancers requireradical/complex surgery. Specialist cancer services are based in Belfast CityHospital, where there are designated ‘cancer’ urologists.Stones/Endourology includes the management and treatment of renal and uretericstones. This involves open surgery, endoscopic intervention or stone fragmentationusing a range of techniques and is provided at the Belfast City Hospital.Andrology includes the treatment of erectile dysfunction, particularly post prostatesurgery, penile curvatures and deformities (Peyronie’s disease) and other conditionsof the male reproductive organs and is provided at both Belfast City Hospital andMater Hospitals.Reconstruction: includes reconstruction of urinary continence in men, bladderreconstruction after oncological surgery and in a neuropathic bladder, bladderreconstruction in congenital and developmental difficulties and reconstruction prior totransplantation. The Consultants in Belfast City Hospital who specialise in this areawork closely with the uro-oncology team and supra regional support is provided byUniversity College Hospital London.Female/functional Urology relates to the management and treatment ofincontinence and bladder dysfunction in women, which on some occasions overlapswith reconstruction surgery. Some of this work is undertaken by urologists at BelfastCity Hospital although the majority is undertaken by Uro-Gynaecologists.Page 8 of 25

83% of the total inpatient and day case service is provided at the Belfast CityHospital with 15% at the Mater Hospital and 2% at the Royal Hospitals. Patients canaccess the service in one or more of the following ways: As an inpatient: an admission to hospital which includes an overnight stay As a day case: surgical treatment which is carried out in a single day, withoutthe patient having to stay in hospital overnightAs an outpatient: care provided on an appointment basis without requiringadmission to hospital. Urology outpatient services are not part of this review.Inpatient general surgery can be delivered along one of two key pathways: Elective: This is when treatment has been planned and booked in advance,for example a patient who is placed on a waiting list for an operation and thenbrought into hospital on a prearranged day. This is the majority (90%) ofurology work. Non-elective or emergency: This is when a patient accesses urology withoutprior planning, for example via one of the Trust’s Emergency Departments.Two of the Trust’s acute hospitals, the Belfast City Hospital and Mater Hospital,currently deliver both elective and non-elective Urology inpatient services as well asday case procedures and outpatients. The Royal Hospitals delivers day case andoutpatients only. The cancer treatment services are primarily delivered at BelfastCity Hospital although there is some cancer diagnostic work undertaken at the MaterHospital. Total inpatient and day case activity is shown in Figure 1.Figure 1 sets out the Urology inpatient Finished Consultant Episodes (FCEs) andday case activity across the Trust.Page 9 of 25

ActivityFigure 1: Urology Activity in Finished Consultant Episodes (FCEs) for Electiveand Non Elective Inpatients 2009/10Urology Inpatient FCEs and Daycases 2009/10900080007000600050004000TOTAL Daycases 2009/103000TOTAL Inpatient FCEs 2009/10200010000BCH MIH RVHLocationsSource: Belfast Trust Information Department May 2010Page 10 of 25

Drive forward service modernisationThe Trust and the urology service will need to continue improving the efficiency of itsservice provision, including additional improvements in length of stay, admission onday of surgery and increased day surgery rates. This is particularly important giventhe tight financial constraints faced by the Trust.3.1 What are the main benefits of reorganising urology services?Having identified the key reasons to review urology services, there are a number ofbenefits for patients, staff and the hospitals which must be delivered in any proposedchange on delivery or location of service. These were summarised into five keyareas, which guided the work of the project team in their review and reorganisationof acute inpatient and day surgery services and they are:The delivery of safe and sustainable services to our patients:Providing safe services and ensuring patients are not at risk in our hospitals is ourtop priority. Having appropriately trained staff working in appropriately sized teamswill assist in both improving patient safety and sustaining the provision of theseservices.To improve service quality, effectiveness, reduce unnecessary duplication andfragmentation of services and deliver value for money:Maintaining and improving the quality of care experienced by patients is fundamentalto any proposals. Reducing the existing duplication of services across three acutesites will mean patients see the right staff in the right place and this will also helpteams deliver a more effective and efficient service.The Trust must optimise the use of the current operating theatre stock and thesupport accommodation available to us and ensure that there is some room forfuture growth, should the funding be available.To ensure services are appropriately clinically linked:Delivering services at the right time and in the right place requires certain services tobe located close to one another; for example, urology patients will potentially needaccess to gynaecology and oncology services.To ensure services are accessible to service users and carers.Service users, carers, families and visitors want to have easy access to theirservices, whether by public transport or by car.Page 12 of 25

To ensure the Acute Services Plan is compatible with the Trust Strategic DirectionThe Trust Strategic Direction, which has been previously publicly consulted upon, forthe four adult hospitals is:Belfast City Hospital as the centre for cancer, renal and a range of generalacute hospital services, with an increased focus on elective services and achronic conditions management;Royal Hospitals as the centre for major trauma services, including a heartcentre, with an increased focus on emergency services;Mater Hospital as the centre for ophthalmology services and general acutehospital services;Musgrave Park Hospital as the centre of specialist rehabilitation services.The urology project team used these benefits criteria to assess how each serviceoption would deliver improvements for patients and staff and considered their impacton each hospital.Page 13 of 25

4. Consideration of options for urology servicesA multi-disciplinary project team was established which brought together a broadrange of clinical and managerial staff from across the Trust, Consultant Urologists,imaging, nursing, Allied Health Professionals (AHPs), trades unions, service usersand other staff identified, and made recommendations on the possible options for thefuture delivery of the service.The options that were considered by the Project Team were:1. Continue with current delivery at all three hospitals (Belfast City Hospital, MaterHospital and The Royal Hospitals)2. Deliver all inpatient and day case urology at Belfast City Hospital3. Deliver all inpatient and day case urology at the Mater Hospital4. Deliver all inpatient and day case urology at the Royal Hospitals5. Deliver all inpatient urology Belfast City Hospital and all day case at MaterHospital6. Deliver all inpatient urology at Mater and all day case Urology at Belfast CityHospital.The project team considered the options against the 5 benefits criteria:To deliver safe and sustainable services to our patientsThe service is currently provided across three hospitals. The project team consensuswas that the current service configuration will not enable the service to meet thechallenges of future service delivery as readily as other options.By bringing together all urology services into one acute hospital there are benefits forboth service users and staff as the Trust will expect to improve productivity, reduceservice duplication and share learning and expertise between staff. For example,urology patients are more likely in the future to receive day surgery treatment ratherthan be treated as an inpatient. Further additional day surgery facilities will berequired to meet this changing profile of urology, which are not available in allhospitals.The limitations on junior doctor availability due to the Working Time Directive meansthat this medical resource must be better organised in order to make the mostefficient use of their time and this can be better accommodated with services on asingle site.The majority of urology services, around 83%, are currently provided at Belfast CityHospital and 15% at the Mater Hospital and 2% at the Royal Hospitals. Thereforethere is insufficient theatre space for the total service to be provided at the MaterHospital or the Royal Hospitals. Option 2 at the Belfast City Hospital has thenecessary capacity for the service.Page 14 of 25

To improve service quality, effectiveness and reduce unnecessary duplicationand fragmentation of services and deliver value for moneyA single site option would reduce duplication of service provision and would thusimprove efficiency. Providing services from one site would yield economies of scaleand would ultimately be more resource efficient.Option 2 removes service duplication by locating all services in the Belfast CityHospital. All members of the urology team would be able to work more closely on asingle site and therefore share expertise and learning which is key to improvingoutcomes for patients.Options 5 and 6 do not contribute to improving service quality and effectiveness orreduce unnecessary duplication of services. Rather, they continue with duplication ofthe urology services across three sites.Urology services in a single hospital would also offer some resource efficiency as aresult of economies of scale and the elimination of duplication.To ensure services are appropriately clinically linkedAt present both the Belfast City Hospital and Mater Hospitals have access to allessential clinical linkages. There are some linkages which urology want to developfurther for example, the link with uro-gynaecology, and general gynaecologyservices, the development of the Laparoscopic Robot, and the link with cancerservices. The strengthening of these links would be more difficult if the servicesremained in two or three hospitals.New Directions proposes that Belfast City Hospital will become the major centre forelective surgery – this is a key linkage for urology services. The review is alsoproposing that Gynaecology Services will be sited at the Belfast City Hospital.Technological advances in robotics can be utilised by uro-gynaecology and thusavoid duplication of investment in equipment. Cancer Services are already providedat Belfast City Hospital.Options 5 and 6 would split the service across two sites, thus compromising theability to meet all of the required clinical linkages.The Belfast City Hospital offers the best current and proposed clinical linkages forurology.To ensure services are accessible to service users and carersThe Belfast City Hospital rates well in terms of accessibility – it has good publictransport access via train, bus and is situated close to the centre of Belfast thusmaking it accessible from all parts of Belfast. There are also adequate parkingfacilities at the Belfast City Hospital, with a number of patient car parks at variouslocations on the hospital site.Page 15 of 25

The Royal Hospitals has fairly good access to public transport by bus; parking canbe an issue on this site and due to the geographical spread of the facilities acrossthe site the proximity of patient car parks to ward areas can vary. Work is ongoing toincrease the number of car parking spaces at the Royal Hospitals.In terms of accessibility, the Mater Hospital is fairly well served by bus. Parkingprovision can be an issue as can the proximity of patient car parks to the wards.To ensure the Acute Service Plan is compatible with Trust Strategic DirectionThe Belfast City Hospital was identified as the major centre for elective (planned)surgery and, given that 90% of urology activity is elective, Option 2 offers morerelevant clinical linkages than Options 3 and 4 and is compatible with the Truststrategic direction.Preferred OptionIn summary, the project team recommendations were that:Urology services should be located together at one acute hospital for thekey benefits of streamlined clinical pathways, team working, clinical rotamanagement and efficiency in service delivery;The Belfast City Hospital offers the best location for the single urologyservice for Belfast because:- The Belfast City Hospital has the key urology clinical linkages withgynaecology and cancer services for both the inpatient and day caseservice.- This single service across Belfast will help deliver the Regional Reviewof Urology which has specifically identified that specialist inpatientservices would concentrate in Belfast. Developments in urology willcontinue to require greater use of day surgery and short stay (23 hour)units. When the proposed replacement day surgery unit at Belfast CityHospital is in place, it is envisaged that a proportion of existing inpatientwork will transfer to day surgery services.- Given that 90% of Urology activity is elective (planned) work, a moreefficient service can be provided by bringing the staff and resourcestogether in the appropriate facilities.Page 16 of 25

5. What would this mean for patients, staff and hospitals?The proposed model for urology is outlined below:The development of a single specialist inpatient and day case unit for electiveand emergency urology services in Belfast at the Belfast City Hospital.Table 2: Urology Service - Current and Proposed Service Location(s)Urology Service Current Location(s) Proposed Location(s)Core UrologyBelfast City Hospital/ Belfast City HospitalMater HospitalUro-Oncology Belfast City Hospital Belfast City HospitalStones/Endourology Belfast City Hospital Belfast City HospitalAndrologyBelfast City Hospital/ Belfast City HospitalMater HospitalReconstruction Belfast City Hospital Belfast City HospitalFemale BladderDysfunctionBelfast City Hospital Belfast City Hospital5.1 What does this mean for patients?A single site location for urology services at the Belfast City Hospital will haveadvantages for patients, across Belfast and Northern Ireland:Providing safe and sustainable servicesBy providing a single consultant on call and junior doctor rotas, patients will haveaccess to these staff on site 365 days per year. This is not currently available at theMater Hospital and is more sustainable in a single specialist unit.Improving service quality and reducing duplicationA single site urology service provides the opportunity to provide more modernservice delivery, for example, 23 hour stay for some procedures. This will reduceservice duplication caused by referring patients between the Mater Hospital andBelfast City Hospital and ensure the scarce specialist resources, such as specialistnurses who also support provision of the diagnostic cystoscopy services, areavailable equally to the population.Page 17 of 25

Accessible for users and carersBelfast City Hospital is in an accessible location for the population of Belfast andNorthern Ireland, with good car parking and public transport access. By bringing theservice together at the Belfast City Hospital, this will improve equity of access forpatients, whereas previously the service delivery by the single consultant at theMater Hospital would have reduced during leave and absence.Ensure services are appropriately clinically linkedPatients would benefit from further development of linkages between urologyspecialists and cancer services and gynaecology, which are proposed to relocatefully to Belfast City Hospital.5.2 What would this mean for each hospital?The delivery of safe and sustainable servicesJunior doctor rotas would provide cover across the service and a single consultanton-call rota will be established. All urology services would be delivered in aspecialist unit in the Belfast City Hospital. This would lead to more efficientmanagement of patients, eliminating inequality of access to surgery and improvingquality of care for patients, and helping the Trust to meet waiting time targets for thebenefit of patients.Compatibility with the Trust Strategic PlanGiven that 90% of the urology service is elective (planned), this proposal iscompatible with the Trust Strategic Plan, with the Belfast City Hospital as the maincentre for elective surgery.Ensuring Services are appropriately clinically linkedThe key urology linkages are at the Belfast City Hospital with cancer services andgynaecology, which is proposed to relocate fully to the Belfast City Hospital. As wellas all the benefits for clinical working, this would ensure joint access to technologicaladvances in robotics which will be particularly valuable to urogynae.5.3 What would this mean for staff?Ensuring Services are appropriately clinically linkedAll members of the urology team would be able to work more closely on a single site,sharing expertise and learning which is key to improving outcomes for patients. Theurology team would have an increased opportunity to engage in multi-disciplinaryworking with colleagues in, for example, gynaecology and cancer services. Multidisciplinaryworking has been shown to improve patient outcomes. There would bea greater number of urologists and other multi-disciplinary team members availablefor a single site rota than is possible with the current situation. Staff would benefitPage 18 of 25

from delivering a Urology service which is more flexible to meet need and respond tothe Working Time Directive challenges as a result of combining services at theBelfast City Hospital.Improving service effectiveness and reduce duplicationThe urology team would be able to better utilise its staff, facilities and equipmentwhen located in one centre and not split across three hospitals. In addition, allspecialist urology equipment would be based in one centre instead of duplicated ontwo or three sites, as is the case currently, providing improved efficiencies in theservice.Page 19 of 25

6. WorkforceThe Trust would put in place a range of support mechanisms for staff to manage thepotential change process. These may include:Staff supportCareer counsellingTraining in application and interview preparationRetraining/re-skilling for new rolesAdvice and guidance on Human Resource policies and proceduresThe main impacts anticipated for staff are:RelocationIf the proposal is approved, it would require the relocation of some staff to facilitateall Urology services being delivered at the Belfast City Hospital. The Trust has inplace agreed protocols with Trade Unions on relocation and/or redeployment.The protocols have been developed in recognition of the fact that location of work isof major importance to staff, and to provide assurance, guidance and a processincorporating best practice, and the provision for regional agreements on excessmileage and the application of the Trust’s flexible working agreements.Consideration may be to redeploying staff to other posts in the Mater Hospital.New ways of working/retraining or reskillingAs the Trust is proposing to provide all urology services on the Belfast City Hospital,staff would be offered appropriate training/retraining if their job roles change.The Trust would work in partnership with Trade Union Side to consider how it wouldminimise any adverse impact on the workforce resulting from the proposed changes.Page 20 of 25

7. Your chance to have your say – Consultation QuestionsThe Trust wishes to consult as widely as possible on the proposal. Please use thisconsultation questionnaire to register your comments by 31 October.Appendix 1 provides additional information on the Trust’s communication,consultation and engagement processes and how you can be involved.1. Do you agree with the proposal to bring urology services onto a single acutehospital site?2. Do you agree with the proposal to locate urology services at the Belfast CityHospital as part of the major elective centre.3. If you do not agree with the proposal to locate urology services at the BelfastCity Hospital , where do you think the service should be located and give yourreasons.Page 21 of 25

Appendix 1 – Programme of Consultation and Your Invitation to CommentThis document is one of a suite of documents that represent a formal publicconsultation between Belfast Trust and the citizens we serve on how we would liketo deliver our acute services. The consultation period will open on 5 July 2010 andclose on 31 October 2010.All the documents will be available to our staff and the public using both the Trust’sintranet and internet pages, and by posting them to relevant organisations.We will hold a series of meetings with staff, Trade Unions, service users, carers andclients to ensure they are fully engaged in the consultation papers.A report will be presented to Trust Board in December 2010. The Trust Boardmeeting is open to the public.We are committed to ensuring that we consult broadly on these proposals. If youhave any enquiries regarding the consultation programme, please contact theCommunication Department at Belfast Trust on 9096 0077.Your invitation to commentPlease tell us your name and address at the beginning of your reply. If you arecommenting on behalf of an organisation, please tell us its name and what it does. Ifyou have consulted other people or organisations, please let us know.Responses in writing should be sent to:William McKee, Chief ExecutiveBelfast Health and Social Care Trustc/o Public Liaison ServicesCommunications Department1 st Floor, Nore VillaKnockbracken Healthcare ParkSaintfield RoadBelfastBT8 8BHAlternatively, comments may also be emailed to:stakeholdercomms@belfasttrust.hscni.netPage 22 of 25

Availability in other formatsIf you have any queries about this document, and its availability in alternative formatsthen please contact:Orla BarronActing Health & Social Inequalities Manager1 st Floor, Graham HouseKnockbracken Healthcare ParkSaintfield Road,BelfastBT8 8BHTel: 028 9096 0069Fax: 028 9056 6701Textphone: 028 9090 2863E-mail: orla.barron@belfasttrust.hscni.netFreedom of Information Act (2000) – Confidentiality of ConsultationsBelfast Trust will publish an anonymised summary of responses following completionof the consultation process; however your response, and all other responses to theconsultation, may be disclosed on request. We can only refuse to discloseinformation in limited circumstances. Before you submit your response, please readthe paragraphs below on the confidentiality of consultations and they will give youguidance on the legal position about any information given by you in response to thisconsultation.The Freedom of Information Act gives the public a general right of access to anyinformation held by a public authority, in this case, Belfast Trust. This right of accessto information includes information provided in response to a consultation. Wecannot automatically consider information supplied to us in response to aconsultation as information that can be withheld from disclosure. However, we dohave the responsibility to decide whether any information provided by you inresponse to this consultation, including information about your identity, should bemade public or withheld.Any information provided by you in response to this consultation is, if requested,likely to be released. Only in certain circumstances would information of this type bewithheld.Page 23 of 25

Appendix 2 – Equality and Human RightsEquality and human rights underpin the services that health and social care provide.They are integral to all functions of the Belfast Health and Social Care Trust such asservice delivery, policy formulation, employment and procurement.The Trust recognises that equality in health and social care is not about peoplegetting the same treatment – equality means people accessing person-centred,person-led, quality care which meets their needs.Human rights are founded on 5 fundamental values: fairness, respect, equality,dignity and autonomy. The Trust has incorporated both respect and dignity in itscorporate values and behaviours.Moreover, the Trust’s higher purpose is to improve health and well-being and reducehealth inequalities - by working in partnership with others and by engaging with staffto deliver safe, improving, modernising cost effective health and social care.Under Section 75 of the Northern Ireland Act 1998, the Belfast HSC Trust is obligedto consider the implications for equality of opportunity and good relations. As part ofthis assessment, the Trust also considers implications for human rights anddisability. This means the Trust is not only morally and ethically bound to deliver itsacute services to its users in an equitable fashion with respect and dignity; but it alsois statutorily bound to do so.Section 75 of the Northern Ireland Act 1998Section 75 (1) of the NI Act 1998 requires Belfast HSC Trust, in carrying out its work,to have due regard to the need to promote equality of opportunity between personsof different religious belief, political opinion, racial group, age, marital status orsexual orientation, between men and women generally, between persons with adisability and persons without and between persons with dependants and personswithout. Section 75 (2) requires the Trust to promote good relations between personsof different religious belief, political opinion or racial group.The Trust is carrying out an equality impact assessment on this proposal to ensurethat it undergoes a full and systematic analysis to firstly, determine the extent ofdifferential impact upon the 9 aforementioned groups and secondly establish if thatimpact is adverseIf so, the Trust must consider alternative policies to better achieve equality ofopportunity or measures to mitigate the adverse impact.The Belfast Health and Social Care Trust is committed to listening to the view ofstaff, service users, carers and families and advocacy groups and the wider publicand making an informed decision on the basis of these consultation responses.Page 24 of 25

Appendix 3 – GlossaryGlossary of abbreviationsAHPBCHEDEQIAWTDFCENIASRGHSpRAllied Health ProfessionalBelfast City HospitalEmergency DepartmentEquality Impact AssessmentWorking Time DirectiveFinished Consultant EpisodeNorthern Ireland Ambulance ServiceRoyal Group of HospitalsSpecialist RegistrarGlossary of termsAllied HealthProfessionDay caseElective surgeryEmergencysurgeryWorking TimeDirectiveFinishedConsultantEpisodeA clinical profession distinct from medicine, dentistry andnursing, such as physiotherapy, occupational therapy, speechand language therapy and dieteticsA surgical procedure carried out without an overnight hospitalstayA surgical procedure which has been planned and booked inadvanceA surgical procedure which is of an urgent nature and has notbeen planned or booked in advanceA law seeking to protect the health and safety of workers whichlimits the number of hours that doctors are allowed to work overan average weekAn episode of medical treatment during which a patient is underthe care of a single, named consultantPage 25 of 25