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Ymchwiliad i’r Adolygiad Blaenoriaethau ar gyfer y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Inquiry into the Priorities for the Health, Social Care and Sport Committee

Ymateb gan: Coleg Brenhinol y Llawfeddygon

Response from: Royal College of Surgeons

Priorities for the Health, Social Care and Sport Committee

Consultation Response

The Royal College of Surgeons

Leighton Veale

Regional Coordinator for Wales

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The Royal College of Surgeons (RCS) is a professional body that sets the highest standards for surgical practice and training in order to deliver safe and high quality patient care.

We welcome the opportunity to respond to this consultation and we would be pleased to appear before the Committee on any of these issues.

We outline below three key areas we believe the Committee should focus attention on during this Assembly term.

Improving access to services

Waiting times for elective surgery has long been a major challenge facing the Welsh NHS.   

Elective waiting times

The current Welsh Government target is for at least 95 per cent of patients to have waited less than 26 weeks from referral to treatment, with 100 per cent treated within 36 weeks.

Figures for 2016 showed that by the end of May the equivalent of 370,000 patients (86%) in Wales waited less than 26 weeks despite the Welsh Government’s target of 95% of patients meeting this figure. This is compared to 83.8% of patients within the target for the same month last year.

Waiting times in Wales are starting to move in the right direction and this is welcome. However, the Government’s target of 95% of patients being treated within 26 weeks is still being missed by a significant margin. The 26 and 36 week planned treatment targets have not been met since September 2011.

Use of waiting times as a standard can be criticised but they are useful as a measurement of performance.

The NHS in Wales is facing increasing demand and is treating more people than ever before. In 2000/01, 275,000 elective inpatient and day cases and a total of 586,000 inpatient and day cases were seen. In 2011/12, 362,000 elective inpatient and day cases and a total of 723,000 inpatient and day cases were seen.  A 2015 report by the Wales Audit Office into waiting times for elective treatment found that: “financial pressures have been a contributing factor to the decline in performance against waiting times targets”.  Such monetary pressures likely result in lower staffing and consultant levels in Wales with comparable parts of the UK.

Wales lost nearly half of its beds between 1999/2000 and 2013/14.

This reduction in bed numbers coupled with an increase in patient demand is a fundamental factor which has not been addressed.  Until this discrepancy is resolved the Welsh NHS will continue to underperform.  At present many patients present to emergency departments, not because they require hospital treatment but because they are frail and have nowhere else to go.  Other patients who have received inpatient therapy cannot be discharged because there are no facilities in the community to care for them.

We believe that the single biggest improvement in waiting times and capacity overall would be achieved by increasing capacity for frail people in the community.    

Critical Care Bed capacity

A  July 2014 report for Welsh Government showed that Wales has the lowest number of critical care beds in Europe. The analysis shows that Wales has 3.2 critical care beds per 100,000 people, compared to 4 in England and the European average of 11.  The report also identifies that the number of critical care beds has fallen by four across Wales since 1999, with most units routinely operating above the recommended 75 per cent occupancy rate.  Another factor is the inappropriate use of critical care beds as a result of delayed discharge, inappropriate admission or a shortage of staff.

Delayed access to and premature discharge from critical care have been identified as important risk factors for post-operative death, as has delayed admission to critical care. Further information on this can be read here: http://www.bmj.com/content/316/7148/1853   Routine admission to critical care after high risk surgery reduces complication rates and subsequent admissions to intensive care. This ultimately saves money through shortened hospital stay and reduced use of ICUs, which currently cost the NHS around £88 million per year.

We believe bed capacity, particularly critical care bed capacity, needs urgent consideration and we would urge the Welsh Government to consider how to increase bed capacity and use existing capacity more effectively.

In England, the number of available and occupied critical care beds is published publicly on a monthly basis. We would like to see similar data published in Wales.

Data and outcomes

Greater transparency in the health service in Wales would improve governance and drive up performance and allow us to make judgements about the quality of patient care in Wales.

As with many parts of the NHS across the UK, data collection in Wales has been historically poor, particularly for outcomes data. There are a variety of reasons for this, but in Wales outcomes and recording activity in particular have historically not been well resourced.

In Wales there is no routine publication of data on how many operations are cancelled and whether the cancellation is for a clinical or non-clinical reason. Data collection is fundamental to increased efficiency and performance.  This is recognised by NHS Wales in the collection of Hospital Episode Statistics, and by all specialty associations across surgery many of which have registries and national audit projects.  In 2013 the Welsh Government undertook to work towards publishing surgical outcomes on a unit level; the RCS strongly supports this initiative.  The RCS has the expertise to work with the Welsh NHS on this project.

Healthcare Inspectorate Wales

There has been criticism of HIW in the past from the medical profession and the Welsh Government indicated it would like to see ‘full formal independence from government’ for HIW. Legislation has been promised during this Assembly term and we support this.

The College supports the Welsh Government’s position that HIW should be an independent body distinct from government.  At present HIW is unfunded and understaffed.  While proportionate regulation will not solve the problems facing the NHS alone, there urgently needs to be a clear inspection system providing external challenge to the NHS to help raise standards and reassure the public about the quality of services. HIW adequately funded could lead this system.