Professor Alex McMahon, NHS Lothian Catriona Renfrew, NHS Greater Glasgow & Clyde David Steel, NHS National Services Scotland Cleft Lip and Palate Surgical Service Options Appraisal Report November 2015 Contents 1. Introduction .............................................................................................................. 3 2. The Cleft Surgical Service Options Appraisal Process .............................................. 4 3. Previous Review Process 2011/12 Cleft Lip & Palate Review…………………………5 4. Current position - Background to the requirement for Option Appraisal………………..6 5. Options Appraisal Process………………………………………………………………….7 6. Discussion of Options………………………………………………………………………..8 7. Scoring Options & Outcome……………………………………………………………….10 8. Conclusions ........................................................................................................... 12 2 1. Introduction 1.1 Following the 2011/12 Review of the Cleft Lip & Palate Surgical Service the NHS Board Chief Executives asked NSD to work with NHS Greater Glasgow and Clyde and NHS Lothian to set up a single surgical service over two surgical sites to meet the needs of all patients with a cleft lip and or palate resident in Scotland. A Cleft Management Board was set up led by NHS Greater Glasgow and Clyde, chaired by Jonathan Best with management representation from NHS GG&C, NHS Lothian, National Services Division with representation from CleftSiS (now Cleft Care Scotland) the managed clinical network for all involved in delivering local services for patients with cleft lip and palate and from CLAPA the main patient group. Despite some progress it became apparent in early 2015 that major challenges remained unresolved which meant that despite 2 ½ years work the revised service had not been delivered. 1.2 The Cleft Management Board took a position paper to the National Specialist Services Committee in June 2015 proposing a number of options for the way forward for the specialist surgical component of the designated cleft lip and palate service commissioned by National Services Division of NHS National Services Scotland (NSD) on behalf of NHS Boards in Scotland. It was noted that all other components of the specialist service, including support for outreach clinics, and the delivery of local services, including orthodontics, speech and language therapy and specialist nursing, were not subject to this additional review. 1.3 The National Specialist Services Committee asked that National Services Division, as commissioners of the service, NHS Greater Glasgow and Clyde and NHS Lothian consider these options, with the exclusion of the possibility of de-designation of the service as a possible recommendation, to determine a way forward to allow implementation of the recommendation of the initial review: to commission a single service to provide specialist cleft lip and palate surgery for patients of all ages in Scotland. 1.4 The three NHS Boards established a Review group to make recommendations on the way forward. 1.4.1 The Review group issued a position paper on 18 August 2015, which detailed the current position of the service, and invited comment on this document to inform the process. This paper was distributed through the Cleft Care Scotland Network and CLAPA, the established patients and parents group representing patients with a cleft lip and/or palate. 1.4.2 Comments were received from a wide range of professional and public stakeholders and these were collated in a paper presented to the Options Appraisal Group 1.4.3 A public engagement meeting was held on 27 October 2015, in the Scottish Health Services Centre in Edinburgh. This was organised with the support of CLAPA and also included an observer from Scottish Health Council. Patients and family members attended from across Scotland although the majority of those present were more familiar with the surgical service currently provided by NHS Lothian. 1.4.4 The Review Group also established an Options Appraisal exercise which was undertaken on 28 October 2015. 3 2. The Cleft Surgical Service Options Appraisal Process 2.1 To take forward the work requested by NSSC, NHS National Services Scotland, NHS Greater Glasgow & Clyde and NHS Lothian convened an Options Appraisal Group with membership ensuring appropriate clinical interest and expertise, and a range of NHS management and lay representation that provided a geographical balance. The membership of the Options Appraisal Group is detailed below. Dr Andrew Russell, Medical Director of NHS Tayside, agreed to act as the independent chair of the Options Appraisal Group. 2.2 Membership of the Options Appraisal Group: Dr Andrew Russell NHS Board Medical Director, NHS Tayside (Chair) (Non scoring) Ms Gillian McCarthy CLAPA Scotland Ms Iona Wallace CLAPA, Patient Service User - Adult user (West) Ms Mandy Temple CLAPA, Patient Service User - Parent Representative (East) Mr Adrian Sugar Cleft and Oral & Maxillofacial Surgeon, NHS Wales Ms Rona Slator Cleft and Plastic Surgeon, NHS England Mr Stephen Robinson Chair- UK Cleft Development Group, Orthodontic Surgeon, NHS England Ms Kerry Russell North of Scotland Planning Group Dr Edward Doyle NHS Lothian, Associate Medical Director (clinical management) Ms Fiona Mitchell NHS Lothian, Service Management Prof Alex McMahon NHS Lothian, Director of Strategic Planning & Modernisation Dr Catriona Renfrew NHS Greater Glasgow & Clyde, Director of Corporate Planning and Policy Mrs Julia Muirhead NHS Greater Glasgow & Clyde, Service Management Mr Jonathan Best NHS Greater Glasgow & Clyde, Senior Management Mr Toby Gillgrass Cleft Care Scotland, Lead Clinician and Consultant Orthodontist Ms Lisa Crampin Cleft Care Scotland (West), Speech & Language Therapy Mr Grant McIntyre Cleft Care Scotland (East), Consultant Orthodontist Mr David Steel Programme Associate Director, NSD Dr Mike Winter Medical Director, NSD In Attendance (non scoring) Mrs Gillian Gunn Scottish Government Representative Ms Lyn Hutchison Senior Programme Manager, NSD Ms Sharyn Montgomery Programme Support Officer, NSD 2.3 The Options Appraisal Group met on 28 October 2015. The rest of this report sets out the process which was followed to assess the three proposed options for service delivery for cleft surgical services using a recognised NHS Options Appraisal methodology; and the outcome. 4 2.4 The group were provided with the information set out below in advance of the workshop. 2.4.1 Cleft Lip and Palate Surgical Service and CleftSiS National Managed Clinical Network Review Report 2012. (Annex 1) 2.4.2 Cleft Lip and Palate Surgical Service Position Paper July 2015 (Annex 2) 2.4.3 Stakeholder comments Received (Anonymised) on Position Paper (Annex 3) 2.4.4 Cleft Care Scotland Audit Report 2013-14 (Annex 4) 2.4.5 Cleft Lip and Palate Surgical Service Specification (Annex 5) 2.4.6 Guide to Options Appraisal – Criteria and Weighting (Annex 6) 2.5 The Group also received submissions from NHS Lothian and NHS Greater Glasgow and Clyde which were tabled on the day. NHS Lothian provided submissions for: Option 1 – status quo (Annex 7) Option 2 – single surgical service provided from NHS Lothian (Annex 8) NHS GG&C provided a submission for: Option 3 – single surgical service provided from NHS GG&C (Annex 9) 2.6 The Options Appraisal Group also received a summary of the comments received from the patients and parents engagement event from the night before the workshop. (Annex 10). 3. Previous process - 2011/12 Cleft Lip and Palate service Review 3.1 The workshop started with a briefing on the previous review process and its recommendations (as detailed in Annex 1 and 2). This review had been a planned follow up to the review that had taken place 2006, which had recommended a reduction in the number of surgical sites from three to two, and had advised that further work be undertaken to move towards a single surgical service, providing cover for each other as well working to develop a case for inclusion of adults within the Cleft Surgical Service. Progress was to be reviewed in 5 years. 3.2 The review in 2011/12 concluded the previous recommendations had only been partially achieved; the surgical service formerly provided in NHS Grampian had been successfully transferred to NHS Lothian; but the paediatric surgical service was not working as a single service, the teams were not working to the same protocols, there had been no progress toward inclusion of adult cleft care within the service and there were ongoing challenges in getting full co-operation with the CleftSiS audit programme. 3.3 The 2011/12 review recommended that the existing model of 2 separate paediatric surgical services should be developed into a single surgical service on one site and should provide expert care for adult patients as well as for the 100 children born in Scotland each year with a cleft lip and or palate. 5 4. Current position - Background to the requirement for Option Appraisal 4.1 The Group received a presentation on the Management Board’s attempts to establish a single surgical service over two sites as requested by the NHS Board Chief Executives and why this further Options Appraisal exercise was required. 4.2 The Group were informed that, as detailed in the Position Paper (Annex 2), in 2013 Board Chief Executives had recommended that a single cleft surgical service should be established for NHS Scotland based on two surgical sites (NHS GG&C and NHS Lothian), rather than invite a competitive assessment of whether the service should be consolidated in either Edinburgh or Glasgow. 4.3 Some progress had been achieved:  The Cleft Management Board had been set up with managerial and clinical representation from NHS Lothian, NHS GG&C, and NSD; chaired by NHS GG&C as the host Board providing the operational management of the integrated specialist service.  Lead Clinician for the surgical service appointed following appropriate open recruitment process.  Mapping of all existing outreach specialist cleft clinics and agreement on the provision of multidisciplinary outreach clinics as an integral aspect of the ‘single service approach’.  Recruitment of additional clinical psychologists to support cleft care across NHS Scotland  Agreement to funding the establishment of 24 specialist cleft surgical sessions based on three surgeons with 8 sessions each. This linked to high level agreement to develop job plans which demonstrated commitment to joint working in both surgical sessions and in MDT outreach clinics. 4.4 Despite this progress, the two surgical sites continued to operate as stand alone services and while a lead clinician had been appointed he did not have a role within the East coast service, nor in the job planning of the Consultant employed in NHS Lothian. 4.5 There was a single national clinical pathway for surgical services, agreed through Cleft Care Scotland based on UK standards, but this was not yet universally implemented. 4.6 A single Service Agreement had been agreed and was held by NHS GG&C, as lead NHS Board, however the two surgical sites continued to retain separate budget and line management structures. 4.7 All 3 surgeons hold honorary contracts with the other sites; and the Glasgow surgeons had covered periods of leave for the consultant in Lothian; however true joint working and cross cover had not been achieved and individual rotas are retained. 4.8 There was no single waiting list, nor any shared distribution of referrals or for new births and as result different waiting times. 4.9 Full multidisciplinary team case review, sharing best practice, working together, supporting and learning to drive continuous improvement in the Scottish cleft service is not in place; differential outcomes continue to be seen as a source of division, not an opportunity for learning and improvement. 6 4.10 The Management Board and the three constituent parts, NHS GG&C, NHS Lothian and NSD, had agreed that this lack of progress meant that this model of delivery was not a viable way forward for the service. 4.11 There was discussion about the points from the presentation. 5. Options Appraisal Process 5.1 The Group were then advised about the procedure for an Options Appraisal - this required the agreement on the criteria on which the options would be assessed and the weightings that should be applied to that criteria. The Group would then discuss each of the options against the agreed criteria and score each option against that criteria based on the evidence provided. 5.2 The criteria and weightings from the 2011/12 Options Appraisal had been circulated and following discussion there was agreement that the six criteria to be used to assess the current options should mirror the previous review. The criteria used are set out in Table 1 Table 1: Criteria Criteria Definition Structure 1. Clinical sustainability The availability of the full range of skilled staff. (Attract and retain skilled staff) Opportunities for training and development and collaborative team working between clinicians. 2. Capacity Physical capacity/flexibility to meet all surgical needs with strength and depth in clinical staffing and collaborative team working between clinicians. Process 3. Timely and Efficient The service needs to be adaptable in order to provide the most appropriate interventions and treatments at the right time to everyone who will benefit and wasteful variation will be eradicated. 4. Patient Centred, Equitable There will be the same equality of opportunity to receive high quality surgical services regardless of where patients, from any background, live in Scotland whilst being responsive and respectful to their needs and values. Outcome 5. Meets National clinical standards Degree to which the configuration is able to comply with National standards such as Cleft Care Scotland (formerly CleftSiS), Clinical Standards Advisory Group (CSAG) and National Institute for Clinical Excellence (NICE). 6. Safe and Clinically Effective Includes both short-term safe outcomes such as avoiding harm and complications, and long term outcomes as determined by CSAG and Cleft Care Scotland. 7 5.3 There then followed discussion around the weighting of the criteria. The scoring of the criteria total 100 and the greater the perceived importance the higher the weight assigned. The Group agreed that Clinical Sustainability should be weighted more heavily and the weighting for capacity should be decreased. 5.4 The weights applied are set out in table 2 below. Table 2: Weighting Criteria Weight 1 Clinical sustainability 20 2 Capacity 10 3 Timely and Efficient 10 4 Patient Centred and Equitable 20 5 Meets national clinical standards 20 6 Safe and Clinically Effective 20 6. Discussion of Options 6.1 The Group was reminded that the options that they were being asked to evaluate were: 1. Status Quo: Continue to seek to implement the previous NHS Board Chief Executives’ direction to commission a single surgical service provided on two sites. 2. Plan and implement a single surgical service for all ages provided in NHS Lothian – This proposal would mean all specialist cleft lip and palate surgery being performed by NHS Lothian. Local clinics and Multi Disciplinary Team clinics would still be provided and supported across NHS Scotland. 3. Plan and implement a single surgical service for all ages provided in NHS Greater Glasgow & Clyde - This proposal would mean all specialist cleft lip and palate surgery being performed by NHS Greater Glasgow & Clyde. Local clinics and Multi Disciplinary Team clinics would still be provided and supported across NHS Scotland. 6.2 Clarity was sought on what was meant by a single surgical service. 6.2.1 This was described as a service provided by a multidisciplinary team that collaborated to provide cross cover to each other and could deliver a resilient and sustainable service. With even distribution of referrals and new births and able to provide support to all MDTs involved in providing aspects of cleft care at a local level. 6.2.2 It was acknowledged that there could still be variation between surgeons in their clinical approach at times; however it was expected that there would be shared decision making within a team working collaboratively 6.3 Other staff 6.3.1 There was confirmation that at present there continues to be separate caseloads and no cross cover in respect of the east and west specialist cleft teams and in particular between the surgical staff. It was acknowledged that cleft care was delivered by a much wider multidisciplinary team and there was 8 no expectation of their having to move base locations or to routinely provide cross cover outwith their employing NHS Board. 6.3.2 There were incidences where on occasions the specialist cleft nurses and speech and language therapist from Glasgow had provided support to Lothian to cover short term staff shortages, but this was in response to individual requests rather than a planned cross cover arrangement. 6.4 Outcomes 6.4.1 There was detailed discussion about the outcome data and a number of specific questions were asked in relation to the outcome data presented. It was noted that the services had good outcomes and that Scotland benchmarked well against similar UK units and excelled in some areas. 6.4.2 It was emphasised that the option appraisal had not arisen because of concern about the service provided by either of the surgical teams or as a result of any of the outcomes shared. 6.4,3 It was also highlighted that audit outcome data is normally used to support service improvement and it was a concern that some of the data is being highlighted as a means of division, and this was symptomatic of the service not working as a Single Surgical Service. 6.4.4 There were areas of strength and excellence in different areas of clinical practice between the East and West services the aim should be that the whole service focussed on providing a resilient and sustainable cleft service with every discipline collaborating and learning from each other to achieve the best outcomes possible for every patient in Scotland regardless of where they live. 6.4.5 It was reported that other disciplines do discuss the outcome data as a means to drive improvements across Scotland within their spheres of practice and not in an adversarial way. 6.5 A number of the specific clinical outcomes were reviewed by the external clinical experts and further detail provided. This reinforced the summary given that there are differences between current service provision but all care in Scotland is delivered safely and is of good quality, there remains an opportunity for improvement if the service were to be working as a single team and using outcomes information as a means of understanding where change could be made. 6.6 Discussion of options 6.6.1 It was queried whether it was worth scoring option 1 (single service delivered on 2 sites) as this had not been achieved despite the time and effort already invested. It was emphasised that scoring should be based on how well the individual member feels that option meets each criterion to assess which would best meet the requirements of the service going forward to meets the needs of patients with a cleft in Scotland. 6.6.2 It was noted that the NHS Lothian submission for Option 2 was only available from late 2017 when the new paediatric hospital would be opened on the site of the Edinburgh Royal Infirmary. Whilst it was acknowledged that the Options Appraisal had been asked to evaluate options on the current situation 9 it was also noted that it was to provide a clinically sustainable service for the future. There was discussion around the fact that action may be required before 2017 to ensure the sustainability of the service but agreed that the Lothian option should be considered as tabled. Therefore the Group agreed to evaluate that option as tabled from NHS Lothian. 6.7 It was queried what would happen for patients with complex co-morbidities, who had been operated by the service in the West due to availability of co-located specialty services that were not available in the East. It was confirmed that if it was recommended that the service move to Lothian the cleft service would not be co- located with a paediatric cardiology centre or paediatric complex airways service. However if a child needed access to these specialities then bespoke arrangements could be made to ensure correct care was provided for an individual child. 6.8 It was noted that adult procedures are already being carried out in multiple locations. In clarification it was pointed out that the expectation for the adult service was to ensure that procedures that required a specialist cleft surgeon intervention would be provided centrally; and those procedures that were currently appropriately undertaken by other disciplines would be supported in continuing to provide locally. 6.9 It was also emphasised that the Group were only asked to consider the cleft surgical service in this option appraisal and the other services provided within NHS Lothian, NHS GG&C and the other NHS Boards were not being considered by this process. 7. Scoring Options & Outcome 7.1 The Group were then taken through the scoring process and advised that against each criteria each option should be scored between 0 (where this represented the least benefit of an option against the criteria) and 10 (where this represented that best possible benefit of an option against the criteria). 7.2 The Options Appraisal was conducted by going through each criterion and scoring each option against this criterion and each of the 18 members who scored did so independently of each other. 7.3 The Group were then asked to hand in their scoring sheets at the end of the process for the scores to be assessed. The scores were then analysed and reported on as agreed by the Group. 7.4 The scores provided by each individual are detailed in Annex 11. Each individual was given a copy of their score with their identifier to check that they had been recorded accurately. 7.5 The following Graph shows the total weighted scores for each option. 10