Written - Independent Adult Neurosciences Expert Review Recommendations for Mid and South Wales

The independent review of Adult Neurosciences led by James Steers, Consultant Neurosurgeon, which I commissioned last autumn, has submitted recommendations for Mid and South Wales. I am pleased to attach a copy of the report for your information.

The recommendations in the report are designed to provide patients with sustainable services, as close to their homes as possible and to improve the quality of care that they experience. It recognises that some existing services, although delivering good standards of care, can be improved.

The report recommends the establishment of a neuroscience network, developing additional inpatient neurology services and strengthening neurorehabilitation. It also recommends improved access to supporting services such as neuroradiology, neurophysiology, neuropathology and neurocritical care. These developments would ensure that neuroscience services could continue to be provided within Wales, improve the quality of patient care and ensure they are provided as close to the patients home as possible.

In relation to stroke services, it recommends the establishment of acute stroke thrombolysis (clot busting) services and rapid access neurovascular clinics, in addition to improved rehabilitation. It also supports the establishment of stroke units in acute hospitals. These recommendations support the programme of action I had already initiated to improve stroke services in Wales and ensure improved access to quality of care and outcomes for stroke patients.

In relation to spinal services, the report recommends that non-complex spinal surgery should be available in both Cardiff and Swansea and improvement to existing spinal injury services. These developments would allow patients access to treatment closer to home and improved quality of care.

The report has shown that currently, access to neurorehabilitation and local access to neurology need to be improved. The current arrangements for some neuroscience specialists are not sustainable and change is required to meet European Working Time Regulations and the training requirements for junior doctors. Such change will also enable more types of neuroscience specialist care, such as Deep Brain Stimulation, used in Parkinson’s and other diseases, to be provided in Wales, closer to patients.

It is important to place the reforms proposed in the Neuroscience Review in the context of demand for neuroscience services in Mid and South Wales. The majority of head injuries do not require hospital admission, of those that do, only about 100 patients a year need a neurosurgical operation, in South Wales. Most patients suffering head injury are admitted to their local hospital for stabilisation, assessment and a CT scan. This initial pattern would continue under the proposals contained in the Review, but more efficient care at this time would reduce the importance of onward patient travel times for those who then need to be transferred to neurosurgical units. Improvements in these services therefore have an impact on devising a networked solution to neurosurgery provision and I will ask the Implementation Group, referred to in more detail below, to advise me particularly on this point.

In that context, and in summary, the report makes the following recommendations:

1. A Managed Clinical Network for neurosciences for Mid and South Wales should be established
2. Four medical neurology services, with in-patient capability, should be established in Cardiff, Newport, Swansea and Carmarthen. Complex care will take place in Cardiff and Swansea. 
3. Acute Stroke Thrombolysis services should be run by the four medical neurology services until it can be established in the other acute admitting hospitals, where stroke units should be being developed in keeping with the UK guidelines. 
4. Two in-patient Neurorehabilitation services should be developed and the spinal rehabilitation service should be close to the Neurosurgical service. This will require an additional WTE consultant at each site.
5. A single Neurosurgical network for South and West Wales, co-located with the complex spinal and spinal deformity surgical service, the Neurocritical care service, the spinal injury unit and principal Neurorehabilitation service should be urgently developed.
6. Non-complex spinal surgery should be available in Cardiff and Swansea and could be provided by either orthopaedic or neurological surgeons.

This report and its recommendations are a useful basis on which to start planning the delivery of an improved neuroscience service to the population of Mid and South Wales and providing more opportunities for education and training, in these specialties, for health care professionals. There are, however, a series of financial and implementational issues, flowing from the Report, which now need to be considered.

I have therefore asked that a Mid and South Wales Implementation Group be established and I have asked Alan Axford, Interim Medical Director of Hwyel Dda NHS Trust, to chair the group. In service terms, including neurosurgery, I will expect the Group to develop its advice within the wider context of existing provision, such as the burns and plastics service at Morriston and paediatric neurosurgery at Cardiff and our links with English services. I have also asked for a financial assessment of the cost of implementing the recommendations contained with the report, for Welsh Health Estates to review the estates implications and for proposals for a Mid and West Wales Neuroscience Network. I expect this financial assessment to take into account the wider costs involved for patients, families, friends and carers.