Neurosurgery Provision Decentralisation Appears to Be the New Policy

BRAIN surgery is an example of one of the most difficult challenges facing the NHS: how to provide the best possible outcome while keeping the service accessible. Strategic planning for the NHS in Scotland has been moving towards a model of specialist centres of excellence, located in the major teaching hospitals, backed by a network of district general hospitals, since Professor David Kerr recommended it in 2005.

That policy has been reversed by the recommendation of the panel of experts set up to decide how best to concentrate neurosurgery services in one main centre of excellence that all four units in Scotland should be retained. This is expected to be endorsed by Health Secretary Nicola Sturgeon, who is also expected to confirm this week that the accident and emergency (A&E) unit at Monklands Hospital will be retained. Taken together, and following a recommendation that the six most rural hospitals in Scotland should employ consultants with a wider than usual range of general skills, these decisions will be seen as a further step towards decentralisation by the SNP government.

Although there is a clear philosophical difference between centralising specialist services and keeping as many as possible locally based, the decision to retain four centres for adult neurosurgery is based on a study of clinical evidence by the Neuroscience Implementation Group, whose initial remit was to move to a single centre. A subgroup of neurosurgeons decided that there could be advantages to a single site, only if the status quo could not be sustained and if transport and access problems could be resolved. One of the factors behind the Kerr recommendations was that, in highly specialised areas, there needs to be a certain volume of cases for clinicians to gain optimum expertise. Centralising all neurosurgery in one unit would obviously achieve that volume of specialist cases, but the group found there was no convincing evidence relevant to Scotland that better outcomes for patients would be achieved by having only one centre.

It should be remembered that the Kerr model was constructed on the principle that the NHS in Scotland should work as an integrated entity. That remains the case. The perennial challenge for any publicly-funded health service is how to provide the best results most efficiently. In this case, it is a welcome step forward that the specialist group, while recommending that neurosurgery should continue in each of the four centres, says that it is no longer acceptable for them to work independently of each other and suggests there could be a single management structure. It concedes that more sub-specialisation is “probably desirable”, but argues that does not mean it should all be undertaken at the same location. If different sub-specialities are to be undertaken in different places, one management system will be vital. More widely, it could provide a useful model for streamlining and centralising management, concentrating very specialised expertise, yet retaining neurosurgical services throughout the country. A question-mark remains over neurological services for children. The recommendation of the experts is for a single paediatric neurosurgery centre: that should not be discounted without good evidence that it is not the best solution.

Health boards and Health Secretaries must listen to public opinion, but strategic decisions cannot be based on public opinion alone. The decision to retain A&E at Monklands was backed by specialist medical opinion and that is now also true of the campaign to retain neurosurgery in Aberdeen. Health service planning must adopt the best models for each set of circumstances.

Originally published by Newsquest Media Group.

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