Inpatient facilities
Reconfiguration took place in five hospitals: Inverclyde Royal Hospital (Greenock), Perth Royal Infirmary (Perth), Royal Alexandra Hospital (Paisley), Dr Gray’s Hospital (Elgin) and St John’s Hospital (Livingston). Figure one displays the location of the reconfigured and adjacent hospitals. Elgin is in the same health board as Aberdeen, and Aberdeen is the designated “adjacent” inpatient facility for Elgin admissions but Elgin is much closer to Inverness than Aberdeen. In recognition that parents from Elgin may present sick children directly to Inverness to avoid travelling to Aberdeen, both Inverness and Aberdeen were considered as “adjacent” hospitals for Elgin. Table one gives details of the reconfigured and adjacent hospitals.
Greenock (Inverclyde Royal Hospital, NHS Greater Glasgow and Clyde). All inpatient facilities ceased after reconfiguration in Nov 2004 and inpatient facilities were provided in Paisley. No resources were put into the community in Greenock. Data between Dec 1999 and Nov 2009 were analysed
Table 1. Characteristics of paediatric facilities included in this study. Vigintile scores represent deprivation with 1 being the most deprived and 20 the least deprived.
Details of the reconfigured hospital
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Details of adjacent hospital
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Distance between reconfigured and adjacent hospitals (miles)
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Name (location)
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Nature of and date of reconfiguration
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Deprivation (1=lowest)
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Average monthly admission in five years pre-reconfiguration/1000
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Name (location)
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Deprivation (1=lowest)
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Average monthly admission in five years pre-reconfiguration/1000
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Inverclyde Royal Hospital (Greenock)
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All inpatient services ceased in Nov ‘04
|
2
|
3.25
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Royal Alexandra Hospital (Paisley)
|
12
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4.46
|
19.3
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Perth Royal Infirmary (Perth)
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Short stay admission unit operational from Apr ’05 8am-8pm until March ’18 when all inpatient services ceased
|
20
|
3.78
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Ninewells Hospital (Dundee)
|
18
|
8.47
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19.6
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Dr Gray’s Hospital (Elgin)
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Short stay admission unit operational from Mar ’18 8am-10pm
|
18
|
5.70
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Royal Children’s Hospital (Aberdeen)
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16
|
5.82
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65.3
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Raigmore Infirmary (Inverness)
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8
|
7.26
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37.4
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Royal Alexandra Hospital (Paisley)
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All inpatient services ceased Dec’17
|
12
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5.38
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Royal Hospital for Children (Glasgow)
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6
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10.74
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6.2
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St John’s Hospital (Livingston)
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A short stay assessment unit was open from July ’17.
|
12
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3.09
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Royal Hospital for Children (Edinburgh)
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19
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4.48
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16.5
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Perth (Perth Royal Infirmary, NHS Tayside). Round-the-clock inpatient facilities ceased in April 2005 and a short stay admissions unit staffed by paediatricians remained open from 8am-8pm until March 2018 when all inpatient facilities ceased. The following provisions were put in place for patients in Perth: there were all day clinics at with spaces for rapid reviews (e.g. patients seen the day before); a list faxed to the inpatient facility (Ninewells hospital, Dundee) every evening listing children in the community in Perth who have been in contact with PRI during the day; children seen through the day at PRI would have open access to Ninewells. The driver for change was the challenge in providing services in two hospitals in Perth and Dundee 23 mile apart, and services were moved to Dundee. A 24-hour inpatient service was provided in Dundee after April 2005. The analysis included data between May 2000 and April 2015.
Elgin (Dr Gray’s Hospital, NHS Grampian). Round-the-clock inpatient services ceased in March 2018 whereafter a short stay assessment unit staffed by a combination of paediatric and emergency department physicians provided a service between 8am and 10pm. The main driver for reconfiguration was a shortage of medical staff. Ambulatory care was provided by the hospital in Elgin where possible (e.g. parenteral antibiotics administered on an outpatient basis for febrile children). An inpatient service was provided by Aberdeen 65 miles away (the second hospital in NHS Grampian). Data were analysed between April 2013 and December 2018. The number of admissions to Raigmore Infirmary (Inverness, NHS Highland) which is only 37 miles from Elgin (figure 1) were also analysed between April 2013 and December 2018.
Paisley (Royal Alexandra Hospital, Greater Glasgow and Clyde). All inpatient facilities ceased after reconfiguration in December 2017. The main driver for reconfiguration was the move of the largest inpatient facility in Scotland (Royal Hospital for Children, RCH) to a new site six miles away. No resources were put into the community in Paisley. Data between January 2013 and February 2020 were analysed. At RCH, throughout 2013 -2019 many referrals are seen and discharged by paediatric emergency department staff and are not recorded as an inpatient.
Livingston (St John’s Hospital, NHS Lothian). Due to an ongoing shortage of medical staffing, in July 2017 a short stay assessment unit was opened, including a facility for daily systemic antibiotic treatment. All unscheduled inpatient services had previously ceased for 3 weeks in July 2014 and for 6 weeks July and August 2015. In summer 2019 24-hour inpatient services were provided four days a week. Data between August 2012 and March 2019 were used to analyse the impact of the reconfiguration in July 2017.
Change in admission prevalence in individual hospitals after reconfiguration
In the months after reconfiguration, the average number of admissions fell in four and rose in one hospital where the reconfiguration took place, table two. Across all the reconfigured hospitals there was a mean fall in admissions/month of 117 [95% CI -156, -78] p<0.001 and for adjacent hospitals there was a mean rise in admissions/month of 82 [95% CI 32, 131] p=0.002. For all adjacent hospitals except Aberdeen, the average number of admissions per month rose by >7% (i.e. twice the national annual rise in admissions across Scotland 2000-2013 (10)).
Change in admission prevalence across paired hospitals after reconfiguration
There was no rise in admission prevalence to inpatient facilities in Inverclyde and Paisley prior to reconfiguration in Inverclyde but there was a rise in admission prevalence in Paisley post-reconfiguration, table 3 and figure 2. In contrast, there was a rise in admission prevalence across NHS Tayside (i.e. Perth and Dundee combined) before reconfiguration of services in Perth but this was followed by a fall in admissions to Dundee post reconfiguration, table 3 and figure 3. Before reconfiguration in Paisley there was a trend for a significant fall in admissions across Paisley and Glasgow (mean reduction 0.15% per month [95% CI -0.01, 0.33]) and this trend was not different post reconfiguration, table 3. Before reconfiguration in Livingston there was a rise in admission prevalence across Livingston and its adjacent hospital in Edinburgh (mean increase 0.36%/month [95% CI 0.16, 0.56]) and there was no change in this rise post reconfiguration, table 3. There was no difference in admission prevalence before or after reconfiguration in Elgin.
Table 2. Average monthly number of admissions in the year before and the year after service reconfiguration in all affected units. *Data in nine months post reconfiguration were analysed
Hospital where services were reconfigured
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Hospital where services inpatient services were moved to post reconfiguration
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% change in admissions/month in adjacent hospital after reconfiguration
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Monthly admissions before reconfiguration
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Monthly admissions after reconfiguration
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Monthly admissions before reconfiguration
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Monthly admissions after reconfiguration
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Inverclyde Royal Hospital (Greenock)
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108
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0
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Royal Alexandra Hospital (Paisley)
|
191
|
253
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+32%
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Perth Royal Infirmary (Perth)
|
66
|
74
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Ninewells Hospital (Dundee)
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446
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479
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+7%
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Dr Gray’s Hospital (Elgin)
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102
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69*
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Royal Aberdeen Children’s Hospital (Aberdeen)
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235
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238*
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+1%
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Raigmore Infirmary (Inverness)
|
297
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321*
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+8%
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Royal Alexandra Hospital (Paisley)
|
351
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0
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Royal Hospital for Children (Glasgow)
|
2358
|
2630
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+12%
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St John’s Hospital (Livingston)
|
539
|
405
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Royal Hospital for Sick Children (Edinburgh)
|
503
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571
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+13%
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Table 3: Regression output for interrupted time series model.
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Emergency admission /1000 population at the end of the period of analysis
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Percentage change (95% CI) in rate of emergency admissions/month before reconfiguration
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Percentage change (95% CI) in rate of emergency admission immediately after reconfiguration
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Regression coefficient (95% CI) for interaction term describing the change in emergency admission/month before and after reconfiguration
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p-value of interaction term
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Admissions to Greenock and Paisley before and after reconfiguration in Greenock
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3.3
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0.05 (-0.01, 0.21)
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6.41 (-1.6, 15.0)
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0.37 (0.16, 0.60)
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<0.001
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Admissions to Perth and Dundee before and after reconfiguration in Perth
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4.3
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0.47 (0.32, 0.62)
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6.99 (-.02, 14.6)
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-0.05 (-0.07, -0.03)
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<0.001
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Admissions to Elgin and Aberdeen before and after reconfiguration in Elgin
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5.9
|
0.12 (-0.03, 0.26)
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-11.80 (-25.0, 3.7)
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1.11 (-1.55, 3.84)
|
0.414
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Admissions to Paisley and Glasgow before and after reconfiguration in Paisley
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3.1
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-0.15 (-0.33, 0.01)
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-2.8 (-11.7, 6.9)
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0.49 (-0.70, 1.66)
|
0.244
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Admissions to Livingston and Edinburgh before and after reconfiguration in Livingston
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3.4
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0.36 (0.16, 0.56)
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-9.77 (-21.5, 3.7)
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0.41 (-0.06, 1.40)
|
0.418
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Admissions to Inverness before and after reconfiguration in Elgin
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7.5
|
0.12 (-0.03, 0.28)
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8.1 (-2.7, 20.0)
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0.21 (-0.08, 1.24)
|
0.681
|