Two hospitals in North Wales are predicted to close, with imaging and injury treatment facilities being lost from others.

Closure of the Flint and Blaenau Ffestiniog hospitals are among proposals drawn up by Betsi Cadwaladr University Health Board (BCUHB) to reduce NHS costs.

BCUHB, which predicts a £65m budget deficit, is the first of seven NHS Wales health boards to propose a solution to the health service’s financial crisis.

The two hospitals would be used to provide “enhanced community services”, with inpatient care transferred to nearby hospitals.

In addition, Llangollen Community Hospital would be turned into an extended primary care resource centre.

Minor injury and X-ray units would close at hospitals in Flint, Mold, Colwyn Bay, Ruthin and elsewhere.

Secondary care in North Wales would be refocused on ten community hospital hubs at locations including Bangor, Wrexham and Llandudno.

Neo-natal care for North Wales could be relocated to the Wirral peninsula in the form of a new neo-natal intensive care service at Arrowe Park.

Mick Antoniw, Labour AM for Pontypridd, said it would be better for people to receive higher quality care at a more distant location than to have local services where “quality and outcome is less”.

Six of the NHS Wales health boards are predicting a combined deficit of around £230m by the end of this financial year.

Final NICE diagnostic guidance on the EOS 2D/3D X-ray imaging system calls for the system’s health benefits to be further investigated in clinical research settings.

The new system (pictured) from US company EOS Imaging uses low-dose radiation imaging to produce 2D X-ray images and 3D reconstructions for bones.

Its innovative slot-scan technology, scanning a line at a time rather than taking the entire image at once, enables it to produce upright and weight-bearing whole-body images.

By showing relationships between the spine, hip, pelvis and knees, the EOS system could particularly benefit the monitoring and treatment of patients with spinal deformities or alignment problems.

The system’s reduced dose also offers potential safety advantages in the repeated imaging of patients with spinal deformities, especially children.

The new guidance encourages the use of the 2D/3D imaging system in specialist research settings to collect evidence about clinical benefits associated with weight-bearing whole-body imaging and 3D reconstruction.

Professor Carole Longson, Director of the NICE Health Technology Evaluation Centre, said: “The EOS 2D/3D imaging system was identified by the Diagnostics Advisory Committee as an important emerging technology. There is evidence showing comparable or better images and radiation dose reduction associated with using the EOS system to image patients with spinal deformities.”

However, she said, there is currently no evidence that compares the diagnostic accuracy of the EOS system with that of conventional radiological examinations. “NICE will follow up the Diagnostics Advisory Committee’s research recommendations on the EOS 2D/3D system and will assess the feasibility of this research with a view to facilitating the development of further relevant evidence.”

Full data sets evaluating the system’s benefits will trace the outcome of its use from planning through to complex surgeries such as hip replacements.

Marie Meynadier, CEO of EOS Imaging, said: “The EOS 2D/3D imaging system is subject to an extensive programme of research associating radiologists and orthopaedic surgeons. We will provide data to NICE as they are established to determine when a cost-effectiveness review based on this evidence would be appropriate.”

The new external assessment centres recently announced by NICE will help to develop and facilitate research products to assist suppliers when NICE medical technology or diagnostics guidance recommends it.

The idea that ‘any qualified provider’ can deliver NHS services may be contentious, but it has roots in existing policy. Thoreya Swage examines the opportunities for industry in the changing health provider landscape.

Successive governments have tried in recent years to shake up the healthcare system in the UK, with England probably being subject to the greatest number of changes. A key element of these shake-ups has been various attempts to expand the healthcare market in order to include the private or independent sector.

This widening of the doorway started in earnest with the deployment of the waiting list initiative in the 1990s, using the spare capacity of independent hospitals to reduce the queues for elective procedures that had built up in the NHS.

The baton was then taken up by the independent sector treatment programme under the last administration: the range of work done by private providers expanded to diagnostic procedures and screening programmes, as well as the construction of bespoke independent hospitals to take on hip, knee and cataract operations from the NHS.

It was at this stage that the concept of patients choosing which healthcare institution to go to for treatment or diagnostic procedures started to take off, with some of those options being in the independent sector. The idea of an ‘any willing provider’ began to take shape, with NHS care being delivered by any appropriate healthcare body as long as it had reached identified quality and safety standards.

However, before the recent change of government this initiative began to cool under external political pressure and at one time even seemed likely to fade away.

What AQP means

Despite opposition, the coalition Government has renewed the ‘any willing provider’ policy, calling it this time ‘any qualified provider’. In July of this year the Department of Health in England issued ‘operational guidance’ to the NHS providing further details to PCT clusters and the emerging Clinical Commissioning Groups (CCGs) – the renamed, modified GP consortia.

This policy has come under the guise of improving the quality of care by widening patient choice for specific services.

The intention is to permit the patient to choose from a list of qualified providers when they require a referral for a specific community or mental health service. To meet the ‘any qualified provider’ (AQP) requirement, a healthcare organisation needs to fulfil the quality, price and contractual obligations for NHS services. This process, as we have seen, is already in place for elective care.

The guidance states that the implementation of AQP will be conducted in phases from April next year. However, some work needs to be done before that. PCT clusters and their associated CCGs need to have decided which community or mental health services they wish to identify for the implementation of AQP locally by October, so that their patients can begin to have access to that care between April and September next year. Three or more services from the following list, drawn up by the DH in conjunction with patient groups, should be identified:

• musculo-skeletal services (neck and back pain)
• audiology services in the community (adults)
• continence care (adults and children)
• diagnostic services (e.g. imaging and heart and lung investigations)
• wheelchair services (children)
• podiatry services
• wound healing and management of leg ulcers
• primary care psychological therapies (adults).

The guidance also says that PCT clusters and CCGs can choose alternative services for AQP in different priority areas if these are supported by local patients – for example, as identified through the shadow health and wellbeing boards (the new joint health and social care joint commissioning boards) – and effective gains in quality and access can be made by doing so.

Getting involved

How can independent provider organisations participate in this process? The principles of the AQP approach are as follows:

• Organisations can qualify and register to provide NHS services as long as they meet NHS assurance requirements.
• Referral pathways and protocols set by CCGs must be accepted by the providers wishing to be on the AQP list.
• Patients are offered a choice of services from the list of qualified providers.
• There will be a fixed price based on a national or local tariff, to ensure that the provider is chosen by quality.

A national qualification process for all AQP providers is currently being developed by the DH in order to minimise bureaucracy and reduce transaction costs. The proposed principles for qualification are that providers:

• must be registered with the Care Quality Commission to demonstrate that they meet the essential standards for quality and safety (or equivalent assurance requirements if providing services not covered by CQC registration)
• are licensed by Monitor (from 2013) so that they are authorised to deliver NHS care
• can meet the terms and conditions of the NHS Standard Contract, including having regard for the NHS Constitution, appropriate guidance and legal obligations
• deliver care at NHS prices
• can meet the service specifications developed by commissioners and comply with referral protocols
• agree with the commissioners on any supporting schedules to the NHS Standard Contract, e.g. on activity levels.

More details of the qualification process will be published this autumn.

The providers that have successfully achieved the national qualification process will be listed in a directory available to GPs later this year.

By November 2011, lead PCT clusters will have produced detailed implementation packs for each service on the AQP list that will include service specifications, contract currencies, tariffs and information models.

It is anticipated that AQP for the services identified above will begin to be implemented from April 2012, with all CCGs having this in place for their patients by September 2012.

What happens next?

AQP will continue to expand: for 2013/14 a further list of services has been identified by the DH for discussion with commissioners, patient groups and providers. The list is not finalised, but will probably include:

• maternity care, e.g. antenatal education and support for breastfeeding
• speech and language therapy
• supporting patients to self-manage long-term conditions
• chemotherapy in the community setting and at home
• primary care psychological therapies for children and adolescents
• wheelchair services (adults).

Opportunities for medtech

The most obvious opportunity for medtech in relation to AQP is in the sphere of direct access diagnostic services, where many investigations such as non-obstetric ultrasound, echocardiography, cardiac physiology, MRI, X-ray, endoscopy and phlebotomy can be provided in the community setting, as indeed some already are (e.g. via Inhealth). These direct referrals can enable GPs to obtain rapid investigations and help to manage their patients in primary care, without having to refer to a hospital consultant.

Another key area is adult hearing services, including audiology and hearing aid fitting. Telehealth and telecare also have a part to play in supporting some of these services by monitoring people with long-term conditions at home. The services identified for the initial phase of AQP have traditionally had poor information systems. Better data collection on activity and health outcomes will be vital for the success of the providers delivering services under this initiative.

The key challenge for medtech companies is to get onto the recognised list of AQP that the DH is drawing up, or to work with partners who will be applying to go onto the list. Rather than regarding independent providers simply as customers, medtech suppliers can work with them to achieve AQP success.

Potential providers need to get up to speed on a number of areas, such as ensuring that they are registered with the CQC, have a good understanding of the standard NHS contract, offer services in keeping with the CCGs’ requirements and can manage within NHS financial envelopes.

The aim should be to identify the lead commissioner(s) within the local PCT cluster and associated CCGs and find out which community services they are planning to include on their local AQP. Alternatively, contacting the local shadow health and wellbeing board (if it is sufficiently developed) may indicate other priority areas for AQP. This is an opportunity for marketing medtech services that can be shown to improve patient care and are aligned with the local health economy’s priorities.

Medtech providers should also be clear about whether they can meet (or help their partner organisations meet) the qualification requirements for AQP. They should look closely at the details of these when they are published by the DH later this year.

Companies should also start doing their homework now on pricing and the care outcomes that can be achieved through their services, bearing in mind that the NHS commissioners will be looking at how the five high-level domains of the NHS Outcomes Framework will be achieved.

Another key milestone to look out for is the implementation packs due in November on service specifications, contract currencies, tariffs and information models. These will require close examination by potential providers seeking to ensure that they are fully prepared for AQP.

Although this initiative seems small in scale it looks set to grow in the future, and further opportunities will present themselves for 2013 and beyond as AQP continues to expand. For more information, visit the Department of Health website.

Dr Thoreya Swage was formerly an NHS clinician and a senior manager in various NHS organisations covering acute and primary care. She has expertise in commissioning health services and is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.

Varian Medical Systems has signed an agreement to acquire Calypso Technologies in a deal worth approximately $10 million.

Varian will acquire Calypso’s portfolio containing 90 current or pending patents, relating to specialised products and software for real-time tracking and motion management during radiosurgery and radiotherapy.

Timothy E. Guertin, President and CEO of Varian, said: “With Calypso's technology, Varian will be able to offer cancer treatment centres real-time, non-ionising tumour tracking tools for enhancing the precision of their treatments.”

It is predicted that the Calypso business will be integrated into Varian's Oncology Systems department and will continue to operate in Seattle, USA.

“We are looking forward to having some of the world's technical thought leaders in tumor tracking from Calypso join with us so that we can work together to develop and deploy this technology for more disease sites,” Mr Guertin added.

Besides the acquisition fee, the deal also requires Varian to pay potential earnouts based on unit sales of Calypso products achieved beyond thresholds over the next 30 months.

The contract is expected to close in early October 2011.

California-based Varian Medical Systems manufactures medical devices and software for treating cancer and other medical conditions with radiotherapy, radiosurgery, and brachytherapy, as well as tubes and digital detectors for x-ray imaging.

Philips Healthcare has launched a new version of its multi-modality cardiology image management, analysis and reporting system.

The Xcelera R3.2 offers improved connectivity with other hospital information systems and electronic medical records, enabling analysis of patient images from other systems and locations.

Building on the successful Xcelera platform, the R3.2 offers a single resource for cardiovascular imaging information and study management that can be configured and developed to meet changing needs.

The system’s telecardiology features allow clinicians to access images and reports remotely through a secure connection.

Optional applications include: clinical review of CT, MRI and electrophysiology images; analytical assessment for ultrasound, X-ray and nuclear medicine; and an interface to view electrocardiograms from other systems in the Xcelera workspace.

New features of the Xcelera R3.2 include:

• Support for the Enterprise Master Patient Index, which allows a single view of patient records and relevant studies from multiple institutions.

• A new DICOM measurement mapping tool that improves interoperability with other vendors’ ultrasound systems.

• The ImageArena suite from TomTec Imaging Systems, which allows images from most major ultrasound equipment suppliers to be assessed.

• Support for new Philips quantification software, which assists with analysis of image data acquired on Philips ultrasound systems.

“The Xcelera 3.2 is an even more robust solution, while still maintaining the system’s original reliability and responsiveness,” said Eckart Fleck, Director of Internal Medicine-Cardiology at the German Heart Institute. “Its advanced image reviewing capabilities enable a complete patient work-up, allowing for the review of ultrasound, CT and MRI images, regardless of the images’ source. This is a major advantage in comprehensive patient care.”

Philips Healthcare is working with the Methodist Hospital Research Institute in the US to develop new imaging systems that could help to trace the origin of an infectious disease epidemic.

The $8.6 million imaging suite provided by Philips for the research project includes MRI, PET-CT and SPECT-CT scanners and a C-arm X-ray device.

The suite will enable medical scientists to study the effects of different infectious disease agents on tissues and metabolism in a safe environment.

An airtight containment vessel linked to an external life support device will allow imaging of infected samples and research models without risk of exposure to patients or clinicians, while rapid scanning technology will be used to produce live time-series images.

The project will study the effects of biosafety level 3 pathogens (such as TB bacteria), working towards a facility for diagnosing infections in human patients through imaging.

Project leader and radiology chair King Li said: “The ability to have imaging suites that can handle high-level infectious agents allows us to be more prepared in the community for these types of events and, more importantly, allows us to study ways to deal with their consequences.”

“This imaging facility will be the first of its kind,” said James M. Musser, director of human infectious diseases research at the Methodist Hospital. “Our facility will permit us to translate critical new discoveries into the clinic, permitting accelerated development of novel diagnostic strategies and assessment of new therapeutic agents and vaccines.”

The long-goal of the partnership is to protect public health by enabling rapid diagnosis, prevention and treatment of epidemic infectious diseases, including possible identification of their origin.

“If the partnership with Philips is successful, The Methodist Hospital Research Institute can take the next steps toward creating the only clinic in the world expressly designed to image patients with infectious agents such as multi-drug-resistant TB,” said King Li.

“This will allow medical centres in the world to be more prepared for emerging diseases and bioterrorism.”

Ed Jones, VP of Operations for the Methodist Hospital Research Institute, summed up the project’s value: “Researchers at Methodist will be able to do live imaging studies that give them crucial information about how and where infections are progressing.

“This is what can happen when the best scientists and engineers from academia and industry become partners in advancing the state of the art in medical technology.”