Specialised Services

Discussion Draft

Health Authority Abu Dhabi

Reliable Excellence in Healthcare

Specialised services summary

• • • • HAAD defines specialised services where there is evidence that concentrating clinical expertise improves outcomes substantively.

HAAD will restrict provision of specialised services to facilities it issues a certificate of need to. All payers must fully and only reimburse certificated providers at a HAAD defined base rate for such specialised services, which are specified at the DRG-level. Current specialised services are – Major Burns at Mafraq – Tertiary Cancer Surgery at Tawam – Cardiothoracic Surgery at SKMC – Neurosurgery at SKMC – Infant surgery at SKMC – Solid Organ Transplantation programmes at SKMC – Major Trauma research centre at SKMC – Major Trauma centre at Al Ain 1

Specialised services

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Certification and audit

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DRG specification for reimbursement

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Service specification

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Clinical rationale and evidence

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Certification and audit

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HAAD issues a certificate of need for 5 years (renewable) based on a successful initial audit. The certificate entitles facility staff to provide the specialised service at other licensed facilities, as appropriate.

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Operators submit to HAAD an activity-based budget for the subsequent Calendar year by April 30, net of all other payments. For any transition period to reach the full service specification, the Operator will also submit service specification milestones to be met by the beginning of each Calendar year.

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HAAD schedules an annual audit of the service against the service specification. HAAD pursues an escalation procedure in case of a failed audit 1. Issue a deficiency letter with 90 days to correct deficiencies identified and re-audit the service after the 90 day period has elapsed. If the re-audit fails: 2. Issue an enforcement notice which may add, impose, vary or remove conditions with a further 120 days (maximum) to comply. Re-audit the service after the 120 day period has elapsed If the second re-audit fails: 3. Consider suspension, removal and replacement of the managing operator responsible for service delivery of the specialised service.

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Specialised services

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Certification and audit

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DRG specification for reimbursement

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Service specification

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Clinical rationale and evidence

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DRG specification for reimbursement

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All DRGs for surgery on infants <1yr of age All surgical DRGs with principal diagnosis malignant cancer The following specific DRGs:

DRG DRG description

051011 IP HEART &/OR LUNG TRANSPLANTATION 051012 IP HEART &/OR LUNG TRANSPLANTATION w/CC 051013 IP HEART &/OR LUNG TRANSPLANTATION w/MCC 051021 IP CARDIAC VALVE PROCEDURES WITH CARDIAC CATHETERIZATION 051022 IP CARDIAC VALVE PROCEDURES WITH CARDIAC CATHETERIZATION w/CC 051023 IP CARDIAC VALVE PROCEDURES WITH CARDIAC CATHETERIZATION w/MCC 051031 IP COMPLEX CARDIOTHORACIC REPAIR OF HEART ANOMALY 051032 IP COMPLEX CARDIOTHORACIC REPAIR OF HEART ANOMALY w/CC 051033 IP COMPLEX CARDIOTHORACIC REPAIR OF HEART ANOMALY w/MCC 051041 IP CARDIAC VALVE PROCEDURES WITHOUT CARDIAC CATHETERIZATION 051042 IP CARDIAC VALVE PROCEDURES WITHOUT CARDIAC CATHETERIZATION w/CC 051043 IP CARDIAC VALVE PROCEDURES WITHOUT CARDIAC CATHETERIZATION w/MCC 051051 IP CORONARY BYPASS WITH CARDIAC CATHETERIZATION 051052 IP CORONARY BYPASS WITH CARDIAC CATHETERIZATION w/CC 051053 IP CORONARY BYPASS WITH CARDIAC CATHETERIZATION w/MCC 051071 IP CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION 051072 IP CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION w/CC 051073 IP CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION w/MCC 051061 IP OTHER CARDIOTHORACIC PROCEDURES 051062 IP OTHER CARDIOTHORACIC PROCEDURES w/CC 051063 IP OTHER CARDIOTHORACIC PROCEDURES w/MCC 111011 IP KIDNEY TRANSPLANTATION 111012 IP KIDNEY TRANSPLANTATION w/CC 111013 IP KIDNEY TRANSPLANTATION w/MCC

Specialised service DRG DRG description

Cardio-thoracic surgery 011011 IP INTRACRANIAL VASCULAR PROCEDURES Cardio-thoracic surgery 011012 IP INTRACRANIAL VASCULAR PROCEDURES w/CC Cardio-thoracic surgery 011013 IP INTRACRANIAL VASCULAR PROCEDURES w/MCC Cardio-thoracic surgery 011101 IP CRANIOTOMY Cardio-thoracic surgery 011102 IP CRANIOTOMY w/CC Cardio-thoracic surgery 011103 IP CRANIOTOMY w/MCC

Specialised service

Neurosurgery Neurosurgery Neurosurgery Neurosurgery Neurosurgery Neurosurgery Cardio-thoracic surgery 011111 IP VENTRICULAR SHUNT PROCEDURES Cardio-thoracic surgery 011112 IP VENTRICULAR SHUNT PROCEDURES w/CC Cardio-thoracic surgery 011113 IP VENTRICULAR SHUNT PROCEDURES w/MCC Cardio-thoracic surgery 011121 IP EXTRACRANIAL VASCULAR PROCEDURES Cardio-thoracic surgery 011122 IP EXTRACRANIAL VASCULAR PROCEDURES w/CC Neurosurgery Neurosurgery Neurosurgery Neurosurgery Neurosurgery Cardio-thoracic surgery 011123 IP EXTRACRANIAL VASCULAR PROCEDURES w/MCC Cardio-thoracic surgery 011201 IP CRANIAL & PERIPHERAL NERVE PROCEDURES Neurosurgery Neurosurgery Cardio-thoracic surgery 011202 IP CRANIAL & PERIPHERAL NERVE PROCEDURES w/CC Neurosurgery Cardio-thoracic surgery 011203 IP CRANIAL & PERIPHERAL NERVE PROCEDURES w/MCC Neurosurgery Cardio-thoracic surgery 011301 IP SPINE PROCEDURES Cardio-thoracic surgery 011302 IP SPINE PROCEDURES w/CC Cardio-thoracic surgery 011303 IP SPINE PROCEDURES w/MCC Cardio-thoracic surgery 091201 IP SKIN GRAFT WITH BURNS Cardio-thoracic surgery 091202 IP SKIN GRAFT WITH BURNS w/CC Cardio-thoracic surgery 091203 IP SKIN GRAFT WITH BURNS w/MCC Transplantation Transplantation Transplantation 071011 IP LIVER TRANSPLANTATION 071012 IP LIVER TRANSPLANTATION w/CC 071013 IP LIVER TRANSPLANTATION w/MCC Neurosurgery Neurosurgery Neurosurgery Burns Burns Burns Transplantation Transplantation Transplantation Source: International Refined Diagnosis Related Groups (IR-DRG v2.2) ICD-9-CM/CPT Definitions Manual, Volume II; www.shafafiya.org

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Specialised services

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Certification and audit

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DRG specification for reimbursement

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Service specification

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Clinical rationale and evidence

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Major burn care

• A specialised major burn care centre provides the highest level of clinical care to patients

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with burn injury. It consists of: Inpatient/outpatient service including: – 24/7 cover of qualified burn surgeons, anesthesiologists and support staff – Dedicated burns ward with temperature-controlled cubicles – – – – – Burns ICU beds Dedicated burns theatre Psychology support Clinical leadership of burn care network Telemedicine links with receiving hospitals

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All other hospitals and ambulances ‘receivers’: stabilisation measures in place (protocols established, local staff trained, kit deployed)

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Effective ‘retrieval’ service from receiver to centre of excellence (protocols established, local staff trained, communications infrastructure in place, financing in place)

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The ‘retrieval’ service may draw on or be used by other services for efficiency purposes, e.g., Trauma, ICU.

Sources: New South Wales Burn Injury Service Model of Care NSW Department of Health 2004; New South Wales Burn Injury Service Burn Transfer Guidelines NSW Department of Health 2004

Cardiothoracic surgery

• A specialised cardiothoracic surgery service provides the highest level of surgical care to patients with heart and lung disorders • A specialised cardiothoracic surgery service consists of: – A fully staffed and equipped cardiac surgical department that includes a consultant led surgical team of qualified adult and pediatric cardiothoracic surgeons available 24/7 that provide cardiothoracic surgery to a minimum required annual volume of 500 patients – Dedicated 24/7 cardiac theatres and operating lists – A full range of cardiology physicians and cardiac trained anesthesiologists available 24 hours a day – Prompt, on site availability of other supporting specialties including: Clinical Perfusion Nephrology CCU, ICU, PICU Interventional cardiac catheterisation • A specialised cardiothoracic surgery service – Achieves average mortality for coronary surgery of <1.8% (30 day post operative) – Achieves average mortality for congenital heart surgery of <4% (30 day post operative) – Provides clinical leadership of the region’s cardiothoracic services – Provides outreach services for outpatient care across the emirate as agreed by HAAD – Runs a Research programme attracting a minimum AED 350,000 funding per annum Source The European Association for Cardio-Thoracic Surgery Adult Cardiac surgery database report 2010. Congenital mortality: Mortality rates after surgery for congenital heart defects in children and surgeons' performance. Institute of Child Health, London 8

Major Trauma research center*

A Major trauma research center* provides the highest level of surgical care to trauma patients. It consists of: • A fully staffed and equipped accident and emergency department that includes a consultant led resuscitative trauma team, a surgical residency programme, dedicated trauma theatres and operating lists • A wide range of general and specialist surgeons, emergency physicians and anesthesiologists available 24 hours a day and admits a minimum required annual volume of 500 surgical DRGs or above of the most severely injured (DRG severity level 2 or 3) patients • 24-hour on site, consultant led, availability of all major including as a minimum: orthopedic surgery plastic surgery neurosurgery oral and maxillofacial surgery interventional radiology ICU, PICU cardiothoracic & vascular surgery internal medicine • Facility to provide clinical leadership of the regions Trauma services and provide: improved survival rates of admitted trauma patients year-on-year an educational programme delivering 500 CME credits annually, a research programme attracting funding of at least AED 350,000 per Year * Based on American definition of ‘Level 1 Trauma center’ Sources: Royal College of Surgeons of England Provision of Trauma Care Policy Briefing 2007. American College of Surgeons – Committee on Trauma designation review. 1997

Major Trauma centre

• Works in collaboration with a Major Trauma research centre. It provides comprehensive trauma care and supplements the clinical expertise of a Level I institution. It provides 24-hour availability of all essential specialties, personnel, and equipment. It consists of: – A fully staffed and equipped accident and emergency department that includes a consultant led resuscitative trauma team, dedicated trauma theatres and operating lists – A range of specialist surgeons – General surgeons, emergency physicians and anesthesiologists available 24 hours a day – Admits a minimum required annual volume of 250 surgical DRGs or above of the most severely injured (DRG severity level 2 or 3) patients – 24-hour on site, consultant led, availability of major specialties including as a minimum: orthopedic surgery and maxillofacial surgery plastic surgery interventional radiology oral • ICU internal medicine Is not required to have an ongoing program of research but is required to collaborate closely with the Major Trauma research centre in research, service delivery and major incident management • Improves the survival rate of admitted trauma patients year-on-year * Based on American definition of ‘Level 2 Trauma center’ Source Royal College of Surgeons of England Provision of Trauma Care Policy Briefing 2007 . American College of Surgeons – Committee on Trauma designation review. 1997

Neurosurgery

A specialised neurosurgery centre provides the highest level of surgical care to patients with disorders of the central nervous system. It consists of: • A fully staffed and equipped neurosurgical department that includes a consultant led surgical team of qualified adult and pediatric neurosurgeons available 24/7 that provide neurosurgery to a minimum required annual volume of 250 patients • Dedicated neurosurgery theatres and operating lists • Anesthesiologists trained in the management of Adult and paediatric neurosurgery patients available 24 hours a day • Prompt, on site availability of other supporting specialties such as: Maxillofacial surgery ICU, PICU ENT Neuro-psychology 24/7 access to Interventional radiology, CT & MRI Occupational therapy • Facility to provide clinical leadership of the regions neuroscience services and provide: – – – Average mortality for Neurosurgery surgery of <4.9% (30 day post operative) Outreach services for outpatient care across the emirate as agreed by HAAD Research programme attracting a minimum AED 350,000 funding per annum Sources : UK specialised services national definitions set (3 rd edition ) 2010. Mortality rate: University HealthSystem Consortium, Mortality statistics. 11

Infant surgery

A specialised Infant surgery service for patients <1 years of age consists of:

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1 Single, designated center-of-excellence inpatient/outpatient service equipped and staffed to deliver all aspects of infant and neonatal surgery • 24/7 cover of paediatric and neonatal surgeons, paediatricians and anesthesiologists qualified and experienced in the care of neonates and infants • Dedicated paediatric operating lists, dedicated PICU, HDU and paediatric ward facilities • Full range of diagnostic and supporting specialties including: MRI, CT interventional radiology PICU, HDU, access to NICU service play therapy Facility to provide clinical leadership of the regions infant surgical services and provide: – Average perioperative (7day) mortality for surgery on children <1 year old of <0.06% – – (excludes cardiac, neurosurgery and neonatal specialties) Outreach services for outpatient care across the emirate as agreed by HAAD Research programme attracting a minimum AED 350,000 funding per annum • For surgical emergencies on infants under 1 years of age all other hospitals and ambulances ‘Receive and refer’: Stabilisation measures in place (protocols established, local staff trained) Sources: Camplin ES, Devlin HB, Lunn JN. Report of the national confidential enquiry into perioperative deaths (NCEPOD) London, 1990. Atwell JD, Spargo PM The provision of safe surgery in children Southampton, UK 1992.. Mortality : Morita K et al. Perioperative mortality & morbidity in the year 2000 in 520 certified training hospitals., Okayama, Japan 2002.

Cancer surgery

A specialised cancer surgery centre provides the highest level of surgical care to patients with cancer. It consists of: • A fully staffed and equipped surgical department that includes a consultant led surgical team of a minimum of 3 qualified adult and pediatric general surgeons available 24/7 that provide complex cancer surgery including thoracic cancers to a required annual volume of 200 or more patients • Dedicated theatres and operating lists • Prompt, on-site availability of other supporting specialties including: ICU, PICU Interventional radiology radiation oncology palliative care Histopathology clinical psychology • Facility to provide clinical leadership of the regions cancer services including teaching, research, quality improvement and program advancement The specialised centre is required to develop systems that enable the benchmarking of outcome performance against international norms Sources: UK Specialised Services National Definitions Set (3rd Edition)2010. Survival rates: Cancer Research/ cancer survival stats. UK 2010.

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Solid organ transplants

• • A specialised organ transplant centre provides the highest level of care to patients who undergo organ transplantation. It consists of a range of transplant services including but not limited to Kidney, Liver and Pancreas transplants Individual service specifications will need to be developed for each type of transplant surgery however as a minimum they should consist of: • A fully staffed and equipped transplantation department that includes a consultant led • surgical team with a minimum of 3 qualified transplantation surgeons available 24/7 Dedicated theatres and operating lists • Prompt, on site, availability of other supporting specialties such as: Cardiology, Haematology Nephrology ICU, PICU, Psychology Interventional radiology • Facility to provide clinical leadership of the regions organ transplant services including delivery of: – an educational programme delivering 250 CME credits annually, – – – a research programme attracting funding of at least AED 350,000 per Year A one year post transplantation survival rate of >96% for patients undergoing kidney transplants from living donors One year survival rates for future transplant surgery equal to or better than the benchmarks provided by The U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients Sources : UK specialised services national definitions set (3 rd edition) 2010. Mortality: Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1992–2001. Rockville, MD: HHS/HRSA/OSP/DOT, 2003.

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Specialised services

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Certification and audit

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DRG specification for reimbursement

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Service specification

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Clinical rationale and evidence

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Major burn care

Burn care is the field of medicine involved in the treatment of burn injuries from the most minor, dealt with in the community, to the most severe and devastating. Burn injuries are highly variable and individual injuries affecting all ages and social groups • In general terms the definition of a major burn is based on the size and anatomical site of the injury, the depth of skin injury, and the presence of co-existing conditions • International experience shows that outcomes are improved when the treatment of major and more complex burns is centralised to a single or fewer sites • The significant expansion of Oil & Gas activities in Al Gharbia is associated with substantial burn risks • This is consistent with it being designated as a ‘specialised service’, for which HAAD will only license one or two facilities in the Emirate Source: UK Specialised Services National Definitions Set (3rd Edition) 2010 .

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Cardiothoracic surgery

• Cardiothoracic surgery is the field of medicine involved in surgical treatment of diseases affecting organs inside the thorax (the chest)—generally treatment of conditions of the heart (heart disease) and lungs (lung disease) • International experience shows that cardiothoracic surgery centers that carry out a higher numbers of surgical procedures perform better, as surgeons and support staff become more experienced/specialized.

• The number of cases presenting each year in Abu Dhabi does not warrant more than a single centre for Cardiothoracic surgery • HAAD has defined Cardiothoracic surgery as a specialized service with a maximum of 1 unit to be designated Source: UK Specialised Services National Definitions Set (3rd Edition) 2010. 17

Trauma service

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Trauma can be defined as physical injury caused by events such as road traffic accidents, falls, explosions etc. Trauma is the second highest cause of death in the emirate

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The region requires a network of hospitals and ambulance services geared to treat trauma patients of varying complexities

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Level I trauma centre provides the highest level of surgical care to trauma patients. It is supported by Level 2 and 3 trauma units that treat less complex trauma patients

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Evidence from the United States shows that positive outcome for major trauma patients depends on them being delivered to a hospital that has the appropriate range of specialist resources to treat multiple injuries. Being treated at a Level 1 Trauma Centre increases a seriously injured patient’s chances of survival by an estimated 20 to 25 percent

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Major trauma patients are 1.5 to 5 times more likely to die than patients transported directly to major trauma centers

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HAAD has defined Level 1 trauma as a specialised service with a maximum of 2 units to be designated Sources: HAAD statistical analysis, Royal College of Surgeons of England Provision of Trauma Care Policy Briefing 2007, American College of Surgeons – Committee on Trauma designation review. 1997 18

Neurosurgery

Neurosurgery is the field of medicine involved in surgical treatment of diseases or conditions of the central nervous system (CNS) and spine. This includes six general categories of neurosurgical diseases: • cerebrovascular (hemorrhage and aneurysms); • traumatic head injury (THI)(traumatic injury caused by accident); • degeneration diseases of the spine; • tumors in the CNS; • functional neurosurgery and neurosurgical management of the CNS. • surgery for congenital abnormalities;

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International experience shows that neurosurgery centers that carry out a higher numbers of surgical procedures perform better, as surgeons and support staff become more experienced/specialized.

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The number of cases presenting each year in Abu Dhabi does not warrant more than a single centre for neurosurgery Source : UK specialised services national definitions set (3 rd edition) 2010.

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Infant surgery

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infant surgery is the field of medicine involved in surgical treatment of diseases affecting children

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Several large studies have confirmed that the incidence of perioperative anesthetic and surgical complications is much higher in neonates and infants than in older children

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International experience shows that mortality and morbidity for surgery on very young children can be dramatically reduced by ensuring all surgery on children <1yr of age is carried out in a specialised infant surgery centre

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The number of cases presenting each year in Abu Dhabi does not warrant more than a single centre for surgery on children <1yr

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HAAD has defined infant surgery under 1 year of age as a specialised service Sources: Camplin ES, Devlin HB, Lunn JN. Report of the national confidential enquiry into perioperative deaths (NCEPOD) London, 1990. Atwell JD, Spargo PM The provision of safe surgery in children Southampton, UK 1992 20

Cancer surgery

• Tertiary cancer surgery — is the field of medicine involving major surgery to repair or remove parts of the body to treat cancer • It remains as the foundation of cancer treatment. Cancer surgery may be supplemented with other treatments, such as radiation, chemotherapy, hormone therapy and biological therapy • International experience shows that cancer surgery centres that carry out a higher numbers of surgical procedures perform better, as surgeons and support staff become more experienced/specialized • The number of cases presenting each year in Abu Dhabi does not warrant more than a single centre for tertiary cancer surgery Source: UK Specialised Services National Definitions Set (3rd Edition) 2010.

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Solid organ transplantation

Organ transplantation is the field of medicine involved in the surgical transplantation of donor organs to treat irreversible failure of a recipient organs including heart, lungs, liver, kidneys or other organs • International experience shows that transplantation expertise should be concentrated as outcomes from transplant surgery improve as surgical, medical and support staff become more experienced/specialized • The number of cases presenting each year in Abu Dhabi does not warrant more than a single centre for organ transplantation; A review will be undertaken to establish whether the volume and legal context support even one centre at high quality • HAAD has defined organ transplantation as a specialised service with a maximum of 1 unit to be designated Source : UK specialised services national definitions set (3 rd edition ) 2010 22