Annual Report 2003 by 3CVp5o2Z

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									1.    Introduction

1.1   The West Yorkshire Critical Care Network (WYCCN) is now in its second year of
      development and the annual report will now come into line with the financial year
      of 1st April to 31st March.

      This report will give information around the objectives that the Network set for
      2002/03, the changes due to the introduction of Primary Care Trusts (PCT) and
      Strategic Health Authorities (StHA) and our plans for the forthcoming year.

1.2   The WYCCN is quickly working towards becoming an integral part of the planning
      and commissioning process for West Yorkshire and this is due to the commitment
      from our lead PCT and StHA. They have recognised the added value the Network
      can bring to the delivery of critical care services to the population of West
      Yorkshire.

      The Network is however still part of the National Critical Care Programme which is
      an arm of the Modernisation Agency. Most of the Network funding is from the
      agency (except network management) & the programme is scheduled to run until
      September 2004. For the Network to continue after this date it will be reliant upon
      support from both PCT’s & StHA.

1.3   Our objectives for last year were:

         To deliver a cohesive strategy for the development of critical care services
         To be advisory to Trusts, Health Authorities, PCT’s on the optimum critical care
          configuration
         To implement recommendations of ‘Comprehensive Critical Care’ (May 2000)
         To implement systems that monitor quality standards and activity
         To ensure that education and training systems are in place to support all
          members of the team
         To coordinate a unified approach across the Network for delivering critical care
          according to agreed standards and guidelines.


2.    Progress to Date

2.1   Patient Transfers

      There have been no non-clinical adult patient transfers occurred outside the
      Network for a ‘general critical care bed’ within the last year. All units now make
      better use of their bed capacity and work flexibly to allow for differing levels of
      patient dependency and improved level of information around bed availability has
      enabled patients to be cared for in a hospital within the Network.




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2.2   The Network Transfer Guidelines
      The Network currently works with agreed & accepted transfer guidelines,
      implemented in October 2001, that offer some protection of tertiary beds in the
      Leeds Teaching Hospitals Trust. The table below identifies non-clinical transfers
      pre and post transfer guidelines implementation.

                                                  NON-CLINICAL TRANSFERS - 2000/01 compared to 2001/02

                                           80                 Pre- Guidelines
                                           70

                                           60
                                                                                   Post Guidelines
                     Number of Transfers




                                           50

                                           40
                                                                                        Pre-Guidelines             Post Guidelines
                                           30

                                           20

                                           10

                                           0
                                                  1/12/00 to    1/12/01 to    1/12/00 to      1/12/01 to      1/12/00 to    1/12/01 to
                                                30/11/01 Non- 30/11/02 Non- 30/11/01 Out of 30/11/02 Out of 30/11/01 Non- 30/11/02 Non-
                                                 Clin Trnsfrs  Clin Trnsfrs  Network Non- Network Non-       Clin Trnsfrs  Clin Trnsfrs
                                                                              Clin Trnsfrs    Clin Trnsfrs    from other   from Other
                                                                                                               Networks     Networks




      To continue to improve the quality of care associated with patient transfer the
      Network in partnership with WYMAS introduced a dedicated Critical Care Transfer
      Call Line. This was designed to reduce the number of 999 calls made to WYMAS
      when there was a need to transfer a critically ill patient. On most occasions there
      was adequate time to request an appropriate ambulance & estimated time for the
      ambulance to arrive at the transferring hospital rather than dispatching a 999 crew.
      This has not only benefitted transferring staff but has improved use of the
      paramedic crews time (see run chart and table below).

                Telephone numbers used from units to WYMAS
                to arrange transfers:

                                            February 2001 to                      February 2002 to
                                            September 2001                        September 2002
                  999                                             119       999                           72
                  Standard tie line                               282       Standard tie line            291
                  Other                                             4       Critical Care Call Line      119
                  No source recorded                               33       Other                         28
                                                                            No source recorded            26

                  TOTAL                                           438       TOTAL                        536


                This shows a 40% reduction in 999 calls for Critical Care Transfers


                Numbers of adverse incidents in transit for critically ill patients –
                not yet available.




                                                                                                                                          2
                                                                                   Introduction of Dedicated Critical Care Transfers
             S ta ff & P ati en ts on L 2 & L 3
                                                                                                 Call Line at W YM A S
             u ni ts w ai ti ng u p to 5 ½ h ou r s
                f or a m bu la nce cr ew s t o
                           ar r iv e
                                                                                 Pickup times negotiated between WY MA S & s taff
                                              400



                                              300



                                              200
                      MIN U T E S D E L A Y




                                              100                                                                      D ed ica ted C al l L i n e
                                                                                                                           im pl em en te d                                                                                       T A R G ET
                                                                                                                                                                                                                               = a m b u la n ce
                                                                                                                                                                                                                               c re w s a r ri ve
                                                  0                                                                                                                                                                              fo r tr a n sf e r
                                                                                13

                                                                                         17

                                                                                                  21

                                                                                                             25

                                                                                                                  29

                                                                                                                       33

                                                                                                                               37

                                                                                                                                        41

                                                                                                                                                45

                                                                                                                                                     49

                                                                                                                                                          53

                                                                                                                                                               57

                                                                                                                                                                    61

                                                                                                                                                                         65

                                                                                                                                                                              69

                                                                                                                                                                                   73

                                                                                                                                                                                        77



                                                                                                                                                                                                       85
                                                       1

                                                              5

                                                                       9




                                                                                                                                                                                               81
                                                                                                                                                                                                                                a s p a tie n t is
                                                                                                                                                                                                                                   r e a dy fo r
                                                                                                                                                                                                                                   tr a n s fe r
                                              -1 0 0



                                              -2 0 0


                                                                                                                                                                                         W ai ti ng t im es fo r al l s taf f & p at ien ts r edu ce d
                                              -3 0 0
                                                                                                                                                                                             to a ccep t abl e l ev el s as p i ck up t im e s ar e
                                                                                                                                                                                               n ego t iat ed b etw ee n s taf f & W Y M AS


                                              -4 0 0
                                                           Pa r a m e d ic s ta f f w ai tin g on L 2 /L 3
                                                           u n its fo r u p t o 4 h o ur s f o r p a tie n t s
                                                                      & s ta ff t o b e re a d y .
                                                                                                                   P A T IE N T T R A N S F E R S
                                                              ? ? d is p a tc h e d a s 9 9 9 c a llls ? ?




2.3      Outreach Services

         There has been no additional development with the setting up of outreach services
         due to resource implications. However all hospitals have piloted or are using an
         ‘early warning scoring system’ (EWS) in an area of their hospital.

         The hospitals with some form of an outreach service, but by no means complete,
         are as follows:

                Airedale General Hospital
                The Leeds Teaching Hospital Trust (targeted service both sites)
                Dewsbury General Hospital

Outreach is seen as a priority at both local and national level and a summary of the work
and results from the above hospitals is detailed below:

     Network Project Group commenced March 2001 with representation from all Trusts
      within the Network. Membership consists of clinicians, nursing staff, Allied Health
      Professionals and Managers.

     Early work was around the identification of a patient Early Warning Scoring System
      (EWS) that could be adapted for use within the Network.

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   The outreach team in Leeds were introducing the EWS to selected wards both at St
    James’s and Leeds General Infirmary, therefore enabling a significant patient
    information base to be established from which we can all draw. Patients discharged
    from the intensive care unit are also followed up with careful monitoring in an effort to
    detect/prevent deterioration.
    A ‘follow up’ clinic has also been established that offers a return visit and assessment
    for patients previously discharged from hospital following a period of intensive care.
    The team consists of nursing staff, physiotherapists and some sessional Consultant
    Intensivist time.
   Dewsbury & District Hospital Outreach Team are also undertaking similar work and
    identifying educational needs at ward level. The outreach team commenced work
    with the surgical wards 7.00am – 7.00pm every day. The team consists mainly of
    nursing staff and physiotherapy sessions.
   Airedale General Hospital have appointed a Nurse Consultant with some of her time
    dedicated to the setting up of an Outreach Service. Early work has been around
    follow up of patients after discharge from intensive care.
   All the other hospitals within the Network have agreed to commence pilot work around
    the EWS and have identified appropriate ward areas within their hospitals.
   Whilst pre & post-implementation statistics show substantial benefits to patient care in
    those hospitals with some form of Outreach service, their services are by no means
    complete and the other hospitals in the Network are unable to begin such work
    without funding.

2.4 Emerging evidence

   The Leeds Teaching Hospitals NHS Trust:
    Commenced Outreach Service 1st November 2000 with 1050 patients having been
    seen since implementation (Sept. 2002). Follow-ups and referrals increased as the
    service became more established.

   Snap shot of 2 x 4week periods (St James’s site) shortly after implementation of
    service:
                                          26 Mar 01 – 20 Apr 01        01 Jun 02 – 27 Jun 02
Number of Patients Seen                            50                           78
Specialty:          General Surgery                14                           15
                  General Medicine                  6                            7
                               Liver                5                           16
Number of Interventions                            66                          120
Number of Re-admissions to ICU                      1                            9
Number of Admissions to ICU                         0                            2
Number of Respiratory Distress                      6                            9
Number of Interventions Required                   23                           33



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   Every patient who leaves ICU with a tracheostomy is seen by the Outreach Team.

   Of the 1050 patients seen by the outreach team at St James’s the following
    information has been extracted:
         55% are acute referrals
         9.5% readmitted to critical care (both level 2 and 3)
         The average duration that each patient is seen is between 4-7 days
         A physiotherapist is involved for 70% of the patients
         38% of the workload involved tracheostomy care

The pie chart (Courtesy of Dr B. Duncan) shows the typical case mix:
                                               Haematology
                                       Hepatology
                                    Gynae                    Orthopaedics
                                                                       Cardiology
                             Urology
                         Oncology                                                   Vascular
                                                                                                                    Orthopaedics
                                                                                                                    Cardiology
                                                                                                                    Vascular
                                                                                                                    General medicine
                                                                                                                    Respiratory
                                                                                                                    Renal medicine
                                                                                                 General medicine   Obstetrics
                                                                                                                    Liver transplant
                                                                                                                    Neurology
                                                                                                                    Plastics
               Gen.surgery                                                                                          Renal tx
                                                                                               Respiratory          Gen.surgery
                                                                                                                    Oncology
                                                                                                                    Urology
                                                                                                                    Gynae
                                                                                          Renal medicine
                                                                                                                    Hepatology
                                                                                    Obstetrics                      Haematology


                                    Renal tx                           Liver transplant
                                       Plastics
                                               Neurology


   St James’s Outreach Team has also carried out a survey (using a questionnaire) of
    ward staff to elicit their views and experiences of the current service.

   On the Leeds General Infirmary (LGI) site Dr Alison Pittard, the Lead Clinician for
    Outreach, has collated the following information from 300 patients that have been
    identified and seen by the LGI Outreach Team:

    1.   Reduction in acute admissions to ICU from 54% to 35%
    2.   Decreased length of stay from 7.4 days to 4.8 days
    3.   Reduced number of re-admissions to ICU from 5.1% to 3.3%
    4.   Reduced mortality rate for patients admitted from pilot wards from 28.6% to 23.5%
    5.   Cardiac arrest calls reduced from 6.7% to 5.6%
    6.   Physiotherapy referrals reduced from 19.3% to 8.7%
    7.   More patients admitted during the day time

   Interestingly, unit occupancy has not fallen but more elective patients are being
    admitted, thus reducing cancelled elective surgery that requires critical care back up.

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   In Dewsbury General Hospital the Outreach Team have seen 877 patients (follow up
    and referrals) for the period 31st August 2001 to 31st August 2002.

    In comparing acute admissions to intensive care, the year 2002 saw an increase of
    5% compared with 2001. The main increase was in acute medical patients (29%) but
    there was a marked reduction in admission of acute surgical patients (19%). There is
    also a reduction in overall mortality by 1.5%.

   In Airedale General Hospital the initial qualitative data indicates a high level of patient
    satisfaction following visits after discharge from ICU. The Nurse Consultant (Rachel
    Binks) has seen 358 patients after discharge from critical care (including 2 patients at
    home) and a further 95 patients have been seen as a result of direct referrals from the
    ward areas when the patients have ‘triggered’ a high EWS score indicating the need
    for early intervention.

These are comments received from some of Rachel Bink’s patients at Airedale:
A lady admitted for an acute exacerbation of her COPD who received early non-invasive
ventilation left the hospital:
       ‘feeling much more supported and less frightened about subsequent
       admissions now that I know I can call you when I get here’….
The wife of a patient who had spent 4 weeks on ICU and been discharged to the ward
with a tracheostomy (supported by the outreach service), rang me from home as the
ambulance was arriving to pick him up for a re-admission,
       ‘just to let you know we are on our way and would like to see you
       when we arrive. You know all about us and can tell the doctor’…..
In a thank you letter from a patient, the outreach service was said to have:
       ‘made my discharge to the ward far less frightening. The transition
       from ICU to the ward could have been terrifying but knowing
       you would visit regularly to check up on me made all the difference…………’
An ex-nurse who had a prolonged admission to the ICU and suffered from ‘ICU
psychosis’ when she regained consciousness, felt that Rachel had
       ‘helped to chase her demons away……….’
by visiting her both on the ward, and at home 6 months later, to discuss her stay on the
Unit.
Rachel’s comments about Airedale’s Outreach service:
“Outreach is not just about saving lives or collecting the data, it’s about filling in
the gaps between critical care, the wards & the community. A seamless service
from emergency admission to discharge home is the ideal & what the patients want
is what should count.”

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2.4     Data and Information
The current number and levels of bed within the Network are as follows:
              Hospital                                 Unit Type                    Number & Level of Bed
Airedale General Hospital                        Combined                              L2 x 4, L3 x 3
Bradford Royal Infirmary                         Combined                              L2 x 4, L3 x 8
Calderdale Royal Hospital                        Combined                              L2 x 4, L3 x 4
Huddersfield Royal Infirmary                     Combined                              L2 x 2, L3 x 6
Leeds General Infirmary                          General                                   L3 x 7
                                                 General                                   L2 x 6
                                                 Cardiac                                  L3 x 14
                                                 Neurology                                 L3 x 7
                                                 Neurology                                 L2 x 8
St. James’s University Hospital                  General                                  L3 x 14
                                                 General                                   L2 x 8
                                                 Orthopaedic/Plastics                      L2 x 6
Dewsbury & District Hospital                     Combined                              L2 x 4, L3 x 6
Pinderfields General Hospital                    General                                   L3 x 7
                                                 General                                   L2 x 4
                                                 Burns                                     L3 x2
Pontefract General Infirmary                     General                                   L2 x4

            Total Number of Adult Level 3 Beds                             78
            Total Number of Adult Level 2 Beds                             54
            Total Number of Adult Beds                                   *132
* Plus 10 Cardiac beds that are part of a ward establishment at Leeds General Infirmary. Therefore total
number of critical care beds is 142 (KH03a data July 2002).

            Total Number of General Adult Level 3 Beds                     55
            Total Number of General Adult Level 2 Beds                     40
The specialist work is generated from the Region & some Supra-regional work such as the liver & renal
services.


The Independent Sector
Colleagues from the independent sector within the Network are represented on the
Network Steering Group and are actively involved in some of the projects that are
currently being undertaken by the Network. The table below highlights the current critical
care level that is available within the independent sector:
            Hospital                                Unit Type                       Number & Level of Bed
BUPA Roundhay, Leeds                        Cardiac/General                               8 x Level 2
BUPA Elland                                 General                                       2 x Level 2
BUPA Methley Park                           General                                       1 x Level 2
Nuffield Hospital, Leeds                    Cardiac/General/Surgical                      8 x Level 2
The Huddersfield Nuffield                   General                              0 x Level 3 and 2 (only L0-1)
The Yorkshire Clinic                        General                                       4 x Level 2
Please note that none of the independent sector hospitals offer Level 3 care.


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Monitoring of bed availability remains with the Yorkshire Intensive Care Bed Bureau
(YICBB) and this service continues to feed the National Intensive Care Bed Information
Service (NICBIS). Unfortunately our local agreements have changed since March 2003.
The YICBB had been collecting more detailed information focusing around the level of
critical care bed availability, potential beds and delayed discharges. They also extended
this service to high dependency units within the Network. YICBB have been unable to
sustain this level of service & the Network has been unable to fund further work to take
forward the web page that has already been developed that would underpin the live bed
information. The service now provided is somewhat less than their original service level
agreements and means that bed availability information is collected on a fraction of the
critical care beds in West Yorkshire rendering the data inaccurate and unusable.

The West Yorkshire Strategic Health Authority have been approached to ensure that the
Network requirements around bed information becomes part of the I.T and Information
strategy for West Yorkshire.

On the National scene the Critical Care Information Advisory Group (CCIAG) which is
chaired by Dr John Morris, is at the centre of the development for the national ‘Critical
Care Minimum Data Set’ (CCMDS). This will utilise the Intensive Care National Audit &
Research Council (ICNARC) data and Augmented Care Period (ACP) data sets. There is
wide representation on this group and the Intensive Care Society has representation on
the group and a member from the WYCC Network attends the meetings/workshops.
However, the data set is not due to be available until 2006/7.

As well as monitoring bed availability the Network has a working group whose remitit is
to assess the relevance and need for information collection to support the services and
future planning.

All units are now part of the (ICNARC) national data collection. Some units have just
become part of the programme and others have a long history of membership. This
programme will give national comparative audit around the case mix of patients, severity
of illness, length of stay and outcomes.

ACP (Augmented Care Period) data is also collected on all level 3 & combined (L3/L2)
units. There are concerns around the accuracy & usage of this data & the Network sees
this as key information in the development of HRG’s (Healthcare Resource Groups). The
Network will be working with the CCIAG (Critical Care Information Advisory Group) as
they develop the minimum data set for critical care and in preparation for the
development of a national HRG for critical care.

The Network has financially supported the participation in the Cost Block Programme
which gives a national comparison of costs between units of similar type. This
programme is undertaken by MERCS (Medical Economics & Research Centre Sheffield)
and the Network has funded 7 units to date for 2002/2003 costs. The Trusts will need to
continue involvement in the programme beyond 2003. This will form part of a Network
data set which the group are currently discussing.



                                                                                            8
In summary the following information is collected by the critical care units within the
Network:

     ICNARC data set
     ACP data set
     Cost Block programme (7 out of 9 units participate)
     Due to recent changes, now only level 3 and combined units (except cardiac)
      participate in the 3 times daily bed monitoring service undertaken by the Yorkshire
      Intensive Care Bed Bureau (YICBB).
     All units collect and submit to the Network office the ‘Global Measures’ as requested
      by the Modernisation Agency & this information is reported back to the units twice
      yearly.

2.5      Education

There has been considerable development with regard to education and training within
the Network during the last year. The Network Education Group continues to be very well
attended and now includes the independent sector as well as a member from the West
Yorkshire Workforce Development Confederation (WYWDC). Contacts with the
universities in West Yorkshire have been made when the need has arisen.

The group organises regular 1 day teaching sessions covering a wide range of generic
topics, for example, respiratory, cardiac, head injury and communication. These study
days are very well attended and attract multi-disciplinary attendees.

The Network gained funding from the WYWDC for the Acute Life-Threatening Early
Recognition & Treatment (ALERT) course. During November 2002 a faculty of 30 people
(Doctors, Nurses, Physiotherapists, Radiographer and Operating Department
Practitioners) underwent the ALERT ‘train the trainers’ course held at Portsmouth and
Gloucester. The faculty includes the Network Manager and the Network Service
Improvement Lead. The Network Manager is the Network ALERT Course Director. The
remaining faculty are from all the hospitals within the Network. The first course was held
at Dewsbury Hospital in February with one per month scheduled for the remainder of the
year up until January 2004. Each hospital is allocated a number of places and they can
select clinical areas that they may wish to target. Feedback is being given to the
WYWDC to ensure that we meet our obligations to supplying the training that we outlined
in our bid. It is hoped that the WYWDC will consider further funding to for the Network to
run the ALERT course beyond January 2004 as it is well received.

The Network has also been successful in a recent bid to UK Transplant for a three year
secondment post (two sessions per week) for a Network Donor Liaison Clinician. This
exciting post has now been filled and it is hoped the successful candidate will begin the
work from 1st May 2003. The clinician will be working across the Network with a focus
around educational needs identified with fellow Doctors on issues pertinent to organ
donation. This work will compliment that of the Transplant coordinators based at LTHT.




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3.    Commissioning Arrangements
Past Arrangements
Commissioning in the past was very much the responsibility of individual Trusts to put
forward their case of need in response to the service changes that were being developed
within their own Trust. This would be presented to the commissioners i.e. the old ‘Health
Authority’. Following the development of the PCG’s (Primary Care Groups) the Health
Authority still remained but in a coordinating role for a given patch.

Future Arrangements
Since the development of the 15 PCT’s (Primary Care Trusts) in West Yorkshire we now
have a PCT whose Chief Executive takes the lead for the development of Critical Care
services. This is Kevin Ellis of Airedale PCT. There has also been the development of a
West Yorkshire Commissioning Group which has been derived from the 15 PCT’s.

The Network is to become advisory to the West Yorkshire Commissioning Group on the
future development of critical care services. This will be supported by information & data
collected from the acute Trusts & presented in a meaningful way that will support the
commissioning process.

One of the recommendations from ‘Comprehensive Critical Care’ (May 2000) was that
each Trust establishes a Critical Care Delivery Group (CCDG). The group should have a
designated Executive lead & here key professions and specialties that deliver the service
would take the lead responsibility for critical care services on behalf of the Trust Board.

The WYCCN Manager works closely with these groups and their designated business
managers to identify the Trust’s critical care development priorities.

This work will take into account the resources required for each Trust to complete the
implementation of the recommendations from ‘Comprehensive Critical Care’ (May 2000),
‘The Nursing Contribution to the Provision of Comprehensive Critical Care’ (Dec 2001) &
the impact of the Modernisation agenda on critical care services within each acute Trust.

This information has now formed part of a draft document which has been presented at
the WYCCN Strategy Group where an assessment has been made from this information
& recommendations prepared on how the developments should be delivered in West
Yorkshire. This document has also been presented to the West Yorkshire
Commissioning Group.

These recommendations for future developments will assist with the delivery of the NHS
plan around patient’s access to treatment, reducing cancelled operations & reduction of
risk. The plan however should remain dynamic so that on-going changes can be made,
as the impact of other service changes become evident. A summary paper of priorities
was prepared by the Network in conjunction with the Trust’s critical care delivery groups
and business managers and presented to the West Yorkshire Commissioners Group.



                                                                                         10
       These priorities are as listed below:

       1.   Development of Critical Care Outreach Services
       2.   To fund the Network (following end of programme September 2004)
       3.   Increase in level 3 capacity at Bradford Royal Infirmary
       4.   Increase in level 2 capacity at Leeds General Infirmary
       5.   Information Systems (Electronic live bed state)
       6.   Development of Non-Invasive Ventilation (All Trusts)

       Unfortunately the t of the pilot scheme for future commissioning of critical care services
       (Modernisation Agency Dec 2002) the WYCCN will focus much of its work around the
       development of a standard data set for the Network.
Ugh!   This will be devised to support the development of HRG’s and will involve an in depth
       analysis of the current ACP (Augmented Care Period) data set which is envisaged will be
       key to the development of the HRG. The Network will be guided by the work of the
       CCIAG (Critical Care Information Advisory Group).

       The Network is also involved in looking at various capacity planning models and is keen
       to see if these have appropriate validation for use in our commissioning process.

       For the duration of the pilot within West Yorkshire the following support will be required:

           A full time person to audit the current ACP data collection and support/educate any
            changes that will be required particularly following the recommendations for the
            Critical Care Minimum Data Set (CCMDS). This person will work with all our units
            during this time and report back to the Network Strategy group as well as to the
            Modernisation Agency.
           To improve the current collection of daily capacity information to a more efficient
            system of both collection and distribution of information. More detailed information
            can then be obtained that will assist with the future commissioning process.
           The services of a dedicated experienced commissioner to support the pilot and advice
            on pertinent issues.
                               See table below for a break down of costs:
            Grade/Item           Recurring Costs (£K)                     Non-recurring Costs £K                Total £K
       F grade or          £22K + on costs £3K                         Lap-top computer
       A&C 6               Travel expenses £3K

                                                          Total = 28                              Total = 2.5         30.5
       Capacity            After initial installation agreement        Installation to 18 units (includes
       information         would be for Trusts/YICBB to                specialist units)
                           maintain system
                                                                                           Approx Cost = 30           30.0
       Services of a       It is assumed that this will be
       commissioner        provided at no cost to the Network

       Total                                                                                                         60.5

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A document issued by the West Yorkshire Primary Care Organisations (WYPCO)
around the future strategic commissioning across West Yorkshire including
specialist services and Networks is anticipated to be accepted by the PCT’s early
in 2003.

This document sets out clarity of roles of commissioners and Networks and takes
into account the governance and accountability issues.

This document will obviously become an integral part of the work that the Network
undertakes as a pilot for the commissioning process.




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