Agenda item

Liz Shutler (Director of Strategic Development & Capital Planning, East Kent Hospitals University Foundation Trust), Rachel Jones  (Director of Business and Strategy Development, East Kent Hospitals University Foundation Trust) and Marion Clayton (Divisional Director, Surgical Services, East Kent Hospitals University Foundation Trust) were in attendance for this item.

(1)       The Chairman welcomed the guests to the Committee and asked them to introduce the item. Marion Clayton began by updating the Committee on the Trust’s service reconfiguration of adult high risk and emergency general surgery.

(2)       A broad definition of high risk surgery was given: patients with a predicted mortality rate of 5%; patients undergoing emergency abdominal procedures, major gastric and bowel surgery; patients over 50 undergoing emergency redo surgery; and acute patients with comorbidities including renal, cardiac, respiratory and thoracic conditions. A number of examples were identified including laparotomy, removal of the spleen, gall bladder and appendix.

(3)       Members were reminded that the Trust had presented their clinical strategy to the Committee in June 2013. A number of options for the provision of high risk and emergency general surgery were presented to the Committee including the centralisation of surgery and a potential hub and spoke model.

(4)       In 2012 the Trust invited the Royal College of Surgeons (RCS) to assess and review surgical service provision.  The RCS had found that the Trust was not providing a continuity of care for patients due to the provision of high risk surgery at three acute sites with different on call models and a mix of appropriately skilled substantive and locum surgeons. The RCS made a number of recommendations including the provision of continuity of care for patients and the recruitment of substantive posts.

(5)       The Trust took on board the recommendations and identified the need to centralise high risk surgery at the Kent and Canterbury Hospital on an interim basis with a robust on call service. This would enable the Trust to provide continuity of care and expertise on a single central site. In January 2014, the Trust began a review into how this model would be delivered. A number of significant risks were identified including the transfer of patients to a central hub in Canterbury; the provision of beds in the Intensive Care Unit (ICU), the High Dependency Unit (HDU) and wards; and the requirement for additional theatre space. The Trust concluded that the centralisation of surgery would not meet the timescale for implementation.

(6)       An interim solution was presented to the Trust Board by surgeons from the William Harvey Hospital and the Queen Elizabeth Queen Mary Hospital.  The surgeons proposed a 1 in 8 model with 8 surgeons with the appropriate skills at each site providing an on call Monday – Friday rota.

(7)       The Trust identified a number of risks with the proposed model; there were concerns that, without additional recruitment, patients would not receive continuity of care from a consultant with the appropriate skills. The Trust revised the proposal to a 1 in 8 model on a 4:3 split. Dedicated emergency surgeons with the appropriate level of skill would provide emergency surgery on Monday – Friday; the same model and level of service would be provided from Friday – Sunday. This would enable the Trust to increase the numbers of surgeons and remove the non-gastrointestinal surgeons (breast and thyroid) from the rota.The Trust was also looking to introduce a consultant led surgical assessment unit.

(8)       The Trust identified six additional posts for gastrointestinal surgeons with additional skills. Interviews for colorectal surgeons were held in June. Four substantive colorectal surgeons were appointed and would start in September; three surgeons at William Harvey Hospital and one surgeon at Queen Elizabeth The Queen Mother Hospital. The advertisement for upper gastrointestinal surgeons would be published in June and interviews would be held in July. The 1 in 8 model on a 4:3 rota would be implemented by the end of the year. The Trust stated that this was a temporary solution and the programme for a longer term solution was continuing. Thirteen work streams had been developed and were being led by a senior clinical lead.

(9)       Members of the Committee then proceeded to ask a series of questions and made a number of comments. A Member raised concerns about the provision of all high risk general emergency and high risk elective surgery on one site.  A Member explained that he had raised similar concerns about the centralisation of vascular surgery. It was explained that there were a number of services where patients had to travel distances for care; patients in East Kent requiring highly specialised tertiary services such as neurosurgery were transported to London for care. On call surgeons were required to get to the hospital within a specific timescale. Highly specialised teams at registrar level were always available on site to prepare patients for surgery. It was not affordable to have consultants on site 24/7; life and limb surgery after midnight was very small. If a consultant was required out-of-hours, they would be called onto site. The majority of patients who require emergency surgery were seen during the working day when surgeons were on site. It was acknowledged that the co-location of vascular surgery in Canterbury had produced some of the best outcomes for patients nationally. Patients from East Kent no longer had to travel to London for vascular surgery.

(10)     A number of comments were made about the cost and funding of the additional surgeons; service provision at the Kent and Canterbury; and the timeline for the implementation of substantive posts. It was reported that the Trust was funding the additional posts; £700,000 had been provided for the recruitment. It was explained that under the interim proposals, there would be no change to care provided at Kent and Canterbury Hospital; vascular surgery and neurology would continue to be provided at the site. The Trust was expecting to meet the September 2014 target for recruiting substantive posts; four colorectal surgeons would begin in September.

(11)     RESOLVED that the Committee thanks its guests for their attendance and contributions today, asks that there is ongoing engagement with HOSC as plans are developed with a return visit at the appropriate time.