Oena Windibank (Programme Director, Kent and Medway Vascular Services Review, NHS England South (South East)) and Dr James Thallon (Medical Director, NHS England South (South East)) were in attendance for this item.
(1) The Chairman welcomed the guests to the Committee. Dr Thallon began by outlining the infomation provided in the report, to address the Committee’s recommendations from 8 January 2016 meeting, including travel times, performance indicators and findings from local reviews which were centralising vascular services in accordance with the Vascular Society guidance. He noted that the Vascular Society was exemplary in providing clear best practice guidance to its members and commissioners and the 2012 guidance was being updated in 2016. He reported that the Kent and Medway review was working with the Vascular Society guidance review group and there would be no significant changes to the guidance. He stated that improving outcomes was driving the review; whilst the two providers in Kent were within the national tolerance levels for mortality, there was a considerable range in performance.
(2) Dr Thallon explained that there were no recommended criteria for travel times in the Vascular Society guidance as the key priority was access to specialist vascular surgery. He quoted Vascular Society guidance which stated that “patient survival after a ruptured aortic aneurysm was between 5-15 percent if they stay in a hospital with no vascular surgeon, compared to 35-65 percent if transferred to an adjacent vascular service. This advantage persists even with up to four hours of hypotension.” He noted that the review programme board favoured a network hub and spoke model with a single inpatient centre and one or more spokes; this model would be out to public consultation in the summer subject to NHS England’s internal assurance process.
(3) Ms Windibank highlighted the ongoing work including a detailed quality assessment for the affected populations. She reported that a qualitative event with patients and relatives representatives was held in February and considered the recommended option from a patient perspective; key messages included travel times for relatives and a sustainable service remaining in Kent and Medway. She noted that there was a draft public consultation plan and any feedback from the Committee would be reported back to NHS England as part of their internal assurance process.
(4) Members of the Committee then proceeded to ask a series of questions and make a number of comments. A Member enquired about co-dependencies with podiatrists and interventional radiologists. Dr Thallon explained that whilst he accepted the importance of podiatry in prevention and noted that there was a shortage of podiatrists; podiatry was not in the scope of the review and was not able to be incorporated into it. He stated that he would be happy to reflect comments made about podiatry to the commissioners. He noted that one group who did have better access to podiatry services were those with diabetic foot problems who were also likely to suffer from vascular conditions. He reported that the review was aiming to create a centre of excellence which would avoid the need for amputation. He explained that interventional radiologists were currently underdeveloped in Kent and Medway and the next generation of vascular surgeons would be hybrid surgeons and interventional radiologists. He noted that whilst a hub and spoke model would create the conditions for interventional radiology to become an attractive speciality, it would take time for this to be developed. He reported that there was agreement from current interventional radiologists to support the new vascular model which was subject to further discussions.
(5) A number of questions were asked about population growth and disease forecast; preventative services; travel times for staff and frail, elderly and low income visitors; and amputations. Ms Windibank reported that population growth and cardiovascular disease forecasts had been included in the modelling. Dr Thallon explained that the abdominal aortic aneurysm screening programme had been key in reducing the number of emergency vascular procedures. He reported that prevention was taken very seriously and highlighted the successful diabetes prevention pilot undertaken by Medway CCG which was being implemented by all Kent and Medway CCGs. Mr Scott-Clark noted that KCC was responsible for commissioning NHS health checks in Kent which could identify patients at risk of vascular conditions. Ms Windibank explained that detailed work was being carried out to look at travel times for staff and low income families particularly in high prevalence areas. Dr Thallon explained that vascular surgeons in the inpatient hub would be responsible for all vascular surgery including repairs of abdominal aortic aneurysms and amputations if related to a vascular condition. He noted that there were variations in outcomes for amputations and this could be incorporated into the review. Ms Windibank stated that the vascular review had whole system support and was aligned to the wider transformation plan.
(6) In response to specific questions about the operational and financial resilience of the two current providers in Kent and Medway, Dr Thallon explained that in terms of operational resilience, at present, both sites were understaffed and access to 24/7 surgery or interventional radiology was not guaranteed; he warned that the vascular service in Kent and Medway would collapse if the new clinical model was not implemented. He reported that even within challenged trusts such as Medway NHS Foundation Trust there were beacons of excellence such as its neonatal ward and there were signs of overall improvement at the trust under the new leadership. He explained that the creation of a vascular unit would be independent from the rest of a trust and create the conditions to attract staff. He noted that the aim of the review was to establish the clinical model and only the procurement would determine the location of the hub. In terms of financial resilience, Dr Thallon explained that if the clinical model based on Vascular Society guidance was implemented, it would provide an adequate revenue base for the chosen provider. Both of the current providers in Kent and Medway had adequate facilities which could be consolidated at relatively small cost.
(7) The Chairman invited Mr Inett to speak. Mr Inett enquired about the services provided at the spokes. Dr Thallon explained that a network model with a single inpatient centre would increase outcomes for patients but may result in them travelling further. He stated that in mitigation, all other services would be provided locally including diagnostics and outpatients. He noted that in the future some inpatient services could be provided in the spokes including angiology and stenting. Ms Windibank reported that at the qualitative and listening events, the priorities for patients and relatives had been access to specialist vascular services in Kent and Medway. Additional travel times for relatives were a concern but a number of initiatives suggested by attendees such as Skype appointments and support with travel were being looked at by the Clinical Reference Group. She noted the procurement would need to respond to those needs.
(8) A number of comments were made about procurement and public consultation including a consultation event in Medway. Dr Thallon explained that he was limited to the type of information he could provide the Committee in advance of the procurement process due to the risk of prejudice. He stated that he could share the key criteria for procurement including facilities and ease of visiting with the Committee. Ms Windibank reported that NHS England, through procurement, had a duty to market test any provider interested in delivering the clinical model for Kent and Medway. Ms Windibank noted that the procurement process would determine the site of the hub and current vascular performance would not be taken into account. She stated that the purpose of the public consultation would be to test the model and criteria for procurement; NHS England would return to the Committee after public consultation and before the procurement process began. She explained that the draft public consultation plan included a survey targeting specific patients in Kent and Medway including those patients who travel to London for their care.
(9) RESOLVED that:
(a) NHS England South (South East) be requested to note comments about amputations; the proposed clinical model; podiatry; procurement and public consultation;
(b) NHS England South (South East) be requested to provide the following additional information to the next meeting of the Committee: key criteria for procurement and travel times for staff and frail, elderly and low income visitors;
(c) NHS England South (South East) be requested to present an update to the Committee on their preferred option for procurement for vascular services before NHS England Specialised Commissioning take a final decision on procurement.