Eight key questions on the future of vascular surgery in Portsmouth

Queen Alexandra Hospital
Queen Alexandra Hospital
QA Hospital in Cosham

Here’s what inspectors found at QA that made them write a scathing report - dirty linen, patients being ignored while choking and medicine left out

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The debate to see whether Portsmouth should keep its vascular services is once again at the forefront of the

health agenda.

National guidelines say having fewer, more specialised vascular centres, is better for patients, and that this needs to be in place by October.

To see if Queen Alexandra Hospital can retain the service, health reporter PRIYA MISTRY asks eight key questions to the trust that provides vascular services in the Portsmouth area and the trust that pays for the service – and finds they are at loggerheads on some issues

1) A minimum population of 800,000 is considered necessary for AAA screening programme, and is often considered the minimum population required for a centralised vascular service. Do PHT and UHS meet this?

Wessex: PHT serves a population of 600,000 which does not meet the minimum standards.

UHS serves a population of 900,000 as it already works as part of a network with hospitals in Winchester and the Isle of Wight.

PHT: PHT is one of the largest acute hospital trusts in the country providing a full range of emergency and other care services to a natural catchment population of 650,000 across Portsmouth and the surrounding areas and beyond.

In terms of demography this population represents one of the most deprived and demanding with poor health outcomes in England.

Conditions that predispose to vascular disease are prevalent, including high levels of smoking, diabetes, obesity and old age.

While the trust does not meet the catchment volume suggested by the Vascular Society of Great Britain and Ireland, this is not relevant in terms of activity delivered at PHT due to the population demographics.

The 800,000 population is irrelevant because we do the required number of cases to be a stand-alone vascular centre as we perform the required number of cases per year (60 aneurysms and 50 carotid endarterectomies) to be a vascular centre.

2) In practice a vascular medical team of a minimum of six vascular surgeons and six vascular interventional radiologists is needed to ensure comprehensive out of hours emergency cover. Do PHT and UHS meet this?

Wessex: PHT does not – and this is our most significant concern about the service. The trust only has two vascular surgeons, plus the support of one renal consultant and two general surgeons. UHS has six vascular surgeons.

PHT only has two vascular interventional radiologists, while UHS has five vascular interventional radiologists, one of whom is also a qualified vascular surgeon.

PHT: Vascular surgeons – elective surgery only; Mr Simon Payne. Emergency surgery only; Mr Graham Sutton and Mr Andras Palfy.

Both elective and emergency surgery – Mr Mark Pemberton; Mr Paul Gibbs; Mr Timothy Whitbread and Mr Perbinder Grewal.

Interventional radiologists trained in vascular interventional radiology are Dr Julian Atchley; Dr Peter Osborne; Dr John Langham-Brown; Dr Simon Coles; Dr Tony Higginson; and Dr Richard Beable.

3) Each surgeon will need to have an appropriate arterial workload, e.g. in the region of 10 AAA emergency and elective procedures per surgeon per year.

Is this happening at both PHT and UHS?

Wessex: As detailed in the recently published National Vascular Registry report about vascular surgical outcomes, PHT only had two surgeons who were undertaking sufficient AAA procedures while UHS had six.

PHT: In 2012/13, vascular surgeons performed approximately 300 major arterial cases. The vascular surgeons at QA performed 64 elective AAA repairs.

Most cases (40), were performed using the latest keyhole techniques.

These keyhole cases were performed in the dedicated radiology suite by vascular surgeon Mr Mark Pemberton, and interventional radiologist Dr Julian Atchley.

Conventional aneurysm procedures (24), carried out when keyhole techniques not possible are performed in the dedicated vascular operating theatre by two consultants operating together.

In the past 15 months, a total of 83 elective procedures were performed – there have been no postoperative deaths.

Only Mr Pemberton performs more than 10 AAA repairs per year.

In common with all specialist vascular units, we concentrate expertise to achieve the best results.

Approximately one emergency ruptured aneurysm per month has been performed over this period.

4) The arterial centre will also perform a high volume of carotid endarterectomy procedures.

A minimum number of 50 is indicated. Is this happening at both PHT and UHS?

Wessex: Yes – both sites exceed the minimum number of carotid procedures.

PHT: In 2012/13, surgeons at QA performed 82 elective carotid endarterectomy procedures.

In the last 15 months a total of 104 elective procedures were performed.

5) Patients with vascular disorders will be cared for by specialist vascular teams.

These teams will include vascular surgeons, consultant anaesthetists, interventional vascular radiologists, vascular scientists, nurses, radiographers, physiotherapists, occupational therapists and rehabilitation specialists. Is this demonstrated by both PHT and UHS?

Wessex: As detailed above, PHT has insufficient numbers of vascular surgeons and vascular interventional radiologists, while UHS has adequate staffing.

Although trusts are not required to publish the number of specialist nurses and therapists they have in post, we know it can be difficult to recruit and retain these staff.

It will be important that their expert skills can be concentrated in a single arterial centre to support the patient’s recovery going forward and to ensure continued multi-disciplinary working.

PHT: PHT has a dedicated vascular assessment unit, vascular theatre and vascular ward staffed by vascular surgeons, consultant anaesthetists, interventional vascular radiologists, vascular scientists, nurses, radiographers, physiotherapists, occupational therapists and rehabilitation specialists.

The combination of the surgical expertise, interventional radiologists and state-of-the-art radiology imaging makes the trust one of the safest and most forward-looking centres for vascular interventions in the country.

6) How would a rota system work between the two trusts to provide full vascular coverage, if Portsmouth is not a main centre?

Wessex: A network arrangement would ensure there are sufficient vascular surgeons and interventional radiologists in southern Hampshire to meet the full range of patient needs whether this is for investigations, surgery or outpatient follow ups.

The small number of patients requiring emergency surgery would be transported to the main arterial centre.

There are a range of different models that can be used, depending on agreements between the two trusts.

For example, this might include a fully networked on-call rota so that regardless of where you have your surgery you would still have continuity of care by the vascular surgeon who undertook your operation.

In addition, any emergencies would be covered within this rota through a surgeon of the week, who would have protected time to respond to emergencies at either site with back-up should there be more than one patient requiring urgent attention.

PHT: There has been a 24/7 specialist vascular service at Portsmouth since 1994.

All the present vascular surgeons had specialist vascular training.

None of the vascular surgeons take part in the general surgical on-call. Sub-specialisation within the team and dual consultant operating ensures outcomes that exceed the standards set out by the Vascular Society.

Local population demographics mean that sufficient volumes of arterial procedures are generated from our catchment population even though this is below the size recommended by the Vascular Society.

Staffing has been difficult due to uncertainty created by the review process over the last three years – despite this cover has been seamless and quality maintained.

7) Would losing vascular services in Portsmouth have an effect on other services, such as renal?

Wessex: Over the past two years we have sought expert advice and have consistently been told that this is not the case, however we are further testing/checking this issue, as it is very important.

We know there are renal units which are not in a vascular arterial centre and they are able to make the network model work.

PHT: The trust provides acute services and many specialist and tertiary services, including the Wessex Renal and Transplant Unit, which is one of only two tertiary centres in all of Berkshire, Buckinghamshire, Hampshire, Oxfordshire and the Isle of Wight. This service covers a population in excess of two million.

The trust is also one of two designated NHS Cancer Centres in Hampshire and the Isle of Wight. PHT is one of only eight designated laparoscopic training centres and one of nine VTE exemplar centres in the country.

A Da Vinci robot enhances our position as a multi-disciplinary training and treatment centre for minimally invasive surgery.

Vascular supports all emergency activity across the trust and interacts with many patient care pathways. In particular, it forms an important part of cancer and transplant services, supports our hyper-acute stroke service and key in diabetic patient care.

The majority of work the vascular service provides at PHT is for non-major procedures such as diabetic foot problems and preventing amputations.

The outcome for these patients is often ignored when plans are made to move procedures. The results for major vascular procedures in Portsmouth are excellent. The vascular service also has close links with and supports the interventional radiology service. Like vascular this service is vital for the renal and transplant service, for cancer care and interventional radiology supports many aspects of the emergency activity of the trust.

8) Is it in the patient’s clinical interest and safety, to either be sent from Portsmouth to Southampton, or Southampton to Portsmouth, if either one becomes the main vascular centre?

Wessex: We absolutely believe that this is so and in the case of Southampton this is particularly important as UHS is the major trauma centre for the area.

For the small number of patients (approximately 34 per year) who would need to be transferred in an emergency, there is evidence to show that there are better outcomes for them if they travel to an arterial centre where there is concentrated expertise.

There is national clinical evidence that there are improved outcomes for patients in these centres because surgeons working there undertake higher volumes of procedures that enable them to hone their skills in this speciality.

PHT: There is no advantage for arterial patients being transferred to Southampton, but the proposal to move all arterial procedures to Southampton would have a deep and significant impact on many services in Portsmouth and could cause the vascular service at PHT to collapse.

Repeated investigations have shown Portsmouth to have good outcomes from the vascular surgery it performs; therefore the clinical outcomes would be no better if patients moved to Southampton.

The proposal offers no advantage to those that would be transferred but would have a significant, negative impact on many Portsmouth patients if vascular services were not maintained at QA.

Vascular commissioners should consider the south coast as a whole and not be influenced by old Strategic Health Authority borders. This would allow a service that mirrored other vascular services such as PCI/acute stroke and would require three centres along the south coast – Brighton covering as far as Arundel, PHT from Arundel to Fareham and UHS beyond.

These would have the required population and expertise to provide a high quality but local service.

Key

AAA – abdominal aortic aneurysm (The abdominal aorta is the largest blood vessel in the body. An aneurysm is a bulge in a blood vessel caused by a weakness in the blood vessel wall. As blood passes through, the pressure causes it to inflate like a balloon. In most cases there are no symptoms until the aneurysm bursts, which can cause massive internal bleeding and could prove fatal).

Carotid endarterectomy – A surgical procedure to unblock a carotid artery. The carotid arteries are the main blood vessels that supply the head and neck. If left untreated it can lead to a stroke.

PCI – percutaneous coronary intervention (A procedure used to widen blocked or narrowed coronary arteries. A short wire-mesh tube, called a stent, is inserted into an artery to allow blood to flow more freely through it).

PHT – Portsmouth Hospitals

NHS Trust (A health provider in the Portsmouth area that runs Queen Alexandra Hospital, in Cosham).

QA – Queen Alexandra Hospital (Acute hospital serving the Portsmouth area).

UHS – University Hospital Southampton NHS Foundation Trust (The trust that runs Southampton General Hospital).

VTE – Venous thromboembolism (A blood clot that develops in the vein).

Wessex – Wessex Area Team (A division of NHS England. It wants to improve health outcomes in the country and also pays for major services, such as vascular).