The GIRFT programme led by Professor Tim Briggs is designed to improve healthcare practices, techniques and processes for the benefit of patients. One of the latest reports is on the vascular surgery service offered in the NHS in England.
Professor Michael Horrocks' and his team have conducted a rigorous review of the current service in order to gain clear insight and better understanding of vascular surgery procedures and how they are delivered.
Seventeen recommendations are set out to improve and transform the future of the NHS vascular surgery service with the ultimate aim of improving patient care.
In this briefing we consider the impact of the Vascular Surgery GIRFT Programme National Speciality Report.
Scope of the GIRFT vascular surgery service review
The purpose of the GIRFT programme is to improve healthcare practices, techniques and processes for the benefit of the patient. The subject of a recent GIRFT report is the vascular surgery services offered in the NHS in England.
Professor Michael Horrocks' and his team have visited each vascular surgery provider in England (70 units), to meet with the clinicians and NHS managers. They have discussed the range of procedures and surgical outcomes as well as practices, service set-up and facilities. Analysis of available NHS vascular surgery data has also taken place. As part of the review variations within practice have been carefully considered. This has allowed learning from those providers 'getting it right' and comparison to those providers facing difficult challenges, or potentially 'getting it wrong'. The result is a detailed picture providing insight and better understanding of current vascular surgery procedures and how they are delivered in the NHS.
Following review of the findings, the report provides 17 recommendations for the improvement of vascular surgery. The overall aim is to transform patient care and the way it is delivered, reduce variation between services, enable patients to receive urgent surgery sooner, and reduce the likelihood of adverse consequences which become more likely due to delay. These include life threatening strokes, transient ischaemic attacks, aortic aneurysm ruptures and arterial blockages. A further benefit of an improved and more efficient service is the opportunity for the NHS to make savings and improve productivity.
What were the findings?
Vascular surgery repairs and restores the blood supply to organs and areas around the body. It can save lives, or even transform them. Vascular procedures can prevent stroke or death, restore mobility and reduce the need for amputation, or provide relief from agonising pain. The report noted that vascular surgery had significantly advanced over the past 30 years allowing a greater number of techniques to be used on a greater number of patients. But it also acknowledged that in comparison to other surgical disciplines most patients are frail with co-morbidities and that whenever major surgery is required 'there is always a risk to life or limb'. With this type of patient 'fitness' for surgery is usually low with increased risks of complications and readmission and requiring more intensive post-operative care.
The review revealed variation in demand, supply, treatment choices, outcomes and costs. To examine variations there was a focus on 3 core vascular surgery pathways; abdominal aortic aneurysm (AAA) screening and repair, carotid endarterectomy (CEA) and revascularisation.
The overall picture was one of too many patients waiting too long for urgent surgery and an absence of any consistency in approach for the treatment of similar conditions.
Long waits for urgent care
The most significant variation between services was the waiting time for clinically urgent surgery. The 3 core pathways were reviewed:
- An AAA is a bulge or swelling in the aorta. Once a patient is identified at risk surgery should be delivered urgently - the longer the wait the greater the risk of fatal rupture. The average wait time for elective surgery ranged from 5 to 21 weeks. Reported costs for elective procedures varied between £2,251 and £19,690.
- Minor strokes or transient ischaemic attacks are key warning signs of a major stroke. To prevent this CEA is recommended to improve blood flow to the brain. NICE Guidance recommends this takes place within 14 days of diagnosis. At least 18 of the 70 providers failed to meet this recommended timeframe and in 4 providers the average wait was 28 days or more. In contrast 2 of the providers were able to move from diagnosis to surgery within 5 days – therefore making it far more likely that a major stroke would be avoided.
- Lower limb revascularisation is the most common type of vascular surgery with over 22,800 procedures conducted per year. If left untreated patients experience agonising pain and can develop gangrene or require amputation. If identified sufficiently early blood supply can be restored through revascularisation procedures. The report noted that timely revascularisation could help to avoid a proportion of the current 8000 amputations performed annually in the NHS.
Various reasons were proffered for the delays including lack of facilities, staff and integration with other departments. While no single cause for the delay was identified, it was noted that the service 'was not configured to meet the clinical need'. The fact that vascular surgery is currently restricted to 'normal working' hours and therefore immediately limited the number of procedures per week was considered crucial. Currently, only 6 NHS Hospitals offer elective vascular surgery at the weekends despite having on-call teams in place for emergency surgery.
What were the recommendations ?
Adoption of a network model to allow 'urgent' care to provided 7 days a week
Of the 17 recommendations the pivotal change underpinning the transformation would be that all patients were treated on an 'urgent' basis, rather than the historical division between elective and emergency surgery which was deemed inappropriate. This urgent care would be provided by creating 'hub and spoke networks' which would hold the capacity and flexibility to offer a 7 day service.
To achieve this GIFRT expected there would need to be a reduction in the number of vascular units. Theatre activity 7 days a week would not be justified on either volume or cost for each hospital. The hub hospitals would be fully equipped and resourced to carry out the majority of all procedures. Centralising resources and expertise at a 'hub' has a number of benefits including a greater number of surgeons available in one location and pooled budgets to invest in facilities. Creating larger teams and better equipped vascular wards would in turn would provide greater patient choice. A larger pool of patients would allow for greater overlap with other medical disciplines such as cardiology, radiology and geriatric care making it easier to provide a multidisciplinary approach.
This model is not new and is working already in different parts of the Country. Existing hubs could be strengthened, and others created although there would be cultural, financial and logistical barriers to overcome.
Working together to reduce length of stay and readmission
It was reported that this new service model, which required close working relationships with other medical specialities, would also assist in achieving several other recommendations within the report; better outcomes, improved perioperative care, rehabilitation and post-operative care. That in turn this would reduce the length of stay and volume of readmissions.
Addressing data quality issues
As part of the review significant discrepancy was noted between the activity recorded within the National Vascular Registry, as opposed to the Hospital Episode Statistics. It was recommended that data collection in both be improved allowing for better future planning and improvement of services. To do so a cultural shift was required whereby data collection was perceived as important and valuable and a tool for individual surgeon feedback during appraisal.
Increasing consistency and reducing costs
The process also identified substantial variation in costs of certain procedures, which was not borne out by correlations in outcomes. As well as procurement playing a role here, it was also noted that a contributing factor was where patients were cared for post-operatively. Those units which chose HDU or ITU increased costs significantly as opposed to those units where patients were cared for on a dedicated vascular ward with enhanced nursing staff.
A comparison of procurement costs similarly found great variation in purchase of the same products albeit different brands. Vast savings could be made by improving procurement and supply chain efficiency. The report calls for greater transparency, aggregation and consolidation to allow for best spending practice.
In terms of litigation, data from NHS Resolution estimated claims following a vascular procedure to a value of between £26m and £41m per year over the past 5 years. When individual units were compared for major vascular surgery the average cost was £650 per admission, with a cost of £6,413 per admission for one particular provider. It was reported that lack of informed consent played a role in many claims which were attributable to poor outcomes or perception of poor judgement or timing. It was recommended that units follow the GIRFT Programme five point plan as described in the GIRFT Litigation in Surgical Specialties data pack. A more systematic learning from claims was also advocated.
Making it happen - implementation
The report underlines a need to transform the service at pace and to be complete by July 2019. Trusts are expected to develop an implementation plan based upon the specific recommendations set out within their GIRFT visit as well as the 17 recommendations within the report.
It is acknowledged that this may be challenging and to assist GIRFT has set up regional hubs across England to support Trusts, amongst other things, providing management and clinical advice. It is also envisaged that the hubs will lead to buddying processes to help spread best practice between Trusts, and manage dependencies with other transformations efforts including STPs, ACCs and NHS RightCare.
Each unit within the programme will be provided with a GIRFT data pack which will compare the Trust's performance with national data, enabling the trust to see how its activity levels, commissioning decisions, costs and patient outcomes for different procedures measure up to those of its peers. These packs are designed to provide insight for trusts and will be discussed in specialist meetings between the Trust and clinical leads appointed by GIRFT. In areas where the Trust is underperforming these can be explored and explanations considered. Conversely if outperforming peers, clinical leads will seek to understand what the Trust is doing differently and how its approach could be adopted by others to improve performance across the NHS.