Vascular Services (Warrington)

Helen Jones Excerpts

Monday 28th November 2011 Commons Chamber

[Helen Jones (Warrington North) (Lab)]

I am very grateful to have the opportunity to discuss vascular services in Warrington, and in particular the decision not to locate a vascular centre there. The review of vascular services conducted by the NHS in Cheshire and Merseyside was fatally flawed. It has no proper evidence base. It failed to engage clinicians in Warrington and Halton and it demonstrated a singular lack of transparency. It failed to adopt the open and transparent procedures used elsewhere and instead held only two meetings—one for staff and one for the public—to cover the two counties. The survey it carried out was on the internet, thus excluding many of the people in the centre of Warrington and in Halton who do not have internet access. The conclusions it drew from that survey were rather bizarre. Although people said that they valued safety first, it does not mean that the position adopted by Cheshire and Merseyside NHS makes things safer. Anyone who follows that flawed logic should not be conducting a review of services in the first place.

We have been left with a decision that will damage service at Warrington and Halton Hospitals NHS Foundation Trust and dismantle the partnership working that has been built up with St Helen’s and Knowsley NHS Trust over the years. It has left unanswered some serious questions about co-dependent services and about possible increased risk and mortality elsewhere. This is a shabby little stitch-up that cannot go unchallenged. If the Minister wants to champion local decision making, it is his duty to ensure that those decisions are properly based on evidence and are reached through due process. That has not been the case here.

This review started by looking at “evac” procedure. It then mutated into a review of vascular services as a whole. It is never a good sign when that sort of slippage occurs. The review then decided that any centre must carry out a minimum of 50 open aortic aneurysm repairs and 100 carotid endarterectomies. Where is the evidence for these figures? The Royal College of Surgeons has never recommended them and many other centres operate using different minima. The suspicion is that the figures were chosen to bolster the case for two centres rather than three, yet Great Manchester will have three, as will Cumbria and Lancaster. Unless the Minister is prepared to argue that centres operating on different minima are unsafe—I do not believe that he is prepared to argue that—there is no evidence base for these figures.

[Derek Twigg (Halton) (Lab)]

I congratulate my hon. Friend on securing this debate and on making an excellent speech. She said that the Minister will probably argue that this is a matter for local decision making but she has shown that there is no clear evidence base, so one would hope that the Minister would ensure that the matter is reconsidered.

[Helen Jones]

My hon. Friend is right. I want to come to some of the other evidence and how the review was carried out. The decision was eventually taken that one centre would be located in Liverpool and one at the Countess of Chester hospital. Originally, the review panel allowed both Liverpool and Chester to take away their submissions and rewrite them from June until October, but it did not allow the same leeway to Warrington and Halton NHS trust. After protests from overview and scrutiny committees, it allowed them only seven days. That is not a fair process.

It is also clear that the review panel originally had reservations about locating a centre at Chester in partnership with Wirral university hospital. It said that

“there were a number of outstanding questions about how the proposed arterial centre would work clinically”.

However, when we asked how those clinical problems have been resolved, answer comes there none.

There were other questions about the skills base, co-dependent services and possible increased mortality rates elsewhere, which it is clear from the impact assessment carried out for Warrington have not been resolved. We were left with the decision to base a centre at Chester—a decision that, I understand, was queried even by its partner at Wirral university hospital NHS trust—that has been designated the south Mersey centre. I have to tell the Minister that I was born and bred in Chester, and it is not on the Mersey but on the Dee, and it is difficult to get to it from elsewhere in the region.

The result of this decision is that centres are concentrated in a relatively small area—one in Liverpool, one in Chester and a satellite one in the centre of the Wirral. There is nothing in the review for those who live in north or east Cheshire, and as a result emergency patients from the Warrington area will now have to travel 30 miles by emergency ambulance instead of the maximum eight miles as before. Those who wish to travel by public transport will, because of the different combinations of buses and trains, be facing a journey of three to four hours. That is important because car ownership in Halton and the centre of Warrington is lower than the national average—people are reliant on public transport.

The questions about access, which were deemed to be important, have not been resolved but there are other troubling issues. It seems that the review—based, after all, on flawed evidence—will form the basis for decisions on other specialties. For example, the review stated that it was highly desirable, if not essential, that hyper-acute stroke units be located with vascular centres. That indicates that Warrington’s chances of getting these services in the future are limited. However, the review also undermines existing stroke services in Warrington—services that are highly rated and delivered in partnership with St Helens and Knowsley trust. If a vascular surgeon is not to be on site, those stroke services will be undermined.

The same is true of trauma care. The review thought it desirable that in the future trauma centres be co-located with arterial centres. That would seem to be pre-judging where those services will be located in future.

As things stand, Warrington often deals with serious cases because it is at the centre of a motorway network. Many will need a vascular surgeon, as well as other specialties. The response from the review was that patients could be stabilised by a general surgeon and that a vascular surgeon would be on site within 30 minutes. Frankly, anyone who knows Warrington’s traffic will know that that is absolute nonsense. The North West Ambulance Service gave evidence to the impact assessment panel about gridlock in Warrington. If the service cannot guarantee that it can get an emergency ambulance through, there is little chance of getting a surgeon through. Indeed, I have done the journey from Chester to Warrington many times, because I still have relatives there. It is not possible to do it in 30 minutes at peak time—one has to get through the traffic in Chester, go along a congested motorway and then get through the traffic in Warrington. Where on earth have those figures come from and how have they been validated?

The suspicion is that the review has been carried out in a cavalier manner in order to fit a predetermined outcome. Indeed, there are also concerns arising from the impact assessment, because the points put by clinicians in Warrington appear to have been accepted, yet nothing has been done about them. For instance, the review panel received evidence that the vascular services in Warrington were well developed and had worked over 10 years in partnership with St Helens and Knowsley trust. The panel accepted that it was desirable to maintain that partnership and that disrupting it was contrary to practice elsewhere in the NHS. The panel said that it hoped that the partnership would be maintained. However, the clinicians in the St Helens and Knowsley trust had already given the panel evidence showing that it could not be maintained if the recommendations of the review were accepted, because transfer times and transport difficulties would mean having to partner with Liverpool.

Similarly, the North West Ambulance Service gave evidence showing that it could not guarantee ambulance response times in Warrington if it had to transfer patients from Warrington to Chester. The service’s figures were accepted by the impact assessment panel, which then said that it was drawing the matter to the attention of commissioners as a cost not yet planned for. Where will the extra money come from to fund extra ambulance services in Warrington, given that the NHS is already expected to take cuts of £20 billion? If the Minister wants to get up and promise us extra money for Warrington ambulance services, we would be very pleased to hear from him, but I do not think he can.

Similarly, the ambulance service drew attention to the fact that Warrington is uniquely prone to gridlock, because if an accident happens on the motorway system, it can gridlock the whole town. The response from the panel was that gridlock was “challenging”. Not being able to get an emergency ambulance through is not challenging; it is life-threatening. Indeed, it is really quite arrogant to dismiss the concerns of those responsible for transferring patients in that way.

However, worse was to come. The clinicians from Warrington and Halton—who, at this stage in the process, were now being consulted for the first time—gave evidence about the impact of removing vascular services on other specialities. In particular, they were concerned about the problems of ensuring support for vascular injury in other surgical procedures and invasive specialities. The panel then said that the volume of patients needing to be transferred could become “unmanageable”. It also said that the number of patients whose services would be disrupted might be greater than the small number who would see an improvement. All that was asked of the review panel was that it should publish its evidence at the same time as its implementation plan. Frankly, that is the wrong way round: if the evidence is not there, there should not be an implementation plan to start with.

[Derek Twigg]

My hon. Friend is most generous in giving way again. I am sure that she will discuss this further, but the areas covered by the two hospitals—Whiston, Warrington and Halton; and Knowsley, St Helens and the centre of Warrington—are some of the most deprived boroughs in the country, and yet the services are being transferred to one of the most affluent parts of the north-west. Does she not think that an odd way to deal with populations that suffer the most ill health?

[Helen Jones]

I agree. One thing that the review appears not to have looked at properly is the incidence of these sorts of vascular illnesses and where the centres should be located to deal with them.

Another interesting issue is that clinicians told the panel that more and more patients would need to be transferred over time as a result of not having vascular services on site. In fact, one clinician on the panel expressed the view that the

“lives at risk in these situations, equalled, or outweighed those saved by the anticipated improvements.”

I have to ask what sort of service improvement it is that can put more lives at risk. Evidence was also given about the difficulty of maintaining cancer services without support from vascular surgeons—Warrington is a centre for renal cancer—about the difficulty of maintaining limbs compromised by diabetes without having those surgeons on site and about the waste of resources, with Warrington having invested in new facilities. It has the most modern vascular lab in the region and the only fully compliant one. That will go to waste if vascular services are transferred, and we will spend millions elsewhere in providing new services on another site.

In short, what we have is a proposal that breaks an existing working partnership—one that has provided highly rated services—that could harm co-dependent services, that could impact on ambulance transfer times in a way that puts other patients in Warrington at risk and that wastes services. In the end, it will seriously damage services at Warrington hospital. In fact, I am told that a consultant interventional radiologist who had already been appointed has now declined to come because of this decision. Yet an implementation plan is going ahead even before we have begun the consultation. That is no consultation at all.

I ask the Minister to look at this seriously. I will support changes in services where they can be shown to improve patient care. I cannot support them where there is no evidence that they will improve patient care and there is a lot of evidence that they will damage patient care in other specialties. The ultimate responsibility, I say to the Minister, is his. I have agreed with Mrs Thatcher on only one thing—when she said:

“Advisers advise, and Ministers decide.”

He has to look very seriously at what has been going on here and he needs to act before other services in Warrington are damaged.

[The Minister of State, Department of Health (Mr Simon Burns)]

I congratulate the hon. Member for Warrington North (Helen Jones) on securing this debate, and I totally agree that it is important for patients to have access to high-quality vascular services. I know that she is an active campaigner locally on health issues and a strong supporter of local health services.

The hon. Lady has raised a number of issues about the current review of vascular services in Cheshire and Merseyside. I appreciate that her constituents may be concerned about proposed service changes and want to be assured that they will have access to these services. Due to the shortage of time available, I hope she will forgive me if I do not go into the detail of the background at national level of all that the Government and the NHS are doing on vascular services, health checks, screening and so forth. I would like to address the situation in her constituency that she has raised. If I do not have enough time to provide all the answers to her questions, I assure her that I will write to her.

Currently, the commissioning of complex vascular services varies. In some areas, they are commissioned by regional specialised commissioning groups, but in others they are commissioned by individual primary care trusts. Evidence shows that, in order to maintain the safety and quality of these services, it is better that they are commissioned for larger populations.

There is robust evidence, highlighted by the work of the Vascular Society of Great Britain and Ireland, which shows that patient outcomes are best when complex vascular care is delivered by units that treat higher volumes of patients. In response to that evidence and national screening for abdominal aortic aneurysms, vascular services are being reviewed locally across England.

Reflecting that approach, in June 2010, the NHS in Cheshire and Merseyside embarked on a review of the way in which vascular services are delivered. It deals with non-cardiac vascular services for conditions such as abdominal aortic aneurysms, strokes and mini-strokes. Cardiac services continue, and will continue, to be provided in local hospitals in Cheshire and Merseyside. Vascular services are provided by nine district hospitals across Cheshire and Merseyside, including Warrington hospital in the hon. Lady’s constituency.

The review proposes that local hospitals should work in partnership to deliver the range of vascular services, with arterial complex interventional radiology and emergency surgery being carried out in a small number of arterial centres. Out-patient clinics, initial investigations and follow-up treatment will continue to be provided in local hospitals, including hospitals in Warrington and Halton. Patients with a vascular emergency will be taken to their nearest local hospital—unless the referring GP suggests otherwise—where they will be stabilised. If they require further emergency or arterial surgery, they will be transferred to the arterial centre. I have been informed that vascular surgeons will be based at local hospitals as well as arterial centres, which will ensure that patients can have access to their expertise.

[Helen Jones]

How many vascular surgeons will be based at Warrington, and what kind of rota will there be? The Minister knows as well as I do that problems occur with rotas when those surgeons are not available.

[Mr Burns]

Given that I want to deal with some of the other points raised by the hon. Lady, may I write to her about that? Given the shortage of time, I suspect that I shall also have to write to her about a number of other issues.

The Cheshire and Merseyside vascular review project board led the review, and was advised by a clinical advisory group consisting of local clinicians, including some from Warrington. The group developed a set of standards that each vascular network would need to meet, along with locally agreed minimum activity thresholds. They were considered in the light of the size of the population served by Cheshire and Merseyside. On the basis of advice from the clinicians, the project board concluded that, given the clinical activity and population size, it would be best for two vascular networks to serve populations in north and south Mersey, and that each network should have its own arterial centre.

In January 2011, the project board undertook a pre-consultation of local people, which included public and NHS staff meetings. They presented the pre-consultation to the local overview and scrutiny committees in every local authority across Cheshire and Merseyside, and wrote to local MPs, including the hon. Lady and, I assume, the hon. Member for Halton (Derek Twigg) and my hon. Friend the Member for Warrington South (David Mowat). In October 2011, the board provided the commissioners in Cheshire and Merseyside with a report setting out its findings and recommendations. The report proposed that the arterial centre in the north Mersey network should be based at Royal Liverpool university hospital, while the arterial centre in the south Mersey network should be based at either Warrington hospital or Countess of Chester hospital. However, the final decision was left to commissioners.

The two joint bids for the south Mersey network from the Warrington and Chester trusts were presented to the clinical commissioning group chairs in Runcorn, Widnes, Warrington, Wirral and Western Cheshire. The commissioning groups, including Warrington, unanimously decided to recommend to the PCT cluster board that the arterial centre for the south Mersey network should be based at Countess of Chester hospital. I understand that they felt that the joint bid from Chester and Wirral contained the most credible plan for developing a networked vascular service for the populations of Warrington, Halton, Western Cheshire and Wirral, while facilitating a full range of local hospital services. I appreciate the hon. Lady’s concerns about the impact on Warrington hospital of the arterial centre being located at Chester. I understand the project board commissioned an impact assessment of the changes on Warrington, which highlighted a number of issues, but it concluded that these could be mitigated. The proposals have been considered by the Cheshire, Warrington and Wirral and Merseyside primary care trust cluster boards, which have supported the project board’s recommendations, subject to formal public consultation.

The proposals will also be subject to gateway review and national clinical advisory team assessment, as well as assurance from NHS North West that they meet my right hon. Friend the Secretary of State for Health’s four tests for service change: the proposals must demonstrate strengthened public and patient engagement; be based on sound clinical evidence; there must be support from GP commissioners; and there must be consideration of patient choice.