Vascular Services (Wycombe Hospital)

Tim Farron Excerpts

Monday 14th January 2013 Commons Chamber

[Steve Baker]

My hon. Friend raises an important point about transport, which will be an issue for many of our constituents, not least because they will not have cars.

People in need of vascular care will include those with abdominal aortic aneurysms, a life-threatening weakness of the main artery that must be repaired, and those who have had strokes or mini-strokes—transient ischaemic attacks. After a stroke, drugs are administered immediately, but they need to be followed up with a procedure to clear the carotid artery, called a carotid endarterectomy or, mercifully, a CEA. Other people requiring care will include those with poor blood supply, including smokers and diabetics, who might endure serious complications that might even lead to amputation.

Wycombe hospital provides the full range of services. It is proposed to move them all to Oxford university hospitals on the basis that the present arrangements are “not sustainable”, but I have yet to see evidence that supports that assertion. Leaked documents suggest that Oxford provides worse outcomes and is struggling to be ready.

[Tim Farron (Westmorland and Lonsdale) (LD)]

I am extremely grateful to my hon. Friend for giving way and congratulate him on securing the debate. Further to the point raised by my hon. Friend the Member for Lancaster and Fleetwood (Eric Ollerenshaw), in the north-west the number of units will go down from four to three. Folks in Morecambe bay will no longer be able to go to Lancaster but will have to go to Carlisle, Blackburn or Preston. Does my hon. Friend the Member for Wycombe (Steve Baker) agree that the majority of vascular surgery these days is not elective but acute, following road traffic trauma and incidents such as coronary emergencies? We are talking not about elective surgery but about acute emergency provision, so it is vital that the services are close at hand.

[Steve Baker]

My hon. Friend is possibly inviting me to stray beyond my expertise, but perhaps the Minister can deal with that point. The concern in Wycombe is about elective treatment of aneurysms, and particularly the treatment that goes with stroke services. The key concern is that it is an excellent service that will be degraded if it is moved to Oxford, according to the clinical evidence.

I am grateful to Dr Annet Gamell, chief clinical officer of the Chiltern clinical commissioning group. She has given me a clear explanation of the position in Buckinghamshire, which is that things are waiting on the outcome of the review in 2014. Once a new theatre is open at Oxford, it is proposed that all complex elective vascular surgery will go there. It is planned that outpatient and diagnostic services will remain at Wycombe. CEA services would be subject to review in 2014, and I understand from Dr Gammell that the group would support moving CEAs to Oxford only if results indicated that patients would benefit from it. The Chiltern clinical commissioning group would take into account the impact of such moves on other services. Dr Gammell points out that if it is agreed to transfer CEAs to Oxford, there would be another local consultation, but on the basis of recent experience it is not clear to me what end that consultation would serve. The decision would have been made and it is clear that there is vast momentum to take services in that direction, despite the clinical evidence.

The key performance indicators for the south central cardio-vascular network show that in the first two quarters of the 2012-13 reporting year, Wycombe performed 17 aneurysm repairs and Oxford 16. Wycombe carried out 31 carotid endarterectomies to Oxford’s 47. Almost half of patient records at Oxford did not provide the dates of patients’ symptoms. Eighty per cent. of CEA patients at Wycombe received the procedure within two weeks of referral. At Oxford, the figure was just 23%, although patients seem to have received their treatment within 48 hours of symptoms. At Wycombe, 58% of patients were treated within 48 hours. Oxford achieved a ratio of total vascular interventions to amputations of 4.55:1, whereas at Wycombe the ratio in the period was 8:1, which shows a considerably greater degree of success in maintaining people’s limbs in very difficult circumstances.

The clear clinical evidence in that period is that Wycombe outperforms Oxford, and it does so with fewer clinical staff. All this is not mentioned in the “Oxford University Hospitals Review of Phase 1 of the Centralisation of Vascular services”, which has been sent to me under cover of a letter dated 12 August from the chief executive of NHS Berkshire. It was among a number of documents leaked to me. The report describes the resignation of a vascular consultant, Mr Peter Rutter, following significant difficulties associated with the move from Wexham Park to Oxford. Those difficulties including antiquated theatre instruments, poor quality theatre lighting and patient safety issues.

Mr Rutter observed:

“Vascular surgery is not very important in Oxford and would take 5 years to bring up to standard.”

He also said that vascular had no champion at Oxford, which is confirmed in other documents. Other remarks in the review include, for example,

“Many outlying district general hospitals have better endovascular facilities”,

“Oxford is not a modern endovascular hospital”

and

“Oxford has no culture of multidisciplinary working”,

which is essential when vascular supports those other specialties. Furthermore,

“Little thought had been given to the effect on Interventional Radiology in DGHs”

and very worryingly, an

“Oxford senior surgeon threatened to make Bucks vascular surgeons redundant unless they toed the line.”

A comment in the review implies that Wycombe’s excellent interventional radiologists would join Oxford University Hospitals only if CEA and bypass surgery stayed at Wycombe, which has been rejected. Presumably, these valuable experts who make the excellent service possible will resign and go elsewhere.

In summarising, the review explains that the impression had been given that OUH had not properly thought through the implications of centralisation. In discussing theatre upgrades, it concludes that

“there remain concerns about the quality of lighting, ventilation, anaesthetic facilities and sterility.”

I am only a humble aerospace and software engineer, but it seems to me that these are fairly basic concerns. Despite all this, the review clearly states:

“It will not be possible for carotid surgery to remain in Wycombe as CE and CAS will not be commissioned from Wycombe beyond 2013.”

Surely this is a matter for the commissioners.

The reviewers are clear that it is not viable for Wycombe to keep carotid surgery and bypass, but they do not state the evidence for their assertion beyond the new status of vascular as its own specialty. Before making recommendations, the review says:

“OUH practices Vascular Surgery more like a DGH than an important Teaching Hospital. Several of the surrounding DGHs, currently being centralised into Oxford, probably provide a better endovascular service.

Vascular surgery at OUH seems to be safe but has not developed in the way that it has in other hospitals in the United Kingdom. It seems to be positioned about ten to fifteen years behind the best.”

Notwithstanding the evidence of superior performance at Wycombe and shortcomings at Oxford, the review insists that vascular services must transfer, ultimately on the basis that it is inevitable that vascular services will be co-located alongside Oxford’s major trauma unit. That is a blatant rejection of the principle that is constantly used to justify centralising services away: clear clinical evidence. All the time that Wycombe provides better care and the team can provide it sustainably, in its opinion, and while local commissioners are prepared to buy it, why surrender to Oxford’s desire to be the Thames valley super-hospital, whatever the cost to patients?

Any responsible Member would admit that the trend in health care is towards specialisation. When my hon. Friend the Member for Bracknell (Dr Lee) was describing his Thames valley super-hospital proposal in Marlow, he said that any politician who claimed that they could restore A and E to a district general hospital would be a liar. I am grateful that I have not fallen into that trap, but it illustrates a point. Politicians are accountable to their electorates and businesmen are accountable to their customers, but managers and clinicians in the NHS who follow rules and guidelines seem to account seriously only to one another and, significantly, to do so on the basis of who carries the greatest authority through prestige.

In the midst of all that, senior NHS executives keep circulating. Stewart George and Fred Hucker—irrespective of their individual merits—who chaired the Bucks and Oxfordshire PCTs, became joint chairmen of the cluster. Mr George is now moving to the CCG, and Mr Hucker to Buckinghamshire hospitals trust. A new era of openness, accountability and genuine public involvement seems unlikely, and continuity seems a dreary inevitability, but all that ought not to be.

Vascular services in the Thames valley appear to be not so much sleepwalking into disaster as positively driving towards it. Vascular services in Wycombe are not some ditch and gatepost operation to be salvaged by the great Oxford University hospitals, as Wycombe outperforms them with a smaller team. In this regard, it is the John Radcliffe that needs saving.

Let me ask the Minister some specific questions. Is the Chiltern CCG able to insist that it will purchase vascular surgery from the Bucks health care trust at Wycombe despite national guidelines? What are the roles and authority of the NHS Commissioning Board, the local health and wellbeing board and the south central vascular network? Crucially, has the elevation of vascular surgery out of general surgery and into a specialisation of its own led to such things as turf wars, demarcation disputes and office politics? What formal influence are locally elected representatives—councillors and MPs—supposed to have?

Wycombe has had its own hospital since 1875. The current hospital was not founded by the NHS; it was built in 1923 with donations from local people, which were mostly given in pennies, as a memorial to the men we lost in the great war. The public are therefore right to be incandescent with rage at changes that appear to be driven by remote sectional interests, not local patient care.

Recently, my right hon. Friend the Secretary of State said:

“I need to say this to all managers: you will be held responsible for the care in your establishments. You wouldn’t expect to keep your job if you lost control of your finances. Well don’t expect to keep it if you lose control of your care.”

What is needed is real accountability. Let us get health under the control of the people who pay for it and start by keeping vascular at Wycombe for all the time that that remains in patients’ best interests.

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

I congratulate my hon. Friend the Member for Wycombe (Steve Baker) on securing the debate and raising issues that are pertinent not only to his constituents but to those of my right hon. and learned Friend the Attorney-General, who has been sitting next to me on the Front Bench listening to the debate and who shares a number of my hon. Friend’s concerns.

Before I discuss the substantive points about Wycombe, I should address my hon. Friend’s point about failing management in the NHS. He is right that there is a tendency to recycle failing managers in the NHS, and I am sure that the House will return to that point when my right hon. Friend the Secretary of State responds to the concerns raised in the Mid Staffordshire inquiry, following the Department’s receipt of the report.

It is worth paying tribute to the dedicated health care workers in Wycombe and the surrounding areas of Buckinghamshire, because my hon. Friend has a number of excellent clinicians. He highlighted several local successes in delivering high-quality care through vascular surgery, and I know that there are good outcomes locally in specialties such as carotid endarterectomy. He has many excellent doctors and nurses and other front-line health care professionals, and also some very good managers, who have the best interests of their patients at heart and deliver high-quality health care outcomes for local patients on a daily basis, 365 days a year.

My hon. Friend rightly highlighted some local concerns about the ongoing loss of services at Wycombe hospital, and it is worth reiterating some of his words. He said that the hospital had lost A and E, consultant-led maternity—retaining a midwifery-led unit as a concession —and paediatrics, and this year the emergency medical centre was downgraded to a minor injuries unit, resulting in a repeat of much of the local outcry at the loss of A and E, and now he has highlighted eloquently the concerns over the potential loss of some of the vascular services at the hospital.

It is worth pointing out that I was reassured today before coming to the debate by local health care commissioners in the Wycombe area that there is a strong future for Wycombe hospital. There is no threat of the hospital being downgraded to the point of closure. Commissioners today reassured me—and I hope that this reassures my hon. Friend—that in many areas Wycombe provides a very good site further to develop health care services the better to meet the needs of the local population. It is an excellent satellite site, combined with Stoke Mandeville, for providing high-quality, close-to-home health care. From discussions that I have had, I believe that there may be the possibility of improving further some of the cardiac care that is offered.

I come specifically to the issues that my hon. Friend raised about vascular services, which are particularly important in Wycombe, which has a large Asian population, among whom, as we all know, there is a higher rate of cardiovascular disease. It has a higher rate of diabetes and many cardiovascular illnesses. My hon. Friend highlighted eloquently the number of local vascular services provided, and particularly referred to amputation services. We know that one of the complications of vascular disease and diabetes is the higher rates of amputation among some patients. It is quite right that he wants to make sure that high-quality services are provided locally to meet the established need for patients who require vascular services, and that those patients have a holistic service that looks not just at their immediate medical needs but provides high-quality surgical care.

We know that as lifestyles, society and medicine change, the NHS must continually adapt. The NHS has always had to respond to patients’ changing expectations and to advances in technology. When we do change and reconfigure services, it must be about modernising facilities and improving the delivery of high-quality patient care. In that context, it is also important that while we have to recognise that some services are better provided in larger centres of care— for example, the John Radcliffe centre, which can offer super-specialist services—where the clinical outcomes for patients are better, we must also provide high-quality local services, particularly for older people. We know that the majority of vascular patients often fall into an older age demographic, and it is important that when there is any service reconfiguration, those day-to-day outpatient clinics for vascular patients are maintained locally. I am reassured that in the potential reconfiguration, bread-and-butter outpatient clinics and continuity of care for vascular patients will be maintained.

The Government are also clear that the reconfiguration of front-line health services is a matter for the local NHS. Services should be tailored to meet the needs of local people, and the four tests laid down in 2010 by the previous Secretary of State for Health, my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), require that local reconfiguration plans demonstrate support from GP commissioners, strengthened public and patient engagement, clarity on the clinical evidence base and support for patient choice. If my hon. Friend is worried that these tests have not been met in the local reconfiguration, he has the opportunity directly to challenge them or to ask the local health scrutiny committee to refer them to the Secretary of State for review.

[Tim Farron]

The Minister rightly says that the NHS reforms allow local councillors to vote to refer such matters to Ministers. In my area of Morecambe bay, that opportunity comes on 22 January. Will he assure councillors that Ministers will take such referrals very seriously and look into them with great rigour?

[Dr Poulter]

Yes. I assure my hon. Friend that when a referral is made by a local overview and scrutiny panel the Secretary of State will look at it and decide whether to refer it to the independent reconfiguration panel. That is often the decision that is made in these cases, but it lies initially with the Secretary of State, who will then have to consider whether to refer it. I am happy to write to my hon. Friend further to outline these steps if that would be helpful.

It is worth highlighting the national parameters that are being set for the delivery of good vascular surgery by the NHS Commissioning Board, which takes over full responsibility for commissioning from April this year. The board published a draft national service specification for vascular surgery for consultation. The consultation commenced in December 2012 and will conclude on 25 January 2013. It identifies the service model, work force and infrastructure required of a vascular centre. It says:

“There are two service models emerging which enable sustainable delivery of the required infrastructure, patient volumes, and improved clinical outcomes. Both models are based on the concept of a network of providers working together to deliver comprehensive patient care pathways centralising where necessary and continuing to provide some services in local settings…One provider network model has only two levels of care: all elective and emergency arterial vascular care centralised in a single centre with outpatient assessment, diagnostics and vascular consultations undertaken in the centre and local hospitals.

The alternative network model has three levels of care: all elective and emergency arterial care provided in a single centre linked to some neighbouring hospitals which would provide non arterial vascular care and with outpatient assessment, diagnostics and vascular consultations undertaken in these and other local hospitals. All Trusts that provide a vascular service must belong to a vascular provider network.”

In essence, this is about making sure that we deliver high-quality vascular care. There are two or three circumstances in which someone would require vascular care. First, there is emergency care—for example, when there is a road traffic accident, or when someone has a leaking aortic aneurysm, which is a very severe and potentially life-threatening emergency. We know from medical data that such service provided in an emergency is much better provided in a specialist centre—an acute setting such as the John Radcliffe, which would be the hub and the central focus. There is also good evidence that trauma care in any setting, including the requirement for neurological specialists potentially to be involved, is better served in a specialist trauma centre. A specialist centre provides better care in emergencies.

At the same time, it is clear from those models that there can also be a strong role for other hospitals as satellites of the central hub at the John Radcliffe. My hon. Friend clearly made the case for the high-quality outcomes at Wycombe hospital for carotid endarterectomies and other vascular services. I would suggest that there is a role for challenging local commissioners if they wished to remove some elective procedures from Wycombe when there is a case that they can still be delivered in a high-quality manner and to a good standard for patients.