Analysed: reconfiguration planned for Merseyside vascular services

Last Wednesday (4 July 2012) NHS Cheshire, Warrington and the Wirral approved a controversial plan for the reconfiguration of vascular services across its patch and Merseyside.

The proposal is to relocate all arterial surgery, and some complex endovascular procedures, to two sites. The Royal Liverpool University Hospital would be designated the “arterial centre” for the north of the health economy, and the Countess of Chester Hospital for the south. The proposals for the north have met with relatively little resistance, and are expected to remain largely uncontested when the reconfiguration plan goes to the board of NHS Merseyside next week (17 July). The proposals for the south, however – which would see some services transferred out of Wirral University Teaching Hospital Foundation Trust and Warrington and Halton Hospitals FT – have been the subject of heated controversy. They have faced opposition not only from local residents and councils in both areas that would see lose complex services, but also from MPs and some vascular consultants in Wirral, and Warrington and Halton Hospitals.

Background

Work began on the reconfiguration plan for the sub-region around two years ago. In common with other parts of the country, the commissioners aim to remodel services in line with Vascular Society guidance, which states that concentrating some procedures in specialist high-volume centres will better prevent unnecessary deaths, strokes and amputations. According to the National Clinical Advisory Team, vascular reconfigurations across England are being driven by research which has found that the country has poorer outcomes for arterial surgery than its international peers. “In particular,” states its review of the Cheshire and Merseyside proposals, “a European report suggested that the mortality from aneurysm surgery in the United Kingdom was significantly higher than that reported elsewhere in Europe.”

“Alongside these poor mortality results,” it continues, “there have been a significant number of studies published in recent years that have documented a significant association between the individual hospital operative case load for aortic surgery and outcome… Increasing case load is associated with better clinical outcomes, access to endovascular surgery and an increase in the percentage of patients offered emergency aortic surgery.”

In Cheshire and Merseyside, the proposals are also being driven by the need to prepare for the advent of the national screening programme for abdominal aortic aneurisms, which is due to be introduced in area in January 2013. According to NCAT, the programme requires a population base of at least 800,000 to “sustain the activity within the vascular surgical centre associated with the screening programme”. It notes that Merseyside and Cheshire have a population of around 2 million, suggesting that the region can sustain two arterial centres. “It may be,” the NCAT review states, that “world class outcomes” can only be achieved by an arterial hub with a catchment population in excess of 800,000. “If three hubs were commissioned,” it continues, “there is a distinct possibility that outcomes would not be sufficiently improved and that a further reconfiguration would be required in a relatively short space of time.”

The dilemma for Cheshire, Warrington and Wirral was which hospital should become this hub. There is “no obvious and natural choice of arterial hub in the South Mersey region,” according to NCAT. The three sites currently accommodating complex vascular work – the Countess of Chester, Wirral FT’s Arrowe Park hospital, and the Warrington and Halton trust’s Warrington hospital – are all “moderate to low volume vascular providers” in national terms. The commissioners’ review received two applications to form “vascular networks” in the south: a joint bid by Wirral and the Countess to site the arterial centre in Chester, and a bid by WHH and St Helens and Knowsley Teaching Hospitals Trust to form a “mid-Mersey network” with Warrington Hospital as the arterial centre. A panel convened to appraise these options – including Mike Wyatt, secretary of the Vascular Society – concluded unanimously in favour of Chester as the arterial centre, NCAT states. While there have been various points in favour of each of the potential sites, it is significant that the Countess sits roughly in the middle of the geographical area to be covered by the network. The paper approved by the primary care trust cluster’s board last week states that locating the centre in “either Wirral or Warrington would potentially exacerbate the travel issues for those patients and visitors who would then need to travel between those two localities rather than to Chester”.

• Download this HSJ Local Briefing now (PDF)

Opposition

When plans first emerged to site the South Mersey arterial centre in Chester, Warrington and Halton Hospitals came out publicly against having just two centres for Cheshire and Merseyside.

In a statement released by the trust on 17 August last year, chief executive Mel Pickup said: “We feel it is vital that we have the opportunity to maintain and develop our vascular service for local patients and our view is that there should be three centres across the region.

“We have the expert staff here who have developed our service to the highest standards and we are perfectly located to provide access to high quality vascular services to a large local population.”

The trust raised concerns about the impact on local people if they had to travel to Chester or Liverpool for emergency treatment, and about the links between vascular services and other “key clinical services” it provided.

These concerns were echoed in the opposition of local residents and politicians. On 8 June this year Warrington South Labour MP Helen Jones submitted a petition of 1,220 signatures to the cluster chief executive Kathy Doran stating the belief that removal of vascular services from Warrington would “damage other services at the hospital and lead to a deterioration in ambulance response times within the borough”. A similar petition of 2,653 signatures was submitted to Wirral Council in April, opposing the transfer of services in Arrowe Park to Chester. Both Wirral Council, and a joint health overview and scrutiny committee of Warrington, Halton, and St Helens councils supported the idea of a single arterial centre for South Mersey. However, they respectively insisted that it should be based in Wirral or Warrington.

In Wirral, two of the four vascular surgeons based at Arrowe Park, also came out against the proposals, telling NCAT that their hospital should be the centre because – among other reasons – it saw “the highest volume of vascular procedures amongst the three hospitals”, was “closest to the main population of vascular patients”, and had “the most co-dependent specialties”.

These polarised views were also reflected in the public consultation on the reconfiguration, with local residents from Wirral, Warrington, and Cheshire West all backing their own local hospital as their preferred site for the arterial centre.

Outcome

However, Ms Doran does not believe the consultation has produced any “incontrovertible argument” as to why they should pick a different hospital as hub for the network. “I think that what we’ve got here is an acknowledgement – certainly by all of the councils, and by some of the public – that it’s the right thing to do to have two centres,” she says. “When it comes to South Mersey, what we’ve got is three boroughs who are exceedingly proud of their good local hospitals, and they want to keep all services with their hospital. At the end of the day we have to make a decision, if we’re going to have one centre, as to where it will go. Wherever we choose the other two will be unhappy, and that’s what’s been reflected in those public comments. That’s almost inevitable.”

By all accounts, Warrington and Halton Hospitals has dropped its opposition to the plans and is working with the other providers on the operational implications of the plans. A spokesman for the trust told HSJ: “Obviously we’re disappointed in some ways, but the decision has been made and now we’ve got to make that network work for our patients.”

It is unlikely that the local authorities that opposed the plans will be so accommodating. Speaking to HSJ on 3 July, Tony Higgins, chairman of Warrington health overview and scrutiny committee, said the council “certainly would” refer the reconfiguration proposals to the health secretary if commissioners approved the Chester option. “We do not believe for one second that this has been an absolutely fair procedure,” he said. “They haven’t considered Warrington at all as a genuine option for one of the arterial centres.”

However, even Councillor Higgins is sceptical that such an intervention could actually be successful in getting the commissioners’ plans overturned. Health secretary Andrew Lansley, he suggests, “isn’t going to listen to a Labour administration in Warrington”.

If this assessment is right, then the most a referral could do would be to delay the changes, but if the health secretary reaches his decision relatively quickly the South Mersey Network could still be in place by the target date of 1 April 2013.

In the meantime, the trusts involved in the network will need to work through the fine detail of the network proposal, including what it will mean for staff rotas and finances. According to Peter Herring, the chief executive of the Countess of Chester, they have “agreed in principle a risk-sharing arrangement whereby as [far] as possible none of the three trusts should be financially disadvantaged” by participating in the network.

The additional costs of the arterial centre should be “largely covered” by the additional tariff income it will attract, he explains. However, “the other hospitals are going to lose that income yet have some costs that they can’t shed. That’s where we need to come to an agreement whereby we can mitigate those costs”.

He adds that at some point during the financial year the network may need to negotiate with its commissioners for some “transitional support” funding. That might be to temporarily help cover fixed costs for the hospitals that are losing services, or set-up costs for the arterial centre at Chester. “If we are going to have a start date of April 2013 we’re going to have to start employing additional staff in advance of that,” he says. The providers have “no commitment” from the PCT cluster to provide transitional support, he adds, but “I think they’ll be open to those discussions”.

• Print this HSJ Local Briefing now