Analysed: North West’s vascular controversy spreads to Lancashire and Cumbria

What is the issue?

Vascular reviews have been taking place across England in response to Vascular Society guidance that high-volume specialist centres can prevent unnecessary deaths, strokes and amputations. However, these reviews have been subject to mounting controversy in the North West, as politicians have mobilised against the removal of services from their local hospitals. Earlier this summer, it was proposals for vascular reconfiguration across Cheshire and Merseyside that were in the line of fire; now Lancashire and Cumbria’s vascular review is facing similar opposition.

The Cheshire and Merseyside review had proposed to centralise all arterial surgery for the patch and some other complex vascular procedures onto two hospital sites in Chester and Liverpool. The plan was opposed by politicians in Warrington and the Wirral, areas that would see services moved from their local hospitals to Chester. When commissioners approved the plan in the face of this opposition, Warrington, Halton and St Helens councillors referred it to the health secretary, saying it would have a “detrimental effect” on local residents.

Now, the political pressure is being felt further north. A review of vascular surgery across Lancashire, Cumbria, parts of Greater Manchester and the Scottish borders, has recommended centralising all complex vascular procedures into three “intervention centres”.

Commissioners have identified Lancashire Teaching Hospitals Trust’s Royal Preston Hospital, East Lancashire Hospitals Trust’s Royal Blackburn Hospital and North Cumbria University Hospitals Trust’s Cumberland Infirmary as their chosen sites.

There are seven trusts currently offering vascular services in the patch, but controversy has centred on the implications for University Hospitals of Morecambe Bay Foundation Trust. The troubled FT, which straddles the border of Lancashire and Cumbria, has appealed against commissioners’ rejection of proposals to establish an intervention centre at its Royal Lancaster Infirmary.

Local MPs have thrown their weight behind Morecambe Bay, with Liberal Democrat president Tim Farron tabling an early day motion in Parliament stating that the reconfiguration would leave “vast geographical areas in between in south Cumbria and north Lancashire dangerously uncovered”. Both the commissioners and Mr Farron’s staff are now focused on winning the support of councillors on Lancashire’s joint health overview and scrutiny committee. If commissioners fail to win the committee’s backing at its meeting next week (25 September) their plan too could be referred to the health secretary.

Background

As in other parts of England, commissioners in Lancashire and Cumbria cite two distinct but related reasons for the review of vascular services. The first is a growing body of evidence and professional guidance that complex vascular procedures will have better outcomes for patients if performed in high-volume specialist centres. The second is the national rollout of a screening programme for abdominal aortic aneurysms.

According to NHS Lancashire medical director Jim Gardner, the latter reason was both the initial catalyst for the Lancashire and Cumbria review, and the reason commissioners are under some time pressure to complete the reconfiguration.

‘MPs in Morecambe Bay’s patch have taken up the case, focusing their concern on travel times’

The programme requires that patients identified for surgery through screening are treated at accredited vascular intervention centres, serving population bases of around 800,000 people. Lancashire and Cumbria have already identified a preferred provider of AAA screening – Northumbria Healthcare Foundation Trust – says Dr Gardner. “The AAA programme is moving ahead, and my understanding is that if that starts in our area and we haven’t got formally authorised AAA surgery centres identified then patients will be expected to go to centres [outside the patch] which are identified,” he explains. A paper he submitted to the NHS Lancashire board this summer warns that this would “seriously compromise all vascular services across Cumbria and Lancashire”.

Extended boundaries

The review began in 2010, pulling together a clinical advisory group of vascular surgeons and interventional radiologists from across the region. The boundaries of the review were extended to include Wigan and Bolton in Greater Manchester and Dumfries and Galloway in Scotland, because of established patient flows between these areas and, respectively, Preston and Carlisle. These additions increased the total population covered by hospitals on the patch by around 750,000, to nearly 2.8 million. The advisory group recommended a single vascular network for the region, with three intervention centres. Under this model, elective patients would continue to be seen at their local hospitals for outpatient and day case vascular services, with all inpatient work transferred to the three centres.

Four trusts were later shortlisted in a competitive tender to provide the intervention centres for the network: East Lancashire Hospitals, Lancashire Teaching Hospitals FT, North Cumbria University Hospitals, and Morecambe Bay.

According to a Morecambe Bay board paper, its bid scored “comparatively or better than” North Cumbria against most of the tender criteria, but “least well” in the risk assessment. This, it says, resulted in the failure of Morecambe Bay’s bid to provide one of the three intervention centres. Dr Gardner says the risk assessment had consisted of the evaluators’ “assessment of any provider’s ability to deliver” as well as of “their governance arrangements, both corporate and clinical”. At the time of the scoring, earlier this year, the trust was in the midst of a care quality scandal, and had been subject to a damning governance review for FT regulator Monitor. Dr Gardner said that while the assessors “couldn’t be wholly ignorant” of these issues, they had tried to be as “coolly objective about the process” as possible.

Political controversy

The board paper which Morecambe Bay’s chief operating officer Juliet Walters submitted on the outcome of the review in July outlined serious possible consequences for the FT from the loss of its inpatient vascular services. The paper warned that it could have a knock-on impact on other specialties that rely on in-house vascular emergency services, undermine the trust’s ability to recruit motivated and ambitious staff, and result in a loss of income of £1.3m a year. (Morecambe Bay is already in some financial difficulty, and projecting a deficit of £30m for 2012-13.)

Ms Walters added that it was “not clear” which of the selected centres would cover North Lancashire and South Cumbria, as only Morecambe Bay had bid to provide services to these populations. Earlier this month the FT submitted a formal appeal to NHS Lancashire against the decision.

MPs in Morecambe Bay’s patch have taken up its case, focusing their concern on the travel times between their area and the proposed vascular centres. John Woodcock, Labour MP for Barrow in Furness, wrote in a letter to the joint Lancashire health scrutiny committee that these would “surely be greater than those recommended either nationally or by the local Clinical Advisory Group”.

Liberal Democrat MP for Westmorland and Lonsdale Tim Farron has claimed that travel to the new centres “from parts of south Cumbria will be over 90 minutes thus constituting a real threat to patient safety”.

Dr Gardner argues that the incidence of “true vascular emergencies is rather low”, and that for the Furness peninsula – the most remote part of south Cumbria – is likely number four or five a year. “We think transferring those patients to a major arterial centre – albeit 90mins away – is a legitimate and safe trade-off,” he adds.

Mr Farron’s office is now focusing on persuading members of Lancashire’s joint overview and scrutiny committee to “overturn” the proposals ahead of their meeting on 25 September. Dr Gardner agrees that this meeting “is a key moment” in determining whether or not the reconfiguration will be referred to the health secretary.

When commissioners presented the vascular proposals to the committee in July, the councillors felt they had been given “insufficient background” and that “more evidence to support them should be made available”. Minutes of the meeting show that members were “very concerned about the lack of public consultation”; they also echoed concerns about the knock-on impact the changes would have on other services at the Royal Lancaster, and the travel times implied for south Cumbria residents.

In theory, it should be easier for the Lancashire and Cumbria proposals to avoid referral to the health secretary than those covering Cheshire and Merseyside. The Cheshire and Merseyside proposals were referred by a joint overview and scrutiny committee that only represented areas that stood to lose local services; the equivalent committee in Lancashire also represents the areas where the proposed intervention centres would be based.

Nevertheless, Mr Farron’s campaigns and press assistant Paul Butters believes communities that would lose local services have enough representatives on the committee to carry a vote. “They do have the numbers to do it,” he said. “Obviously they all have to vote the way we think they should vote.” At the time he spoke to HSJ, Mr Butters said his office had been in touch with “quite a few” of the councillors. “Some are very supportive and say we need to keep the services [at Morecambe Bay] and some are hedging their bets and saying they’ll listen to the case the NHS puts forward,” he said. “We’re just trying to make sure the public come on side. When these people get dozens and dozens of letters we think that might be able to sway them.”

Dr Gardner says the commissioners went away from the committee in July “with a clear sense of what it was they wanted reassurance on, and we believe we can reassure them on those points.”

Negotiating a settlement

Even if commissioners can win the committee’s endorsement on 25 September, there will be a number of questions hanging over the future configuration of vascular services in Lancashire and Cumbria. Among them is how exactly the network’s population would be divided between the three intervention centres.

HSJ understands that there are, essentially, two issues that would need to be resolved through detailed negotiations: the first is which centre or centres would serve the populations of North Lancashire and South Cumbria; the second is how the populations in the south of the network would be split between Lancashire Teaching Hospitals and East Lancashire Hospitals.

Dr Gardner says that in their bids these trusts “essentially proposed covering the same area”; and while providers other than Morecambe Bay had told commissioners that they could cover North Lancashire or South Cumbria “they acknowledged they hadn’t had the discussions with Morecambe Bay or Blackpool [Teaching Hospitals FT]”. He adds: “They recognised they could do it in terms of access times and physical capacity, but the diplomatic effort as it were hadn’t taken them down that path.”

One of the wildcards in this game is the geographical boundaries of the proposed network. For example, Wigan and Bolton were included in the review because their hospitals trusts were already part of an established vascular network with the Royal Preston.

But HSJ understands that Greater Manchester commissioners have reserved the right to see in detail how the reconfiguration is going to work; if they were to determine that the detailed Lancashire and Cumbria plans did not best serve the populations of Wigan and Bolton, they could want to bring those areas back into the orbit of Greater Manchester’s own vascular review. That would reduce the population covered by the Lancashire and Cumbria vascular network by around 600,000, which would – at the least – add complexity to the task of ensuring each centre in the network had a sufficiently large patient population.

‘One of the wildcards in this game is the geographical boundaries of the proposed network’

One thing that can be said with some certainty is that, whichever hospitals are ultimately designated intervention centres, reconfiguration need not necessarily be to the financial detriment of others. In south Merseyside the three trusts affected by the proposed reconfiguration agreed in principle a “risk-sharing” deal, to ensure that as far as possible none should be financially disadvantaged by the changes. At least one of the proposed intervention centres in Lancashire – Lancashire Teaching Hospitals – told HSJ it was in favour of negotiating a similar deal on its patch.

Trust chief executive Karen Partington said: “We absolutely recognise some of the potential difficulties for other organisations, and we think it’s incredibly important that we work with other trusts so that it’s win-win”.

She continued: “We have no intention of financially destabilising the organisations that we’re working with. We have to make sure that if patients come to us as one of the centres they have somewhere to go back to.”

Not “managing the money appropriately”, she added, would potentially “make it difficult to repatriate patients and could potentially de-skill organisations, and that’s not what we want to do”.