Exclusive: Specialist service changes an ‘unmitigated disaster’, says review

Nottingham University Hospitals Trust significantly “scaled back” its internationally renowned acute adult dermatology service earlier this year after five of its 11 consultants quit rather than transfer to private provider Circle following its successful bid to run the Nottingham Treatment Centre in 2013.

Medical students who previously trained at the trust have also been transferred to Royal Derby Hospital, while Leicester Royal Infirmary is now providing emergency dermatology care for patients who would have previously been seen at Nottingham.

A draft copy of a report by an independent review panel, seen by HSJ, has revealed Circle is relying on six long term locums costing £300,000 a year each because it cannot fill vacant consultant posts. Some of the locums are not sufficiently qualified to be included on the General Medical Council’s specialist register for dermatology.

The panel featured former national clinical director for primary care at the Department of Health David Colin-Thome and three other consultants.

They found an attempt by the trust to sustain its dermatology workforce by creating a separate specialist service last year was thwarted following a legal challenge, which HSJ understands was from lead commissioner Rushcliffe Clinical Commissioning Group.

A lack of flexibility about how the region’s dermatology services should be delivered led to an “adversarial” relationship between commissioners and the two providers, the panel said.

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The review described how the trust’s consultants had concerns about transferring “to an uncertain model at Circle”. The consultants said the company had no experience of the highly specialist work they provided and that this would “inevitably lead to a downscaling of their ability to deliver effective training and research”.

The consultants believed the commercial approach of Circle would “inevitably lead to a poorer service” and the lack of response to these concerns by both providers and the commissioners led to the difficulties in recruitment.

The review said the handling of the concerns had been “an unmitigated disaster”, which led to “the situation whereby Nottingham is now faced with a service on a knife edge, with the imminent loss of a further consultant rendering the acute rota unworkable and the possibility that, if any of the remaining consultants leave, the demise of the tertiary paediatric [dermatology] service.”

The panel urged Rushcliffe CCG to sign a memorandum of understanding with the trust and Circle “within weeks” to agree common objectives focused on how to keep services in Nottingham.

Nottingham University Hospitals chief executive Peter Homa said: “The report highlights that there are lessons for NUH and the wider health system to learn from the experience of dermatology. Even as the report is being finalised, we are working with our commissioners and Circle to take forward the recommendations with the clear intention of securing a future for adult dermatology in Nottingham.”

The report also said despite the poor handling of the changes by all parties, the company “have managed to provide a good dermatology service”.

A Circle spokesman said: “This isn’t the final report and it’s important not to pre-judge its conclusions. It’s clear though that Circle has always done what was asked of us, and that staff who did transfer thought we are a good place to work. At no point has there been any doubt we provide a good service, and our recent CQC inspection specifically noted the quality of our service and staff in dermatology.

“We accept there are lessons to learn. In particular, it’s clear that Circle, NUH and the CCG need to work together. We will play our full part, and commit to working collaboratively to secure patient services.”

Rushcliffe CCG chief officer Vicky Bailey said: “We welcome the findings and will be acting upon the recommendations being made.”

Updated 12.00 28 May: To reflect the fact Nottingham’s acute adult dermatology service was not closed, but was significantly “scaled back”, and additional information from Circle.