Kent and Medway Vascular Programme: 2021 Refresh of Options Appraisal - PowerPoint Presentation

Slide1

Kent and Medway Vascular Programme: 2021 Refresh of Options Appraisal

Pack for Options Panel

September 2021

Contents

Background

3

Options long list

6

Options short list

9

Criteria used for options appraisal

9

Ask of the refresh panel

Refreshed 2021 information available for each criteria

12

13

A 2014 case for change identified that a different set-up of vascular services was required in Kent and Medway

The Kent and Medway Vascular review in 2014 developed a case for change for vascular services.The review identified that the two existing providers of specialised vascular inpatient care within the Kent region, East Kent Hospitals Foundation Trust and Medway Foundation Trust, were not able to deliver against either the national specialised vascular service specification or the guidelines from the national Vascular Society for Great Britain and Ireland.

Specifically, neither trust were able to meet the standards in relation to:

- Having a large enough population to treat

Carrying out too few or borderline numbers of core index procedures

Having too few staff, particularly consultants, to provide 24/7 on site vascular surgery and interventional radiology on-call rotas (with clinicians that are able to undertake the required minimum numbers of interventions).

Further work was then undertaken to consider the options for specialist vascular services in the future and consider how these options would address the issues identified in the case for change, looking to ensure the people of Kent and Medway were able to access high quality, safe and sustainable specialist vascular services. An options appraisal exercise was carried out by the local Clinical Reference Group in 2016 which started with a long list of seven potential options, of which only two were taken forward when considered against the standards outlined above and the case for change.

A single arterial centre has been the preferred model of care since 2016, but the East Kent Transformation Programme will determine the long term location of this

In 2016, the options appraisal work was presented to the JHOSC and it was recommended that a single dedicated specialist vascular service was commissioned for Kent and Medway, based on the agreed model developed by the Clinical Reference Group which adhered to national best practice. Further engagement undertaken with stakeholders to consider and discuss the model in more detail prior to presenting the recommended model to JHOSC included clinicians, patients, carers and other interested parties representing the population of Kent and Medway.

Following the options appraisal work undertaken during 2017 and 2018 around the optimal sites for delivery of the clinical model for vascular services it was agreed that the permanent location of the main arterial centre (the hub) for Kent and Medway should be determined through the East Kent Transformation programme. This programme is considering the provision of a wide range of services across the East Kent area, linked to potential large-scale capital investment in a new hospital for the region. The specialist vascular hub has a number of interdependencies with other services, and therefore needs to be considered within this overarching transformation programme to ensure the longer-term provision of specialist vascular services is located in the optimal place.

Due to the length of time it will take the complete the East Kent Transformation programme and given ongoing issues within the current provision of specialist inpatient vascular services across Kent and Medway, a paper was presented to the JHOSC setting out that a medium-term solution would need to be found to ensure the safety and sustainability of the service.

In 2019, NHS England & Improvement undertook an options appraisal to consider how to provide a medium term solution that would deliver a safe and sustainable specialist vascular service (the arterial hub) whilst the East Kent Transformation Programme progressed.

Changes to services since previous options appraisal

Due to the COVID-19 pandemic, transformation work on the Kent and Medway vascular programme was paused for much of 2020. During this time, services at Medway hospital became increasingly challenged due to a shortage of consultant staff and additional consultant support was provided by EKHUFT in order to maintain safe services on both sites.

On the 6 January 2020, MFT implemented an emergency move of all elective and non-elective AAA surgery to Kent and Canterbury Hospital. This has helped stabilise the vascular surgical services at MFT and ensured the safety of the most high-risk surgical patients. This emergency move remains in place to date and making this move permanent is now part of the proposal that we are consulting on. If the option of siting the medium term arterial centre at Medway Hospital was preferred, the emergency move of AAA surgery would be ended and the service would return to Medway hospital.

Since early 2021 vascular service provision at MFT has become further challenged due to staff isolating and absence during the COVID-19 pandemic and, at the request of NHS England specialised commissioning, EKHUFT has been providing additional on-call consultant support to allow a 24/7 presence to be maintained at MFT. Since this time, the Kent and Medway vascular network has been operating more closely in line with the national recommendations, albeit as a temporary measure, and with some inpatient procedures continuing to happen on more than one site. This model of network working would continue under either of the two options being considered.

‘Hurdle’ criteria were identified based on the case for change and these are still relevant in 2021

Initial hurdle criteria for options identified from the case for change (all from the NHS England National Service Specification and the Vascular Society Guidance):

Minimum population volumes (

800,000 per arterial centre

)

Minimum procedures

undertaken (

a minimum of 60 AAA and 40 carotid procedures per annum. Each surgeon should undertake at least 10 AAA procedures per annum

)

Minimum staffing numbers for consultant surgeons and interventional radiologists (

a rota of at least 1:6 for each

)

Specialist facilities including dedicated hybrid theatres and wardsAbility to meet targets for key outcome measures (access to highly specialised interventions such as thoraco-abdominal aneurysms)Working within a network, using a hub and spoke delivery modelHurdle criteria are assessed on a pass or fail basis.

These hurdle criteria are still relevant, as the two documents referenced are still the key standards that vascular services should work to.The programme team have also added an additional hurdle criteria, which we believe was implicit in the original case for change and options appraisal (which concluded that an arterial hub would have to be provided within Kent and Medway).This is that the option must:7. Provide access to a vascular arterial centre for the whole of the Kent and Medway population (measured by providing access within a 60 minute travel time* for the whole area.)

* Recognised as a reasonable timeframe for access to specialist care in an emergency situation

The long list of seven options was reduced to a short list of one option when reviewed against these criteria

Option

Original options appraisal

2021 refresh

1 (No change) - Two arterial hub sites in Kent and Medway, retaining flows into London

Not taken forward

Doesn’t meet minimum population volumes or minimum procedures undertaken

2 – No arterial hub sites in Kent and Medway, with all inpatient flow into a London provider

Not taken forward

Unacceptable due to excessive travel times for large parts of Kent and Medway (see travel map)

3 – Two arterial hub sites in Kent and Medway, removing any patient flows into London

Not taken forward

Pathways to London must be maintained for highly specialised procedures

4 – One arterial hub site in Kent and Medway, removing patient flows into London

Not taken forward

Pathways to London must be maintained for highly specialised procedures

5 – One arterial hub site in Kent and Medway, retaining patient flows into London

Taken forward for considerationMeets all hurdle criteria6 – Two networked arterial hub sites in Kent and Medway, removing patient flows into LondonNot taken forwardPathways to London must be maintained for highly specialised procedures7 – Two networked arterial hub sites in Kent and Medway, retaining patient flows into LondonNot taken forwardDoesn’t meet minimum population volumes or minimum procedures undertaken

For completeness, a refresh of this process has been completed and is

shown along with the original options appraisal outcome.

There are only two plausible locations for the medium term location of the single arterial centre

Only two hospitals within the Kent and Medway region currently provide arterial vascular services; Kent & Canterbury hospital (part of East Kent Hospitals University Foundation Trust) and Medway Hospital. For completeness, we have assessed all major hospitals in the area against the essential clinical interdependencies for arterial vascular services (using the NHS England national service specification), and to confirm whether they have the essential specialist facilities required to deliver a vascular service (such as an endovascular theatre), and whether locating a single arterial centre there would result in excessive journey times for some patients (see travel map).

Conclusion: In 2021, there are still only two plausible locations for the medium term location of the single arterial centre

Hospital

Travel times of less than <60minutes for the whole of K&M?

Essential specialist facilities required to deliver a vascular service?

Relevant clinical interdependencies?

Kent & Canterbury Hospital

Yes

Yes

Yes

Medway Hospital

Yes

Yes

YesWilliam Harvey HospitalYes

No

Yes

QEQMNoNoNoMaidstone HospitalYesNoNoTunbridge Wells HospitalNoNoNoDarent Valley HospitalNoNoNo

Affordability and value for money

Quality of care for all

Access to care for all

1

2

3

Profit/Loss

Meet license conditions

Capital cost to the system

Clinical effectiveness and responsiveness

Patient experience

Distance and time to access services

Patient choice

Safety

Service operating hours

Does the option provide improved delivery against clinical and constitutional standards, access to skilled staff and specialist equipment, comparison of current clinical quality of sites?

Which option would provide a better experience for patients using patient experience surveys and looking at the quality of the buildings and facilities?

What is the expected impact on excess mortality, serious untoward incidents and patient harm?

Do any options keep to a minimum the increase in the average or total time it takes people to get to hospital by ambulance, car (at off-peak and peak times) and public transport?

Which options would give people in Kent the greatest choice of hospitals for each service under consideration across the greatest number of trusts?

What is the ability of model to facilitate 7 day services and improved access to care out of hours?

Which options would have the lowest capital costs (cost of buildings and equipment)?

Does the option meet regulatory requirements e.g. surpluses generated by each Foundation Trust? (

2021 – updated to reflect new System Oversight Framework)

What is the Profit/Loss of the options? (

2021 – updated to reflect additional ICS system costs from change)

Clinical co-dependencies

What are the clinical co-located services required for vascular and other services that required vascular inputs?

Clinical outcomes

Which option would provide a better clinical outcomes for patients using mortality rate and re-admission rates?

What is the affordability to commissioners?

Affordability to commissioners

We are refreshing the medium term options appraisal against the original criteria set out by the Vascular Programme Board

Domain

C

riteria

Evaluation questions/ Key Lines of Enquiry (KLOE)

We are refreshing the medium term options appraisal against the original criteria set out by the Vascular Programme Board

Research and Education

Deliverability

4

5

6

Workforce

Support current & future education & research delivery

Expected time to deliver

Scale of impact

Co-dependencies with other strategies

Disruption to education & research

Sustainability

Impact on local workforce

What is the potential impact on current medical and non medical staff and retraining / relocation required?

What is the likelihood of each option to be sustainable from a workforce perspective, facilitating 7 day services and taking into account recruitment challenges and change in what work force does i.e. ability to ensure sufficient people with the right skills in the right places?

What is the potential impact on staff attrition due to change?

How easy will it be to deliver change in 3-5 years? (2021 – Updated to reflect need to deliver the medium term option within twelve months)How well does each align with other strategic changes and provide a flexible platform for the future? Which options best fit with current research and education to minimise disruption in these areas? Which options best support current and developing research and education? Domain

C

riteria

Evaluation questions/ Key Lines of Enquiry (KLOE)

The 2021 options appraisal refresh will collate updated information against each criteria to support assessment of each option by the panel

The panel is being constituted of:

Medical Director or representative, MFT

Medical Director or representative, EKHUFT

Medical Director or representative, MTW

Medical Director or representative, GSTT

Kent & Medway CCG director or representative

NHS England, Specialised Commissioning director or representative

Medical Director, NHS England

Independent Vascular Clinician

Healthwatch representative

SECAmb

representative

NHS England, Quality team representativeNHS England, Finance representativeProject leads, NHS England Spec Comm and Kent & Medway CCG

The following slides set out the updated information against each criteria within the six domains

The Panel are asked to review the information presented and score each option in the accompanying scoring template.

There is a free text field for additional comments against each criteria which is optional for members to complete.

The original scoring included options for -2, -1, 0, +1 and +2. For this refresh we are only using the scores of:

0 (this option does not meet this criteria),

+1 (this option partially meets this criteria)

+2 (this option fully meets this criteria)

Each criteria will be scored and will be weighted equally, in line with the original options appraisal.

Scores should be returned in advance of the panel and a draft conclusion developed by the programme team. The overall results will then be presented at the panel meeting. The scores will be averaged to give all members equal weighting.

At the panel meeting, areas of difference in scoring will be discussed by the group (criteria where some have scored 0 and some have scored +2) or where free text comments have been made that require panel discussion.

The panel will then agree on a consensus on these areas of difference and the preferred option will be confirmed and noted.

Following the panel meeting, the outcome of the refreshed options appraisals will inform the developed of the Pre-consultation Business Case and required assurance processes for this programme of work.

Refreshed Information against Domain Criteria for Panel Assessment

Domain: Quality of care for all (1/2)

Quality of care for all

1

Clinical effectiveness and responsiveness

Patient experience

Safety

Does the option provide improved delivery against clinical and constitutional standards, access to skilled staff and specialist equipment, comparison of current clinical quality of sites?

Which option would provide a better experience for patients using patient experience surveys and looking at the quality of the buildings and facilities?

Clinical co-dependencies

What are the clinical co-located services required for vascular and other services that required vascular inputs?

Clinical outcomes

Which option would provide a better clinical outcomes for patients using mortality rate and re-admission rates?

Criteria

Option A – Medium term site at Kent and Canterbury

Option B – Medium term site at Medway

Clinical effectiveness and responsiveness

CQC rating: Requires Improvement

CQC rating: Requires ImprovementPatient experienceEKHUFT’s most recent patient experience survey (July 2020) had an overall score of 7.7/10 which was ‘About the Same’ as other TrustsMaximum of 269 patients (2019/20 baseline excluding day cases) would be impacted by this optionMFT’s most recent patient experience survey (July 2020) had an overall score of 7.4/10 which was ‘About the Same’ as other TrustsMaximum of 601 patients (2019/20 baseline excluding day cases) would be impacted by this optionClinical co-dependencies

Essential co-located services from national service specification (intensive care and interventional vascular radiology) available on site.

Essential co-located services from national service specification (intensive care and interventional vascular radiology) available on site.

NB: the majority of quality of care benefits from the changes to vascular services will come from the hub and spoke network model so these will be achieved irrespective of the location of the arterial hub

Domain

Criteria

Original Options Appraisal KLOEs

Domain: Quality of care for all (2/2)

Quality of care for all

1

Clinical effectiveness and responsiveness

Patient experience

Safety

Does the option provide improved delivery against clinical and constitutional standards, access to skilled staff and specialist equipment, comparison of current clinical quality of sites?

Which option would provide a better experience for patients using patient experience surveys and looking at the quality of the buildings and facilities?

Clinical co-dependencies

What are the clinical co-located services required for vascular and other services that required vascular inputs?

Clinical outcomes

Which option would provide a better clinical outcomes for patients using mortality rate and re-admission rates?

Criteria

Option A – Medium term site at Kent and Canterbury

Option B – Medium term site at Medway

Clinical outcomes

Latest NVR data covering 2017 – 2019 does not show any significant outlying numbers for survival. Case numbers are average compared to national averages for most procedures.

Elective AAA 53 cases (Survival 99.4%)Ruptured AAA 22 cases (50% EVAR)Complex cases 17 (65% EVAR)Carotid endarterectomy 46 (Survival 98%)Lower Limb Angio/Stent 314 (Survival 98.5%)Lower Limb Bypass 77 (Survival 97.3%)Lower Limb Amputation 113 (Survival 97.3%)Latest NVR data covering 2017 – 2019 does not show any significant outlying numbers for survival. Case numbers are below average compared to national averages for all procedures.Elective AAA 21 cases (Survival 98.4%)Ruptured AAA 21 cases (50% EVAR)Complex cases 10 (90% EVAR)Carotid endarterectomy 11 (Survival 95.9%)Lower Limb Angio/Stent 62 (Survival 98.3%)

Lower Limb Bypass 130 (Survival 96.2%)

Lower limb amputation 39 (Survival 100%)

Safety

CQC rating: Requires Improvement

CQC rating: Requires Improvement

NB: the majority of quality of care benefits from the changes to vascular services will come from the hub and spoke network model so these will be achieved irrespective of the location of the arterial hub

Domain

Criteria

Original Options Appraisal KLOEs

Domain: Access to care for all

Access to care for all

2

Distance and time to access services

Patient choice

Service operating hours

Do any options keep to a minimum the increase in the average or total time it takes people to get to hospital by ambulance, car (at off-peak and peak times) and public transport?

Which options would give people in Kent the greatest choice of hospitals for each service under consideration across the greatest number of trusts?

What is the ability of model to facilitate 7 day services and improved access to care out of hours?

Criteria

Option A – Medium term site at Kent and Canterbury

Option B – Medium term site at Medway

Distance and time to access services

2015 travel time analysis shows:

MFT would have most accessibility within 30 minutes

MFT and K&C are equally accessible within 45 minutes

An MFT service would be over 60 minutes from East Coast/Thanet which has a high number of admissions from circulatory disease.

A K&C service would be over 60 minutes from Tunbridge Wells, but this has a lower number of admissions from circulatory disease2015 travel time analysis shows:MFT would have most accessibility within 30 minutesMFT and K&C are equally accessible within 45 minutesAn MFT service would be over 60 minutes from East Coast/Thanet which has a high number of admissions from circulatory disease. A K&C service would be over 60 minutes from Tunbridge Wells, but this has a lower number of admissions from circulatory diseaseService operating hoursWith the appropriate TUPE arrangements and increased catchment population, the service would be able to facilitate 24/7 consultant led working sustainablyWith the appropriate TUPE arrangements and increased catchment population, the service would be able to facilitate 24/7 consultant led working sustainablyPatient choiceThere would be no overall difference in patient choice between the two options, but fewer patients would be affected by the change (up to 269)There would be no overall difference in patient choice between the two options, but more patients would be affected by the change (up to 605)

Domain

Criteria

Original Options Appraisal KLOEs

Domain: Affordability and value for money (1/2)

Affordability and value for money

3

Profit/Loss

Meet license conditions

Capital cost to the system

Which options would have the lowest capital costs (cost of buildings and equipment)?

Does the option meet regulatory requirements e.g. surpluses generated by each Foundation Trust?

What is the Profit/Loss of the options?

What is the affordability to commissioners?

Affordability to commissioners

Criteria

Option A – Medium term site at Kent and Canterbury

Option B – Medium term site at Medway

Profit/Loss

High level assumptions on additional revenue required to deliver service: £342k (transitional revenue support agreed by commissioners)

High level assumptions on unmitigated stranded costs at MFT: Up to £1.4m

High level assumptions on additional revenue required to deliver service: £603k (no agreement yet in place to support these costs)High level assumptions on unmitigated stranded costs at EKHUFT: Up to £1.8m Affordability to commissionersThe lower MFF on tariff at EKHUFT was identified in the previous options appraisal as leading to a lower cost for commissioners if the activity was delivered by EKHUFT, but this is not a significant differentiatorThe higher MFF on tariff at MFT was identified in the previous options appraisal as leading to a higher cost for commissioners if the activity was delivered by MFT, but this is not a significant differentiatorDomain

Criteria

Original Options Appraisal KLOEs

Domain: Affordability and value for money (2/2)

Affordability and value for money

3

Profit/Loss

Meet license conditions

Capital cost to the system

Which options would have the lowest capital costs (cost of buildings and equipment)?

Does the option meet regulatory requirements e.g. surpluses generated by each Foundation Trust?

What is the Profit/Loss of the options?

What is the affordability to commissioners?

Affordability to commissioners

Criteria

Option A – Medium term site at Kent and Canterbury

Option B – Medium term site at Medway

Capital cost to the system

No additional significant capital cost to the system as IR suite build covered by Trust’s internal capital plan (>£100k)

Could be significant additional capital cost to the system, in the region of £16m - £20m* if additional ward and critical care space needed to be built. Alternative options could include a refurb of the Ruby ward space on MFT site (although likely to be too small and also at significant additional cost). As no capital monies identified for this programme, a low capital solution would require moving of alternative services off the MFT site to enable space to be created for vascular patients.

Meet license conditionsThe previous options appraisal did not identify any differentiating factor between the sites that would make meeting license conditions any easier or harder. In the new regulatory regime, both Trusts are receiving support as SOF 4 Trusts and both fall under the Kent and Medway ICS SOF.The previous options appraisal did not identify any differentiating factor between the sites that would make meeting license conditions any easier or harder.In the new regulatory regime, both Trusts are receiving support as SOF 4 Trusts and both fall under the Kent and Medway ICS SOF.Domain

Criteria

Original Options Appraisal KLOEs

* NB: awaiting final confirmation of potential new build/refurb costs from regional team.

Domain: Workforce

4

Workforce

Scale of impact

Sustainability

Impact on local workforce

What is the potential impact on current medical and non medical staff and retraining / relocation required?

What is the likelihood of each option to be sustainable from a workforce perspective, facilitating 7 day services and taking into account recruitment challenges and change in what work force does i.e. ability to ensure sufficient people with the right skills in the right places?

What is the potential impact on staff attrition due to change?

Criteria

Option A – Medium term site at Kent and Canterbury

Option B – Medium term site at Medway

Scale of impact

Number of staff potentially affected by TUPE: 10

NB: this is only staff who currently spend more than 50% of their time on vascular work. There would also be impact on non-vascular staff who do a smaller amount of vascular work such as interventional radiologists and ward nurses.

Number of staff potentially affected by TUPE: 20

NB: this is only staff who currently spend more than 50% of their time on vascular work. There would also be impact on non-vascular staff who do a smaller amount of vascular work such as interventional radiologists and ward nurses.

SustainabilityBoth options should be sustainable in the longer term as part of network model with a single arterial centreBoth options should be sustainable in the longer term as part of network model with a single arterial centreImpact on local workforceLimited as due to interim moves of vascular activity, additional workforce has already had to be recruited at K&CMore significant as due to interim moves of vascular activity, fewer staff are employed by MFT for specialist vascular servicesDomain

Criteria

Original Options Appraisal KLOEs

Domain: Deliverability

Deliverability

5

Expected time to deliver

Co-dependencies/Alignment with other strategies

How easy will it be to deliver change in 3-5 years?

How well does each align with other strategic changes and provide a flexible platform for the future?

Criteria

Option A – Medium term site at Kent and Canterbury

Option B – Medium term site at Medway

Expected time to deliver

Able to deliver full arterial hub service from Spring 2022 with the completion of the IR suite build.

Requirements for public and staff consultation timelines would be the same for both options.

Timescale to deliver the full arterial hub service is likely to be longer than Spring 2022 due to the necessary capital or enabling/refurb works having to be started from scratch. With the minimum enabling and refurbishment works, and the necessary move of other services, the earliest plausible delivery date could be 2023.

Requirements for public and staff consultation timelines would be the same for both options.

Co-dependencies/Alignment with other strategies

East Kent transformation programme has identified East Kent Hospitals University Foundation Trust as the site of a future Major Emergency Centre to include vascular services.

East Kent transformation programme has identified East Kent Hospitals University Foundation Trust as the site of a future Major Emergency Centre to include vascular services.DomainCriteriaOriginal Options Appraisal KLOEs

Domain: Research and Education

Research and Education

6

Support current & future education & research delivery

Disruption to education & research

Which options best fit with current research and education to minimise disruption in these areas?

Which options best support current and developing research and education?

Criteria

Option A – Medium term site at Kent and Canterbury

Option B – Medium term site at Medway

Disruption to education & research

Both services are under the remit of the same Deanery and neither are a teaching hospital.

There are no current major research projects that wouldn’t be able to continue under this option.

There are three current vascular junior doctor training posts at EKHUFT that would need to be accommodated elsewhere and covered separately by EKHUFT.

Both services are under the remit of the same Deanery and neither are a teaching hospital.

There are no current major research projects that wouldn’t be able to continue under this option.

Support current & future education & research delivery

The original options appraisal felt that current and future education and research delivery would be equally good under both options. Both Trusts have programmes of work to expand research delivery over the coming years and the wider vascular network would contribute to this whichever site the hub was located.The original options appraisal felt that current and future education and research delivery would be equally good under both options. Both Trusts have programmes of work to expand research delivery over the coming years and the wider vascular network would contribute to this whichever site the hub was located.DomainCriteriaOriginal Options Appraisal KLOEs