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Vascular Services

2nd August 2022

Dr Nick Lyons, Executive Medical Director at Betsi Cadwaladr University Health Board said:

“In response to feedback received from external reviews and our continual focus on patient safety, we have again reviewed the way we deliver care to patients on some of our vascular pathways. This includes contingency planning to ensure that there is no interruption of care for those needing aortic surgery.

“As a result, a very small number of patients each week may receive their surgery at the Royal Liverpool University Hospital - or the Royal Stoke University Hospital, as already happens for North Wales residents with major trauma injuries. Each patient will be contacted to discuss their care and will be supported as required.

“Very specialised care for some patients is already provided by specialist vascular centres in England and we work in partnership with them to manage complex cases. We are grateful for their continued support.

“These contingency plans recognise the operational challenges we are experiencing due to staff sickness absence combined with recruitment difficulties.

“We also have concerns about a small number of vascular surgical cases. This follows independent scrutiny by the Vascular Quality Panel, which the Health Board commissioned and established in response to the findings of the invited review by the Royal College of Surgeons, the second part of which was published in February this year.

“We expect these arrangements to remain in place until we are assured that the service is deliverable, robust and sustainable. The service will be kept under review and updates will be provided as appropriate.

“We remain committed to the model of a networked vascular service for North Wales and continue to work to secure its sustainability and deliverability.”

The Patient Advice and Liaison Service have a dedicated helpline to provide support and guidance to vascular patients who may have questions about their treatment and care.

Telephone:  03000 851389  
Open 9am to 5pm Monday to Friday, except Bank holidays. 

 

15th July 2022

As part of our ongoing work to strengthen some of our specialist vascular services we have implemented some new measures to support specialist aortic vascular surgery, working in collaboration with our colleagues at the Liverpool vascular network. This includes:

  • Multidisciplinary team support from Liverpool University Hospital Foundation Trust (LUHFT) for all aortic surgery
  • Dual consultant operating for all aortic surgery

Dr Nick Lyons, Executive Medical Director at Betsi Cadwaladr University Health Board, said: “As part of the work we are carrying out to implement the recommendations of the Royal College of Surgeons reports on our vascular service we are continuing to work in close collaboration with the Liverpool vascular network on complex vascular cases. This involves having additional expertise when we review and plan procedures, as well as specialist consultant support to carry out procedures.

“This collaborative approach will allow us provide more professional support in the short-term while we continue our work to strengthen vascular services for our public across North Wales.

“We will continue to keep this and other measures under close review.”

30th March 2022

Betsi Cadwaladr University Health Board has taken the decision to put additional staffing and support measures in place until May 23.

This is to make sure we continue to provide a safe service and continue to update our plans in response to recent incidents. The arrangement will also allow the health board to move forward with our current recruitment plans.

Betsi Cadwaladr University Health Board’s executive medical director, Dr Nick Lyons, said: “My primary concern is the safety of our patients.

“I also want those using our vascular service to have confidence they will receive the standard of care they expect and deserve.

“I believe being certain about the duration of our collaboration with our partners in Liverpool, in the medium term, helps to give such assurance.

“Also critical is our recruitment to key roles – and this is something we are working very hard to achieve.

“I believe the oversight from our partners within the Liverpool Vascular Network will help us to consistently review incidents and ultimately strengthen vascular services for our public across North Wales.”

16th March 2022

Recently there have been two concerning safety incidents in the vascular service. We are investigating these to ensure that we learn from them to improve the service we provide for our patients. We are currently experiencing staffing capacity issues and are in the process of recruiting to help address these. A strengthened team will ensure that we are better placed to deliver the service that the people of North Wales have a right to expect.

The safety and experience of our patients is our utmost priority. While we continue to appoint additional expertise to strengthen our team, a very small number of complex vascular cases will receive very specialist care from our colleagues at the Liverpool vascular network. We expect around four additional emergency procedures per week will take place at Liverpool University Hospitals NHS Trust, rather than Ysbyty Glan Clwyd. This arrangement will be in place for four weeks and then reviewed.

This follows our public commitment to work in closer collaboration with colleagues at the Liverpool vascular network in response to the recommendations made in the recent Royal College of Surgeons report on our vascular service.

The majority of vascular service activity such as routine surgery, diagnostic procedures and outpatient appointments will continue in North Wales as usual. This means that most patients will continue to receive their vascular surgery at Ysbyty Glan Clwyd, though we expect a further five patients per week over the same four week period to have their surgery delayed.

Additionally, some 12 outpatient appointments per week (around 50 during this four week period) will be postponed.

Each patient will be contacted to discuss their care and will be supported as required.

Our Patient Advice and Liaison Service have established a dedicated helpline to provide support and guidance to vascular patients to discuss their experiences, treatment and care. The telephone number is 03000 851389  and is open 9am to 5pm Monday to Friday, except Bank Holidays. 

Dr Nick Lyons, Executive Medical Director at Betsi Cadwaladr University Health Board said:

“We are implementing the recommendations of the recent Royal College of Surgeons reports on our vascular service. These include working in closer collaboration with the Liverpool vascular network on complex vascular cases.

“During the next few weeks, we expect to be strengthening the capacity and capability of the existing vascular team further. We are also temporarily adding more consultants onto our on-call rota to ensure the safety of our patients. 

“We are being open and transparent about the challenges in this service. It is the only way we can build trust and confidence with the public we serve.

“I am sincerely sorry for the delay to the treatment of our vascular patients and recognise that it may cause inconvenience and distress. Patient safety and experience is the driver of this decision, which is a temporary solution while we put in place steps to assure ourselves that the service has the right workforce capacity and capability.

“Our relentless focus is on doing the right thing for our patients and delivering the best possible outcomes across our North Wales network.

“We remain resolute that the Board decision to consolidate the vascular service in a hub and spoke model was the right one and is supported by the Royal College of Surgeons as the best arrangement for the North Wales population.”

25th February 2022

Susan Aitkenhead
Susan Aitkenhead has been appointed as the independent chair of Betsi Cadwaladr University Health Board’s Vascular Quality Panel.

The panel has been set up by the Board in response to the findings contained in a review of its Vascular service, which was conducted by the Royal College of Surgeons (RCS).

A review of the region’s Vascular service, delivered in two parts, was commissioned by the Board in response to feedback from both patients and North Wales Community Health Council.

There were nine recommendations - five of them urgent - contained within the second part of the study, which looked at patient case notes.

In response, Board chair Mark Polin said it was time to accelerate the rate of improvement within the service.

To ensure rigorous oversight of the process he has appointed Ms Aitkenhead as independent chair of the Vascular Quality Panel.

Susan Aitkenhead has extensive clinical, operational, governance and strategic experience in delivering healthcare across a variety of settings and sectors.

She has held previous executive roles at board level both within the UK and overseas and taken a variety of national policy roles.

Ms Aitkenhead has worked at the Department of Health, providing advice and support to ministers and officials across central government departments, at NHS England and NHS Improvement, where she was Deputy chief nursing officer - and in professional regulation at the Nursing and Midwifery Council.

Mr Polin said: “It is vitally important the North Wales public has confidence in our vascular services. In setting up this independently chaired panel to oversee the work we are doing, I intend to give those who use the service and our wider public that confidence.

“Everyone within the health board is committed to providing excellent care. In making such a high calibre appointment as Susan Aitkenhead, to oversee and quality check the work we are doing within vascular services, I believe our public can be assured we are serious about that commitment.

“We never forget we are here to serve the public of North Wales and I’m committed to seeing our health board provides them an excellent vascular service.”

Additional information: A hub and spoke model, recommended by the Royal College of Surgeons, was implemented in 2019.

The model sees spoke sites at Ysbyty Gwynedd in Bangor and Ysbyty Wrexham Maelor supporting a main vascular hub at Ysbyty Glan Clwyd.

The hub, supported by a state of the art hybrid operating theatre, is intended to create enough work for consultants in the field to retain their competencies.

The Royal College of Surgeons has recommended this model, as splitting the service over three acute sites does not allow consultants to complete the volume of work needed to remain professionally competent.

The first part of the RCS review can be read here: Bundle Health Board 20 May 2021 (nhs.wales)

The second part can be viewed here: Report on 44 clinical records relating to vascular surgery on behalf of Betsi Cadwaladr University Health Board

21st February 2022

Vascular helpline

The Patient Advice and Liaison Service have implemented a dedicated helpline to provide support and guidance to Vascular patients who may be dissatisfied with their experiences, treatment and care.

Telephone:  03000 851389  
Open 9am to 5pm Monday to Friday, except Bank holidays. 

3rd February 2022

Clinical Record Review Report relating to vascular services, January 2022, PDF

Health Board's response to the report: 

Dr Nick Lyons, Executive Medical Director at Betsi Cadwaladr University Health Board said:

“This report provides us with valuable feedback from expert reviewers and we have already acted in order to improve the care we provide to our patients.

“The Health Board asked for the review in 2020 as part of its own checks and balances on the standards of quality and care in the service and it takes the findings of this and the earlier report very seriously. We acknowledge that the service we have implemented is not always delivering the high standard our patients deserve. We would like to apologise to those who have been affected.

“Since I joined the Health Board, it has become very clear to me a significant amount of improvement work is needed to enable us to deliver the very best outcomes for our vascular patients across our North Wales network.

"I am very concerned to note the review's findings in relation to the quality and consistency of care provided - we must do better".

“I am clear the Board decision to consolidate the service in a hub and spoke model was the right one and is still advocated by the Royal College of Surgeons as the best for North Wales.

“It should be noted that this report covers a period from 2014 through to July last year, so this is not necessarily a snapshot of where we are now and some improvements have already taken place.

“To ensure improvements are embedded into our ways of working, I have commenced an audit of the quality of patient notes and documentation of patient consent across the Health Board. The Health Board has also convened a panel to oversee a review of clinical notes. This process has begun.

“Our vascular improvement plan has been revised and strengthened in order to drive the real progress needed, including the work to ensure that vascular patients receive the most appropriate and timely care.

“We have invested in a state of the art hybrid theatre and a committed multidisciplinary vascular team, which we continue to recruit to. New colleagues are taking up post in the coming weeks to bolster the existing team across our North Wales network.

“But, as the report concludes, we must communicate across sites and teams more regularly and effectively in order to improve decision-making for every patient.

“To assist with this, we are investing in training to build and improve working relationships and we are exploring the possibility of closer collaboration with the Liverpool vascular network.”

Background note – The Royal College of Surgeons were asked by the Health Board to review vascular services and has completed a two stage report into the service. This report compliments the report published in May 2021 and builds on the feedback from expert reviewers.

14th May 2021

A copy of the independent report produced by the Royal College of Surgeons is available as part of the agenda for the Board meeting on May 20. A copy can be found here.

Prof Arpan Guha, Acting Executive Medical Director said:

“We’re pleased to receive the first part of the independent review of vascular services the Board requested from the Royal College of Surgeons, and thank the College for its work in compiling its report under the difficult circumstances presented by COVID-19. This has provided us with an objective perspective on our service and we welcome its findings and recommendations. We await further feedback from the College based on their independent review of 50 sets of patient notes.

“The review reiterates the urgency at which we needed to act to put in place an appropriate hub and spoke model so as to avoid compromising patient safety, which was a significant risk at the time. We’re pleased that the overwhelming commitment from all involved to improve the service has been recognised and that “an excellent foundation” is in place to continue the development and improvement of vascular services in North Wales.

“The report details that the service now has a robust surgical on-call arrangement, appropriate pathways for emergency and complex vascular intervention and no “red flags” in relation to mortality, readmission and length of stays.

“The review has also provided us with an opportunity to review and clarify the further work that needs to be completed to achieve the outstanding service we want and which our patients and communities deserve.

“We recognise that more work is needed, in particular to continue to develop our pathways for vascular and diabetic patients so that we can deliver the best outcomes in the right place.

“We remain committed to providing appropriate vascular services at all three acute hospitals in North Wales. Work is underway to strengthen the delivery of services at our spoke sites, as well as team working throughout the vascular network.

“As the report acknowledges, progress has already been made to address many of the areas for improvement highlighted. Patient representatives and the North Wales Community Health Council remain engaged in our work to continue these improvements, and we look forward to addressing the issues raised in the review at pace.”

 

21st May 2020

Today Betsi Cadwaladr University Health Board held a Board meeting virtually. Due to government guidance, it was not possible to hold the meeting in public, as is usual. Unfortunately, due to technical issues it was not possible to livestream this meeting as planned. We apologise to those who were unable to observe the meeting. We recorded the meeting and it will be available to view through our social media channels.

On the agenda was the Health Board’s review of the current provision and delivery of vascular services in North Wales following the implementation of a reconfigured service in April 2019. The new model is an integrated vascular network with Ysbyty Glan Clwyd as the single site for major arterial surgery. Vascular clinics, investigations, diagnostics, vascular access and varicose vein procedures are provided at all three district general hospitals.

The review paper was presented by Executive Medical Director Dr David Fearnley and Deputy Chief Executive and Executive Director of Nursing and Midwifery Gill Harris.

They explained how significant investment in additional staff and resources, including the development of a new £2.3m hybrid theatre at Ysbyty Glan Clwyd, has supported the establishment of a stable, fit-for-purpose, modern vascular service for the North Wales population.

Dr David Fearnley said: “We recognise that the reconfiguration of this service has caused concern amongst some and we have published a review and action plan to be open and transparent about the further improvements required. We are committed to addressing current challenges to ensure that North Wales residents receive an equitable, safe, high quality service.

“Our investment in this evidence-based new model, informed and supported by the Vascular Society for Great Britain and Ireland and the Royal College of Surgeons, has enabled us to recruit eight vascular consultants. This means we now have a sustainable 24/7 on-call rota for patients in need of emergency care, which we did not have before.

“Clinical pathways for a range of conditions have been implemented and improved, but we recognise that there is more to do, particularly for the management of patients with diabetic foot problems.

“Prior to the reconfiguration of the service, waiting times for some procedures including treatment for aneurysms were inconsistent across the Health Board as cases were discussed locally. There is now a North Wales-wide weekly multidisciplinary team meeting for the management of all complex cases, which meets the requirement from the Welsh Abdominal Aortic Aneurysm Screening Programme.”

Gill Harris added: “Establishing and embedding any new services and introducing new ways of working takes time and we are working hard to ensure that further progress is made. We are pleased to see evidence of multidisciplinary team training and the sharing of learning across the service with regular governance meetings being held to ensure that clinical issues and risks are discussed openly. This points to a change in culture within the service that is focused on patient and service needs.

“We value the feedback on the service that the Community Health Council compiled following their engagement events and acknowledge that their report highlights some issues which we take very seriously and are committed to addressing. We will continue to work closely with Community Health Council colleagues.

“We are actively engaging with staff and patients to listen and learn from their experiences and act upon them to make further improvements.”

The Board approved the establishment of a Task and Finish Group, to be chaired by Dr Fearnley, to oversee the implementation of the vascular services review recommendations and to consider the draft action plan to identify further actions and recommended key performance indicators.

The Board also agreed to commission an external, independent multi-disciplinary assessment of the North Wales Vascular Service provided across the Health Board to assess the quality and safety of the service and patient outcomes. The Board would like this work to begin as soon as possible and will explore timescales, which will be dependent on the availability of expert assessors during the COVID-19 pandemic.

The full review and appendices are available here.

24th February 2020

BCUHB Executive Medical Director Dr David Fearnley said:

“Significant investment in additional staff and resources, including the development of a new £2.3m hybrid theatre, means we now have a stable, fit-for-purpose, modern vascular service.

“Under the previous service model, patients who live in rural locations in Anglesey and Gwynedd had to travel to Wrexham for emergency vascular surgery for half of the week.

“It is widely recognised that the previous service model was too stretched and did not meet national guidelines. Without changing the service, we would not have been able to recruit doctors in the future, meaning we would lose the service in North Wales altogether.

“We have recruited seven vascular consultants since moving forward with the change in service, and now have a sustainable on-call rota which can care for patients in need of emergency care."

March 2019

From 10 April 2019, Glan Clwyd Hospital will become the arterial centre for the vascular network and will provide all emergency and elective arterial surgery and complex endovascular interventions. In order to support this the Health Board has appointed clinical staff, opened an additional ring fenced arterial ward and installed a state of the art hybrid operating theatre. 

The 24-hour-a-day, 7-days-a-week consultant vascular emergency rota will run from Glan Clwyd Hospital. It currently runs from Ysbyty Gwynedd and Wrexham Maelor Hospital on an alternating basis. In simple terms, at present for half of the week emergency care is available in Wrexham, and for half of the week it’s based in Bangor. By locating the small number of emergency cases in one site, it means everyone has equal access to the best expertise, regardless of where in North Wales they live.

The acute hospitals; Wrexham Maelor Hospital, Glan Clwyd Hospital and Ysbyty Gwynedd will continue to have a consultant surgeon presence and will provide the following clinical services: vascular clinics, diagnostics, interventions including renal access and varicose vein procedures, review of in-patient vascular referrals, and rehabilitation. Day-case peripheral angioplasty and simple stenting will also continue at all sites. 

Why is this service changing?

  • The service as it stands is too stretched and does not meet national guidelines
  • Evidence from elsewhere in the UK shows that clinical outcomes are improved at sites where there is a higher volume of procedures
  • Without changing the service, we would not be able to recruit doctors in the future, meaning we would lose the service in North Wales altogether
  • Having committed to a new service model, we have recruited six new vascular consultants, as well as many other clinical staff. This means that we will have a sustainable on-call rota for patients in need of emergency care

Are renal services moving?

  • Renal services, including acute dialysis, are not moving from the sites where they are currently delivered – Ysbyty Gwynedd, Ysbyty Alltwen, Glan Clwyd Hospital, and Wrexham Maelor Hospital.
  • In January, the Health Board announced a new multi-million pound investment in renal services across North Wales, which will also include the development of a new satellite unit in Mold.

Media reports have made reference to dangers if patients are not seen in “the golden hour”

  • The concept of the “golden hour” is not generally used in relation to patients in need of vascular emergency care
  • For patients who suffer a major vascular emergency such as rupture of a major aneurysm, without almost immediate specialist intervention the prospects of survival are not good, no matter how speedy the transfer to hospital.
  • If a patient is too unwell to travel, provision would be available for an on-call surgeon to travel to them to provide treatment.
  • All other emergency arterial patients would be stabilised at their nearest district general hospital before being transferred to Glan Clwyd Hospital for treatment.

Who has supported the decision the board made in January 2013?

  • The development follows guidance from, and is supported by:
    • The Royal College of Surgeons
    • Vascular Society of Great Britain and Ireland
    • Welsh Abdominal Aortic Aneurysm Screening Programme
    • North Wales Community Health Council
    • North Wales LMC

Useful resources    

Chronology of public discussion of Vascular Services 

View our Board Papers here