Improving specialist cancer and in north and east London and west Essex cardiovascular services
The case for change Contents Contents
Foreword 3 Introduction 4
Cancer 7 Why we need to improve 12 Improvements underway to cancer services 14 Our vision for cancer services 15 The evidence for specialist care 17 Brain cancer 19 Head and neck cancer 24 Urological cancers 29 Acute myeloid leukaemia and haematopoietic stem cell transplantation 35 Oesophago-gastric cancer 40 Conclusion 44
Cardiovascular 45 Context – national and London-wide reviews 51 Improvements underway to cardiovascular services 52 Why we need to change 54 Our vision for improving cardiovascular care 62 How we could improve services 63 What this would mean for patients 66 What other options did we consider? 67 Conclusion 69
Get involved 71
2 Royal LondonHospital,St Bartholomew’s However, forcancertreatments, The patientreferrals.national andinternational money from more research investmentand cost-effective services, aswellbringingin local healtheconomybyproviding more These centres ofexcellencewouldboostthe The NHSfacesatoughfinancialclimate. better localservices. outcomes, abetterexperienceofcare and and cardiovascular care would have better means patientswhoneedspecialistcancer improve thewholepathwayofcare. This together incentres ofexcellencewecan technologies, research andeducation By bringingexpertise,state-of-the-art College Hospital. and oneforcancerservicesatUniversity services atStBartholomew’s Hospital and eastLondon,oneforcardiovascular two world-classspecialistcentres innorth view andrecommend thedevelopmentof the bestchanceofrecovery. We share this with thebestequipment,togivethem critically illtheywantthebestspecialists, are locallyaccessible.Butwhentheyare Patients wanttohavehealthservicesthat improve them. have developedavisionforhowwecould services innorthandeastLondon.Andwe have examinedhowweprovide these To supportthisstraightforward aim,we So wecanandmustdobetter. over 1,200livesayear. at leasttherateforEngland,wecouldsave for heartdiseaseandallcancersinlinewith If wewere toimprove localsurvivalrates two-thirds ofearlydeathsinLondon. Cancer andcardiovascular diseasecause Foreword 3 NHS England Director ofCommissioning(London Region) Simon Weldon NHS England Medical Director (LondonRegion) Dr AndyMitchell comments by4December2013. are onpage71.We needtoreceive your for change.Detailsofhowyoucanrespond We are keentohearyourviewsonthiscase centre development. University CollegeHospital’s cancer facility atStBartholomew’s Hospitaland lifetime opportunityarisingfrom thenew They are designedtoseizetheonce-in-a- around theworldoverpastfewyears. developments across thecountryand best todothis.Theproposals buildon expert advicefrom localcliniciansonhow patients andfuture generations.Italsogives to changeimprove servicesfortoday’s This documentsetsoutwhyservicesneed of itclosetopeople’s homes. comprehensive systemofcare, much specialist centres theywouldprovide a specialist care andfacilities.Working as tumour types,providing theverybest develop expertiseandservicesforspecific Free Hospital wouldalsoretain and Hospital, Queen’s HospitalandtheRoyal
Foreword Introduction Introduction North and east London has some of the ■ For cardiovascular care, clinicians have best cancer and cardiovascular experts in told us we should combine services the country but our specialist services are currently provided at The Heart Hospital, not organised in a way that gives patients The London Chest Hospital and St the best chance of survival and the best Bartholomew’s Hospital to create a experience of care. single integrated cardiovascular centre. With The London Chest Hospital closing Specialists, technology and research are next year and The Heart Hospital not spread across too many hospitals to having capacity for the whole region, provide the best round-the-clock care to clinicians have recommended we locate all patients. the centre in the new building at St Bartholomew’s Hospital (which is 2.5 In 2010 a clinical review recommended miles from The Heart Hospital). The changes to cancer and cardiovascular Royal Free Hospital and the integrated services in London. After discussion with cardiovascular centre at St patients and the public, the review Bartholomew’s Hospital would act as concluded that fewer specialist high- heart attack centres for the area. volume units would improve clinical outcomes, accelerate the uptake of new ■ For five complex or rare cancers, technologies, achieve greater quality and clinicians have told us we should optimise efficiency. provide specialist treatment in four centres of excellence across the area Building on the London review and using with a hub at University College clinical evidence, local doctors, GPs, Hospital. We would continue to nurses, health professionals, public health provide services locally for other types professionals and patients have looked at of cancer and general cancer services, how we could improve cancer and such as diagnostics and chemotherapy. cardiovascular services in north and east London. This case for change is part of a UK-wide Clinicians want to bring together expertise strategy to bring fairness and excellence to to give better care and save more specialist services1, and to strengthen the lives. To do that, we need to change the NHS’s status as a pioneer of medical way we deliver specialist cancer and innovation2. In developing their ideas, cardiovascular services: clinicians have been guided by the
What are specialised services? Specialist services are those provided in only a few hospitals, to only a few patients. These services should be located in specialist centres that can recruit staff with the right expertise and enable them to develop their skills. So you only tend to go to these places if you have a condition that needs really specialist care, perhaps because it is particularly rare or complex.
4 https://www.gov.uk/government/news/accelerating-adoption-of-innovation-in-the-nhs 2 DepartmentofHealth, loads/attachment_data/file/213055/121109-NHS-Outcomes-Framework-2013-14.pdf 1 DepartmentofHealth, patient care isprovided seamlessly. with localhospitalsandGPstoensure more efficient care. Theywouldworkclosely overall plantoestablishbettercoordinated, Specialist centres ofexcellenceare partofan the wholepathwayofcare foreveryone. treatment, butthesechangeswill improve cardiovascular disease needspecialist Not allpeoplewithcancerand service specifications. strategies andNHSEngland’s national Department ofHealth’s nationaloutcomes services acrossnorthandeastLondon. cancer services UCLPartners’ recommendationstocommissionersin UCLPartners havegiventocommissioners.Furtherinformationisavailablein This documentsummarisestheexpertclinicaladvicethatteamsworkingacross develop carepathwayswhereservicesarebetterintegrated. UCLPartners isalsolookingatwaystopreventanddetectdiseasesearlier population. Aswellasimprovingspecialistcancerandcardiovascularservices, together totacklethemostpressinghealthcarechallengesfacedbylocal Hertfordshire, BedfordshireandEssex.Itsmemberorganisationsareworking the healthcaresystemthatservesoversixmillionpeopleinpartsofLondon, innovation andresearchintoroutinepracticeintheNHS.UCLPartnerssupports Academic healthsciencenetworksareakeypartofNHSEngland’s plantobring together throughUCLPartners–anacademichealthsciencepartnership. All hospitaltruststhatprovidecancerandcardiovascularserviceshavecome been involvedindevelopingthevision. vision forcancerandcardiovascularservices.Patientrepresentativeshavealso Clinicians fromacrossnorthandeastLondonwestEssexhavedevelopedthis most communityhealthservices,includingafewassociatedwiththeseproposals. urgent andemergencycare,mentalhealthlearningdisabilityservices specialised services).Theseincludeplannedhospitalcare,rehabilitative commission mosthealthcareservicesfortheirlocalpopulation(excluding clinical commissioninggroups(CCGs).CCGsareofGPpracticesthat of specialistcancerandcardiovascularservices,togetherwithanumberlocal NHS England,themaincommissionerforspecialisedservices,isleadingreview Who isleadingthisreview ofcancerandcardiovascular services? Innovation Healthand Wealth: Accelerating AdoptionandDiffusionintheNHS The NHSOutcomesFramework2013/14 and A proposalforclinicalchangeinspecialistcardiovascular , November2012.Available at:https://www.gov.uk/government/uploads/system/up- 5 recommendations forchange. ('commissioners') todevelop preferred those whocommissionhealth care cardiovascular services. Thiswillhelp for improving specialisedcancerand your viewsontheclinicalrecommendations NHS EnglandandCCGswouldnowlike health outcomes. technology andclinicaltrials,whichimprove also givemore patientsaccesstothelatest focus onresearch andeducationwould referralsinternational ofpatients.The for theNHSthrough research fundingand cost-effective andcouldgenerateincome These specialistcentres wouldbemore A caseforchangeinspecialist , December2011.Available at:
Introduction Who uses these services? Most of the hospitals that are part of this review are located in north and east London. But many
Introduction patients from elsewhere use their services, particularly those from west Essex.
We will be discussing this document's recommendations with people from these areas.
Wherever you live, we encourage you to send us your feedback as outlined on page 71.
Travel and patient choice Clinicians know that concentrating specialised cancer and cardiovascular The Macmillan Cancer Centre at University services in fewer hospitals would College Hospital, which opened in April 2012. increase travel times for some patients, many of whom are very ill and coping with severe symptoms and the The potential options considered in side effects of treatment. this document are subject to further analysis and the ongoing assessment Clinicians only want patients to travel and investigation of patient benefits, further when it is absolutely necessary for which involves additional analysis in them to receive better, more specialist compliance with our statutory obligations care. Most patients would continue to be and the guidance surrounding them diagnosed and, where possible, receive (not included or addressed in this their outpatient treatment and follow-up document as not directly relevant to the care at their local hospital. clinical case for change).
Clinicians think the proposals in this If you have any comments or document would greatly improve their questions on these issues, email ability to provide the highest quality care [email protected] and better outcomes for patients.
The impact of longer travel times for patients and carers will be carefully considered as the proposals develop. We will be asking patient groups to tell us what they think and how we could lessen any problems. Options include better car parking and taxi services for those in need.
6 Cancer
Improving specialist cancer services in north and east London and west Essex
Why we need to improve 12 Improvements underway to cancer services 14 Our vision for cancer services 15 The evidence for specialist care 17 Brain cancer 19 Head and neck cancer 24 Urological cancers 29 Acute myeloid leukaemia and haematopoietic stem cell transplantation 35 Oesophago-gastric cancer 40 Conclusion 44
7 Cancer Cancer
Cancer is one of the biggest causes of death ■ brain cancer and disability in the UK. Every year, around ■ urological (bladder, prostate and kidney) 13,600 Londoners die from the disease. The cancer number of new cases is predicted to rise from 27,000 a year to 28,500 in 2022. ■ head and neck cancer ■ In north and east London, it is estimated around acute myeloid leukaemia (AML) and 12,900 people are diagnosed with cancer and haematopoietic stem cell transplantation 5,700 die from the disease each year. (HSCT – transplanting stem cells derived from the bone marrow or blood) Over the last decade, good progress has been ■ oesophago-gastric cancer (OG – cancer of made in prevention and treatment, so more the stomach or oesophagus). people are surviving cancer, but there is still a lot of room for improvement. Cancer patients in London have worse survival rates and lower satisfaction about the care they receive To achieve world-class standards of care and compared to the rest of England. Within ensure that local specialist cancer services can London there are also inequalities in specialist continue long term, clinicians agree we have to cancer care and outcomes between areas. change the way we provide these services.
Local clinicians – working under the leadership Most care will continue to be provided locally. of London Cancer (part of UCLPartners) – have But clinicians believe that centralising services been reviewing local cancer services and looking for these tumour types into specific specialist at how outcomes could be improved. centres will save more lives and help to achieve the wider improvements that are needed along This section focuses on the recommendations the whole pathway of care, as we have seen that London Cancer clinicians have made about with stroke care in London. specialist services for:
We propose changing specialist These include: services, such as surgery, for five ■ types of cancers. tests such as X-rays, ultrasounds, genetic screening, mammograms We do not propose to change general and scans cancer services and all services for ■ chemotherapy other types of cancers such as bowel ■ follow-up checks and breat cancer. However, clinicians are ■ looking at how these services can support services such as continue to be improved. physiotherapy, occupational therapy and counselling This means your local hospital or GP will ■ palliative care. continue to provide most services.
8 ■ them isshownbelow: fewer sitesbuttheircurrent thinkingabout clinicians are notcurrently recommending could beimproved. Forthesecancerservices, types ofcancertoseehowservices London Cancer Whilst notpartofthiscaseforchange, (design notyetfinalised). An artist’s impression ofthenewproton beamtherapycentre atUniversityCollegeHospital multi-disciplinary teamwith aleadprovider. cancer thiscouldinclude a singlespecialist these more commoncancers.Forlung improve servicequalityandoutcomesin looking atarangeofoptionstohelp services bereorganised. Commissionersare recommend tocommissionersthat hospital specialisation ofteams.Infuture theymay better jointworkingandsomefurther standards andbestpractice.Thiswillinclude pathway couldbeimproved tomeet service Clinicians are lookingathowthecare and colorectal cancer Common cancerssuchasbreast, lung has beenreviewing other 9 ■ information andwaysofdoingthings. London Cancer services are workingasajointcentre through both cases,thetwohospitalsproviding these north andeastLondon,aswellEssex.In Royal LondonHospitalprovide servicesfor cancers, theRoyalFree HospitalandThe areas ofHertfordshire. Forliverandpancreatic north andeastLondon,westEssexmany provide gynaecologicalcancerservicesto University CollegeLondonHospitalTrust population theyserve.BartsHealthand for thenumberofpatientsand centralised andare meetingservicestandards specialistserviceshavealreadyThese pancreatic cancers Gynaecological andliver to share bestpractice,audit
Cancer Hospitals in north and east London and west Essex providing specialised cancer services Cancer
Population of over 3.2 million 10
1 2
3
15 9 14
13 16 6 4 5 12 1112 8 7
Barnet and Chase Farm Hospitals NHS Trust University College London Hospitals NHS Foundation Trust (UCLH) ■1 Chase Farm Hospital ■11 University College Hospital ■2 Barnet Hospital ■12 The National Hospital for Neurology and Neurosurgery (NHNN) 13 North Middlesex University Hospital NHS Trust ■3 North Middlesex University Hospital Royal Free London NHS Foundation Trust ■13 Royal Free Hospital Barts Health NHS Trust (Barts Health) ■4 Mile End Hospital Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) ■5 Newham University Hospital ■14 Queen’s Hospital ■6 The London Chest Hospital ■15 King George Hospital ■7 The Royal London Hospital ■8 St Bartholomew’s Hospital ■9 Whipps Cross University Hospital Homerton University Hospital NHS Foundation Trust
Princess Alexandra Hospital NHS Trust ■16 Homerton University Hospital ■10 Princess Alexandra Hospital
10 L -Localservice S -Specialistprovider Where localcliniciansare recommending specialisedcancerservicesbeprovided Where specialisedcancerservicesare provided now OG AML HSCT Kidney Prostate andbladder Head andneck Brain OG AML HSCT Kidney Prostate andbladder Head andneck Brain Future Current QH KGH NUH WX RLH BH HUH PAH NMUH NHNN UCH WHIT RF CFH Barnet Queen’s Hospital King GeorgeHospital Newham UniversityHospital Whipps Cross University Hospital The RoyalLondonHospital St Bartholomew’s Hospital Homerton UniversityHospital Princess AlexandraHospital North MiddlesexUniversityHospital National HospitalforNeurology andNeurosurgery University CollegeHospital The WhittingtonHospital Royal Free Hospital Chase FarmHospital Hospital Barnet Hospital Barnet Barnet S L L L L CFH CFH S S S L L L L L RF RF S S S S L L L L WHIT WHIT L L L L L L UCH UCH S S S S S S S S S S S L NHNN NHNN S S 11 NMUH NMUH Barking, HaveringandRedbridgeUniversity HospitalsNHSTrust Barts Health Homerton UniversityHospitalNHSFoundationTrust Princess AlexandraHospitalNHSTrust North MiddlesexUniversityHospitalNHSTrust University CollegeLondonHospitalsNHSFoundationTrust Whittington Health Royal Free LondonNHSFoundationTrust andChaseFarmHospitalsNHSTrustBarnet Trust S L L L L L L L PAH PAH S L L L L L HUH HUH S L L L BH BH S S S S S L RLH RLH S S S L L L L L WX WX S S L L L L NUH NUH S L L L KGH KGH S S L L QH QH S S S S S S L L
Cancer Why we need to improve Cancer
Clinical outcomes for patients with rare or ■ There are inequalities in patient complex cancers and patients’ experience of outcomes cancer services in north and east London are Cancer rates and survival vary significantly not as good as in other areas of the country. within London and between ethnic and One local borough – Barking and Dagenham – socio-economic groups. For example, the UK has the country’s lowest proportion of total five-year survival rate for Afro-Caribbean cancer patients who survive more than a year men with prostate cancer is 30% worse after their diagnosis. than for white men. While there has been significant improvement, ■ Services are fragmented services often fall short of the high standards that local patients expect. In the past year, Local cancer services have developed at cancer patients in England have rated nine out numerous hospitals over the years in an of the 10 worst trusts as being in London – four unplanned way. They do not make the most of those were in north and east London. efficient use of the limited and highly skilled workforce so patients are not fully benefiting Every cancer type is different, but local from advances in medical care. Specialist clinicians have given the following reasons for teams are spread across too many hospitals, changing the way we provide our specialist making it difficult to provide all patients with cancer services: the best quality care. For example, not all patients with acute myeloid leukaemia have ■ Local cancer patients have relatively enough input from clinical nurse specialists poor clinical outcomes with specific expertise in their condition. Over recent years, improvements in one-year Locally, there are also high staff turnover and survival in the region have lagged behind vacancy rates. those reported in England as a whole (Office ■ Patients do not always have a good for National Statistics 2011). The London- experience wide review estimated there are 400 avoidable deaths from cancer in north and The 2012/13 national cancer patient east London and west Essex every year. experience survey found that patients diagnosed with rarer cancers tend to have For some types of cancer, where services are a worse experience (i.e. lower levels of spread across a number of local hospitals, satisfaction) than patients with more clinicians do not see enough patients to common cancers. Locally, an average of build and maintain their skills. For example, 85% respondents rated the care provided National Institute of Health and Care by hospitals in north and east London as Excellence (NICE) Improving Outcomes very good or excellent, compared with 91% Guidance for Cancer recommends hospitals for the Royal Marsden Hospital which is a serve a population of between one and two specialist cancer care centre. million, which would mean they perform at least 60 operations for oesophago-gastric cancer each year. None of the hospitals in our local area meet this minimum number.
12 donhp.nhs.uk/wp-content/uploads/2011/03/Cancer-model-of-care.pdf 3 NHSCommissioning SupportforLondon, ■ director ontheboardof Elizabeth Benns,member ofIndependentCancerPatients’Voice andanon-executive bring cancerintotherealmsofachronic(orcurable) illness.” difficulties ofcancer treatment,intoapositivecontributiontotheongoingwork cancer patients.It’s alsoawaytoturnthenegativityofcancerdiagnosis, andthe outcomes forthemselves,whileothersit’s aboutimprovingtreatmentsfor future clinical trialsforavarietyofreasons.Somepeople hopeatrialwillleadtoimproved improvements incancertreatmentsandoutcomes. Peoplearekeentoparticipatein “Clinical trialsareimportanttousaspatients because webelievethattheyarekeyto side effects ofradiationtherapyforsome proton beamtherapy, whichcanreduce the one oftwositesinEnglandthatoffer 2017, UniversityCollegeHospitalwillbe reduce thesideeffects oftreatment. From more precise radiationdosesandcan radiation therapy. Thistechniquedelivers techniques, suchasintensity-modulated access toadvancedradiotherapy all headandneckcancerpatientshave become more specialised.Forexample,not clinical staff andequipmentneedto Advances inmedicineandsurgerymean most ofthelatestadvancesintreatment Not enoughspecialisationtomakethe types ofbrainandheadneckcancers. A model of care for cancer services: Clinical paper A modelofcarefor cancerservices: London Cancer 13 ■ outcomes forcancerpatients Taking partinclinicaltrialsimproves clinical trials Not enoughpatientsare involvedin drugs andtreatments. many are missingtheopportunityofnew trials duringtheirtreatment. Thismeans quarter ofcancerpatientstakepartinclinical research takesplacelocally, butlessthana , August2010,p.110-112. Available at:http://www.lon- 3 . Alotof
Cancer Improvements underway to cancer services Cancer
Specialist treatment is only a small part of a ■ Supporting patients who are living long and difficult journey for cancer patients. with and beyond cancer Work is needed across all services to reduce Patients with cancer who receive holistic, the number of people who die from the coordinated and personalised care have a disease. NHS England, CCGs, London Cancer better experience. Over the next two years, and local authorities across north and east London Cancer aims to work with expert London and west Essex are working hard to groups to introduce the recovery packages improve all cancer services. recommended by the National Cancer For instance, London Cancer aims to reduce Survivorship Initiative. These will start at avoidable deaths from cancer in the local the point of diagnosis by offering everyone population by 200 each year from 2015/16 living with cancer a holistic needs by increasing screening for people at risk and assessment, treatment summaries detailing supporting GPs to detect signs and symptoms their care and key staff, as well as health of cancer earlier. and wellbeing sessions to learn about local support services and healthy lifestyles. ■ Earlier detection and intervention Patients will also receive cancer care reviews with their GP after they have Cancer is no longer a fatal disease. been diagnosed. Advances in medicine mean many forms of cancer have high survival rates, ■ Developing pathway specifications provided they are diagnosed early. Health professionals and patients have However, 16-35% of all new cancers in developed care pathway specifications north and east London and west Essex that tackle all aspects of the care a are diagnosed only when a patient arrives patient receives. These focus on the whole at hospital in an emergency4. This means patient pathway – from prevention to the cancers are often detected late, diagnosis and treatment. They are planned resulting in poor survival rates one year around patient need and they are after diagnosis. motivated by the wish to reach ‘global In Camden, commissioners, clinicians excellence’ for each cancer area. The local and academic experts are working specifications are in line with the national together to design a programme to specifications for specialised services improve early detection in people most (where these apply). at risk of cancer. This work includes analysis to understand ‘at risk’ groups and the use of community champions to encourage people with symptoms to visit their doctor.
4 National Cancer Intelligence Network (NCIN), 2011
14 system ofcare. care isthedevelopment ofanintegrated the heartof across allcare settingsandorganisations.At that improvements incancercare are provided London Cancer and peerreview. clinicians haveaccesstotraining,support services are coordinated andthatalltheir during theirtreatment. Itisessentialthat range ofcliniciansandorganisations Patients withcancerare cared forbya Our visionforcancercare London Cancer’s plays aleadrole inensuring vision forcancer 15 potentially life-savingsurgery. oesophago-gastric cancerpatientsayear example, thatwecouldoffer upto190more Building specialistteamswouldmean,for experience forpatientsandtheirrelatives. practice, resulting inamore joined-up with localhospitalsandGPstoshare best cancer pathway. Thesecentres wouldwork research excellencealongthewholeof Specialist centres wouldprovide clinicaland were centralised. would havebetteroutcomesifspecialistcare patients withrare orcomplexcancers But Most care will continuetobeprovided locally. London Cancer clinicians agree that
Cancer Fewer, specialist centres would provide Clinicians believe that concentrating specialist the following: cancer services at fewer higher-volume sites would save more lives and provide more Cancer ■ Expert care closer to where patients live – productive, efficient and sustainable services. through joint consultant appointments, outreach clinics, joint multi-disciplinary Their view is backed by the following national teams and local ‘one-stop’ diagnostic guidance and London-wide strategies: clinics for patients who urgently need a range of tests. ■ The Department of Health’s Improving Outcomes: A strategy for cancer, which ■ Multi-disciplinary care teams including sets out the Government’s plans to raise specialist nurses, anaesthetists and England’s cancer survival rates and therapists with enough qualified staff to improve survivors’ experience of care and give suitable cover. quality of life. ■ Better access to research and clinical trials, ■ The London-wide model for cancer which are essential for finding new services5,6, which sets out the capital’s treatments and therapies. needs for cancer services. The strategy was ■ An improved working environment for developed by lead cancer clinicians after a all staff, better access to improved training review of cancer services. and more opportunities to get involved ■ NICE Improving Outcomes Guidance, in research. which recommends which professionals ■ The opportunity to collect better data on should be involved in treating and caring outcomes and quality of care to continually for cancer patients and the types of raise standards for patients. hospital or cancer centre that are best suited to give that care.
NHS England’s national service specifications set out the requirements for a world-class service. All hospitals providing specialist cancer care are being assessed against these national service standards. Action plans will tackle any shortfalls. In some cases, hospitals will not be able to meet the national standards and commissioners will need to make other plans to ensure high-quality services.
5 NHS Commissioning Support for London, Cancer services: Case for change, March 2010. Available at: http://www.londonhp.nhs.uk/wp-content/up- loads/2011/03/Cancer-case-for-change.pdf 6 NHS Commissioning Support for London, A model of care for cancer services: Clinical paper, August 2010. Available at: http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/Cancer-model-of-care.pdf
16 England, 2004–2008’, Gut,2013;62:961–966. Hetal.‘Hospitalvolume, proportion11 Coupland,Victoria resected andmortalityfrom oesophagealandgastric cancer:apopul cancer services. found thisisveryimportantforspecialist Numerous studies overthepast10yearshave survive aftersurgeryandlivelonger, fullerlives. are treated inthesecentres are more likelyto 10 TvanHeek,etal,‘HospitalVolume andMortality AfterPancreatic Resection’, procedures’, 9 MNuttall,etal,‘Asystematicreview andcritiqueoftheliterature relating hospitalorsurgeonvolume tohealthoutcomes Internal Medicine 8 EAHalm,CLee,MRChassin,‘Isvolume related tooutcome inhealthcare? Asystematicreview andmethodologiccritiqueofth Survival forCancerSurgery’, 7 KBilimoria,DJBentram,JMFeinglass, etal,‘Directing Surgical QualityImprovement Initiatives:ComparisonofPerioperativ ■ ■ ■ (known ashigh-volumecentres) numbers ofpatientswiththesamecondition have betteroutcomesincentres thatseelarger There isstrong evidencethatcancerpatients The evidenceforspecialistcare in hospitalsperformingmore than24 mortality ratesofbetweenzero and 3.5% 13.8% and16.5%,compared with pancreatic operationsayearwere between in hospitalsperformingfewerthanfive each surgeonsaw hospitals sawandthenumberofpatients conditions lookedathowmanypatients a rangeofsurgicalprocedures orclinical A review of 135 publishedstudiescovering pancreatic operationsayear. more people outcomes improved ashospitalstreated Another review foundthatpatient patients, thebetteroutcomes surgery foundthatthelargernumberof A USliterature review ofurological cancer treatment. or high-riskprocedures, includingcancer outcomes. Thiswasstrongest incomplex numbers ofpatientsandimproved found adirect relationship betweenhigher The JournalofUrology , 2002,137:511-52. 10 . Mortality(i.e.death)rates Journal ofClinicalOncology 8 . Mostofthesestudies , 2004. 7 . Patientswho , 2008,26:4626-4633. 9 . 17 receive thebestpossiblecare. raise clinicalqualityandensure allpatients staff levelsare sufficient. Theseimprovements clinical expertise,supportstrainingandensures centres ofexcellencebringstogetherscarce to maintaintheirskillsandexpertise.Creating suitably qualifiedteamswithenoughpractice Specialist servicesneedtobeprovided by ■ ■ patients treated Annals ofSurgery Number of further centralisationofsurgicalservices long-term outcomes.Thereview supported volume hospitalshadthebestshort-and found thatpatientsoperatedoninhigh- oesophagus between2004and2008 England forcancerofthestomachor A recent review ofallpatientstreated in cancer surgery. had muchbetteroutcomesforcomplex the UKfoundthathigh-volumehospitals A 2005review ofcancerprocedures in , 2005,242(6):781–790. for 3urological cancer e MortalityandLong-Term ation-based studyin e literature’, outcomes Better Annals of 11 .
Cancer Cancer
Treating more patients also improves research, You can find out more about the evidence for particularly for rarer cancers. There is evidence creating specialist, high-volume centres in that cancer patients who take part in clinical A case for change in specialist cancer services. trials have better outcomes. Indeed, all patients treated in centres that undertake clinical research do better whether or not they are part of a trial12,13.
12 J West, J Wright, D Tuffnell, D Jankowicz, R West, ‘Do clinical trials improve quality of care? A comparison of clinical processes and outcomes in patients in a clinical trial and similar patients outside a trial where both groups are managed according to a strict protocol’, Qual Saf Health Care, 2005;14:175-178. 13 Peppercorn JM, Weeks JC, Cook EF, Joffe S., ‘Comparison of outcomes in cancer patients treated within and outside clinical trials: conceptual framework and structured review’, Lancet. 2004 Jan 24;363(9405):263-70.
18 Hospitals providing specialistbraincancerservicesinnorthandeastLondon multi-disciplinary team: malignant tumours),eachwithitsown surgery centres (formalignantandnon- There are currently three neuro-oncology follow-up care. (neurosurgery) withhighlevelsofsupportand have tumours.Mostpatientsrequire surgery Patients referred tohospitalbyGPsrarely with severe symptomssuchasseizures. Patients withbraincancerusuallyattendA&E serious symptomsandbelife-threatening. chemotherapy becausetheycanalsocause are sometimes treated withradiotherapyand ‘malignant’ (cancerous). Benignbraintumours class themas‘benign’(non-cancerous) or other typesofcancer, itisnotalwayseasyto There are manytypesofbraintumour. Unlike Brain cancer Cancer Centre Mount Vernon Neurology andNeurosurgery The NationalHospitalfor St Bartholomew’s Hospital 19 East andNorthHertfordshire NHSTrust. place atMountVernon CancerCentre, partof Oncology forbraincancerpatientsalsotakes oncology atStBartholomew’s Hospital. The RoyalLondonHospital’s patientshave oncology (radiotherapyandchemotherapy). Romford haveonsiteornearbyaccessto Both theNHNNandQueen’s Hospitalin the wholeofEssex. neurosurgical andneuro-oncology servicefor Queen’s Hospitalprovides theregional ■ ■ ■ The RoyalLondonHospital The RoyalLondonHospital. Queen’s HospitalinRomford Neurosurgery (NHNN) The NationalHospitalforNeurology and Queen’s Hospital
Cancer “We aim to provide world-leading brain integrated cancer care that meets the holistic needs of our patients – including access to rapid and accurate diagnosis,
Cancer all the most effective treatment options, cutting-edge clinical trials and innovation in rehabilitation. “We will judge our success, not just on clinical outcomes, but on the quality of the patient experience, and whether our patients feel fully supported throughout their care, whether it is in hospital or at home.” Mr Andrew Elsmore, Pathway Co-Director for Brain and Spine Cancer, Consultant Neurosurgeon and Dr Jeremy Rees, Pathway Co-Director for Brain and Spine Cancer, Consultant Neurologist
Brain cancer procedures in north and east London (2010/11)
The Royal London Hospital 156
952 Total number of 490 The National Hospital for neuro-oncology Neurology and Neurosurgery operations a year14 306 Queen’s Hospital
14 Activity at the NHNN increased by 29% between 2011 and 2012. Data from 2011/12 is not available for Queen’s Hospital in Romford or The Royal London Hospital. This increase in activity at NHNN follows the trend of recent years due, in part, to the move of the neuro-oncology surgery service from the Royal Free Hospital in Hampstead to NHNN during this time.
20 content/uploads/2013/06/b13-cancr-brain-cent-nervous.pdf 16 NHSEngland, http://www.nice.org.uk/nicemedia/pdf/CSG_brain_manual.pdf 15 NICE, serving apopulationoftwomillion. patients bereduced tofour, each specialist servicesforbraincancer of hospitalsinthecapitalproviding recommended thatthenumber The London-widereview ■ ■ ■ ■ ■ NICE guidance Overview ofservicestandards standards recommend that: in dedicatedspecialityclinicsfor surgery andberegularly involved of theirtimeinneuro-oncological brain tumoursspendatleast50% neurosurgeons whomanage population oftwomillion cancer centres servinga are basedinneuroscience and specialist multi-disciplinaryteams occupational therapist. as aphysiotherapistor an alliedhealthprofessional such coordinated ineveryregion by neuro-rehabilitation services patients haveaccesstospecialist neuroradiology least 50%oftheirtimein brain tumourpatientsspendat radiologists whoinvestigate aspects offollow-uptreatment team todealwiththeoncological ‘cancer network’multi-disciplinary centred onneurosurgery witha neuroscience specialistteamsare these patients Guidance on Cancer Services –ImprovingOutcomes forPeoplewithBrainandOtherCNSTumoursGuidance onCancerServices –TheManual Service specification for brain/central nervous systemtumours specificationforbrain/centralnervous Service 15 and national 16 service Not allpatientsaregettingthebestpossiblecare national standards. of theirtime.Thisisbelowthelevelsetby investigating braincancerforlessthan50% neurosurgeons andradiologistsmanaging To varyingdegrees, allthree localcentres have and radiology Time dedicatedtoneuro-oncologysurgery million setbythenationalstandards. they are wellbelowtheminimumpopulationoftwo million (northandeastLondonEssex).Thismeans Currently, three centres serveapopulationofover3.9 of care Services arenotmeetingrecommendedlevels Why servicesneedtochange ■ ■ ■ ■ a dedicatedbraincancerward withspecialist specialist nursingsupport,whereas theNHNNhas oncologist onedayaweekandonlylimited particular, TheRoyal LondonHospitalonlyhasan supportive care ofbraintumourpatients.In Royal Londontomanagethenon-surgicaland multi-disciplinary teamateitherNHNNorThe Currently, there isnofull‘cancernetwork’ neuro-rehabilitation services. need more coordinated andconsistentaccessto services remains anationalproblem. Locally, we Improving OutcomesGuidance services. ThisisakeyprincipleoftheNICE depend ongoodaccesstoneuro-rehabilitation life andminimisingthesideeffects oftreatment Maximising thechanceofanimproved qualityof waiting oversixweeks. some patientsatTheRoyalLondonHospital variation inwaitingtimesatlocalcentres, with within sixweeks.Anaudithasshownwide should takeplaceassoonpossibleandalways Radiotherapy forsometypesofbraincancers well asthoseattheothertwocentres. at TheRoyalLondonHospitaldonotperformas A clinicalaudithasshownneuropathology services staff –oneofthefewnationally. 21 , 2013.Available at:http://www.england.nhs.uk/wp- but providing these , 2006.Available at:
Cancer Clinical recommendations together as a team to reduce delays in the patient pathway. Local clinicians recommend that the three ■
Cancer current neuro-oncology surgery services should Suitable follow-up – neuro-oncology be consolidated to two centres. This would surgery centres should work in partnership mean keeping the service at Queen’s Hospital in with oncology centres, local cancer units, Romford (for Essex and outer north-east GPs and hospices to implement new London) with services at The Royal London methods of long-term follow-up. Hospital and NHNN coming together, providing ■ Improved access to neuro-rehabilitation – for a population in excess of two million. all patients should have access to a Clinicians have recommended that the NHNN suitable level of neuro-rehabilitation. should become the single centre for inner Neuro-oncology teams should work with north-east London and north-central London. commissioners, charities, community care The Royal London Hospital is currently the and other neuroscience colleagues to smallest centre and lacks access to the full improve access to neuro-rehabilitation. range of specialist clinical and support service staff available on the other two sites. The NHNN has a national and internationally established reputation for excellence and a range of specialist facilities for brain cancer patients.
In addition to consolidating care onto two sites, clinicians have recommended ways of improving the patient pathway:
■ Immediate referral – local hospitals should refer patients with a suspected brain tumour immediately to a neuro-oncology surgery centre. These referrals should include clinical information, the original CT scan, and the named point of contact at the referring unit. ■ Clinical nurse specialist support – all patients should have information and support from a clinical nurse specialist at diagnosis and before surgery. These nurses would do holistic needs assessments at key points in the pathway, including start and end of treatment, and proactively support patients. ■ Rapid diagnosis and referral to oncology after surgery – all patients should experience a seamless pathway. Neuropathologists, neuroradiologists, neurosurgeons, radiotherapy physicists and neuro-oncologists should work
22 department asanoutpatient. When shewasreadyforherfurthertreatmentattendedchosenradiotherapy Margaret thenreturnedtoherlocalhospitalforfollow-upcarebeforegoinghome. neighbouring area.Thiswasarrangedforherwithoutdelay. at UCLH,aradiotherapycentreelsewhereinLondonor have radiotherapy– They setouttheoptions,risksandsideeffects. Shewasgivenachoiceaboutwhereto explained thediagnosisandrecommendedtreatmentplantoMargaretCharlie. After theteamhadmet,consultantsurgeonandaclinicalnursespecialist Margaret’s ongoing treatment. care consultant,radiologistandradiotherapist)mettodiscusstheresults team (includingasurgeon,pathologist,oncologist,clinicalnursespecialist,palliative team quicklyestablishedthetypeoftumour. Theneuro-oncologymulti-disciplinary The tumourwasremovedandsamplesweresenttopathologywhereaspecialist further treatmentwouldbeneeded.Margarethadsurgerythenextday. pressure onherbrain,allowtheteamtogiveanaccuratediagnosisandseewhat had asuspectedbraintumour. Theysaidshewouldneedurgentsurgerytorelievethe Having seentheresults,consultantsurgeonandnursespecialisttoldMargaretshe specialist neuro-oncologysurgeryteam.MargarethadanMRIscanwithoutdelay. scan fromthelocalhospital,whichwastransferredelectronicallyforreviewby Margaret andCharlieweretakentotheNHNN.Theyarrivedatsametimeas centre atNHNNincentralLondon. brain tumourandMargaretwasimmediatelyreferredtotheneuro-oncologysurgery In A&E,theteamorganisedaCTscanofherbrain.Theshowedsuspected husband Charlie.AnambulancetookthembothtotheirlocalA&Edepartment. Margaret, 64,fromnorthLondon,hadaseizurewhileshewasathomewithher How serviceswouldwork:anexample 23
Cancer Head and neck cancer Cancer
Most patients with head and neck cancers are Surgery is the most common treatment middle-aged or older. Survival rates depend although more head and neck cancers are mainly on the site of the cancer and how far it being treated with chemotherapy and has spread when first detected. radiotherapy.
Most head and neck cancers are found on the lip, Specialist surgery for head and neck cancer is mouth, back of the throat, voice-box and upper currently carried out at three local centres: gullet. Other rarer forms of head and neck cancer ■ Chase Farm Hospital include the salivary glands, nose, and sinuses. Those that start in the connective tissues of the ■ The Royal London Hospital head and neck are even rarer. ■ University College Hospital.
“There is a real will amongst us all to shape the future of head and neck cancer care for the benefit of our patients. My role is to lead the process of integration and improvement and to ensure head and neck cancer care compares to the very best international standards, which our patients and local population deserve.” Mr Simon Whitley, Pathway Director for Head and Neck Cancer, Consultant Oral and Maxillofacial Surgeon
Hospitals providing specialist head and neck cancer services in north and east London
Chase Farm Hospital
University College Hospital
The Royal London Hospital
24 Head andneckcancerpatientsinnortheastLondon(2012/13) palliative treatment. to shrinktumoursbefore surgery orfor with radiotherapy. Very occasionally, itisgiven Chemotherapy isusuallygivenincombination cancer recurring. along withsurgerytoreduce theriskof functions suchasspeech.We oftenuseit surgery couldseriouslyaffect important are smallandhavenotspread, orwhere We mayuseradiotherapytotreat cancersthat Non-surgical treatment same period. Hospital and56atChaseFarminthe were around 149patientsatUniversityCollege around 163headandneckpatients.There In 2012/13,TheRoyalLondonHospitalsaw University CollegeHospital 149 Chase FarmHospital 56 of headandneck cancer patients Total number per year 368 25 163 The RoyalLondonHospital
Cancer Overview of service standards Why services need to change National service standards and NICE Not all services meet recommended levels of care Cancer guidance17 recommend specialist Some head and neck cancer services in north and multi-disciplinary teams for head east London do not meet the recommended levels and neck cancer serving populations of care. For example, the number of patients of at least one million. Also all treated at Chase Farm Hospital is well below the surgery should be provided by a recommended level. specialist multi-disciplinary team in a designated centre, and surgeons Unequal access to the right people and facilities and their teams should manage at Currently not all patients have access to the wide least 100 new cases of head and range of specialities they need, such as plastic neck cancer a year. surgery, specialist nurses, dentists and dieticians, all in one place. As a result, patients often have to The 2010 London-wide review18 make many trips to hospital. said services for head and neck cancers should be brought together. Hospitals providing head and neck cancer services in It recommended that London should north and east London are only doing relatively low have five surgery providers, with volumes of surgery, which does not allow surgeons two centres for base-of-skull and to develop expertise such as robotic surgery and pituitary cancers. surgical voice-box reconstruction. Currently, not all hospitals provide cutting-edge technology such as advanced radiotherapy techniques, which can reduce side effects. Only University College Hospital will provide proton beam therapy, which may be used for this type of cancer to reduce side effects.
Lack of joined-up care results in delays and a poorer quality of care ■ Diagnosis of head and neck cancer often takes too long as patients may be referred to several different services, need numerous tests and have to wait for test results. The 2012 National Cancer Patient Experience Survey found that only 60% of head and neck cancer patients felt they were seen as soon as necessary; only 56% felt their tests were properly explained to them; and over 20% felt their symptoms got worse while waiting for a diagnosis. ■ Currently there are no enhanced recovery programmes. These programmes cut the time in hospital after surgery by up to half. And because they reduce complications, patients can return home sooner to recover.
17 NICE, Guidance on Cancer Services – Improving Outcomes in Head and Neck Cancers – The Manual, 2004. Available at: http://www.nice.org.uk/nicemedia/live/10897/28851/28851.pdf 18 NHS Commissioning Support for London, A model of care for cancer services: Clinical paper, August 2010, p.86-88. Available at: http://www.londonhp.nhs.uk/wp-content/uploads/2011/03/Cancer-model-of-care.pdf
26 ■ ■ of themworkedwelltogether. and neckcancerpatientssaythepeopletakingcare between care providers meansonly36%ofhead therapists anddieticians.Poorcommunication patients haveaccesstospeechandlanguage assessment are notwidelycarriedout.Notall diagnosis, andfollow-upholisticneeds Not allpatientshaveaccesstoakeyworkerat trials, andeachcentre collectsdatadifferently. Local surgicalcentres enrol fewpeopleinclinical 27
Cancer Clinical recommendations ■ Discussing treatment options – Patients should be offered all suitable Local clinicians recommend that the current treatment options and reconstruction.
Cancer three head and neck cancer surgical services The decision-making process should for the local population of 3.2 million should involve rehabilitation and supportive be centralised onto one specialist surgical site. care professionals. All patients would Low patient volumes and planned changes as be discussed in coordinated multi- part of the Barnet, Enfield and Haringey disciplinary meetings. Clinical Strategy mean that Chase Farm ■ Radiotherapy services – All patients Hospital would no longer be able to sustain would have access to cutting-edge specialist head and neck oncology surgery. techniques, such as intensity-modulated radiotherapy, where suitable. This Clinicians recognise that whilst the two reduces the harmful side effects of remaining centres meet national minimum radiotherapy. Care would be coordinated volumes and service standards they to allow patients to be treated at the recommend centralising services at University most convenient of the four current College Hospital. Clinicians believe this would radiotherapy centres. create the best possible head and neck cancer services and enable all patients to access the ■ Local follow-up – After treatment at wide range of specialists they need in one the specialist surgical centre or place. These include facial reconstruction radiotherapy centre, patients should get surgeons; ear, nose and throat surgeons; their ongoing care closer to home. Regular plastic surgeons; clinical oncologists; speech patient follow-up clinics should be held and language therapists; dieticians; restorative locally to tackle patients’ holistic needs. dentists; and clinical psychologists. Each team should include a surgeon, oncologist, clinical nurse specialist, As University College Hospital is also rehabilitation specialists (speech and developing advanced treatments such as language therapists, dieticians, occupational proton beam therapy and specialist radiology therapists, and physiotherapists), and treatments, centralising services at University palliative care specialists. College Hospital would ensure that all patients ■ could readily get these new treatments. Implement an enhanced recovery programme – Enhanced recovery reduces Clinicians have also recommended ways of the time patients need to spend in hospital improving the patient pathway: and they recover faster. A larger-volume centre staffed with specialist surgeons, ■ Faster diagnosis and screening – nurses, anaesthetists and therapists would Most patients who are referred with a be able to develop and provide an suspected head and neck cancer turn out enhanced recovery programme for head not to have cancer. The maximum time and neck cancer patients. patients with suspected head or neck cancer should wait before being seen by a consultant would fall from two weeks to one. In addition the waits for diagnostic scans such as MRI and CT would also fall to a week. Wherever possible initial assessment and diagnostics tests would take place at a local hospital close to home.
28 east London Proportion ofurological cancerpatientsneedingspecialisttreatment innorthand Number of surgical procedures prostate cancertookplacelocally. 2010/11, only220complexoperationsfor each yearbutfewneedcomplexsurgery. In men –around 1,500localmenare diagnosed Prostate canceristhemostcommonin Prostate cancer chemotherapy. with complexmajorsurgery, radiotherapyand have spread. Theseoftenneedtobetreated than 100ayearlocally, are more advancedand in mosthospitals.Farfewerbladdercancers,less often betreated byrelatively simplesurgery them haveearlybladdercancer, whichcan cancer eachyearlocally. Eightypercentof Around 400peopleare diagnosedwithbladder Bladder cancer and reducing theriskoflong-termsideeffects. them thebestchanceofcontrolling theircancer cancer patientsneedcomplexsurgery. Thisgives bladder andprostate patientsand300kidney east Londoneachyear. Ofthese,around 300 prostate, bladderorkidneycancerinnorthand Around 2,300peopleare diagnosedwith Urological cancers 1,000 1,500 2,000 500 0 lde acrPott acrKidney cancer Prostatecancer Bladder cancer surgery specialist 80 requiring 29 robotically assistedsurgery. technologies suchaskeyholesurgeryand very complex.Allrely increasingly onemerging surgical. Someoperationsare simple,othersare choices forkidneycancerandismostoften men asinwomen.There are fewtreatment cases locallyeachyear. Itistwiceascommon in Kidney cancerisrare –onlyaround 400new Kidney cancer side effects suchasincontinenceorimpotence. eachwithdifferent risksof treatment options– for thesepatientsbecauseoftherange treatment isbestforthem.Thisveryimportant unbiased supporttohelpthemdecidewhat diagnosed patientsneedclearinformationand increasingly beingdonerobotically. Newly treatment) orsurgery, includingsurgerythatis heating treatment), cryotherapy(afreezing therapy, high-intensityfocusedultrasound(a radioactive seedsintheprostate), hormone radiotherapy orbrachytherapy(implantingsmall options includemonitoringthecancer, different benefitsandsideeffects. Treatment There are manytypesoftreatment and eachhas common andmaystayinactiveformanyyears. Small areas ofcancerintheprostate are very surgery specialist 220 requiring surgery specialist 300 requiring
Cancer Current services In 2010/11, each bladder and prostate centre carried out between 54 and 89 specialist There are four bladder and prostate cancer operations – a total of 296 (220 for prostate
Cancer surgical centres in north and east London, cancer and 76 for bladder cancer). each serving a population of between 600,000 and one million. They are: Currently, bladder and prostate surgery does not take place at Chase Farm Hospital; these ■ Chase Farm Hospital patients have their surgery at University College ■ King George Hospital Hospital. Most bladder and prostate surgery previously done at Whipps Cross University ■ University College Hospital Hospital takes place at University College ■ Whipps Cross University Hospital. Hospital as more patients are taking up the option of robotic surgery.
“I believe that the new system would allow us to achieve substantial improvements in our patients' care and experiences at a rapid pace. It would enable us to offer all our patients access to innovation and the best treatment options, regardless of location and circumstances. As a result, our service will flourish far into the future.” Mr John Hines, Pathway Director for Urological Cancer, Consultant Urological Surgeon
Hospitals providing specialist bladder and prostate cancer services in north and east London
Chase Farm Hospital
King George Hospital
Whipps Cross University Hospital
University College Hospital
30 University CollegeHospital ■ ■ ■ ■ ■ ■ ■ ■ ■ provided at: Across thesamearea, kidneycancersurgeryis Hospitals providing specialistkidneycancerservicesinnorthand eastLondon Homerton UniversityHospital. Princess AlexandraHospital Newham UniversityHospital Royal Free Hospital Whipps Cross University Hospital University CollegeHospital The RoyalLondonHospital King GeorgeHospital Chase FarmHospital Royal FreeHospital University Hospital Whipps Cross The RoyalLondonHospital Chase FarmHospital Homerton UniversityHospital 31 Newham UniversityHospital 292 operations. and 72kidneycanceroperations–atotalof In 2010/11,theyeachcarriedoutbetween10 Princess AlexandraHospital King GeorgeHospital
Cancer Overview of service standards Why services need to change NICE guidance for urological cancer Services are not meeting recommended levels Cancer services recommends that patients of care with cancers that are less common Some concentration of services has already or need complex treatment should happened. However, four centres currently provide be managed by specialist multi- bladder and prostate cancer services for a population disciplinary teams in large hospitals of over 3.2 million, which does not meet national or or cancer centres-, serving at least London-wide standards. Also, all the current centres one million people. fall short of the recommended yearly number of bladder and prostate operations. The London-wide review recommended five specialist surgical Unequal access to the right people and centres in the capital serving a equipment population of at least two million. Specialist services for urological cancer patients Each centre should carry out at least are currently widely dispersed, particularly for 100 operations a year for bladder kidney cancer, with some centres only doing 10 and prostate cancer. For kidney operations a year. This means some clinicians do not cancer, the review concluded that see enough patients to develop or maintain their these cases should only be expertise in these procedures. In addition, not all managed by specialist urology hospitals have access to the latest technologies, such multi-disciplinary teams. as robotic surgery.
Clinicians estimate that up to 50 bladder and prostate patients each year do not receive beneficial surgery because not all treatment options are discussed with them. The challenge is to ensure that everyone who needs specialist surgery is offered it. It is also important to prevent unnecessary operations where less invasive treatments might be suitable.
Access to other specialities As kidneys are close to other organs, surgery should be carried out in a hospital with liver and pancreas surgeons. Kidney cancer can spread through blood vessels to the heart so it may be necessary for cardiac surgeons to assist. Kidney cancer surgery should also take place in a hospital that has renal medicine and dialysis facilities.
Clinical recommendations hospitals would still be below the minimum recommended population size). The London-wide model for cancer care recommended five specialist surgical centres in Local clinicians think a more ambitious the capital, serving a population of at least two approach is needed to provide the world-class million. For north and east London, that would services local people deserve. They recommend mean reducing the current four to one, or a centralising all complex bladder and prostate maximum of two, hospitals providing specialist procedures at one specialist centre. bladder and prostate cancer care (two
32 services inearly2013,some stakeholders potential changestobladder andprostate During acommissioner-led discussionon ■ ■ ■ ■ College Hospitalanditwould: This specialistcentre wouldbeatUniversity The interiorofUniversityCollegeHospital’s MacmillanCancerCentre. research iftheywishedtodoso. cancer patientstakingpartinclinical increase thenumberofnewurological as robotics advanced techniquesandfacilities,such and research and theuseofmost maximise investmentinskills,technology specialist centre andlocalhospitals and specialistteamswouldworkatboththe after patientsduringandtheirsurgery, professionals withspecialistexpertisetolook employ asuitablenumberofhealth and otherpost-operativecomplications expertise, reducing theriskofincontinence health professionals withspecialist ensure thatpatientsreceive care from 33 remain thesameasnow. Services forpenileandtesticular cancerwould and 24-hourinterventionalradiology. liver andpancreatic surgery, renal medicine support surgery, includingvascularsurgery, it hasmanyofthenecessaryspecialitiesto specialist centre at the RoyalFree Hospitalas consolidating surgicalservicesintoasingle For kidneycancer, cliniciansrecommend George HospitalmovingtoQueen’s Hospital. This wouldmeanthecurrent serviceatKing second centre atQueen'sHospitalinRomford. prostate cancersurgerycouldbeoffered ata University CollegeHospital,somespecialist (undertaken robotically) wouldbecentralisedat surgery andmostcomplexprostate surgery Under thisoption,whilstallcomplexbladder in Romford. specialist prostate surgeryatQueen’s Hospital should lookatthepossibilityofproviding some proposed adifferent option.Theysaidwe
Cancer How services would work: an example Michael from Leyton was diagnosed with prostate cancer after tests at his local Cancer hospital, Whipps Cross University Hospital. His consultant urological surgeon explained the diagnosis in detail and discussed the treatment options, which included robotic surgery for a prostatectomy. Michael was told about the side effects and benefits of each option and was supported in his decision to have robotic surgery.
On the day of the operation, Michael travelled by train to the specialist urological unit at University College Hospital where a team performed the surgery using the latest technology and medical advances.
Two days later, after recovering from surgery, Michael was able to go home. Michael had one follow-up appointment at University College Hospital, where the team assessed the results of the surgery and he was given the all-clear.
Michael now has his follow-up appointments at his local hospital to assess how he is getting on.
34 need duringtheillness. coordinated care andtheinformationthey patients andtheircarers receive support, care specialistshavea central role. Theyensure Clinical nurses,psychologistsandpalliative the clock. specialist nursesanddoctorsavailablearound it occurs.Thisisbestprovided byateamof of infectionandtreat itrapidlyandeffectively if Great care hastobetakenminimise therisk monitoring ona24-hourbasisare essential. High-quality facilities,closesupervisionand 15-20% ofpatientsrequire intensivecare. to infectionandothercomplications.About time. Duringthisperiodpatientsare vulnerable white bloodcellsforthree tofourweeksata inpatient basis,leavesthepatientwithout Each courseofchemotherapy, givenonan Chemotherapy forAMLisverydemanding. significantly extendtheirlifeexpectancy. intensive chemotherapytocure themor with AMLneeduptofourcoursesof age – usually under70yearsof Younger patients– ■ ■ main types: need immediatetreatment. There are two of whitebloodcellsthatprogress rapidlyand Acute leukaemias stem celltransplantation Acute myeloidleukaemiaandhaematopoietic does notformpartofthisreview. leukaemia isalready centralisedandsoit response. Treatment forthistypeof infections andgenerateanimmune lymphocytes, whichmostlyfightviral Acute lymphocyticleukaemia(ALL)involves spread oftissue damage. body againstparasitesandpreventing the fighting bacterialinfections,defendingthe myeloid cells,whichperformsuchtasksas Acute myeloidleukaemia(AML)involves are rare aggressive cancers 35 intensive therapyforAML. services are often thesameasthosewhogive as thefacilitiesandstaff whogiveHSCT cover bothtransplantservicesandAML Local cliniciansagree thatanyreview should potential complications. or hospitalhotelsandbecloselymonitored for During thistimepatientsneedtobeinhospital recover andmakeenoughnewbloodcells. take severalweeksforthebonemarrow to Transplantation isanintensivetreatment. Itcan also bereadily availableonsite. replacement therapyandbronchoscopy should patients tobeavailable.Facilitiesforrenal care teamswhoknowhowtomanagesuch It isessentialforon-sitefacilitiesandintensive needed from othersurgeons. complications canoccur, supportisoften infectious diseases.Becausemany cardiology, microbiology, virology, and including thoseinrespiratory medicine, well assupportfrom otherclinicalspecialists include specialistmedicalandnursingstaff as expertise andsuitablesupportfacilities.These and blooddisorders. HSCTneedsclinical remission forvarioushaematologicalcancers transplant increases thechanceofacure or derived from thebonemarrow orblood.The (HSCT) Haematopoietic stemcelltransplantation of thisreview. being treated non-intensivelydonotformpart manage complications.Servicesforpatients patients, theaimistocontrol thediseaseand a day-caseoroutpatientbasis.Forthese would betreated ‘non-intensively’,usuallyon cannot withstandintensivetherapiesand Some patients,particularlyolder means transplantingstemcells
Cancer “Our vision is to provide people in our area with an excellent integrated haematological cancer service that can compete with the best centres in the world.
Cancer A service that helps people to be diagnosed as quickly as possible, have full access through a seamless service to all available treatment options and innovative research.” Dr Kirit Ardeshna, Pathway Director for Haematology, Consultant Haemato-Oncologist
This review focuses on our level 3 treatment centres and which level 2b units should continue to treat patients who have AML and those who need intensive chemotherapy.
Current services Six centres in north and east London provide level 2b treatment for patients with AML, each with their own multi-disciplinary team:
■ Queen’s Hospital in Romford ■ North Middlesex University Hospital ■ Barnet Hospital ■ St Bartholomew’s Hospital
Levels of care ■ Royal Free Hospital The British Committee for Standards in ■ University College Hospital. Haematology defines four levels of care:
■ Level 1 – Outpatient units provide treatment orally or intravenously, which does not In 2012/13, the centres treated 179 new normally cause significant loss of white patients, 104 of whom had intensive blood cells. treatment. Each centre treated between 2 and 39 new patients intensively. ■ Level 2a – These centres provide treatment that results in short periods (less than seven days) of bone marrow and white blood cell loss, requiring short hospital stays. ■ Level 2b – These centres provide complex chemotherapy needed to treat patients with relapsed lymphomas, as well as providing intensive treatment for AML. ■ Level 3 – These centres provide intensive treatment for acute lymphoblastic leukaemia and transplant services.
36 Number of new NHS patients diagnosed with AML and the number of patients treated intensively
April 2011 – March 2012 April 2012 – March 2013 Cancer
Number of Number of Number of Number of new patients patients new patients patients diagnosed treated diagnosed treated with AML intensively with AML intensively
Queen’s Hospital 34 16 36 9
North Middlesex 9 5 3 2 University Hospital
Barnet Hospital 12 9 14 5
St Bartholomew’s 51 30 58 39 Hospital
Royal Free Hospital 26 15 23 15
University College 41 36 45 34 Hospital
Total 173 111 179 104
Hospitals providing AML and HSCT services in north and east London
Level 2b (intensive AML treatment provider)
Level 3 (intensive AML treatment and HSCT provider)
Barnet Hospital
North Middlesex University Hospital
Queen’s Hospital
Royal Free Hospital
University College Hospital
St Bartholomew’s Hospital
37 Transplant services are provided at three centres:
Cancer ■ Royal Free Hospital ■ St Bartholomew’s Hospital ■ University College Hospital.
These centres perform a total of around 310 transplants a year. St Bartholomew’s Hospital and University College Hospital each perform over 100 of these. The Royal Free Hospital performed only 45 transplants in 2011/12.
Transplants in north and east London (2011/12)
45 Royal Free Hospital
310 140 Total number University College Hospital of transplants per year 125 St Bartholomew’s Hospital
38 21 NHSCommissioning SupportforLondon, 20 NHSCommissioning SupportforLondon, http://www.nice.org.uk/nicemedia/pdf/NICE_HAEMATOLOGICAL_CSG.pdf 19 NICE, clinicians recommend thatservicesshouldtreat treating AMLhasbecomemore complex.Local Since theNICEguidancewaspublished, Hospital andUniversityCollegeHospital. services wouldcontinueatStBartholomew’s College Hospital.Level3HSCTandAML sense forthisservicetotransferUniversity recommended numberofcases,it wouldmake Royal Free Hospitaltakeslessthanhalfthe be reduced from three centres totwo.Asthe hospitals providing level3care includingHSCT Local cliniciansrecommend thatthenumberof Clinical recommendations on atleast100newcasesayear guidance recommends thatcentres take For HSCT, NICEandLondon-wide therapy neededtocure AML. sufficiently familiarwiththecomplex number enablesclinicianstobecome AML ayear. Theybelievethatthis chemotherapy atleast10newcasesof providers shouldtreat withintensive Local clinicianshaverecommended that specialist nursesandhaematologists. wards withcontinuousaccessto on anyonehospitalsite,indesignated treatment be provided atasinglefacility patients ayear. Itrecommends that intensively atleastfivenewAML disciplinary teamsshouldtreat London-wide review from eighttofive. providers inLondonshouldbereduced transplants, thenumberofHSCTservice range offacilitiesrequired forstemcell that, giventhespecialistexpertiseand NICE Overview ofservicestandards Guidance on Cancer Services –ImprovingOutcomesinHaematologicalCancersTheManual Guidance onCancerServices 19 guidance statesthatmulti- 21 recommended A model of care for cancer services: Clinical paper A modelofcarefor cancerservices: Clinical paper A modelofcarefor cancerservices: 20 . The provide thecare patientsneed. services willbemore cost-efficient andbetterableto time andexpertiseistherefore costly. Larger Intensive treatment forAMLandHSCTtakesalotof Centres needalong-termfuture can betreated byclinicianswithsuitableexpertise. available out-of-hours.ThismeanspatientswithAML managing canceron-siteduringworkinghoursand Each centre should havehaematologistsfamiliarwith Not allpatientshaveaccesstospecialistsupport University Hospitaltreated fiveorfewerpatients. HospitalandNorthMiddlesex Last yearBarnet treat intensivelyatleast10newAMLpatientsayear. Local clinicianshaverecommended thatunits currently treats lessthanhalfthatnumberofpatients. by theLondon-widereview. TheRoyalFree Hospital minimum 100transplantseachyearrecommended Not allourHSCTservicesare carryingoutthe of care Services donotalwaysmeetrecommendedlevels Why servicesneedtochange 39 recommended minimumof10casesayear. enough newAMLcasestomeetthelocal in Romford istheonlyhospitalto have After theRoyalFree Hospital,Queen’s Hospital located atQueen’s HospitalinRomford. has recommended thatthethird centre be University CollegeHospital. centres atStBartholomew’s Hospitaland located withtherecommended level3HSCT London tothree. Two ofthesewouldbe the current sixcentres innorthandeast year. To achievethistheyrecommend reducing at least10newAMLcasesintensivelyeach , pp.88-89. , August2010,p.93. , 2003.Available at: London Cancer
Cancer Oesophago-gastric cancer Cancer
Oesophago-gastric (OG) cancer is cancer of the radiotherapy or endoscopic therapy to relieve stomach or oesophagus. It is the fifth most symptoms. Specialist multi-disciplinary teams common cancer and the fourth most common have to make the treatment recommendation cause of cancer death in the UK, affecting for these patients, but the actual treatments around 13,500 people each year22. Each year may be provided in local units. 830 new patients are likely to be diagnosed locally. The rate of OG cancer is increasing and Specialist areas of OG cancer services include: the five-year survival rate is poor. ■ endoscopic therapies Diagnosing and managing patients with OG ■ all surgery, whether life-saving or palliative cancers involves a number of professional groups including GPs, specialist OG surgeons, ■ chemotherapy, radiotherapy and clinical nurse specialists, dieticians, radiologists brachytherapy provided by a specialist and physiotherapists. team at a place decided by the network guidelines. Surgery offers the best chance of long-term survival for patients with early-stage OG cancer if it is operable. Usually, these patients also OG cancer patients who undergo surgery need need chemotherapy. 24/7 specialist care for around 30 days to give them the best chance of survival. About 75% of OG cancer patients have inoperable disease and need palliative and non- surgical treatment such as chemotherapy,
Proportion of OG cancer patients needing specialist treatment
25% Specialist treatment
OG cancer patients 75% Local treatment
22 Cancer Research UK 2011; Office of National Statistics 2010.
40 multi-disciplinary team. and 54operations.Eachcentre hasitsown procedures ayear, each doing between41 These centres performatotalofaround 150 ■ ■ ■ in northandeastLondon: Currently, there are three specialistOGcentres OG cancerprocedures innorthandeastLondon(2012) Upper GICancer, Consultant Surgeon Professor inSurgery, ConsultantSurgeon andMrDavidKhoo,PathwayCo-Directorfor Professor MuntzerMughal, PathwayCo-DirectorforUpperGICancer, HonoraryClinical from participationinclinicaltrials.” where theyliveorfirstaccessourcare,andwherever appropriate,theyshouldbenefit for everypatienttohaveaccessthebestavailable treatmentoptions,nomatter the world.We wantpatientstofeelfully-supportedintheircareandtreatment; equitable, effective andresponsiveserviceintheUK,comparablewithverybest “As clinicians,weaimtoprovideuppergastro-intestinal cancerpatientswiththemost Queen’s HospitalinRomford. The RoyalLondonHospital University CollegeHospital Queen’s Hospital 53 University CollegeHospital Total numberof procedures 148 41 41 well asnursinganddietetics. surgery, oncology, pathologyandradiologyas meetings involvingspecialistcliniciansinOG patients through multi-disciplinaryteam their localhospitalstodiagnoseandtreat The specialistcentres workinpartnershipwith The RoyalLondonHospital 54
Cancer Overview of service Why services need to change standards Services are not meeting recommended levels of care Cancer National service standards Currently, three units serve a population of over state that patients with OG 3.2 million, each doing an average of 50 operations a cancers should be managed year. This means none of the current services meets by specialist multi-disciplinary national or London-wide standards. teams in centres serving at least one million people and Larger-volume OG cancer surgical centres have lower performing at least 60 death rates in England and internationally. OG patients operations a year. are more likely to survive for five years after their operation if it is done in a centre that performs over 60 The Association of Upper such operations a year. Recent studies show that mortality Gastrointestinal Surgeons rates are even lower in centres that perform over 80 recommends that an operations a year23. individual specialist surgeon should carry out at least 15 Limited ability to provide 24/7 surgical cover to 20 operations a year at The current surgical work volumes cannot support an centres that have four to six increase in the numbers of surgeons if three centres surgeons and serve a remain. This limits the ability of each centre to provide population of 1.5-2 million. 24/7 consultant cover, which has been shown to reduce the length of stay in hospital and increase survival NICE guidance recommends chances. Concentrating surgeons in fewer centres would that OG cancer centres serve also maximise training opportunities and improve services a population of one million. for patients in the future.
The 2010 London-wide The current system is not sustainable strategy recommended that Clinicians recognise that the current system is unlikely to OG surgical centres serve a be sustainable beyond the next few years. Improvements population of at least two in earlier diagnosis and non-surgical treatments will million people. eventually mean fewer patients need surgery. So the number of surgeons should fall in the future, and this will result in unworkable on-call arrangements unless the number of centres also falls.
Leading improvements along the pathway OG cancer patients are more likely to have a planned treatment if they are diagnosed by a GP or hospital doctor. Existing centres lack the capacity to improve local screening and early detection.
23 Victoria H Coupland, Jesper Lagergren, Margreet Lüchtenborg, et al ‘Hospital volume, proportion resected and mortality from oesophageal and gastric cancer: A population-based study in England', 2004–2008.
42 College Hospital. into asinglespecialistcentre atUniversity recommend theworkbeconsolidatedfurther In themediumtolongterm,clinicians fields ofwork. best practiceforOGcanceracross allspecialist would enablesharingandstandardisation of chemotherapy forOGcancer. Inaddition,this the mostup-to-dateradiotherapyand The specialistcentres wouldbeabletoprovide three centres bereduced totwo: years. Initially, cliniciansrecommend thecurrent in northandeastLondonoverthree tofive recommend astagedconsolidationofservices To achievethesestandards, localclinicians each year. least 60oesophagealandgastricoperations working inOGcentres shouldcarryoutat within theCancerServices GuidanceonUpperGastro-intestinal Cancers,March 2013. 24 NICE,Reviewconsultationdocument: Reviewofthesectiononorganisationspecialistteamsforcurativesurgery foroesop ■ ■ meet nationalstandards provide thebestoutcomesforpatientsand disciplinary teamsshouldreduce inorder to specialist OGcancercentres andmulti- Local cliniciansagree thatthenumberoflocal Clinical recommendations University CollegeHospital. One centre ininnernorthLondonat Queen’s Hospital,Romford. One centre inouternorth-eastLondonat 24 . Surgicalteams 43 team meetings. Abeeda’s progress in theirweekly specialist centrecontinuetoreview local hospital.Thehospitaland home andhasfollow-upchecksather team. Aftertwoweeksshereturns is monitored24/7bythespecialist stays inthespecialistcentrewhereshe After thetumourisremovedAbeeda nurses atAbeeda’s localhospital. specialist, whotalksregularlywiththe she iscaredforbyaclinicalnurse surgeon. Throughouthertreatment operation isperformedbyanexpert tumour. Abeeda agreesandher recommend surgerytoremovethe consider Abeeda’s caseand chemotherapists andsupportservices A teamofsurgeons,radiotherapists, information andtestresults. sends thespecialistcentreherclinical the specialistcentre.Herlocalhospital cancer. Sheisimmediatelyreferredto and biopsy, whichshowstomach the localhospitaltohaveaCTscan previous month.HerGPsendsherto difficulty swallowingduringthe Abeeda, 43,visitsherGPafterhaving an example How serviceswouldwork: hago-gastric cancer
Cancer Conclusion Cancer
Local clinicians have highlighted areas where we are not making the most efficient use of staff and resources to care for patients or to introduce innovations and make improvements. They provide strong reasons for change. These reasons are supported by work done nationally and across London, which also puts forward strong arguments for making changes in these specialist cancer services.
We need to ensure that surgeons and care teams have the best opportunity to improve their expertise. We also need to consider cost-effectiveness and hospitals’ long-term ability provide services.
Local clinicians believe their recommendations for reorganising specialist cancer services take advantage of this unique opportunity to provide better outcomes, better coordination of care and a better experience for our patients.
44 htohrotosddw osdr 67 66 63 54 62 51 52 Conclusion What otheroptionsdidweconsider? What thiswouldmeanforpatients How wecouldimprove services Our visionforimproving cardiovascular care Why weneedtochange Improvements underwaytocardiovascular services Context –nationalandLondon-widereviews cardiovascular services Improving specialist in northandeastLondonwestEssex 45 69
Cardiovascular Cardiovascular
Cardiovascular Cardiovascular disease affects millions of people in the UK and is one of the biggest causes of early Cardiovascular disease includes all the death and disability. It is estimated that 5,436 diseases of the heart and circulation people in north and east London die early because such as: of heart disease and stroke. ■ cardiomyopathy (deterioration of the heart muscle) Prevention and treatment have improved over the ■ last decade but more needs to be done to bring the arrhythmias (irregular heart beat such UK in line with the best international outcomes, as atrial fibrillation) and to speed up the adoption of new technologies. ■ congenital heart disease ■ coronary heart disease (angina and Local clinicians have identified the need to make heart attack) further improvements along the cardiovascular ■ heart failure pathway – from prevention and detection to ■ treatment and follow-up care. stroke (stroke services are not in the remit of this review). Improving specialist cardiovascular services is one part of clinicians’ vision for the whole pathway of Cardiovascular disease risk increases with: care. They agree that, to achieve world-class standards, we must change the way we provide ■ smoking specialist adult cardiovascular services including: ■ high blood pressure ■ ■ adult congenital heart disease high blood cholesterol ■ being physically inactive ■ cardiac anaesthetics and critical care ■ being overweight or obese ■ cardiac imaging ■ diabetes ■ cardiac rhythm management ■ family history of heart disease ■ ■ cardiac surgery ethnic background ■ gender – men are more likely to ■ general interventional cardiology develop cardiovascular disease at an ■ management of complex/severe heart failure earlier age than women ■ age – the older you are, the more ■ inherited cardiovascular disease. likely you are to develop cardiovascular disease.
46 patients will continue atTheRoyalLondon at theendof2014.Cardiology supportfor Hospital complex,whenthe buildingiscomplete state-of-the-art facilityin the StBartholomew’s Hospital andStBartholomew’s Hospitaltoanew services currently provided atTheLondonChest Health isduetomovethespecialistcardiac Green andStBartholomew’s Hospital.Barts services atTheLondonChestHospitalinBethnal Barts Healthprovides specialistcardioascular with otherconditions. from UniversityCollegeHospitaltosupportpatients Some generalcardiology servicesare alsoprovided provided from TheHeartHospitalinWestminster. UCLH’s specialistcardiovascular servicesare mainly which isnotchangingaspartofthisreview. Havering andRedbridgeUniversityHospitalsTrust), (Barts Health)andKingGeorgeHospital(Barking, takes placeatWhippsCross UniversityHospital NHS FoundationTrust. Someinvasivecardiology Foundation Trust (UCLH)andtheRoyalFree London Health), UniversityCollegeLondonHospitalsNHS mainly provided byBartsHealthNHSTrust (Barts supporting services,innorthandeastLondonare Specialist cardiovascular services,andarangeof 47 Great Ormond Street HospitalNHSFoundation Trust. Specialist cardiac care forchildren isprovided at vascular surgery. Hospital provides complexinvasivecardiology and As wellasheartattackservicestheRoyalFree Free Hospitalreceives more ofthesepatients. Heart Hospitalcomefrom northLondon. TheRoyal patients takentotheRoyalFree HospitalandThe from eastandnorth-eastboroughs ofLondon.Most north andeastLondon.Thesepatientsmainlycome year –thehighestnumberofthree centres in Hospital currently receives around 1,500patientsa The heartattackcentre atTheLondonChest Heart Hospital. Chest Hospital,theRoyalFree HospitalandThe three innorthandeastLondon–The There are eightheartattackcentres inLondon, London andprovide 24/7emergencyservices. are bothelectrophysiology hubsfornorthandeast St Bartholomew’s HospitalandTheHeart major traumacentre there. Hospital –mainlytotreat acuteadmissionsatthe
Cardiovascular Hospitals providing specialist cardiovascular services in north and east London Cardiovascular
4
1 3 2
1 The London Chest Hospital (Barts Health) Some invasive cardiology takes place at Whipps Cross University Hospital (Barts Health) and King St Bartholomew’s Hospital (Barts Health) 2 George Hospital (Barking, Havering and 3 The Heart Hospital (UCLH) Redbridge University Hospitals Trust), which is not changing as part of this review. 4 Royal Free Hospital (Royal Free London NHS Foundation Trust)
48 Heart attackcentres inLondon 8 7 6 5 4 3 2 1 St Thomas’Hospital St George’s Hospital Royal Free Hospital King’s CollegeHospital The HeartHospital Harefield Hospital Hammersmith Hospital The LondonChestHospital 3 2 6 7 4 8 5 49 1
Cardiovascular Number of patients taken to heart attack centres by borough (2012/13)
Cardiovascular The London Chest Hospital The Heart Hospital Royal Free Hospital
240
220
200
180
160
140
120
100
80
60
40
20
0 Barnet Enfield Haringey Camden Islington Barking & Havering Redbridge Waltham Forest City & Hackney Newham Tower Hamlets Dagenham Westminster Brent
This document describes why we need to change Further information is available in UCLPartners’ and how we can improve these services locally. recommendations to commissioners A proposal for Clinicians recommend that to do this we should clinical change in specialist cardiovascular services bring together the specialists, facilities and across north and east London. research currently at The Heart Hospital (part of University College London Hospitals NHS Trust) with services currently provided at The London Chest Hospital into a single, world-class integrated cardiovascular centre at St Bartholomew’s Hospital.
Emergency care for heart attacks would be provided at two hospitals in north central and east London – the integrated cardiovascular centre proposed at St Bartholomew's Hospital and the current heart attack centre at the Royal Free Hospital.
50 Cardiovascular DiseaseOutcomesStrategy publishedanational In 2013thegovernment volume ofpatients. care cometogetherinfewerunitsseeingahigher hospitals providing specialistcardiovascular The London-widereview recommended that The review highlightedtheimportanceof: patient experience. were inequalitiesinaccesstotreatment and for surgeryandhospitaltreatment, andthere for patients.Patientswere waitingtoolong London foundsignificantvariationinoutcomes NHS England,Cardiac Surgeryservicespecification, Available at:http://www.england.nhs.uk/resources/spec-comm-resources/npc- 27 NHSEngland, Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/214895/9387-2900853-CVD-Outcomes_web1.p 26 DepartmentofHealth, content/uploads/2011/03/Cardiovascular-case-for-change.pdf . 25 NHSCommissioningSupportforLondon, ■ ■ ■ ■ ■ ■ The 2010review ofcardiovascular services Context –nationalandLondon-widereviews outcomes to international standards.outcomes tointernational It identifiedactionsneededtoraisepatient rapid accesstospecialistexpertise. dedicated 24/7rotas, enablingpatientstohave areas ofcardiac surgery greater specialisation,specificallyincertain length ofstay example coronary arterybypassgraftand reducing waitingtimesforurgentsurgery, for and improving cooperationwithuniversities consolidating andintegratingresearch activity set standards forfuture use suitable infrastructure andstaff experienceto in fewercentres toensure there wouldbe concentrating theroll-out ofnewtechnologies multi-disciplinary teamworking Complex Invasive Cardiology service specification Complex InvasiveCardiologyservice Cardiovascular DiseaseOutcomesStrategy: Improvingoutcomesforpeoplewithoratriskofcardiovasculardisease Cardiovascular project:Thecaseforchange 26 . Available at:http://www.england.nhs.uk/resources/spec-comm-resources/npc-crg/group-a/a09/; 25 . in 51 comply withthem England’s nationalservicespecificationsand have bothself-assessedtheirservicesagainstNHS The HeartHospitalandLondonChest clinicians toshare expertisealongthepathway. specifications andcreate anopportunity formore improve theircomplianceagainstthenational ■ ■ ■ These include: , August2010http://www.londonhp.nhs.uk/wp- attack, unstableanginaandacutearrhythmias. world-class specialist24/7servicesforheart improving acutecare, includingproviding prevention inthecommunity better earlymanagementandsecondary improving prevention andriskmanagement 27 . Mergingthetwocentres will crg/group-a/a10/ df. , 5March 2013.
Cardiovascular Improvements underway to cardiovascular services
Cardiovascular Improving the cardiovascular health of people in north and east London is a key priority for local NHS organisations and local authorities28.
There are high levels of need in local communities and evidence shows that up to 30% of cardiovascular disease patients on GP registers are on unsuitable medication29. Clinicians say more co-ordinated care is needed between community services, GPs, hospitals and providers of specialist services.
Local providers of cardiovascular care are working together as an ‘integrated cardiovascular system’ through UCLPartners31. Working across organisational boundaries and with CCGs and local authority partners, the integrated system aims to improve services along the whole cardiovascular pathway. These include:
■ preventing cardiovascular disease by identifying patients with hereditary risk factors and modifiable life-style risks and ensuring they have access to adequate screening and support Preventing and diagnosing cardiovascular disease ■ earlier detection of cardiovascular disease, earlier will save lives. It will also ensure that more offering health checks to all eligible people people living with cardiovascular disease get the support and treatment they need. ■ improving treatment of people with cardiovascular disease. For example, better These are changes we are already making to management of atrial fibrillation will help improve cardiovascular services and provide a prevent major cardiovascular events such as smooth pathway for patients. heart attack or stroke.
“UCLP is working for Camden CCG on a range of joint community initiatives aimed at preventing heart attacks and stroke. These include identifying high-risk patients, improving blood pressure monitoring through new technologies, improving management of patients with atrial fibrillation. These actions should complement the wider work on cardiovascular services and improve outcomes for Camden residents.” Dr Caroline Sayer, Chair, Camden Clinical Commissioning Group
28 All local authorities in north and east London recognise cardiovascular disease in their joint health strategic needs assessments. 29 Department of Health, CVD Mortality Audit. Available at: http://www.institute.nhs.uk/images/documents/wcc/HPHL/HINST%20resources/Mortality%20Audit.pdf
52 nurses tomanagepatientsinthecommunity. admissions tohospital.GPsinEnfieldandCamdenareworkingwithspecialistheartfailure under-diagnosis ofheartfailureanditaccountsforfivepercentallemergency Chronic heartfailureaffects overhalfamillionpeopleinEngland.Thereiswidespread Chronic heartfailure have accesstocarecloserhome. and specialistcare.WithservicesbasedatlocalhospitalssomeGPpractices,patients succeeded inidentifyingpatients,providingtherapyandreducingreferralstosecondary Nurse-led primarycarearrhythmiaserviceshostedbyBartsHealthNHSTrust have Cardiac rhythmmanagementgroup diagnosis ofuncomplicatedheartconditionssuchassuspectedfailure. monitoring andsupportinthecommunityforpatientswhohaveheartdisease them astheyreturntofullandnormalalifepossible.Theteamalsoprovides treatment. Theserviceaimstohelppeoplemakebeneficiallifestylechangesandsupports The multi-disciplinaryteamhelpspeopletounderstandandmanagetheirillnessits Redbridge supportslocalpeoplewithheartproblemsandsuspectedproblems. The coronaryheartdiseasecommunityserviceinBarking,Dagenham,Haveringand Community coronary heartdiseaseservice Examples oflocalinitiativesforimproving cardiovascular health 53
Cardiovascular Why we need to change
Cardiovascular In north and east London, we have some of the The risk of cardiovascular disease is already best cardiovascular experts in the country. high and is increasing, with evidence of However, services are not organised in a way that significant unmet need enables us to give patients the best outcomes. North and east London has a diverse, ageing and Clinicians have identified five main reasons why growing population, with many people facing we need to change: significant deprivation. These factors increase the risk of cardiovascular disease and the resulting 1. The risk of cardiovascular disease is already demand for services in the future. high and is increasing with our growing and ageing population. People with heart Locally, many of our communities have deep disease in north and east London are more health needs and there is clear variation in likely to die prematurely than other people in outcomes from cardiovascular disease. London or England30. 2. Current services cannot meet recommended On average, people with heart disease in north standards for care. We have high levels of and east London die earlier than people with heart 32 unmet need and unequal access to treatment. disease in the whole of London and in England . Clinicians think they could save more lives if Eight of the 12 London boroughs in this area have expert teams saw more patients. premature death rates far higher than in England as a whole33. The rate of early death in north and 3. Specialists are needed 24/7 to provide expert east London is also much higher than in other emergency care and enable them to do more European countries34; if our rate of early death was work as sub-specialists, such as in aortic valve in line with the European average, about 2,200 disease. Our medium-sized units cannot lives would be saved each year. sustain this. 4. Too many people are waiting too long for routine surgery. Patients at both The London Chest Hospital and The Heart Hospital are waiting longer for surgery than the national average of 63 days. Some patients at The Heart Hospital wait up to 93 days31. Capacity We could save 1,117 lives a year locally if at The Heart Hospital is limited, with no room we could bring our rate of early deaths for expansion. from cardiovascular disease into line with 5. There is an opportunity to integrate research the England average. and innovation into daily practice. This would We could save about 2,200 lives if our rate improve care for local people and attract of early deaths was the same as Europe’s. extra funding.
30 South East Public Health Observatory, CVD profiles 2011-12. Available at: www.sepho.org.uk. 31 Dr Foster Intelligence. Available at: www.drfosterhealth.co.uk 32 The rate of early deaths from heart disease and stroke in north and east is 84.8/100,000, significantly higher than the rate for London (71.5/100,000) and England (67.3,100,000). South East Public Health Observatory, Health Profiles, 2012. Available at: www.sepho.org.uk 33 The gap between the estimated and observed prevalence in heart disease in north and east London (43.7%) is wider than for London as a whole (47%), and considerably wider than for England (58.2%). South East Public Health Observatory, Health Profiles, 2012. Available at: www.sepho.org.uk 34 The European rate of early deaths is 50.4/100,000. ‘UK health performance: findings of the Global Burden of Disease Study 2010’, The Lancet, March 2013, Volume 381, Issue 9871, Pages 997–1020.
54 40 NICE, 39 NICE, Observatory, CVDprofiles 2011-12. Available at:www.sepho.org.uk 38 Therateofemergencyadmissionsin northandeastLondonis224/100,000population.TherateforEngland198.3/100,000. measures-monitoring/nhs-health-checks-data/ 37 2012-13Healthchecks,Integratedperformance monitoring.Available at:http://www.england.nhs.uk/statistics/statistical-work 36 SouthEastPublicHealthObservatory, CVDprofiles 2011-12.Available at:www.sepho.org.uk 35 SouthEastPublicHealthObservatory, CVDprofiles 2011-12.Available at:www.sepho.org.uk cardiovascular diseaselocallyare undiagnosed death. Itisestimatedthatoverhalfofpeoplewith cardiovascular disease,whichcontributestoearly Locally, wehaveahighrateofunidentified ensure allpatientshavethe bestchanceofsurvival. coordinated across northandeastLondonto Cardiovascular servicesneedtobebetter ranking 141stand144th. of thehighest– England. NewhamandTower Hamletshavesome is rankedninthoutof150localauthoritiesin it premature deathfrom cardiovascular disease– local areas. hassomeofthelowestrates Barnet There isalsoahugevariationbetweenandwithin Premature deathfrom allcirculatory disease(2008-10) coronary heartdiseaseevent(suchasastroke) of menand50%womenwithFHwillhavea are livingatriskofFHinourregion. Around 70% which suggeststhatover5,400unidentifiedpeople familial hypercholesterolemia orFH)are detected, disorder ofhighcholesterol intheblood(known as For instance,only15%ofpeopleatriskagenetic they needtobehealthy. These peopledonothaveaccesstothesupport Chronic HeartFailure: CostingReport:ImplementingNICEGuidance Prevention ofcardiovascular disease:CostingReport:Implementing NICEGuidance 100 120 140
20 40 60 80
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. , 2010,NICEClinical Guideline108,p.19. Haringey
55 admissions ayear, savingnearly£2.6million rate wouldprevent around 1,120emergency Reducing admissionsforheartfailure totheEngland Havering admissions ayear, savingnearly£3.2million rate wouldprevent around 700emergency admissions forcoronary heartdisease totheEngland high unmetneedamongourpopulation.Reducing management ofcardiovascular riskfactorsanda fewer thanhalf(47%)takeuptheoffer are offered ahealthcheckandofthoseoffered it, aged between40and74innortheastLondon in England and heartfailure are muchhigherinourregion than Emergency admissionsfrom coronary heartdisease to alltheeligiblepopulation. as localauthoritiesleadadrivetooffer healthchecks cardiovascular diseaseriskfactors,islikelytogrow cardiovascular disease,orforthemanagementof proportion ofpeopleweidentifyfortreatment for Latest data heart diseaseeventsinunder65yearolds. FH populationwecouldprevent 3,254coronary before theyare 65.Byidentifyingandtreating our
, June2010,NICEPublic HealthGuidance25,p.21. Islington 38 36
. Thissuggestspoorprevention and
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South EastPublicHealth Tower Hamlets Tower Waltham Forest Waltham 37 . The 40 39 . .
Cardiovascular Current services do not always meet access mitral valve repair is less invasive and recommended standards for care enables patients to recover faster – three weeks instead of three months – and return home Prompt access to sustainable emergency 24/7 sooner43. It requires specialist surgical, imaging and services for unstable angina, complex surgery and anaesthetic skills. Achieving the desired ratio other urgent care will save lives. would improve outcomes for around 100 patients
Cardiovascular Medical advances also mean clinical teams are now a year. The surgical techniques are changing specialising in a field of cardiac surgery such as rapidly which is another reason why teams benefit revascularisation, aortic valve disease, complex valve from treating more cases. disease and other cardiac surgical procedures41. The Heart Hospital and The London Chest Such sub-specialisation in small or average-sized Hospital both provide good outcomes and patient units will not be possible. experience but neither is large enough to meet all current and future expectations for high-quality Primary percutaneous coronary intervention service. Here are some of the reasons: Service standards recommend hospitals do 300 ■ Surgical teams see too few patients to achieve primary percutaneous coronary intervention (PCI – full subspecialisation in mitral valve. Neither also known as coronary angioplasty) procedures, hospital has a dedicated surgeon to perform and at least 100 procedures, a year42. Last year The mitral valve repairs. Heart Hospital only took 156 primary PCI cases. ■ For PCI in general, there is evidence suggesting Neither hospital has the full range of improved outcomes for patients who are treated in cardiovascular services in one place. For higher-volume centres, particularly those that do example, vascular surgery is an important 400 procedures a year. linked service for major aortic surgery and is not available at The Heart Hospital. The new Centres in the UK with the highest volumes (such as facility at St Bartholomew’s Hospital will have a Leeds General Infirmary, which did around 1,200) significant on-site presence for vascular surgery tend to have good outcomes. In a national audit of and interventional vascular radiologists. primary PCI there was no significant difference in the results of any of the centres but there is a ■ Meeting the challenge of seven-day working national trend towards higher-volume centres will be difficult, particularly for support services having lower death rates. and intensive treatment unit staff. Given national workforce shortages in areas such The combined unit would have similar levels of as cardiac physiology, it is unlikely that either activity to the UK's top-performing units. hospital will be able to have the staff they need under the current services set-up. Mitral valve repair Neither the London Chest nor the Heart Hospital currently provide the 85% ratio of mitral valve repair to mitral valve replacement recommended for patients with degenerative mitral valve disease specified by the London-wide review. Minimal-
41 NHS England, Cardiac surgery service specifications. Available at: http://www.england.nhs.uk/wp-content/uploads/2013/06/a10-cardi-surgery-adult.pdf 42 NHS England, 2013/14 NHS England Specialised Commissioning Service Specification for Complex Invasive Cardiology, 2013. Available at: http://www.england.nhs.uk/wp-content/uploads/2013/06/a09-cardi-prim-percutaneous.pdf 43 Cleveland Clinic. Available at: http://my.clevelandclinic.org/heart/disorders/valve/mitral-valve-repair.aspx
56 content/uploads/2013/02/ICVS_Percutaneous.Coronary.Intervention-_FEB2013.pdf 44 UCLPartners,Percutaneous Coronary InterventionProcedures, p.9fig.3. Available at:http://www.uclpartners.com/lotus/wp- cardiology onanurgentoremergencybasisrather we domore cardiac surgeryandinterventional people whohaveacuteheartattacks.Asaresult, such asprimaryPCI,meanwecannowsavemore Medical advancesintechniquesandtechnology, emergency care Specialists are needed24/7todeliverexpert they havereachedtheirlifespan. And theydonotneedriskyrepeatoperations,suchasthoseneededtore-replacevalvesonce selected patients.Theydonotneedlong-termanticoagulationdrugs,whichcancausebleeds. improves lifeexpectancyandqualityoffor thanreplacement– rather Mitral valverepair– An extra364heart-failurepatientsayearwould surviveifmanagedbyacardiologyteam. 57 24/7 service. provided in large specialistcentres thatcangivea This typeofurgentoremergencycare needstobe now givenonanemergencybasis given itonaplannedbasis.Two-thirds ofPCIsare most heartattackpatientswhoneededaPCIwere than asplannedcare. Forinstance,10yearsago 44 .
Cardiovascular Cardiovascular
The new facility being built at St Bartholomew’s Hospital in Farringdon.
Providing more care on a 24/7 urgent or The number of heart attack patients at The Heart emergency basis has also increased the on-call Hospital is likely to reduce further when The commitments of clinical teams. These 24/7 heart London Chest Hospital moves to St Bartholomew’s attack centres need rotas of highly trained staff in Hospital in Farringdon. Many patients in Islington, adequate numbers – it is hard to maintain this Enfield and Haringey live closer to the St level of staffing (in particular, physiologists) at Bartholomew’s Hospital than to The Heart Hospital three centres in north and east London. With and in an emergency would be taken directly to two heart attack centres nearby and the London St Bartholomew’s Hospital by the LAS. Ambulance Service (LAS) already taking fewer patients there compared with the Royal Free Centralising care would ensure that people Hospital and The London Chest Hospital, it is likely needing urgent expert help could get it 24 hours that The Heart Hospital would not see enough a day, seven days a week. patients to sustain this rota of experts.
58 now overdue. or movedtoanewlocationinthefuture; thisis 2001 weexpecteditwouldneedtobereorganised demand isincreasing. Whenthehospitalopenedin Located incentralLondon,itcannotexpandyet The HeartHospitalfacesanumberofdifficulties. quality care and goodpatientexperience.However, services innorthandeastLondonprovide high- All hospitalsproviding specialisedcardiovascular Limited capacityatTheHeartHospital national averageof63 days. Patients whoneedheart bypasssurgerywait30dayslongeratTheHeart Hospitalthanthe St Bartholomew’s Hospital The LondonChestHospital The HeartHospital (NHS Choices,2013) Information aboutwhetherpatientswouldrecommend ahospitaltofriendsandfamily 21% 22% 32%
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Cardiovascular Cardiovascular
Main difficulties: ■ Surgical procedures are increasingly being cancelled. Critical care capacity limits surgical ■ The hospital has little room to expand. This and catheter lab interventions. Around 250 has already contributed to higher-than-average planned operations were cancelled at The Heart waiting times for surgery and higher Hospital last year. readmission rates45. For instance, coronary angiography patients wait 10 days longer at ■ While most patients are happy with their overall The Heart Hospital than The London Chest care, limited capacity is reducing their Hospital and readmission rates are above the satisfaction. In a recent survey patients at The national average46. Bed occupancy at The Heart Hospital reported less choice of admission Heart Hospital currently approaches 95% dates and were more likely to have their and activity is increasing year on year and appointment changed than the national will continue to grow. average47. Patients at The Heart Hospital were also more likely to share a sleeping area with Demand is also increasing particularly for patients of the opposite sex than at other sites48. conditions such as adult congenital heart disease, inherited cardiac conditions and other highly specialised areas in cardiology.
45 Dr Foster Intelligence. Available at: www.drfosterhealth.co.uk 46 Dr Foster Intelligence. Available at: www.drfosterhealth.co.uk 47 Picker Institute Europe, Inpatient Survey 2012, Site Report: The Heart Hospital, 2013. 48 Picker Institute Europe, Inpatient Survey 2012, Site Report: The Heart Hospital, 2013.
60 and clinicalservicesonasinglecampus.Thiswould nearby sites,theycombinetheirspecialistacademic outcomes if,ratherthanworkingseparatelyontwo they canhelpachievebettercardiovascular cardiovascular research resources. Cliniciansthink Both UCLHandBartsHealthhostmajorbiomedical innovation intodailypractice Opportunity tointegrateresearch and integrated cardiovascularsystem Professor JohnRobson,Tower HamletsGPandprimarycareleadfortheUCLPartners and equitablyimprovethehealthofourpopulation.” deliver abetterpatientexperience,optimalmanagementtoreduceheartattackandstroke, “Integrating primary, secondaryandspecialistcareprovidingclosertohomewill 61 able totakepartinclinicaltrials. improve outcomes becausemore patientswillbe high-quality research opportunities.Itwillalsohelp practice, engagingtraineesandencouraging provide abetterenvironment forsharingbest
Cardiovascular Our vision for cardiovascular care
Cardiovascular Our vision is to provide world-class experience and Clinicians have identified a strong and pressing outcomes for patients, underpinned by world- need to change the way we deliver specialist leading academic research and education. cardiovascular services in north and east London. They recommend developing a single integrated To achieve this vision clinicians have identified cardiovascular centre at St Bartholomew’s Hospital seven key aims: with the Royal Free Hospital remaining as a second 1 Establish a seamless pathway and better co- heart attack centre. ordination of care for cardiovascular patients Existing cardiology services would continue to be across all NHS organisations. provided at UCLH to support routine and other 2 Provide world-class standards of care and specialist care (for example, cancer care). improve patient outcomes and experience. 3 Improve access to cardiovascular care and reduce waiting times. 4 Ensure our population benefits from the latest technological advances, research and access to clinical trials. 5 Ensure services are sustainable for the future. 6 Maximise efficiencies and attract national and international investment in research. 7 Ensure continuous training and education in cardiovascular disease is of a high standard across north and east London. An artist’s impression of a general ward at the new facility at St Bartholomew’s Hospital.
How services would work: an example Robert, 47, has a heart attack at home in Haringey. His wife calls an ambulance and he is taken to the specialist heart centre at St Bartholomew’s Hospital by ambulance. The ambulance arrives at the emergency entrance and the crew take him to the specialist heart centre. Robert reaches the assessment unit via a dedicated lift for emergency patients, which the crew know will be available for their immediate use. As Robert arrives at the cath lab floor he suffers a cardiac arrest. This is managed in a dedicated private receiving room next to the cath labs. His circulation returns and he is taken into the cath lab for a primary angioplasty. His family is reassured that he is receiving the best possible care.
62 implantation procedures performedby physicianstreating medicare beneficiaries’, 52 Al-Khatib,S.M.,L.Lucas,J.G.Jollis, D.J. Malenka,andD.EWennberg, ‘The relation betweenpatients’outcomesand the vol 51 Aliot,E.M.,W.G. Stevenson, J.M.,‘Almendral-Garrote etalEHRA/HRS Expertconsensusoncatheterablationofventriculara 50 Van deWerf, F. etal.‘Managementofacutemyocardial infarction inpatientspresenting withpersistentST-segment elevati 2001, 130:415-422. would create anincomestream thatdoesnotrely patientreferrals.national andinternational This technologies andtreatments wouldattractmore In addition,asinglecentre offering thelatest more work. so itcaninvestinnewtechnologiesandcopewith help toimprove productivity, whichtheNHSneeds technology-driven. Betteruseofresources would particularly inafieldthatisincreasingly duplication, sowecouldrationaliseinvestment, provide world-classresults. Alsowewouldreduce east London,theywouldworkatascaleto If webringtogetherspecialistservicesinnorthand 49 Birkmeyer, J.D.,Findlayson,E.V.A. &Birkmeyer, C.M.,‘Volume Standards forHigh-RiskSurgicalProcedures; PotentialBenefi valve surgery complex andemergencyprocedures suchasmitral and havehighvolumesofcases.Thisincludes patients treated byclinicianswhoare experienced Evidence showsthatoutcomesare betterfor would improve outcomesforlocalpeople. integrated high-volumecardiovascular service and TheLondonChestHospitalintoasingle, cardiovascular servicesfrom TheHeartHospital Clinicians believethatbringingspecialist How wecouldimprove services implantable cardioverter defibrillatorimplantation Dr EdwardRowland,ClinicalDirector, UCLH environment andprevention.” continues toimprove,isdeliveredmorepatients, andisfocusedoncareinthebest “Clinical staff areambitious tobringtogethertheirexpertisesothatcardiovascularcare 49 , primaryangioplasty 50 , ablation 51 and 52 . 63 Journal ofAmerican Cardiology the following: centre atStBartholomew’s Hospitalwoulddo A singlehigh-volumeintegratedcardiovascular by theacademichealthsciencepartnership. research andcooperationwithindustry, supported us tomaximiseinvestmentthrough increased only onlocalNHSresources. Itwouldalsoenable ■ ■ make itcost-effective toinvestintechnology Similarly, largersub-specialistteamswould England, helpingittogrow andimprove. among thecardiac unitsinLondonandmostof work together. Thisfacilitywillbeunique surgeons andinterventionalradiologiststo the-art 3D-imagingwithinatheatre, enabling for aorto-vascularsurgerywillplacestate-of- new developmentatStBartholomew’s Hospital example, thehybridtheatre plannedforthe Enable ustoinvestinnewtechnologies.For aorto-vascular centre withaspecialist24/7rota. centre formitralvalverepair andaregional would enableustodevelopahigh-volume supporting servicessuchasanaesthetics.This Achieve sub-specialisationinsurgeryand such asrobotic equipment. , 2005,46:1536-1540. ts oftheLeapfrog Initiative’, rrhythmias’, on’, ume ofcardioverter-defibrillator European HeartJournal Eurpace , 2009,11:771-817. , 2008. Surgery ,
Cardiovascular “Creating partnerships with the life sciences industry is at the heart of the UK health and wealth agenda. Industry wants to align with the biggest and the best. Integrating cardiovascular services would create the biggest cardiovascular clinical and research centre in Europe, on a par with the best in the world – an unbeatable proposition for London.” Professor Bryan Williams, Professor of Medicine and Director of the Biomedical Research
Cardiovascular Centre, UCLH
■ Help us meet and surpass the recommended ■ Strengthen research, science and clinical trials. number of complex and emergency procedures By creating access to data from such a large, in cardiology, which is a recognised marker for diverse population and broad range of activity, clinical safety and quality. we would attract funding for clinical trials. This would benefit local patients. ■ Create a regional service for transcatheter aortic valve implantation (where the aortic valve is replaced without full open-heart surgery) for The specialist centre would provide overall system high-risk patients and those who are unsuited to leadership, working with local acute hospitals and conventional surgery. primary and community health services to improve ■ Enable us to offer on-site 24/7 services such as care, ensuring that we provide the benefits of vascular surgery. world-class research and development along the whole pathway. ■ Streamline care pathways and create clearer referral routes for emergency units, ambulance services, GPs and community services. ■ Create greater capacity and flexibility to respond to demand, reducing waiting times and cancellations. ■ Drive innovation forward – a high-volume centre is more likely to be selected to test innovative technology and create models of use across cardiovascular units. ■ Maximise efficiencies and enable us to invest in the latest technologies and medical advances. ■ Increase expertise among the whole workforce, improving outcomes and giving patients a better experience of care. Many services at the new centre would be the largest in the UK, bringing the benefits of high-volume work to our population. ■ Improve training and recruitment – creating one of the UK's largest surgical units would enhance education and training opportunities for all staff. The service would be able to recruit from a world-class pool of expertise.
64 Jonathan Hanbury, DivisionalSenior Nurse,TheHeartHospital,UCLH patient pathwaysand experience.” establishment ofrolessuchasnursepractitioners whowouldimprovetheefficiency of allied healthprofessionals.Treating highervolumesofrareclinicalcaseswouldsupportthe “Creating anintegratedcardiovascularcentre wouldbeagreatopportunityfornursesand representative forNorth-CentralandEastLondon LocalEducationandTraining Board Professor JeanMcEwan,ConsultantCardiologist andHigherEducationInstitute programmes willbringtothemandtheirfuture patients.” very bestnationalandinternationaltraineesinrecognitionoftheadvantagesourtraining “A centreofglobalexcellenceinthemanagementcardiovasculardiseaseswillattract 65
Cardiovascular What this would mean for patients
Cardiovascular Clinicians believe we can save more lives, ■ A high-quality environment with greater ensure all patients have a good experience and access to new diagnostics and state-of- improve the quality of life for people with the-art equipment in all departments. Local cardiovascular disease. people would experience the same high standards of care no matter where they live. Cardiovascular care would be provided as part of ■ an integrated system with an expert specialist Expert multi-disciplinary teams with the centre at its hub. Patients and carers would be knowledge and understanding that comes treated by a specialist service working closely with from treating lots of similar conditions. local hospitals, GPs and community services to Emergency services would be provided 24/7 support prevention, early identification of disease, by highly skilled individuals and more services diagnosis, treatment and rehabilitation. Patients could be provided seven days a week and for would continue to access a range of cardiovascular more hours of the day as a result of larger services locally, including outpatient services. pools of expert staff. ■ Patients would be able to take part in a wider The integrated system would ensure that patients range of clinical trials. They would know they get ongoing support, with a clear management or were being treated by teams working at the care plan understood by everyone involved in their forefront of innovation. Patients would be able care. Patients and carers would get information to to contribute to and benefit from the help them make choices about their treatment and development of new technologies. Patients with work with clinicians to speed up their recovery. rare diseases would be treated by teams who Clinicians believe their vision for specialist see some of the highest numbers of patients in cardiovascular services would produce benefits the world with their condition, making clinical including these for local people: and research breakthroughs more possible.
■ Improved patient experience and outcomes, which would be measured to ensure that services continue to provide high-quality care. ■ A single integrated centre, which would provide prompt access to treatment in all departments. This would help reduce long waits and cancellations.
Consolidating services would create the largest cardiac surgery centre in England based on number of patients seen.
66 would havegreat benefits. Hospital ontoanew, state-of-the-artcampus services locatedattheoldStBartholomew’s Hospital andTheLondonChest–the average-sized specialistcardiac centres –TheHeart Local cliniciansbelievethatbringingtogethertwo 3. StBartholomew’s Hospital as partofthenewhospitaldevelopment. moving toStBartholomew’s Hospitalinlate2014 The LondonChestHospitalservicesare already 2. TheLondonChestHospital noroom toexpand. as ithas centre couldnotbelocatedatTheHeartHospital A singleintegratedhigh-volumecardiovascular 1. TheHeartHospital about theoptionsproposed. We are keen tofindoutwhateveryonethinks cardiology care. be aheartattackcentre andprovide planned offered attheRoyalFree, whichwouldcontinueto would benochangetothecardiovascular services If theserecommendations are agreed, there option. investment sowedidnotconsiderthis the RoyalFree Hospitalwouldneedsignificant cardiac surgery. Establishingasurgicalserviceat cardiovascular services,itdoesnotoffer specialist While theRoyalFree Hospitalprovides some The HeartHospitalandStBartholomew’s Hospital. LondonChestHospital, The and eastLondon– providing specialistcardiovascular care innorth We haveconsidered thethree mainsitescurrently What otheroptionsdidweconsider? 67 this activityatamuchlowercost. accommodate, orbeadaptedto hospitals. TheNHSalready hasfacilitiesthatcould We couldnotafford newbuildings atthese or UniversityCollegeHospital 4. NewbuildingatTheRoyalLondonHospital surgery inLondon. standards ofcare. Fiveothertrustsprovide cardiac getting abetterserviceproviding world-class choice needstobeconsidered, patientswouldbe attending TheHeartHospital.Whilepatient any increase timeforpatientscurrently injourney are only2.5milesapart,whichwouldminimise The HeartHospitalandStBartholomew’s Hospital complementary services. cardiovascular activity, whichideallywouldhave the newhospitalbuildingforadditional care. We currently haveanopportunitytoutilise enough capacitytosupportclinicians’visionof integrated purpose-builtcardiovascular centre with Hospital givesusauniqueopportunitytosetupan The newhospitalbeingbuiltatStBartholomew’s staff andgive patientsaccesstonewtechnologies. to improve trainingandresearch wouldattract University CollegeLondon.Strong academiclinks Queen MaryUniversity, UniversityofLondonand for therapeuticinnovation,inpartnershipwith Bartholomew’s Hospitalwouldalsobecomeacentre bringing incomefrom outsidetheNHS.St patientreferrals,attract nationalandinternational A newworld-classcardiovascular centre would
Cardiovascular Patient flows for The Heart Hospital West Essex
1-3 Enfield 4-7 8-11 Barnet 12-16 Cardiovascular 17-20 Waltham Redbridge Havering 21-25 Haringey Forest 26-33
City and Islington Camden Hackney Barking and Dagenham
Newham Tower Hamlets
The Heart Hospital St Bartholomew’s Hospital The London Chest Hospital
Patient flows for The London Chest Hospital
1-3 Enfield 4-7 West Essex 8-12 13-17 18-22 Barnet 23-28 Haringey Waltham Redbridge Havering 29-33 Forest 34-38 39-44 City and Islington Hackney 45-51 Camden Barking and Dagenham
Newham Tower Hamlets
The Heart Hospital St Bartholomew’s Hospital The London Chest Hospital
These maps show that most people who are currently referred to The Heart Hospital live in north-central London and most people who are referred to The London Chest Hospital live in north-east London. So travelling to an integrated cardiovascular centre at St Bartholomew’s Hospital would be a reasonable alternative for patients who are currently treated at The Heart Hospital.
5. Options outside north and east London Bartholomew’s Hospital would be the nearest If these proposals proceed, a few patients currently alternative. Because of this we have worked on the accessing care at The Heart Hospital would basis that cardiovascular services should be probably be treated by hospitals in west and south concentrated in north and east London. We have London (The Royal Brompton Hospital and Guy’s not tested in detail any options that would mean a and St Thomas’ Hospitals). lot more patients travelling to be treated in west or south London. However, for most people (about 80-90%) who currently access care at The Heart Hospital, St
68 events suchasheartattacks. access tothehighest-qualityservicesforacute unmet needs,ensure earlydiagnosisandprovide these approaches are necessary ifweare toidentify services togetherinasingleintegratedcentre. Both treatments, andtheopportunitiesforbringing vision focusonmore specialistinterventionsand unsustainable inthefuture. Otherpartsofthe cannot meetrecommended standards andare services inourgrowing population.Current services care. There ismajorunmetneedforcardiovascular co-ordination betweenGP, hospital andcommunity along thecardiovascular pathwaywithmore ofthisvisionrelate toimproving care Parts would helpusachievethisvision. medicine andresearch inapurpose-builtfacility Bringing togetherthebestincardiovascular cardiovascularleaders ininternational medicine. most innovativecare forpatients,andtobe This visionistoprovide thehighest-qualityand to provide improved outcomesforpatients. depend onexpensivetechnologiesandinnovations trained staff withspecialistskillsandincreasingly are unlikelytobesustainable.Bothneedhighly specialist cardiovascular hospitals,2.5milesapart, In thecurrent economicclimatetwomedium-sized Bartholomew’s Hospital. services intonewstate-of-the-artfacilitiesatSt outcomes byintegratingspecialistcardiovascular We needtoseizethisopportunityimprove patient the bestinworld. integrated specialistcardiovascular servicestorival north andeastLondonhavecreated avisionfor Clinicians andawiderangeofstakeholdersin Conclusion 69
Cardiovascular Cardiovascular
70 them tous. comments afterthisdate,dopleasesend 4 December2013.However, ifyoudohave for changebyemail,letterorphone We alsowelcomecommentsonthecase meeting ofyourlocalgroup, pleasecontactus. you wouldliketoinviteaspeakerattend If youwouldliketoattendanevent,orif cardiovascular services. they wanttochangespecialistcancerand and meetingswithclinicianswhowillexplainwhy During November2013,there willbeworkshops recommendations. feedback tohelpusdevelopourpreferred We are keentohearyourviewsandwilluse other stakeholders–onthisvisionforchange. including staff, clinicians,patients,thepublicand We are nowseekingtheviewsoflocalpeople– Get involved 71 Visit: www.england.nhs.uk/london/engmt-consultVisit: London EC2A2DU Support UnitCliftonHouse,75-77Worship Street, c/o NorthandEastLondonCommissioning Write to:Cancerandcardiovascular programmes Telephone: Email: or large-print: format document inanotherlanguage,alternative To getinvolvedortorequest asummaryofthis [email protected] 020 36881086
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