Urology

Develop a structured training curriculum for specialist urological nurses and establish accredited training departments. 1A: GIRFT to engage with BAUN, BAUS, Health Education England (HEE), Council of Deans, and the Royal College of Nursing (RCN) with a view to developing and implementing a specialist training curriculum for urological nurses, as well as an accreditation scheme for training within departments or networks. Any outputs would need to be consistent with the national ACP framework.

Provide job planning for clinical nurse specialists and ensure appropriate skill mix. 2A: Trusts to provide job planning for clinical nurse specialists, and review skills mix to ensure clinical nurse specialists carry out work appropriate to their grade, utilising their skills as fully as possible. 2B: GIRFT, BAUN and NHSI Clinical Productivity programme to develop any guidance product to support further improvement. 2C: Trusts to review skills mix and job plans using the guidance product.

Increase the provision of Urological Investigations Units (UIUs), providing a dedicated resource for urological outpatient care. 3A: Trusts to consider development of UIUs, implementing where necessary and in agreement with commissioners. GIRFT to consider possible joint working with NHSI on this point. 3B: Concurrent to 3A, GIRFT to develop case studies covering implementation, costs and benefits. 3C: GIRFT to discuss any possible joint working in this area with NHS England.

Review follow-up rates against a median of 1:2 first outpatient to follow-up. 4A: If the follow-up rate is high, providers and clinicians to consider reducing follow-up towards the median to help avoid RTT or capacity issues. If the follow-up rate is low, check that patient outcomes are not being compromised. This review should be undertaken jointly with CCGs to ensure that any dependencies with primary care capacity are considered. 4B: Based on results of 4A, providers to agree planned changes with commissioners and enact them. 4C: Concurrent to 4A and 4B, GIRFT to consider with NHSI pricing colleagues any tariff changes that could support optimisation of follow up rates.

Take further action to improve RTT performance for common conditions and pathways. 5A: GIRFT to work with NHSI and NHSE to investigate causes of consistently insufficient RTT performance for Urology, with a view to develop an improvement plan.

Address the potential adverse effects of existing cancer diagnostic and treatment standards. 6A: Trusts to use NHSE's timed prostate cancer diagnostic pathway handbook to improve performance against diagnostic pathways. 6B: NHSE and GIRFT to assess potential negative impacts of current treatment targets with respect to prostate cancer, which may include unjustifiable pressure on patients to make decisions about treatment and inefficient use of diagnostics. 6C: NHSE and GIRFT to ensure that current practice in the management of muscle-invasive bladder cancer is quantitatively examined and to consider redefining clock-stop points for bladder cancer patients, to address any delays in treatment that occur as a result of 'clock stops' being triggered before definitive treatment is provided.

Review guidance for urology cancer MDT working. 7A: National Cancer Board to continue work reviewing cancer MDT meetings. 7B: GIRFT, BAUS and BAUN to collaborate with the NHS England on implementation in Urology on forthcoming guidance on cancer MDT working. 7C: GIRFT, working with national and professional bodies as appropriate, to identify best practice case studies in effective MDT use.

Reduce average length of stay across the specialty through enhanced recovery and increased use of day case pathways, while monitoring causes and rates of emergency readmissions. 8A: Providers and clinicians to aim to achieve day surgery rates defined by the British Association of Day Surgery in table 1, by adopting practices described above. 8B: Providers to adopt enhanced recovery techniques, increase consultant involvement in day-to-day care and ensure that the wider clinical team is fully engaged in the enhanced recovery process. Providers should monitor patient experience as new processes are adopted.

Improve the secondary care pathway for patients with urinary tract stones. 9A: Providers to deliver effective conservative treatment and follow-up to reduce the need for emergency readmissions and surgical intervention, by: • providing specific stone clinics to offer conservative treatment; • providing timely follow-up to patients discharged with stones still in situ; • providing timely readmission for definitive surgery for patients in whom stones fail to pass spontaneously; and • assessing financial impacts prior to implementation and agreeing changes with commissioners. 9B: Where clinically indicated, providers to deliver definitive surgical treatment of renal and ureteric stones, rather than a ureteric stent insertion, to reduce unnecessary second procedures, by: • ensuring staff required to assist the procedure are trained to assist with ureteroscopy and laser lithotripsy; • introducing bookable emergency operating lists designated to the urology unit; and • assessing financial impacts prior to implementation and agreeing changes with commissioners. 9C: GIRFT to work with BAUS and NICE to: • ensure NICE guidance review underway on renal and ureteric stones is used to inform service development; • agree an outline of stone management best practice for inclusion in the GIRFT template for developing Urology Area Networks (see below). 9D: GIRFT and Elective Care Transformation Programme to consider any joint working in this area.

Provide consultant-delivered emergency urology care in every trust by reducing elective commitments for consultants on call. 10A: GIRFT to work with NHSI to assess impact of recommendation on workforce capacity. 10B: Conditional on outcome of 10A, Providers to move progressively to a business as usual where consultants on call for emergency care have no, or reduced, elective commitments whilst on call. 10C: To achieve 10B, providers should consider adoption of the consultant of the week model. 10D: GIRFT to progressively build a catalogue of best practice case studies in this field, troubleshoot any challenges in adoption, and support the commissioning of further quantitative research to demonstrate causal impact of reducing elective commitments for on call consultants, including through the consultant of the week model.

Review workloads of on-call consultants to ensure the sustainability of on-call arrangements. 11A: Providers to review consultant on-call workloads and look at ways of avoiding excessive and unnecessary work, including but not limited to those suggested in this report.

Ensure high-quality emergency urological care is available in all areas seven days a week by focusing available resources at weekends on a smaller number of departments, while allowing some departments to operate on a five-day basis. (This may be supported by a move to a networked model, as recommended below.) 12A: Trusts to progress as far as possible within the context of existing network arrangements. 12B: Further action to be taken within the context of recommendation 14.

Review the approach to providing care for patients who require urgent surgery for urinary tract trauma and related conditions. 13A: Trusts to consider options for improvement locally. 13B: BAUS and GIRFT to develop guidance for local adoption. 13C: Trusts to implement guidance as appropriate. 13D: GIRFT to discuss workforce issues with HEE.

Establish urology area networks (UANs), comprising several urology departments that provide comprehensive coverage of urological services, beyond existing network arrangements, to optimise quality and efficiency. 14A: GIRFT National Team, BAUS and BAUN, drawing on advice from NHSE, to develop guidance for model urological area networks, to support service specification development and service design locally. 14B: GIRFT Hubs and clinical lead, working with STPs and local partners, to identify pilot areas for development of UANs. 14C: Pilot UANs to be implemented and evaluated within STPs. 14D: Concurrently, GIRFT Hubs to identify further network areas in a way which leads to a coherent model of urology UANs that covers the whole country. 14E: STPs to progress implementation of UANs.

Reduce the numbers of complex surgical procedures that are carried out in small volume centres, using UANs as they develop. (Note: A "procedure" refers to a specific operation e.g. radical cystectomy, laparoscopic pyeloplasty etc. For very rarely performed operations it might be appropriate to consider a bundle of operations where the procedures clearly utilise a common surgical skill-set). 15A: GIRFT, with the support of BAUS, to initiate or support further research to investigate the volume-outcome relationship in urology, with a view to defining minimum and optimum volumes for specialist urological procedures including complex stone surgery, surgery for Peyronie's disease, urethroplasty, neurological urology and specialist female urology. 15B: Ahead of this research, clinicians and providers should reduce low-volume operating within trusts based on the following guidelines: • complex cancer surgery should be performed by surgeons carrying out 20 or more procedures a year; • complex surgery for conditions other than cancer should be carried out by surgeons performing more than 10 procedures per year. 15C: When developing plans for UANs, STPs/ICSs should consider the following guidelines ahead of further research: • complex cancer surgery should be performed in centres performing 40 or more procedures per year; • complex surgery for conditions other than cancer should be performed in units performing more than 20 procedures a year.

Align data collection efforts across urology and ensure that data are collected that are relevant and has a value that is in proportion to the resources needed for its collection. 16A: GIRFT, NHS Digital, NHSE, NHSI, BAUS and BAUN to collaborate in order to achieve this.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and the spreading of best practice. 17A: GIRFT to work closely with sources of procurement data such as PPIB and PLICS, and use relevant clinical data to identify optimum value for money procurement choices, considering both outcomes and cost/price. 17B: GIRFT to identify opportunities for improved value for money, including the development of benchmarks and specifications, and locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. 17C: Trusts and STPs to work with GIRFT and the new Category Towers, to benchmark and evaluate their products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.

Reduce litigation costs by application of the GIRFT Programme's five-point plan. 18A: Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per unit of activity. 18B: Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk. 18C: Once claims have been verified, clinicians and trust management to review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trust's panel firm should be able to provide support. 18D: Claims should be triangulated with learning themes from complaints, inquests and serious untoward incidents (SUI) and where a claim has not already been reviewed as an SUI, we would recommend that this is carried out to ensure no opportunity for learning is missed. 18E: Where trusts are outside the top quartile of trusts for litigation costs per activity, GIRFT will be asking national clinical leads and regional hub directors to follow up and support trusts in the steps taken to learn from claims. Clinical leads and regional hub directors will also share with trusts examples of good practice.