Vascular Surgery

Ensure ALL units are operating within a hub and spoke network model, as defined by the national service specification, emulating the most advanced hub and spoke models that exist currently. This in turn should deliver improved early decision-making capability and access to diagnostics, allowing early treatment, prioritised by degree of urgency. 1A: Hubs must perform a minimum of 40 carotid endarterectomy and 60 AAA procedures a year and must be staffed by a minimum of six vascular surgeons and six vascular interventional radiologists. Hubs should seek to perform greater volumes than these minimums where possible. 1B: Where appropriate, NHSE Specialised Commissioning hubs should consider using existing contract management levers to achieve compliance. 1C: Hubs to provide access to CT 24/7 within 30 minutes of patient arrival. 1D: Hubs to provide rapid access to theatre for ruptured AAA, within 30 minutes, covering staff and facilities for both open and EVAR modalities, ideally in a hybrid theatre. 1E: Hubs to provide scheduled operating, including at weekends. 1F: Hubs to provide timely vascular opinion to spoke hospitals. 1G: NHSE Specialised Commissioning to continue developing a service specification enabling consolidation of the most complex activity in a limited number of centres, seeking GIRFT clinical lead input as appropriate. 1H: NHSE Specialised Commissioning Regional Hubs and GIRFT Hubs to ensure existing hub selection activity and GIRFT programme activity is co-ordinated effectively. 1I: Prior to implementing new or developed hub and spoke arrangements, GIRFT to work with STPs to consider and provide for the resource impact on ambulance services, including the need for vehicles and paramedics. Any possible impacts on indicative activity plans or local quality requirements would need to be accessed. 1J: Prior to implementing new networking arrangements, financial impacts must be considered by both NHSE Specialised Commissioning and providers, with support from NHSI pricing and GIRFT, who are working together to address these issues. 1K: NHSE to lead proposed service changes, in collaboration with GIRFT, NHSI, STPs, and trusts, following necessary assurance changes. 1L: GIRFT to advise NICE of recommended change to practice for consideration in development of NICE Guideline Abdominal aortic aneurysm: diagnosis and management. 1M: GIRFT anaesthesia and perioperative medicine workstream to provide direct advice to providers to support implementation of urgent care, ensuring anaesthetic and perioperative medicine are co-ordinated effectively to support transition. Vascular workstream to provide reciprocal advice as necessary. 1N: GIRFT to add case studies of most well-developed hub and spoke models to the GIRFT Good Practice Manual. 1O: GIRFT Regional Hubs to liase with NHSI Operational Productivity Estates sub-programme.

Reduce the time from presentation to surgery for all patients in need of CEA to seven days from presentation. 2A: Clinicians and providers to reduce presentation to operation to within seven days of onset of stroke or TIA symptoms, as recognised as desirable in the existing service specification, reflecting high risk of stroke in first 2 to 3 weeks from onset. 2B: GIRFT to inform NICE of change to practice applicable to existing guideline on Stroke and transient ischaemic attack in over 16s: diagnosis and initial management.

Accelerate the referral to treatment time for ALL patients identified as in need of AAA surgery, whether identified via a screening programme or any other route. 3A: NHSE Specialised Commissioning to consider introducing a referral to treatment timeline of eight weeks, following definitive CT scan, for all AAAs of 5.5cm or above, regardless of whether they were identified via screening or not, given that unscreened AAAs represent higher risk. Treatment to include any medical support to optimise patient. 3B: Ahead of implementation, any impacts on local quality requirements and indicative activity plans would need to be assessed. 3C: GIRFT to advise NICE of recommended change to practice for consideration in development of Abdominal aortic aneurysm: diagnosis and management.

Continue ongoing work to promote the NAAASP to help ensure early identification, enabling treatment before emergencies occur. 4A: GIRFT Regional Hubs to identify any options for joint working or information sharing with NHSE Local Area Teams.

Increase the early availability of revascularisation surgery where lower limb ischaemia is present, to reduce amputation rates. 5A: GIRFT and NHSE to discuss faster referral to treatment times for revascularisation, as well as more rapid referral from primary care, and ensure evidence base for any proposed change. 5B: Clinicians and trust management to progress as far as possible within units and existing networks. 5C: The Vascular Society to design a Lower Limb Ischaemia Quality Improvement Framework (LLIQIF) to improve revascularisation rate and reduce amputation, indicating clear pathway timelines from referral. 5D: Providers to follow the requirements of the new LLIQIF, and NHSE Specialised Commissioning to consider reflection in service specification. 5E: Primary care to consider use of NICE clinical audit tool to implement diagnosis recommendations in NICE guideline Peripheral arterial disease: diagnosis and management and refer accordingly, alerting commissioners prior to change in practice. 5F: GIRFT Regional Hubs to discuss provision of urgent outpatients' appointments for non-diabetic ischaemic foot with providers and CCGs to enable early referral and thus identification of the need for revascularisation.

Ensure optimum list scheduling. 6A: Trusts to organise vascular surgery around combined 'urgent' lists. 6B: Clinicians and trust management to ensure surgeons perform a minimum of three inpatient half-day lists, two outpatient sessions and a day-case list per week. 6C: GIRFT to work with Vascular Society to develop prioritisation methodology based on risk. 6D: NHSI Operational Productivity Clinical Productivity sub-programme to reflect this recommendation in any guidance products, seeking further GIRFT Clinical Lead input as necessary. 6E: Trusts to engage with NHSE Specialised Commissioning to inform them of any possible increase in activity flowing from this recommendation. Any possible impact of indicative activity plans would need to be assessed.

Assess the need and options to increase the vascular surgery and interventional radiology multidisciplinary workforce to support sustainable delivery of recommendations 1-5. 7A: GIRFT and Vascular Society to discuss Workforce Report with HEE, to consider next steps. 7B: GIRFT and NHSE Specialised Commissioning to discuss possible joint working in this area.

Improve prehabilitation for AAA, PVD and CEA, particularly with regards to perioperative medical input. 8A: Clinicians and providers to improve use of multidisciplinary prehabilitation using known best practice. 8B: GIRFT to inform NICE of proposed changes to practice linked to this recommendation for consideration in development of NICE Guideline Abdominal aortic aneurysm: diagnosis and management. 8C: NHSE Specialised Commissioning to review AAAQIF with a view to promoting consistency in prehabilitation. 8D: GIRFT Regional Hubs to identify cases in which the 30-day readmissions rule appears to be contributing to increased length of stay and discuss with commissioners and providers a possible review of thresholds. GIRFT to inform NHSI and NHSE pricing teams of any evidence emerging. 8E: GIRFT to add relevant existing guidance to the GIRFT Good Practice Manual, as well as any case studies it identifies.

Reduce avoidable readmissions by improving perioperative care and follow up. 9A: Clinicians and trust management to ensure close liaison with medical specialties and seven-day physiotherapy, as part of multidisciplinary package of enhanced recovery. 9B: Clinicians and trusts to ensure early post-operative contact with patients, as well as readily available emergency contact information and outpatient clinics for patients with concerns. 9C: GIRFT to add existing guidance relevant to the GIRFT Good Practice Manual, as well as any case studies it identifies. 9D: NHSI Operational Productivity Clinical Productivity sub-programme to reflect recommendation in any guidance products, seeking further GIRFT Clinical Lead input as necessary.

Ensure case ascertainment of the National Vascular Registry to HES reaches 85% for AAA, CEA and lower limb revascularisation and amputation procedures. 10A: Trusts to improve data recording to the National Vascular Registry and HES to achieve case ascertainment of at least 85%. 10B: NHSE Specialised Commissioning to consider use of Information Breach, or alternatively a Data Quality Improvement Plan to encourage delivery of 10A.

Improve quality of routine data entry and collection. 11A: GIRFT and NVR to consider providing guidance on the coding and recording of complex aneurysms, and the definition of elective/emergency or planned/urgent with respect to vascular surgery procedures. 11B: GIRFT to discuss with the NVR a change to the post-surgical destination data item to include enhanced ward-level care. 11C: Trusts and surgeons to improve recording of the Fontaine classification in the NVR, as a standard clinical scale for lower limb ischaemia.

Improve coding for complex aneurysms and emergency vascular surgical activity. 12A: Surgeons to meet with trust information teams to implement changes to coding practice which would provide improved clinical accuracy as defined by NVR and GIRFT. 12B: Trusts to agree any proposed changes internally with a view to any change impacting on NHS Standard Contract service conditions on the counting and coding of activity, being proposed to commissioners. 12C: If and once agreed with commissioners, trusts to implement any change. 12D: Surgeons to meet trust information team and coders and review activity attributed to them once a month. 12E: Trust management to facilitate time for surgeon and coder engagement, using job planning if needed. 12F: GIRFT to consider development of guidance, consistent with existing coding guidance, to support improved collaboration between coders and surgeons.

Improve insight into patient experience in vascular services, to support clinically led improvement. 13A: Vascular surgery providers to review their FFT response rates and, where response rate appears low, use suggestions in FFT guidance to improve rate. 13B: GIRFT to work with other national bodies to consider how best to gather and apply insights on patient experience to support improvements in clinical care – including by engaging with on-going work on FFT. 13C: NHSE Specialised Commissioning to seek GIRFT Clinical Lead involvement in its work on Patient Reported Outcome Measures and Patient Reported Experience Measures.

Require at appraisal surgeon-level intelligence on activity and outcomes. 14A: Trust management to ensure all appraisals are informed by best quality data.

Increase use of ward-based recovery to a level of approximately 90%. 15A: Trusts to assess needs for enhanced nursing numbers and medical input on ward to deliver this recommendation. 15B: Trusts to recover patients to the ward, unless contraindicated, or where nursing and medical input cannot be achieved on the ward.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and the spreading of best practice. 16A: GIRFT to work closely with sources of procurement data such as PPIB and relevant clinical data to identify optimum value for money procurement choices, considering both outcomes and cost/price. 16B: 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. 16C: GIRFT to engage the NHS procurement community, including the new Category Towers and the HCTED programme, to develop commercial plans for supporting trusts and STPs to deliver the identified value for money opportunities.

Reduce litigation costs by application of the GIRFT Programme's five-point plan. 17A: Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts will have received an updated version of this for vascular surgery in the GIRFT 'Litigation in surgical specialties data pack', December 2017. 17B: 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, and inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk. 17C: Once claims have been verified clinicians and trust management to further 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 trusts' panel firm should be able to provide support. 17D: Claims to be compared with learning themes from complaints, inquests and serious untoward incidents (SUI). Where a claim has not already been reviewed as SUI, this should be carried out to ensure no opportunity for learning is missed. 17E: Where trusts are outside the top quartile for litigation costs per activity, GIRFT to ask national clinical leads and regional hub directors to follow up and support trusts in the steps taken to learn from claims and share examples of good practice where it would be of benefit.