North Wales Vascular Services de-escalated as a service requiring significant improvement

Vascular Services in North Wales have been de-escalated as a service requiring significant improvement by Healthcare Inspectorate Wales (HIW). ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

In February 2022 Betsi Cadwaladr University Health Board came under fire after a “damning” report by the Royal College of Surgeons (RCS) into vascular services in the region, which raised serious questions about the quality and consistency of care. ‌ ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

Concerns raised at the time focused around the quality of clinical care and risks to public safety, poor MDT working and poor documentation and record keeping. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

It led to the service being designated a Service Requiring Significant Improvement (SRSI)​ by the health inspectorate. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

However a report released today found that although more work is needed in some areas, there is evidence of progress in relation to patient safety and the quality of care being provided, which enabled the de-escalation. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

A review carried out by the inspectorate found that whilst some issues remained, the health board had made “sufficient progress” with addressing and implementing the nine recommendations put forward. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

During the review HIW explored whether the actions implemented by the health board had addressed the recommendations made by the RCS and improved the quality of care being provided. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

It also considered whether vascular care was consistent. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

In its report HIW found that as well as addressing the nine recommendations outlined by the RCS team, prompt action has also been taken to address five urgent patient safety risks. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

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Despite this, HIW say: “Further work is still required to strengthen some aspects of clinical record keeping, and to ensure a patient’s journey through the vascular pathways is consistent and robust. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“The health board must ensure the quality of written communication is sustained, and records are filed in a timely manner and in chronological order to maintain patient safety. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“A Vascular Quality Review Panel was set up by the health board to undertake further scrutiny of the patient records and is reviewed by the RCS on an individualised basis. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“This has led to new information being identified and resulted in the health board referring four people to the coroner. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“Through our review, we found the health board has made satisfactory progress with the recommended improvement for Multidisciplinary Team (MDT) decision making. A ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“n MDT is a group of healthcare professionals from different specialties, such as surgeons, anaesthetists, nurses or physiotherapists, who work together to make decisions regarding the treatment and care of a patient. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“Inspectors also found immediate action had been implemented within the vascular surgery service, which including enhanced consultant cover and closer MDT decision-making support. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“Although marked improvements have been made, further work is required for the health board to ensure MDT discussions are always filed promptly within clinical records. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“Our review highlighted concerns with the culture of working between some teams involved within different care pathways of the health board’s vascular services, which may impact on patient care. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“This was evident through our interviews with staff, who suggested there was poor communication. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“Clearer working relationships must be established, to ensure that patients are being referred promptly, and patients are assessed by the most suitable team, to provide more timely advice and care.” ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

As part of its review HIW also found that satisfactory progress had also been made by the health board for the consent-taking process within vascular services along with evidence of improvements through consent process audit results, and through our clinical records review. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

However, it concluded that further work is required to ensure the records always demonstrate the entire consent process accurately and appropriately ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

Finally when HIW explored whether the governance arrangements in place within the health board were effective in monitoring the response to the RCS findings in 2022 and their recommendations, it found these to be satisfactory. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

Healthcare Inspectorate Wales Chief Executive Alun Jones said: “It is positive to hear vascular services are improving in a number of areas. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“However, our review did make eleven recommendations for further improvement to strengthen the current arrangements in place. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“The health board must ensure measures are in place to assure itself that the improvements and processes implemented since the RCS review are sustainable now and in the future. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

“The health board must consider our recommendations, and it is our expectation that these are taken forward in the context of broader improvement work.’ ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

Moving forward the health board is expected to maintain the progress it has made in improving its vascular service since the RCS review. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

The health board will be required to submit an improvement plan in response to our review’s findings and recommendations. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

This is to ensure that the issues raised by the HIW review are being appropriately addressed. ‌​‌‌‌​‌‌‍‌​‌‌‌​‌​‍‌​‌‌‌​‌​

Doctor Nick Lyons, executive medical director of Besti Cadwaladr University Health Board, admitted to BBC Radio Wales Breakfast that the transfer of vascular services from Bangor and Wrexham to Ysbyty Glan Clwyd “wasn’t done as effectively as it should have been”.

He said: “We have always maintained that, it was right to centralise to bring all our resources into one place, so that we could ensure the potential for excellent care was there.

But that wasn’t done as effectively as it should have been.

I think it the decision was the right one and that is now beginning to be demonstrated with this new report.

There is still more work to be done, there’s still further improvements that we need to do, but we are absolutely on the right path now.

I hope that gives real confidence to your listeners who may be awaiting surgery in that unit and their families of those where perhaps we haven’t always done as we should’ve done.

Their concerns had been listened to and that the improvements they be lobbying for the last months and years are now taking place.”

In response to questions about the appointment of a new Chief Executive, Dr Lyons said the health board is looking for the “right person”.

He said: ” The Health Board’s problems that have been very public, not least on the BBC.

We have a very experienced interim Chief Executive Carol [Shillabeer] who joined us about eight weeks ago and I think it’s right that we wait to have just the right person with all the skills and experience to help steer the health board forward.

Perhaps this report today demonstrates the fact that improvements can be made and they will continue to be made, not just in vascular but in other areas as well.”