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Vascular Surgery - the latest report from Getting It Right First Time (GIRFT)
The latest report from the GIRFT programme has been published, revealing its findings and recommendations for improving the way vascular surgery is delivered by the NHS in England. Funded by the Department of Health and overseen by NHS Improvement and the Royal National Orthopaedic Hospital NHS Trust, GIRFT is proving successful in helping the NHS to learn and improve its practises by identifying variations in NHS care, sharing best practice with clinicians and hospital managers across the country whilst supporting necessary changes, thereby saving costs.
The latest report sets out 17 recommendations for improvement based on information gathered from NHS data and visits to each of the 70 NHS Trusts which provide vascular surgery services. In addition to raising concerns about quality and discrepancies in the available NHS data, the report highlights fundamental weaknesses in the way that vascular surgery is delivered. Patients are routinely experiencing unacceptable and potentially dangerous waiting times for surgery. These delays increase their risk of experiencing major strokes, life threatening rupture of abdominal aortic aneurysms and amputation, depending on their condition. The report emphasises that by its very nature, even where the need for vascular surgery is not classed as an emergency, it must always be regarded as urgent.
Currently, 43,000 vascular surgery procedures are performed in England each year by 450 consultant vascular surgeons, often working with vascular interventional radiologists, in 70 NHS Trusts. In order to ensure that NHS patients needing vascular surgery can be treated urgently in accordance with NICE guidelines and in a way that minimises their risk, GIRFT recommends that this important and often life-saving surgery must be provided through a reduced number of properly staffed and equipped specialist centres, via an advanced yet proven ‘hub and spoke’ network model that has worked effectively elsewhere within the NHS.
If implemented, the recommended changes could improve surgical outcomes for seriously ill patients whilst also achieving costs savings by reducing length of hospital stays, reducing the number of readmissions and making better use of surgical resources. Other recommendations include opportunities to save money which is currently wasted through variations in the procurement of equipment and other products.
What is vascular surgery?
Vascular surgery saves lives through a variety of important procedures such as reconstructing, unblocking or bypassing arteries that are blocked by atherosclerosis. This hardening or furring of the arteries reduces blood flow to vital organs and, if untreated, can lead to sudden death, strokes and amputation. Another life-saving procedure deals with aortic aneurysms before they rupture, often causing death.
Where surgery is delayed there is always a risk to life or limb. Patients needing vascular surgery are, by definition, very frail and their condition is often compounded by additional complications (or co-morbidities) such as hypertension, diabetes, chronic lung disease or ischaemic heart disease. This puts them at greater risk from surgery, increases their need for intensive post-operative care, raises the likelihood that they will need to be readmitted to hospital and increases their mortality rate when compared to other types of surgery.
The GIRFT report highlights some key procedures in which delays are increasing those risks:
Abdominal aortic aneurysm (AAA)
An abdominal aortic aneurysm is a bulge or swelling in the aorta. If it ruptures it causes internal bleeding and sudden loss of blood pressure and is usually fatal without emergency surgery. Most procedures are, therefore, carried out before rupture, with the aim of preventing rupture. Once a patient is identified as being at risk of rupture, surgery should take place urgently. However, GIRFT found that patients whose AAA surgery was classed as ‘elective’ (i.e not yet ruptured) rather than ‘emergency’ (already ruptured) were often having to wait several weeks for surgery.
Carotid endarterectomy (CEA)
Carotid endarterectomy removes atherosclerotic build-up in the carotid arteries which carry blood to the brain. This procedure is usually performed on patients who have suffered a minor stroke or transient ischaemic attack (TIA) to prevent the life threatening and disabling major stroke which often follows a minor stroke. NICE guidelines mandate that CEA should be carried out within two weeks of diagnosis of a minor stroke or TIA. However, GIRFT found wide variation between NHS Trusts in the waiting time from diagnosis to CEA surgery, with some patients having to wait for 28 days or more.
- Lower limb revascularisation
Lower limb revascularisation treats peripheral vascular disease (caused by blocked arteries) by improving blood flow through the arteries in the legs. Timely revascularisation by angioplasty (using a ‘balloon’ to widen the artery or a stent to keep it open) or bypass can prevent the need to amputate. Around 8,000 lower limb amputations are performed on the NHS each year. Major amputation currently has a 16.5% high emergency re-admission rate and a 7.5% mortality rate. GIRFT found that earlier identification of risk and reduced waiting times for revascularisation could reduce the numbers of amputations.
Dealing with delay
The GIRFT report found that lack of available facilities and lack of integration with other departments were often a cause of delay. However, the key finding of concern was that vascular surgery tends to be carried out only in ‘normal’ working hours, which limits the number of procedures that are carried out each week. Only six NHS hospitals in England currently offer elective (non-emergency) vascular surgery at weekends, even though they all must have on call teams available at weekends to deal with emergencies.
The key recommendation of the report was that vascular surgery should be delivered seven days a week, centralising resources and expertise through specialist hubs. In doing so, patients will be given greater choice from a range of available procedures, surgery will be performed more quickly by more experienced surgeons using better facilities and specialist equipment in an environment where there is appropriate multi-disciplinary support. Recommendations were also made in relation to pre-habilitation and planning for perioperative care thereby reducing avoidable post-operative readmissions.
At Boyes Turner we specialise in helping brain injured and amputee clients rehabilitate and rebuild their lives following severe injury caused by unacceptable treatment delays. We understand the physical and psychological damage that is caused by these injuries and we work hard to obtain compensation which can pay for prosthetic limbs, specialist equipment, adapted vehicles and homes, along with meeting the costs of necessary care and replacing lost earnings.
Whilst the findings of the GIRFT report into vascular surgery highlight the number of patients who are potentially suffering amputations and other serious injury unnecessarily, GIRFT’s previous reports and successful implementation of its recommendations provides hope for improvement.
Boyes Turner welcome the courageous and valuable work that is being carried out by GIRFT’s clinical leads and their teams to identify areas where unnecessary suffering can be avoided and champion best practice to bring about change.
If you or a family member have suffered serious injury as a result of hospital negligence during vascular surgery call our specialist medical negligence solicitors on 0118 952 7219 or email firstname.lastname@example.org.
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