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Urology Services (East Kent)
4.28 pm
Mr. Julian Brazier (Canterbury) (Con): On a point of order, Mr. Bayley. I have not yet cleared it with you and the Minister that my hon. Friend the Member for Faversham and Mid-Kent (Hugh Robertson) may join me in the debate.
Hugh Bayley (in the Chair): He may contribute if it is all right with the Minister.
Mr. Brazier : Thank you, Mr. Bayley, that is splendid.
I am grateful for the opportunity to raise the subject of the proposed reorganisation of urology services in east Kent. I am delighted to see the Minister in her place. She will know that the new model of care in east Kent has been through a traumatic birth and that finally, after a six-year battle, things settled into the new configuration in February. In a moment I shall describe how the proposals that I want to discuss this afternoon, for the provision of surgery for bladder and prostate cancer in Kent, threaten the heart of the new model of care. However, I want first to raise a number of specific objections to the proposals.
Briefly, the proposals would remove bladder and prostate surgery from the new east Kent urology centre at the Kent and Canterbury hospital to two hospitals in west Kent. My first specific objection relates to the issue of quality of clinical care. In January last year, a Kent and Medway cancer network internal peer review, including external reviewers, identified the East Kent Hospitals NHS trust as an excellent provider of surgery for bladder and prostate cancer. The unit was described as having the most advanced multidisciplinary team in Kent.
A recognised and internationally used measure of quality and cost-effectiveness in those procedures is the average post-operative length of stay for patients. Audit of radical prostatectomy in Canterbury shows a post-operative stay of 2.6 days. That is outstanding compared with other major providers—two that I could find the figures for were Bristol at 3.6 days and Basingstoke at 5.3 days. America publishes a national league table, in which the spread is from 2.4 to 4.8 days, so Canterbury, by American standards, would be one of the very best. Perhaps the most impressive statistic of all is that 96 per cent. of Kent and Canterbury patients were fully continent one year after the radical prostatectomies.
That audit was carried out against the criteria laid down in 2002 by the National Institute for Health and Clinical Excellence, which stated that a unit should perform a critical mass of around 50 operations a year to maintain standards. Kent and Canterbury, with about 60 a year, was well within those guidelines. However, the goalposts have now been arbitrarily moved. An amendment to the improving outcomes guidelines changed the requirement to insist that each unit serve a population of 1 million in order to perform that surgery. Time prevents me from going into much detail on that matter, but no academic evidence that I know of has been offered to suggest that that is a good idea. Indeed, I have received e-mails about a whole string of studies that suggest that it is not. One study in
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Glasgow, carried out by McCabe et al., suggests that for radical cystectomy, for example, a case load of eight operations a year—a very low case load—is associated with the lowest mortality rate.
Such a population base is, in practice, outside the reach of most British district general hospitals. Implementing the IOG is causing havoc in Kent and across the country, threatening to ruin carefully developed models of care and to disrupt teams of surgeons, anaesthetists and nurses who provide excellent standards of care.
We are therefore faced with a situation in which important cancer services are reshaped according to theoretical criteria, rather than the actual outcomes, which have been shown to be excellent. Kent and Medway cancer network says:
"This review was about making a judgement on what would be the most sustainable and deliverable configurations of prostate and bladder cancer surgery."
Yet, barely nine months after the excellent report that I mentioned earlier, the external review panel said, on the one hand, that East Kent Hospitals NHS trust scored extremely poorly on the critical criterion of clinical quality but, on the other hand, that it had
"a currently excellent service with low lengths of stay, strong nursing support, patient focus, community-based post-operative care and a newly formed urology team at Kent and Canterbury Hospital."
That team, which has taken seven years to develop, is under threat from the theoretical criteria that have generated that ghastly exercise in tick-box planning.
I have worked with the Minister in a number of capacities, when we were both Back Benchers, and I do not believe that she wants to take the NHS into territory where words start to mean whatever the speaker wishes. If both the peer review and the report acknowledge that the service in east Kent is excellent, there is something bizarre about theoretical criteria that are used to tick boxes and conclude that the service is of poor quality.
I shall speak more briefly on my second objection to the proposals, which concerns accessibility. The effect of the reorganisation would be to leave no facility at all in east Kent but to provide two units in west Kent. Those units are only 12 miles apart and have an excellent road connecting them. Patients in east Kent will have great difficulty if they are reliant on public transport to access those units, and our ambulance service is already overloaded. How will east Kent patients benefit from travelling many miles for operations that, based on current audit data, will be performed no better in west Kent than in east Kent? In fact, they will be performed slightly less well, according to current figures. Obviously, the proposals must be considered on their merits, but to people living in the comparatively poor area of east Kent, they conform to an all-too-typical pattern across many public services, some of which are completely unconnected with the NHS. The team of nurses, anaesthetists, surgeons and recovery staff, who were carefully put together and have built such a good reputation in a short time, would go to waste.
Those are the specific objections, but the most important objection is more general and involves the threat that the proposals pose to the whole model of care
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so painfully assembled in east Kent over the past six or seven years. That model of care provides two acute hospitals in east Kent, supported by a specialist hospital in Canterbury, which in practice is by far the most accessible of the three sites, especially for elderly people. It has a local emergency care centre, the first of its kind in the country. Medical specialties such as acute medicine, coronary care, health care of older persons and the Kent renal unit are also included. All those services require 24-hour resident surgical cover. The arithmetic is that, between them, the urology unit and the vascular surgery unit have just enough posts to provide the necessary number of doctors for a safe and sustainable surgical rota.
The proposed removal of those operations and the resulting changes in consultant posts would reduce training opportunities and experience. House officer and trainee posts at Canterbury would be at risk of losing the crucial training recognition from deaneries and colleges. Even without a loss of training recognition, the loss of income from the operations would severely reduce the number of training posts at Canterbury. It would then be impossible to run an on-call rota for surgical emergencies that complied with the European working time directive on the Canterbury site. The whole edifice of the model of care, built up over seven years of battles, would simply collapse under the current proposals, unless there was further reorganisation that provided surgeons from another source.
We are talking about the loss of the local emergency care centre. Acute general medicine, coronary care, health care of older people and the Kent renal unit would become non-viable on the Canterbury site, as would vascular surgery and in-patient urology in the long run. Would the additional capital and revenue required to provide those services elsewhere in east Kent be made available? Would east Kent develop yet another new model of care after all the changes and reorganisations, or would yet more of east Kent's specialist services be moved to west Kent?
The primary care trusts expressed concerns on that when they arrived at a verdict in favour of the changes by a six-to-three vote. I need hardly say that it was the three easternmost PCTs that voted against. They all made it clear, however, that the changes must be contingent on not undermining that critical mass. They put the Canterbury and Coastal PCT—one of the three that opposed the proposals—in charge of the change process, with a brief specifically to that end.
Survey after survey has shown that Canterbury is by far the most accessible hospital in east Kent. For the people living in Canterbury, Whitstable and Faversham—I am particularly glad to have my hon. Friend the Member for Faversham and Mid-Kent here—and the people in most of the villages, which provide more than a third of the population of east Kent, Canterbury is the most accessible site. The devastation of its model of care and the undermining of the whole settlement in east Kent is threatened by these terrible proposals.
I shall ask the Minister another question as I come to a close. I understand that the reviewer of the process was supposed to be independent. He was independent in the sense that he came from outside Kent, but will the Minister tell us whether that reviewer, who I suspect had
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a hand in formulating this bizarre policy with the critical mass of 1 million and the rest of it, has ever been called in anywhere and found in favour of a distributed rather than a centralised model? I ask that because the view locally is that he is an avowed centraliser brought in by the Kent and Medway cancer network to rubber-stamp its solution rather than a genuinely independent figure.
There is too much at stake to leave the matter to drift away. The first local emergency centre in the country is running well. After some extremely painful teething problems—one of the staff nurses happens to be a close neighbour of mine—it is now a fully recruited establishment. At one point it did not think that it would achieve that. It would be monstrous if all that were put at risk by the empire-building of one small group of people.
I welcome the fact that Kent county council's scrutiny committee has insisted that there should be a public consultation noting that the recommendation does not support the interests of east Kent. That scrutiny committee is led by an experienced doctor whose constituency lies far to the west of Kent, and I hope that that consultation will be a genuinely independent process. I urge the Minister to support the professionals in the East Kent Hospitals NHS trust and the people of east Kent, by rejecting this illogical and unbalanced proposal.
4.41 pm
Hugh Robertson (Faversham and Mid-Kent) (Con): I apologise to the Minister for not declaring an interest in this debate. I should tell her that my constituency is in a curious position because it spans both hospitals. My constituents in and around Faversham—the Swale borough council area—almost all use the Kent and Canterbury hospital referred to by my hon. Friend the Member for Canterbury (Mr. Brazier). My constituents in the Maidstone area benefit from the Maidstone hospital.
Having considered the matter as a whole, I am convinced that the proposal is very poor. There are five reasons for that. First, the Kent and Canterbury hospital has just got over a long and bitter fight concerning its future. Secondly, very specific undertakings were given by the Government, and there is a feeling that in sucking urology away from Canterbury, the proposal breaks the spirit, if not the letter, of that agreement. It certainly goes against the spirit of what the Secretary of State told my hon. Friend and me a short while ago.
Thirdly, it is immensely unsettling for staff. Many of the nurses who work in the hospital live in my constituency, and I have had many letters from them about the matter. Fourthly, there is the worry locally that sucking the service away will undermine the critical mass of the Kent and Canterbury hospital.
Finally, if one happens to live in Faversham or in the marshes beyond it, which have no public transport and are on a pretty dodgy road network, it is extremely difficult to get to Maidstone. Quite a lot of elderly and vulnerable people live in that area and, for them, getting to Canterbury is a reasonably viable proposition. Getting all the way over the top of the downs and turning right to go to Maidstone is extraordinarily difficult, and there is no direct public transport link from
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Faversham to Maidstone. For all those reasons, I entirely support my hon. Friend. I hope that the Minister will see fit to overturn the proposal.
4.43 pm
The Parliamentary Under-Secretary of State for Health (Caroline Flint) : I congratulate the hon. Member for Canterbury (Mr. Brazier) on securing today's debate, and I welcome the presence of the hon. Member for Faversham and Mid-Kent (Hugh Robertson), who clearly wishes to support his point of view. I acknowledge that they have come to the debate with concerns—whenever there is change in health service provision, people need to be reassured about the reasons for that change and the impact both on staff who provide services and on present and future patients.
I would like to take the opportunity to pay tribute to all the staff, in the area in question and beyond, who are committed to the improvement of local services. I shall talk about the peer review a little later, but it is difficult when there are hospitals that are—
4.44 pm
Sitting suspended for a Division in the House.
4.52 pm
On resuming—
Caroline Flint : I thank the hon. Member for Canterbury for warning me which issues concern him most.
I want first to say something about the significant progress made towards the objectives set out in the NHS cancer plan to reorganise, standardise and rejuvenate cancer services so that we can compare to the best in Europe. We are delivering better treatment more quickly to more people than ever before. Cancer mortality in the under-75s has fallen by over 12 per cent. in the past six years, which equates to around 33,000 lives saved. Some 99 per cent. of patients with suspected cancer are seen by a specialist within two weeks of being referred by their GP, and in the hon. Gentleman's area nearly all suspected cancer patients—99.9 per cent.—received an appointment within two weeks at the East Kent Hospitals NHS trust. I am sure that he agrees that cancer services must continue to modernise to improve the service to patients.
We need to establish in Government how clear national standards and securing unprecedented increases in resources can contribute to empowering local health communities to deliver high-quality cancer services for their population. One way that we are doing that is to ensure that the NHS has clear guidance, and the NHS cancer plan set out the intention to make available authoritative guidance on all aspects of cancer care. The guidance is aimed at helping those involved in planning, commissioning, organising and providing cancer services to ensure that those services are organised to ensure appropriately high-quality care.
In September 2002, the National Institute for Health and Clinical Excellence issued guidance on improving outcomes for urological cancers, which is being used as a framework for the NHS to ensure delivery of high-quality services for patients with those cancers. The
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guidance recognises that the diagnosis, treatment and care of a person with a urological cancer can be complex and is best provided by bringing together people with all the necessary skills, knowledge and experience. My understanding is that the patients requiring radical surgical management of bladder and prostate comprise less than 5 per cent. of the urology patients treated at the Kent and Canterbury hospitals.
There is, generally, an increasing demand for urology services. Therefore, it is highly likely that we will need at least to maintain the level of consultant cover, to ensure support both for all urological services and for the hospital in general. It is for that reason that the guidance recommends that all patients with urological cancer should be managed by multidisciplinary urological cancer teams. Another key recommendation, which was mentioned by the hon. Gentleman, is that radical surgery for prostate and bladder cancer should be provided by teams typically serving populations of 1 million or more and carrying out a cumulative total of at least 50 such operations per annum. I take on board the point that the hon. Gentleman made about there being 60 operations per annum at his hospital.
The NICE guidance is based on sound evidence, which is available on our website. It is supported by a wide range of key stakeholders, including the prostate cancer advisory group and signatories to the prostate cancer charter for action. It has been widely supported throughout the cancer network and community. The guidance is not about recommending change for change's sake but about considering how outcomes can be improved for future patients by centralising expertise in highly specialised fields. As I mentioned, there will be an increased need for other services in the area at local level.
As the hon. Gentleman is aware, responsibility for delivering cancer services rests with the 34 cancer networks that have been established throughout the country. In Kent and Medway, there is a local commitment to bringing specialist urological cancer services up to national standards. As he knows, specialist urological services are provided by East Kent Hospitals NHS trust, Maidstone and Tunbridge Wells NHS trust, Medway NHS trust and the Dartford and Gravesham NHS trust.
Following the publication of the NICE guidance in 2002, the Kent and Medway cancer network agreed to undertake an external review to test the feasibility of centralising specialist urological cancer services for more radical treatments at one or two sites. The review was chaired by Mr. Mark Fordham from the Royal Liverpool and Broadgreen Hospitals University NHS trust. He is one of Britain's leading authorities on urological cancers. The panel also included specialist urologists, oncologists, pathologists, radiologists, clinical nurse specialists and local service users.
I am aware that concerns have been raised locally about the review process. The hon. Gentleman has added his voice to those concerns. However, I am assured that the process was both thorough and objective and that the criteria used by panel members,
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and their relative weightings, were agreed by medical and surgical specialists from all local trusts providing that service.
Mr. Brazier : The Minister is right on that point. However, crucial to those criteria was the agreement that quality of service should be high. I set out for the Minister in detail why the quality of service in east Kent was, by any objective measure, very high indeed. It is higher than in west Kent or in other parts of England and America. The measure that the panel used on quality meant something different. It was considering theoretical criteria so, absurdly, the same organisation with a service rated as excellent was deemed to be poor in the review process. The service did not meet the theoretical criteria, although the performance has been excellent on all the objective measures that I listed.
Caroline Flint : In addition to what the hon. Gentleman just said, he mentioned that an internal peer review carried out by the Kent and Medway cancer network last year praised the team and the work being done at Kent and Canterbury hospital. However, the peer review commented only on the current provision of services and did not inform the Kent and Medway cancer network on the future strategic direction of specialist urological services.
That is why we return to the NICE guidance about planning cancer services for the future. That was why the network had to commission an external review to consider how services throughout Kent could be brought in line with national best practice guidelines.
I hear what the hon. Gentleman said. I know that he has been in discussion with various people from the strategic health authority and other organisations. Although there is no doubt that the work at Kent and Canterbury hospital is to be praised, it fell short when lined up against other centres in the determination of which hospitals and sites were best served to provide the complex package of surgical procedures. That was a process that Kent and Canterbury hospital understood and contributed to.
Mr. Brazier : I am grateful to the Minister for giving way, but what she just said is incorrect. Kent and Canterbury did not fall short of any other centre. No other centre anywhere has been shown to be superior, to the best of my knowledge, and certainly not the other centres in Kent. All that it was found to fall down on were theoretical tick-boxes of population sizes and other factors, which were in the NICE criteria. In the actual measures of performance, it out-performed not just the rest of Kent but other comparable places in this country and in America. It performed far above the national average on all the performance criteria, such as length of stay and the proportion of people who were still continent at the end of the process.
Caroline Flint : As I have said, I do not doubt issues of performance and quality of care, but the review took into account a range of factors, in order to identify the best way in the future to provide the best services within that part of the country. That is not to say that no other services will be needed in other parts of the Kent and Medway cancer network area. As I said, patients requiring the radical surgery that we are discussing
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comprise less than 5 per cent. of the number of urological patients treated at the Kent and Canterbury hospital. After considering a wide range of issues, including performance, it was felt after the review that that hospital would not be included in the future site.
I hear what the hon. Gentleman says about the criteria and the weighting of scores, although he obviously disputes that weighting process. However, that is the conclusion to which the team came. It recommended that Maidstone hospital and Medway Maritime hospital should be the chosen sites. That recommendation was subsequently endorsed by all nine primary care trusts at a meeting in May 2005. It is important to stress that the proposals developed by the cancer network are about how to provide the best possible specialist urological, bladder and prostate cancer services for the future. The proposals are not about the relocation of the entire urological cancer service or about urological services as a whole. Under the proposals, the urology unit at the Kent and Canterbury will still have a key role to play.
I appreciate the concerns raised by the hon. Gentleman about the distance that his constituents and other residents in east Kent will have to travel—that point was also made by the hon. Member for Faversham and Mid-Kent. The external review team gave that consideration, but it was also impressed by the views of both hospital staff and service users that patients would be prepared to travel for higher quality specialist care. The result will mean that patients will get better care because the change in provisions represents progress towards national standards.
As the hon. Gentleman will know, the next steps on the matter have been discussed locally by representatives of primary care trusts, the Kent and Medway cancer network and the local authority overview and scrutiny committees. It was agreed at a meeting on 29 June 2005 that some form of further consultation on the proposals would occur. The Kent and Medway cancer network has been considering how that further review should best be implemented, and I understand that the chair of Kent and Medway strategic health authority has spoken to the hon. Member for Canterbury in the last few days.
This week, following legal advice, it has been decided that the PCTs in Kent and Medway will not implement their decisions about future radical bladder and prostate cancer surgery pending the outcome of a further review of the impact of the decision on services at Kent and Canterbury hospital. The hon. Gentleman made a number of points about whether there would be a knock-on effect on other services, which may feel that their future could be jeopardised because of other services moving away to another centre. That change in
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services is solely about specialised urological cancer surgery, and the east Kent review will consider the impact of the change in the Kent and Canterbury hospital. I hope that that will be an opportunity for the hon. Gentleman and his hon. Friend the Member for Faversham and Mid-Kent, and others, to take part in the process.
The overview and scrutiny committee process is meant to play a part in the issues. In preparing for the debate, I asked some questions about how that had been done. The Kent county council overview and scrutiny committee was contacted before the review was carried out and before the process of the review was agreed to determine how it wanted to be involved and whether at that stage it thought that any consultation was necessary. I am advised that in response it asked only to be kept informed. It was given an opportunity to comment on the criteria, and I understand that no formal response was received. It was given an opportunity to shadow the external review, and I understand that it did not offer any names.
I bring those points to the debate because it is important to have confidence in the overview of such processes and the way in which such discussions are held. It is important that the overview and scrutiny process works well and involves local stakeholders.
I have taken into consideration the remarks made by the hon. Gentleman, and also his concern. I urge him, the hon. Member for Faversham and Mid-Kent and their constituents to take part in the further review that the east Kent PCTs will undertake. The details will be announced locally, and I hope that all views will be heard. The PCTs throughout Kent and Medway will, I hope, be reassured that their final decision will deliver the best services.
Mr. Brazier : I welcome the Minister's remarks. Will she clarify who is leading the review? Is it the East Kent Coastal primary care trust or all the primary care trusts?
Caroline Flint : I understand that the East Kent Coastal PCT will lead. I hope that ultimately everyone concerned will be reassured that we will have 21st-century cancer services that are fit for purpose and, most importantly, fit for the needs of local communities.
Hugh Bayley (in the Chair): It is always confusing to Members when the debate is interrupted. I should like to thank hon. Members on both sides of the House for co-operating and getting back to the Chamber quickly.
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