The Democratic Services Officer advised the panel that a number of senior NHS representatives were in attendance at todays meeting to provide a presentation on Breast Services for patients in south tees. The panel was reminded that in October 2015 South Tees Hospitals NHS Foundation Trust had announced temporary changes to the Breast Radiology Services at James Cook University Hospital (JCUH). In January 2017 the Service Manager for the Planned Care Centre, Service Manager for Clinical and Diagnostic Support Services and the Clinical Director of Urology had attended a meeting of the Health Scrutiny Panel to provide the panel with an update.
At that meeting Members had been advised that the Breast Radiology Unit at JCUH had been out of use for approximately 18 months. There had been difficulties in recruiting Radiologists and patients had had to travel to University Hospital North Tees (UHNT) for diagnosis. Treatment was still being delivered at JCUH, however, at that time there was a recognised need to reopen the unit. The panel was advised that the unit was scheduled to reopen on 1 July 2017. It was also advised that a representative would attend the April meeting of the panel to confirm that the plans remained on track. Unfortunately owing to the Purdah period it was later advised that it was not possible for the Trust to provide an update during the election period.
In light of the above the Chair had requested that an invitation be extended to representatives from South Tees NHS Foundation Trust and South Tees Clinical Commissioning Group (STCCG) to attend the panels September meeting to provide an update on this topic. The Chair had been aware in the interim period that the unit would no longer be opening on 1 July 2017, as previously advised.
Representatives from STCCG, South Tees Hospitals NHS Foundation Trust and North Tees and Hartlepool NHS Foundation Trust were in attendance at the meeting and introduced their joint presentation.
In terms of background information the panel was advised that there had been:-
A lack of consultant radiologists for Breast Services at South Tees Foundation Trust (2015)
A failure of mammography equipment at the James Cook University site
Symptomatic breast services were fragile - main challenge was the imaging side of the service (as imaging techniques involved taking specimens)
Collaborative approach to a Teeswide Breast Service
Symptomatic breast multi-disciplinary team (MDT) merged with North Tees
Cancer Alliance initiated a Breast Service Review (2016)
The Clinical Lead for the Northern Cancer Alliance was in attendance and advised Members that Cancer Alliance had been commissioned (in 2016) to undertake a Regional Breast Cancer Service Review for North East and Cumbria in response to a number of key concerns, namely:-
The multi-disciplinary workforce was aging, especially diagnostic services
Screening services were more able to recruit
At least one symptomatic service was currently fragile
Was the current service model the best for patient outcomes?
A regional solution was required and it was advised that currently there were a total of 6 providers of symptomatic services across the North East and Cumbria. Sunderlands diagnostic services were now managed by Gateshead. In considering possible solutions four options were considered and these included:-
Model 1 - Continue with the status quo
Model 2 - Support services which are currently struggling
Model 3 - Breast Screening Unit Hub (centralisation)
Model 4 - Hub and Spoke
The review concluded that Model 1 was likely to lead to further service suspensions with need for crisis management. Model 2 was too informal for sustainability. Model 3 maybe necessary in the short term as an interim sustainable route to Model 4 for some services due to workforce challenges. Model 4 was the most patient centred (preferred model) but challenging to achieve universally in the near future with existing diagnostic workforce.
The Commissioning Manager for STCCG advised that in respect of the commissioning model for south tees patients Model 4 had been approved by STCCG and Hartlepool and Stockton (HaST) CCG Executive as the preferred model. Model 3 had also been approved by STCCG and HaST CCG Executives as the interim model.
In terms of current service provision by North Tees NHS Foundation Trust it was explained that screening services were provided for the whole of Teesside and parts of Durham and North Yorkshire (55,000 patients per year). Symptomatic services were provided for Stockton, Hartlepool, South Durham, Redcar and Cleveland and Middlesbrough (7,000) per year and the diagnostic symptomatic service was provided as a Teeswide service from North Tees and Hartlepool sites.
The panel was informed that all diagnostic tests were undertaken by North Tees and Hartlepool NHS Foundation Trust and the panel queried how a south tees patients experience differed from before. It was explained that previously the patient would have gone to JCUH for the initial diagnostic appointment. However, patients were now sent to UHNT for a triple assessment, which included clinical examination and patient history, imaging and pathology. It was emphasised that the service women were receiving at North Tees was very good and all tests were completed on the same day. If the results were negative it was the end of the patients journey.
If the results were positive the patient would be discussed at the joint Multi-Disciplinary Team (MDT) meeting for decision on a treatment plan. The MDT included staff from North and South Tees. Once MDT had agreed a plan the patient would meet with the clinical nurse and specialist consultant to talk through the treatment plan (South Tees). Treatment would then commence (surgery, chemotherapy, radiotherapy at South Tees NHS Foundation Trust.) Once treatment finished the patient would be passed to the 5 year surveillance programme. Currently this was undertaken at North NHS Tees Foundation Trust and the Friarage.
In response to a query from the panel it was confirmed that the vast majority of south tees patients received their treatment from the South Tees NHS Foundation Trust. The patients postcode was considered when allocating a clinic appointment.
Reference was made by Members to the importance of early intervention and the fact that putting in barriers only prevented people from accessing services. The point was made that they were a number of deprived areas in Middlesbrough and travelling to UHNT by bus took an awful long time. The panel requested that the 'did not attend' (DNA) figures by postcode for breast diagnostic screening appointments at UHNT be provided for Middlesbrough residents.
The Head of Radiology and Breast Services and the Breast Imaging Service Manager were in attendance and updated the panel on patient feedback to date in respect of Model 3. It was advised that a questionnaire had been developed to understand the experience of patients, who had attended the symptomatic breast clinics at UHNT and University Hospital Hartlepool (UHH). A total of 350 surveys had been distributed to patients from the Breast Units at both hospitals during August 2017. A total of 124 surveys had been completed, a response rate of 35%. The results highlighted that the majority of patients travelled between 10 and 20 miles to attend their diagnostic appointment. 55 per cent were happy to travel to the specialist breast clinic, 32 per cent were happy to some extent and 9 per cent were not happy, with 3 per cent providing no response. It was initially advised that the surveys had been completed in clinic. However, during the course of the meeting it was confirmed that the survey had been undertaken as a postal survey.
In terms of the current and future constraints it was that advised that the key issues were as follows:-
national shortage of radiologists
age profile of current radiologists
recruitment difficulties due to geographical area
alternative workforce implemented however, 5 year training and still required consultant radiologist mentorship
Interdependencies for supporting other aspects of the service
The panel made reference to the information provided at its meeting in January 2017 and the assertion at that point that work would be undertaken to upskill Radiographers, with a view to effectively 'growing our own' Consultant Practitioners in the region. It was explained that work had been undertaken in partnership with Leeds and Nottingham University, as well as the School of Radiology to assist with this work.
With regard to the current workforce position it was explained that there were currently 6 Breast Radiologists employed in the Teeswide service. However, 4 had retired and returned to work on a part time basis and their hours made up the equivalent of 1 whole time Consultant. The remaining two Consultants also undertook other general radiology duties to maintain their skills and made up 0.75 of a Consultant post. In total there were 1.75 whole time equivalent Radiology Consultants to run the Breast Service across Tees.
In terms of workforce planning for the future a Consultant Radiologist (breast/general) had recently been appointed (September 2017). A Clinical Fellow (breast/general) had been appointed with the possibility of consolidating knowledge for a possible Consultant post in 2018. The skill mix of Radiologists v Consultant Practitioners had been maximised (lowest per cent of Radiologists in the North East & Cumbria region). Radiologists were required for expertise, mentoring and supervision, cross sectional reporting and MDT leadership.
A Consultant Practitioner had been appointed in September 2016 and was currently undergoing a preceptorship (a period of supervision). An additional Trainee Consultant Practitioner also commenced the 2 year training programme in October 2017. A well-established training programme for Radiographers to ensure succession planning in advanced clinical practice was also in place. Close links had been established with Leeds and Nottingham Universities where mammography training was provided. The School of Radiology, which provided sub specialist training in Breast Radiology provided training for the Trusts Radiographers. However, the point was made that nationally there were only a handful of Consultant Radiologists qualifying each year. All hospitals were competing to attract the same individuals.
The Commissioning Manager for Early Intervention and Prevention at STCCG advised that the aspiration was still to work towards Model 4, which was the Hub and Spoke model. Work was continuing in collaboration with partners to ensure patients received the best service while planning for Model 4. Estate plans were being progressed to provide a spoke model at South Tees NHS Foundation Trust in the future. However, at present workforce recruitment and retention remained the key priority for partners and patients.
The panel queried the amount of time it would potentially take to achieve the ambition of delivering a spoke unit at JCUH. The Director of Programmes and Primary Care Development at STCCG advised that it was not possible to answer that question at present, as ultimately it depended on the workforce.
The Chair stated that the information provided to the panel in January 2017 was incorrect. The changes to breast diagnostic services in South Tees were effectively permanent and had this originally been proposed as a long term arrangement, it would have required a statutory consultation. The panel was dissatisfied that the promises made to it had not been fulfilled and 2 to 3 years on the same issues were still not resolved. The response had been unsatisfactory from the panels perspective. Access to services remained a key issue and given the levels of deprivation in the town the panel was concerned about the travel issue. Figures on the number of symptomatic patients from South Tees who delayed accessing their diagnostic appointment at UHNT and UHH were requested. It was highlighted that the patient survey had shown that 41 per cent of patients had given an answer other than yes definitely to the question are you happy to travel to this specialist breast clinic?
A suggestion was put forward that a brave decision be taken on a date to work towards delivering a spoke at JCUH given that it was known what was needed to achieve this ambition. The Director of Programmes and Primary Care Development at STCCG advised that North Tees and Hartlepool NHS Foundation Trust was continuously recruiting and it was not possible to put a date on delivering this service. The panel was informed that the national Director of Cancer Strategy advised that having the correct medical workforce in place was a key issue nationally. In response to the question as to when south tees patients could expect to receive breast cancer diagnostic services in the south of the region it was advised that at this stage this was simply unknown. No single organisation controlled all the variables and with the main medical schools located in Leeds and Newcastle, once people graduated they tended to stay in the big cities.
In terms of regional employment the question was posed as to whether it would be possible to have a 'moveable hub' with diagnostic services being delivered in the south of the region. North Tees and Hartlepool NHS Foundation Trust advised that unfortunately there were constraints in that the Consultant Radiologists were required to undertake theatre work and therefore it was not simply a case of arranging for them to hold a clinic in the south of the region. In terms of treatment, however, patients were still able to receive their treatment at JCUH and the majority of south tees residents underwent treatment at JCUH. In terms of how much money was following south tees patients to North Tees for the diagnostic assessment it was advised that the annual figure was in the region of £300,000.
The message was reiterated that the challenges faced in relation to delivering a Hub and Spoke model were not financial. Numerous collaborate financial agreements were in place between North Tees and Hartlepool NHS Foundation Trust and South Tees Hospitals NHS Foundation Trust. However, the crux of the issue was about ensuring the best possible service for the patient. The panel was advised that the reality of working in the NHS at present was that staff had to be creative in terms of finding solutions. An extension of staff roles where possible were used and many areas had had to reconfigure services in response to staff shortages. It was emphasised that the 2 week wait from GP to assessment continued to be monitored and that the clock was not stopped for cancer.
In respect of extending the screening service to include younger women it was advised that women across Teesside were already screened from the age of 47, and had been for a number of years. There had been an increase in the aging population resulting in an increase in demand for screening services, however, the figures for symptomatic screening were not affected. In terms of take up for screening services the panel was informed that the worst take-up rates across Teesside were for Bowel Screening, where figures were on a par with Tower Hamlets in London.
The question was posed by the panel as to why the NHS was making it harder to access services when it needed to making it easier. STCCG advised that its concerns were no less than those expressed by the panel and that it was a continuous process for STCCG to work towards the delivery of a Hub and Spoke model.
The Chair of the panel expressed the view that given the information presented at todays meeting the panel would formulate a report for the Councils Executive. The report would highlight the information presented at todays meeting on the recent developments in relation to Breast Radiology Services for patients in the south tees. The report would also flag up the panels concerns and reference its disappointment at the fact that breast cancer diagnostic assessments were unable to be carried out in the south of the region. Patients therefore had to travel to UHNT for initial assessment. The panels report would seek to translate the panels concerns into a wish list of what it wanted to see achieved in the future.
AGREED as follows:-
That a draft final report on Breast Radiology Services for patients in South Tees be prepared on behalf of the panel.
That regular quarterly updates be provided to the panel to ensure that the aspiration to deliver Model 4 - a Hub and Spoke model was achieved at the earliest opportunity.
That information on the 'did not attend' (DNA) figures for symptomatic patients in the South Tees be provided to the panel by STCCG.