Download Partnership working

Proposals for future partnership working for Urology
services at United Lincolnshire Hospitals NHS Trust
March 2015
Introduction
This proposal summarises the current Urology configuration at United Lincolnshire
Hospitals NHS Trust (ULHT) and the requirement for formalised partnership working.
It is anticipated that the partnership will commence during 2015 and may include one
or more organisations which will be agreed through formal provider-to-provider
dialogue.
The department of Urology at the ULHT delivers secondary care urological services
to the people of Lincolnshire. Formed by the merger of the departments of urology at
the Pilgrim Hospital and Lincoln Hospital in 2006, the eight consultant department
provides general elective and emergency urology and specialist services for
urological cancer, endourology, continence and andrology. The management of
urology cancer has provided a particular focus for the department, with Lincolnshire
experiencing incidences of prostate, kidney and testicular cancers that are
significantly higher than the national average (NCIN 2014). The department has
historically undertaken high volumes of surgical treatments of urological cancer by
comparison with regional peers (fig 1).
The Trust currently has contractual relationships, in relation to Urology activity, with
both Lincolnshire Clinical Commissioning Groups (four in total; coordinated by
Lincolnshire West Clinical Commissioning Group) and Specialised Commissioning
(held with NHS England and negotiated by the Leicestershire and Lincolnshire Local
Area Team). For the avoidance of doubt, any provision provided under this
partnership will need to deliver the core key standards commissioned by these
bodies including (but not exhaustive):

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Core constitutional standards including the three Referral to Treatment access
standards and cancer delivery standards;
National service specifications relating to Urology activity falling under the
Specialised Commissioning umbrella.
It will therefore be expected that any partnership organisation(s) will have a proven
track record of delivering against core constitutional standards.
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Fig 1.
Major urological cancer surgery by site 2007-11 (Dr Foster)
For prostate cancer, the East Midlands Prostate Cancer Project demonstrated
continued high levels of prostate cancer treatment in ULHT in 2012 (fig 2) and 1 and
5 year survival data among the best in the region (fig 3).
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Fig 2.
Prostate cancer treatments by Trust 2012
Fig 3.
Prostate cancer survival by diagnosing Trust
The department strives to manage urological cancer in line with best current practice
and offers prostate HDR and seed brachytherapy, conformal EBRT, multiparametric
MRI and prostatic template biopsies. However, it recognises that it cannot currently
offer laparoscopic or robotic pelvic surgery nor is the volume of radical cystectomy
now sufficient to maintain expertise. Consequently, it is seeking to develop a
partnership agreement with another Trust to allow a high quality, secure urological
cancer service to continue for the population of Lincolnshire.
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Sites and services
The Urology service provides a range of general and specialist urological services
across the sites of the Trust. The focus of inpatient and emergency services is at the
Lincoln County and Pilgrim Hospital sites, with daycase and short stay surgery
offered additionally at the Grantham and Louth Hospitals. Outpatient activity is
supplemented by clinics in peripheral hospitals across the county.
Lincoln County Hospital provides outpatient, diagnostic, day case and inpatient
urological services. Inpatient activity centres on Clayton ward, supporting elective
activity including radical cystectomy, radical prostatectomy, radical nephrectomy,
PCNL, upper tract endourology (including holmium laser stone surgery) and short
stay endoscopic and general core urology. Urological day surgery is supported by
the surgical day unit, which itself is co-located with the urological investigation suite,
delivering flexible cystoscopy, transrectal ultrasounds, urodynamics and specialist
continence and andrology services. Emergency care is focused on the Surgical
Emergency Assessment Unit (SEAU). There are close working relationships with the
Intensive Care Unit/High Dependency Unit and the department of Oncology, with
urology consultants providing HDR and seed brachytherapy within the oncology
department and the oncologists providing external beam radiotherapy on site.
The Pilgrim Hospital, Boston, provides outpatient, diagnostic, day case and inpatient
urological services. Inpatient activity is focused on the Bostonian Unit, supporting
specialist continence and endourological surgery, including holmium laser upper
tract surgery and PCNL, together with short stay endoscopic and general core
urology. In addition, the department has recently developed a template biopsy
service for prostate cancer diagnosis. Urological day surgery is delivered through the
Day Surgical Unit which also supports intravesical treatments and lithotripsy through
a mobile service. The urology departmental area delivers diagnostic activity including
both conventional and non-invasive urodynamics and continence assessments
together with transrectal ultrasounds; flexible cystoscopy is undertaken in the
endoscopy unit. Emergency care is focused on the Clinical Decisions Unit.
Grantham Hospital Urology is supported by two visiting consultants and one
specialty doctor. The department offers outpatient and diagnostic activity together
with daycase/overnight core urological surgery.
Louth Hospital Urology is supported by one visiting consultant and one specialty
doctor. The department offers outpatient and diagnostic activity together with
daycase/overnight core urological surgery and lithotripsy from a visiting mobile unit.
Outpatient clinics are also supported by the urological consultants visiting
Gainsborough, Skegness, Spalding and Holbeach hospitals.
Emergency care is delivered on the Lincoln and Boston sites between Monday and
Thursday, with a single receiving site operating Friday to Sunday, alternating
between Boston and Lincoln.
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The activity profile across the sites for 2013/14 is shown below
Lincoln
Boston
Grantham
Louth
Gainsborough
Holbeach
Spalding
Sleaford
Skegness
Daycase
Elective
Emergency
OP First
FCE
FCE
FCE
attendance
1152
886
1393
1450
569
556
272
122
11
482
86
2
OP Follow on
attendance
3774
2398
1153
1598
207
89
175
62
225
Staffing profile (Jan 2015)
The department is staffed by eight substantive consultants, as follows
Mr Nazeer Dahar
Clinical Director
Mr Haradikar Varadaraj Head of Service
Mr Shaukat Memon
Head of Service
Mr Pallon Daruwala
MDT lead
Mr Ian Mark
Mr Kattedath Madhavan
Mr Andrew Simpson
Mr Anser Yousuff
Lincoln/Boston
Lincoln
Boston
Lincoln
Lincoln
Boston
Lincoln
Boston
Oncology
Oncology
General/Continence
General/Oncology
Oncology
General/Stones
General/Stones
General
The consultants are supported by middle grade staff as follows:
Mr S Murali
Mr I Donkov
Mr K Bonev
Mr I Chukov
Mr O Muoka
Mr A Sanjrani
Mr S Nissar
Mr R Radcliffe
Associate Specialist
Associate Specialist
Specialty Doctor
Specialty Doctor
Specialty Doctor
Specialty Doctor
Specialty Doctor
Specialist Trainee
Lincoln
Lincoln
Lincoln
Louth
Grantham
Boston
Boston
Lincoln
There is a specialist nursing team comprising a trainee nurse consultant, two Band 7
clinical nurse specialists, two band 6 clinical nurse specialists and 2 continence
nurse specialist on the Lincoln and Boston sites. Additionally, there are three acute
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7202
4060
2153
2717
350
152
399
28
331
care practitioners based on the SEAU at Lincoln who work with the medical team in
the diagnosis and treatment of acute surgical and urological emergencies.
The department actively supports postgraduate and undergraduate education, with
foundation year 1 and 2 doctors rotating through urology. We also support medical
students from Leicester, Nottingham and Lincoln.
Furthermore, the service is has access to a full range of clinical and non-clinical
support services including (but not exhaustive) diagnostics, pathology and therapies.
It is anticipated that any partnership organisation(s) will utilise these existing
services. In the unlikely event that the partnership organisation(s) use their own
diagnostic and/or pathology services, it should be agreed with ULHT and both
parties must ensure the safe transfer of all appropriate images and results.
MDT working
2ww cancer referrals and diagnostic work up, including one stop assessment clinics,
takes place across all 4 main sites under the direction of the urology MDT. This
functions as an enhanced local MDT, with the following procedures undertaken on
the Lincoln site:
Radical Nephrectomy
Radical Prostatectomy
Radical Cystectomy
Management of high risk superficial bladder cancer
Prostate Brachytherapy
External beam radiotherapy is also undertaken on the Lincoln site.
The volume of major cases by consultant (2013-14) is given below
Procedure
Radical
Prostatectomy
Radical Cystectomy
Radical Nephrectomy
Mr
Mark
Mr
Dahar
23
0
15
Mr
Daruwala
24
4
7
0
0
11
Mr
Varadaraj
0
6
12
Total
47
10
45
Patients within the following groups are referred to tertiary centres (typically
Leicester or Nottingham)
Nephron sparing surgery
Renal tumours invading the IVC / heart
Bladder reconstruction
Penile cancer surgery
RPLND for testicular tumours
Robotic surgery
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The MDT meeting is video conferenced between Lincoln and Boston with urologists,
pathologists, oncologists, radiologists and specialist nurses in attendance. The case
volume is large, with typically 30 cases from the Boston site and 50 from the Lincoln
site each week.
The cancer performance targets achieved in August 2014 showed 84.2% of cases
achieved the 62 day target and 89.7% achieved the 31 day target. However, the
MDT does not have the resources or surgical expertise at present to deliver robotic
surgery or laparoscopic pelvic surgery. In addition, the volume of cystectomies
undertaken was raised as an immediate concern by internal peer review as
insufficient to maintain expertise. In view of this the department is now seeking to
develop a formal working relationship with a partner organisation to facilitate the
delivery of major surgical cancer treatments for the people of Lincolnshire.
The benefits of such an arrangement could include the following:

Access to a full range of cancer treatment including minimally invasive and
robotic techniques

Integrated care pathways across the partner organisations including locally
based diagnostics, with major interventions coordinated through a single
specialised MDT.


Local MDT overseeing MDT clinics and local non-complex treatments.
Joint approach to audit and professional development across the partner
organisations.
Utilisation of capacity across the sites of the partnership, with a balanced flow
of patients.
Development of a virtual single workforce, with flexibility and resilience
including appointments spanning the two partner organisations.


Envisaged MDT configuration
Patients referred through the 2ww system with suspected urological cancers would
undergo initial assessment and diagnosis locally within Lincolnshire, as currently.
All patients newly diagnosed with urological cancer will be discussed at the
Lincolnshire MDT. Specific diagnosis groups would be selected for further discussion
at the specialist MDT with the partner organisation. This would include:


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

Renal cancer with renal vein, IVC or heart invasion.
Bilateral renal tumours
Patients with von Hippel-Lindau disease
Predicted need for renal replacement therapy after treatment
pT1a/b renal tumours suitable for nephron sparing surgery
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
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




Muscle invasive bladder cancers and persistent high risk superficial cancers
after BCG therapy
Urethral cancers
Squamous cell carcinoma and adenocarcinoma of bladder (including
adenocarcinoma of the dome of the bladder suitable for partial cystectomy)
Patients suitable for radical prostatectomy
Patients with penile cancer
Patients with testis cancer considered for RPLND
Complex patients requiring specialist opinions
After specialist MDT discussion some patients from Lincolnshire may need to
undergo surgical intervention at the partner hospital. These may include patients in
the following groups:

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
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
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Renal cancer with renal vein/IVC/heart invasion
Surgery for metastatic renal cancer
Nephron sparing surgery
Surgery where the need for dialysis is predicted
Radical cystectomy (with or without bladder reconstruction)
Resection of urethral cancer
Radical prostatectomy requiring laparoscopic or robotic approach
RPNLD for testicular cancer
Surgery for penile cancer
Patients requiring robotic surgery for other conditions
The likely annual volume of cases travelling out of Lincolnshire (including those
already being referred outside at present) would be as follows:
Treatment group
Volume
Cystectomy +/- reconstruction
15
Minimally invasive prostatectomy
40
Complex Nephrectomy
20
Penile and testicular surgery
20
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Patients with the following conditions may continue to receive treatment at Lincoln,
after agreement with the specialist MDT

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Radical nephrectomy
Resection of upper tract urothelial tumours
Open radical prostatectomy
Radical external beam radiotherapy
Prostatic brachytherapy
Radical orchidectomy
Chemotherapy
ULHT would be willing to offer services to patients from the catchment area of their
partner organisation to maximise utilisation of capacity across the partnership. The
clear expectation would be for there to be a two way flow of patients across the
partnership sites. Examples of patient groups from across the partnership who might
have treatment in Lincolnshire would include:



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Prostatic brachytherapy
Open radical nephrectomy
Core urological treatments including TURBT
Non-cancer specialist treatments including upper tract endourology and
PCNL, anti-incontinence surgery, non-invasive urodynamics
The existing range of outpatient, diagnostic and core therapeutic activity for core
urological cancer, and for specialist and core non-cancer urological conditions would
continue to operate across ULHT sites. Some theatre and consultant capacity would
be freed up on the Lincoln site by migration of the major cancer cases detailed
above which could either be employed for increased non cancer activity for patients
across the partnership or utilised as a cost saving.
Partnership working
It is envisaged that common assessment, treatment and follow up pathways would
be utilised by the partner organisations, leading to a common approach to the
management of urological conditions. The increased volume of cases handled by the
partnership would facilitate audit and entry into clinical trials and would be supported
by a common clinical governance structure.
There would be opportunities for individuals to network across the partnership,
promoting training and CPD; and there would also be more formalised, job planned
arrangements, to allow members of partner organisations to undertake clinical
activities on other partnership sites. This would include uro-oncology outpatient
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support to the Lincolnshire sites by the partner specialist MDT consultants and
clinical/operative sessions at the partner site by Lincolnshire consultants.
In time, this could result in joint appointments reflecting the developing needs of the
service, providing a responsive and resilient workforce which could become
integrated into a virtual single workforce. In response to changes in approach to the
delivery of surgical care, for example in the wider adoption of robotic and minimally
invasive techniques, we would expect the partnership to support the development of
robotic capacity within ULHT for a range of urological and non-urological conditions
in the medium to long term, with new appointments reflecting the skills needed to
support this on ULHT sites.
ULHT is now seeking to enter into a dialogue with interested parties to develop a
formal partnership arrangement for the delivery of urology services based on the
structure outlined above.
It is anticipated that the partnership will commence in 2015 and will be subject to an
annual review. It is anticipated that the partnership will operate for 3 years in the first
instance.
Proposal Review Schedule
10th March – 31st March: Advertisement for expressions of interest
w/c 13th April: Initial meetings with interested parties
w/c 27th April: Additional meetings with interested parties (subsequent meetings to
be held if required)
TBC – ITT issued for final written proposals to potential partners
+3weeks – Submission of final proposals to ULHT
+2 weeks – Trust Evaluation and award notification
+2 weeks - Award of contract (commencement date and form to be agreed)
Evaluation criteria
Bidders will be required to demonstrate the following:
1. Established Urology MDT managing full range of urological cancers which
should include
 Renal cancer with renal vein/IVC/heart invasion
 Surgery for metastatic renal cancer
 Nephron sparing surgery
 Surgery where the need for dialysis is predicted
 Radical cystectomy (with or without bladder reconstruction)
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



Resection of urethral cancer
Radical prostatectomy requiring laparoscopic or robotic approach
RPNLD for testicular cancer
Surgery for penile cancer
2. Experience in delivering minimally invasive surgery for management of
urological cancers including laparoscopy and robotics.
3. Audited outcome data demonstrating practice in line with network and national
practice.
4. Willingness to enter into partnership with ULHT urology offering equitability in
access to treatment for patients across the partnership.
5. Willingness to adopt common pathways for cancer management across the
partnership
6. Willingness to protect diagnostic urology, core urology and non cancer
specialist urology activity on ULHT sites.
7. Commitment to two way flow of patients within the partnership, with an inflow
into ULHT for the following patient groups:
 Prostatic brachytherapy
 Open radical nephrectomy
 Core urological treatments including TURBT
 Non-cancer specialist treatments including upper tract endourology and
PCNL, anti-incontinence surgery, non-invasive urodynamics
8. Commitment to joint working, with partnership clinicians undertaking sessions
on sister sites, and in time joint appointments to develop a single virtual
workforce.
9. Commitment to service development on ULHT sites in line with national
standards of care, including development of robotic capacity in the medium to
long term.
10. Proven track record of meeting core constitutional standards. To include any
formal contract or performance notice, raised under the NHS Contract, and
the status of any subsequent remedial action planning.
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11. An understanding of any formal / informal / ad hoc sub-contracting
relationships that will impact on the delivery of the aforementioned activity.
12. An understanding of the support services required (i.e. diagnostics, pathology
etc). Key criteria and access standards and availability of results/scans.
Please note; the Trust is keen to ensure that all routine diagnostics take place
within the Trust. In the unlikely event that these types of tests are undertaken
by the partnership organisation(s)’s own teams, the partnership
organisation(s) will ensure that there are appropriate technology and
governance structures in place to ensure the safe transfer of results/images
etc
13. An agreement to the cost/tariff structure under which the partnership
agreement will operate.
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