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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): 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. 1 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). 2 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. 3 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. 4 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 5 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 6 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: 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 7 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: 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 8 Patients with the following conditions may continue to receive treatment at Lincoln, after agreement with the specialist MDT 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: 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 9 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) 10 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. 11 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. 12