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Urology Services (East Kent)

Part of the debate – in Westminster Hall at 4:28 pm on 20th July 2005.

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Photo of Julian Brazier Julian Brazier Shadow Minister (Transport) 4:28 pm, 20th July 2005

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 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 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 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.