Published on: 20 May 2019

Neeraj_Bhasin.jpgHello, my name is Neeraj

I feel both fortunate and privileged to be a Consultant Vascular Surgeon and Associate Medical Director in my home town of Huddersfield. More recently I was appointed as Regional Clinical Director for Vascular Services across West Yorkshire through West Yorkshire Association of Acute Trusts (WYAAT). A post I’m very proud to do.

In 2018 the WYAAT hospital trusts agreed that it would be best for people needing vascular care if all vascular services in West Yorkshire (except Harrogate, who work with York Teaching Hospitals NHS Foundation Trust to provide vascular services for people in their area) were brought together into a ‘single regional service’ under one management team. 

This will create one of the largest vascular services in England covering a population of over 2 million and with almost 40 specialist vascular consultants (surgeons and interventional radiologists).

When applying for the role of Regional Clinical Director for Vascular Services I knew this would lead to me reducing my commitment as Associate Medical Director at Calderdale and Huddersfield Hospitals, although I could continue in my clinical role. Although I will miss the fantastic colleagues I worked with in the AMS capacity on a day to day basis, I’m very excited to be part of this new service, which I felt a personal responsibility to be involved with, and know will lead to better health outcomes for people. This is after all what it is all about.

I must admit it’s been a wrench. However, I very quickly realised that the best way to create positive change is to get involved, be a part of it, and immerse myself in it – and hopefully above all make a real positive difference to people’s health and their lives.

In 2014 NHS England commissioned a stocktake of vascular services, surgery and interventional radiology across Yorkshire and Humber. Following this a Clinical Senate review recommended only two arterial centres for West Yorkshire. This was for a number of reasons –including workforce pressures and the sharing of expertise.

It was recommended that Leeds, who are already a hub and spoke model with Mid-Yorkshire Hospitals Trust, would remain as one centre due to being a specialist and major trauma centre.

This meant that either Calderdale or Bradford would become the remaining centre. The recommendation was made for a number of reasons, including the population the centres would support and procedures per centre.

[At this point it’s important I say that a number of service reconfiguration are based on improving outcomes. I’m extremely proud that the health outcomes for people following vascular procedures across all West Yorkshire centres are very good. You can read more here.]

An options appraisal was undertaken with a number of clinical and non-clinical teams across WYAAT, and on the sole discriminating factor of an in-patient renal unit at Bradford, the WYAAT Committee in Common (where recommendations are considered) made a recommendation to NHS England that Bradford should be the second arterial site. The arterial centres will provide all elective arterial and acute work as well as high risk Interventional Radiology (IR). Day case (minor surgery), diagnostics and outpatient clinics will remain at the local hospitals. We are currently engaging with the West Yorkshire Joint Health Overview and Scrutiny Committee and due to enter a period of NHS England public consultation.

This presents a huge opportunity, not just to staple together the five units and bring together the existing care pathways, but the chance to think about things completely differently. A rare chance to create a new exciting, responsive, excellent service that has the ability to evolve and be sustainable for the future.

I absolutely believe the best way to deliver this is by creating the West Yorkshire Vascular Service (WYVaS) - a truly collaborative, regional single service moving away from the traditional network models some may be more familiar with. The regional single service way of working will deliver numerous benefits for the people receiving care, staff, and the wider healthcare system. More later.

Clare_Vickers_Jane_Lang.jpgClare Vickers will join me as Head of Nursing alongside Jane Lang as General Manager. I’m really excited to have them work with me on this new single service. Between them they bring a great deal of expertise and experience which we know will lead to better health outcomes for people. I also believe creating this transformation to a regional single service model is a trailblazer for West Yorkshire and Harrogate Health and Care Partnership. It has been referenced in the Getting It Right First Time: Getting It Right in Leadership national publication. No pressure then!

Albeit the challenge will be significant, I feel the vision and benefits of regional single service working are far greater. The person at the centre of our care is out utmost priority and focus – yet our staff are very important too.

Like many services that come together, the challenge will be embedding a culture we all share and one we can develop and share.

As mentioned earlier, our health outcomes are good across the region (this won’t change), however, we do now have workforce pressure, mainly in interventional radiology where there are anecdotally over 200 vacancies nationally.

The transformation needs to proceed at a good pace. I’ve been asked to ensure we note and share learning through this process. I know most change processes take time, however, I don’t mind admitting that with the process starting in 2014 the pace had created a lingering, frustrating within me and some uncertainty within the clinical team which has affected morale, including my own, and hangs over dedicated people doing an outstanding job within a pressured environment. It has caused experienced, valued colleagues to leave.

We therefore have to acknowledge this – I would be doing my colleagues an injustice if I didn’t. I do fully recognise that due process and protocol must be followed but the pace must be a consideration for any similar future work. 

Starting from the above point, my initial focus will be on addressing the challenge, questions and resistance that may well come from the obvious hesitation and anxiety in my medical, nursing, and therapy colleagues. ‘How will this affect me’ is an understandable question and communication is key. We have an absolute duty of care not only for those receiving treatment, but also for the wellbeing of colleagues.

We have to address these challenges with complete visibility, openness, courage, honesty and direct genuine, authentic communication. I desperately want the transformation to take the path of ‘hearts and minds’ rather than a ‘burning platform’, and desperately want the transformation to be created, moulded and invested in by the staff, patients, their families and carers, who will live the single regional service model on a daily basis.

We’d also like to create a new WYVaS brand. A visual identity, to express this is not a shuffling of the existing pack but a brand new separate entity that will be collaboratively developed to inspire people, allow them to think differently, and personally invest in its development. At this very early stage we are already pressing small, but significant points, with the language around our vision. We do not have ‘hubs and spokes’, we are not creating a network – it is a single service.

So what are the benefits of transforming to a regional single service model – why am I and others so convinced?

For people receiving treatment it will improve ease and equity of access to vascular services as well as continuity of care. Although our outcomes are very good, there are pockets of knowledge, expertise, and technical developments held in different unit across the region. We need to embrace the ‘best’ practice and share the skills and break down any organisational boundaries.

A single service would allow development of regional wide sub-specialist teams to ensure everyone receives the same care and treatment no matter where they live.

The Getting Right First Time National Vascular Report suggests all who need it should have access to endovascular (stent) repair for ruptured abdominal aortic aneurysms (leaking blood from an abnormal enlargement of the main blood vessel in the body). We need to ensure that we have the skills in all sites to deliver recommendation such as this in all arterial centres.

This regional model of working can reduce clinical variation and standardise care, not just by all adhering to an existing pathway from one site but giving the opportunity to introduce a novel pathway, possibly utilising all the positive facets from current practice, but also by introducing different ways of working such as virtual clinics.

It is true that for certain procedures, patients and visiting relatives will have to travel further for initial specialist treatment that will save people’s limbs and lives. This is not unusual for other specialist hospital care, for example major trauma and cancer care.

However, it is important to note that this new way of working for some groups of people will bring more care delivered closer to home. In some areas the out-patients, in-patient cover to other specialties and elective minor surgery is covered by a single practitioner. With a regional service we should have the ability to provide cover to those areas to ensure that the service does not stop when that practitioner is on annual leave or off sick. Working as one service will mean that clinicians from other hospitals will be able to ensure clinics continue locally to prevent travel. We should also be able to expand the care carried out within a day surgery facility to lessen some people having to travel, and ensure all the sites have a vascular presence during working hours to provide cover to the whole hospital. The transformation will also mean that some people will be discharged home quickly or supported at home (where safe to do so) through virtual rehabilitation, virtual wards, and admission avoidance clinics with robust out-patient management pathways for treatment such as intravenous antibiotics. 

Regional working as a single service should also work to give people increased choice. If there is a long waiting list at one site for a certain type of procedure but a shorter wait on another site, we should be able to offer the person the procedure sooner by moving outside of the currently established organisational or commissioning boundaries. To me that’s a real tangible benefit.

It’s also important we determine the benefits for staff.

As mentioned I have talked about how staff may move around across the service to give treatment and care – for some colleagues the thought of travelling and working somewhere different may create anxiety.  I both understand and appreciate these concerns. I myself have personal and childcare commitments.

I can only talk through personal experience, but my experience has shown that working with new people in new environments has been both interesting and refreshing. It has exposed me to different cultures, processes, new ways of working – and career opportunities. I have personally found it has broadened my horizons and enabled me to consolidate the good practices and share the learning wider.

In terms of recruitment and retention a single service model will give colleagues greater choice. Due to the range of locations and breadth of work I hope my colleagues will have greater career opportunities – should they want it. 

I believe we should be able to provide roles with that elusive balance of satisfying career aspirations whilst establishing a work-life balance. Individuals coming in to the service may want to pursue a complex, demanding line of work to satisfy their career and personal aspirations, but that can be emotionally and physically demanding when exposed to that environment constantly. This constant pressure is not sustainable for many in the long term. Again, given the breadth of sites and work under the single regional service there should be the opportunity to work in that complex pressured environment for a week or two, for example, and then for a week or two in a different site doing more routine, less intensive work to restore some balance.

I also believe that WYVaS and the regional single service model brings with it wider healthcare benefits. There is significant variation in the cost of the same piece of equipment between neighbouring trusts and working as part of WYAAT and one vascular service will give us greater procurement and purchasing power to drive down the cost for the NHS and the tax payer.

Finally, once WYVaS is established we will be offering people who access care the opportunity to participate in research and development projects so that health researchers have access to a bigger pool of people to make studies more successful in this region – and most importantly improve the health and care provided in the future.

So we set out on this slightly scary, hugely exciting, transformation opportunity which I hope to achieve through collaboration, personal communication, strong relationships, and fostering a great culture.

How will we know if we’ve been successful? Some people say we will have succeeded when the pathways are embedded and people are receiving high quality, personalised care. It will be a really satisfying point to get to, but for me that isn’t the real measure of our success, that’s completion of a task. Success to me will be when the overwhelming majority of people receiving care and staff are proud to have been treated by, and work within, an identifiable regional single service entity, where the staff live and role model the positive values and enthuse about the culture within which they work and develop – and we have ensured people have healthier lives both inside and outside of hospital or work.

We all need to ‘unplug’ now and again, so I hope you all have a great weekend.

Neeraj

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