Gynaecological Oncology at Liverpool Women’s Hospital

This is the second of four blog posts about plans currently being made by the management of the Liverpool Women’s Hospital for the future of the hospital.This hospital is much valued by the people of the area and by all women who want to see a more women centred future for the NHS, a future that would hopefully see women live lives without chronic illnesses, for many more years than they do now. The expertise of the hospital in terms of women’s health should not be underestimated nor undervalued. The blog posts are split into these sections so lay camapigners can more easily access the reports.

This post is about the significant challenges facing LWH in delivering Gynaecological Oncology (cancer treatment).

LWH has, since 2015, been involved in attempts to fundamentally change the hospital. This, coupled with misleading press comments about the safety of the Hospital, made in support of the CCG plans, has probably made recruitment more difficult. This for example in the Liverpool Echo “Health chiefs say women and babies would be safer in a new building as they would no longer have to be taken across the city to be treated for medical complications.” The number of women moved out of LWH is very small and in none of the plans published would babies have stopped moving to Alder Hey Children’s Hospital but such misleading statements abound. LWH has had difficulties recruiting Gynacological oncologists, for many different reasons

Whilst the flawed plans to move the LWH to the Liverpool Royal Site have gone on for so long, some key necessary modernisations have been missed. Our campaign has called for imaging, diagnostics and blood services to be improved. We have also expressed concern at the staff satisfaction scores recorded at the hospital. LWH could clearly be made a better place to work. National issues too impact of the nature of the Gynaecological work force and this too is of interest to all concerned with women’s health.

What follows is the report to the board on November 7th 2019. The full paper work for the board is here

Gynaecological Oncology The gynaecological oncology service at the LWH is under significant pressure at the present time, with a high level of activity required yet a low number of consultants with subspecialist skills available to deliver the clinical work. Of the 6.0 WTE budgeted subspecialist consultant posts, the trust currently has 4.0 WTE in post and of these, one is currently on long term sick leave and one will be leaving the trust for Manchester within the next month.

In recent years, recruitment to these posts has proven to be extremely challenging. This has in part been due to the fact that there are more posts available across the UK than there are subspecialist trainees to fill them. LWH does not present itself as an attractive prospect to candidates, however, because of its isolated position on Crown Street. Modern gynaecological oncologists expect to work in a facility with full access to multidisciplinary care, access to robotic surgery and access to an ITU since these services are necessary for the best clinical outcomes to be achieved

 Partly as a consequence of senior staffing shortages, the trust is not currently meeting its 31 and 62 day referral to treatment cancer targets and activity is underperforming against plan. In mitigation, the job plans of the trust’s remaining gynaecological oncologists have been re-written with all benign gynaecological commitments now removed. In addition, a (non-subspecialist) consultant gynaecologist with an interest in oncology has been appointed, who is providing clinical support and who is helping to co-ordinate clinical activity. The drive to recruit subspecialists, however, continues.

 In order to make these senior posts more attractive to potential candidates and simultaneously to improve our clinical services, an increased level of access to operating lists at LUH has been achieved. These consist of one all day list at Aintree University Hospital each week and one extended (10 hour) all day list at The Royal Hospital each fortnight, each with colorectal support and access to the respective ITUs. Discussions about the future provision of surgery at LUH are on-going but the present aim is to achieve:

 · One all day list for open surgery at either The Royal or Aintree each week

· One all day list for robotic surgery at The Royal each week

· Each with access to critical care and ward accommodation for LWH patients · Protected multidisciplinary team working from all relevant specialties

· Formal pathways to be established around access to specialist pre-operative testing

 · Establishment of gynaecological nursing support on the LUH sites for LWH patients

 · Improved access to imaging and diagnostic services

· Improved access to therapies and support services

These matters are being pursued individually by the MD at LWH and DMD at LUH but they will also be formalised as part of the Partnership Board’s workstream once it has been established, described in more detail below.

Repatriating Gynaecological Oncology The option of repatriating the gynae oncology workload has been considered. There are three options. The first option would be to discontinue the service at LWH and recommission it at either Preston or Manchester, both of which are presently active in the field. This option has been excluded to date in part because of geographical constraints – the patients using the service live across the Cheshire and Mersey footprint but most live in Liverpool.

 Equally pertinent is the fact that it is highly unlikely that either Preston or Manchester would have the physical or operational capacity to deal with the increased volume of work that would accompany the change. The option remains under consideration but is presently seen as impractical.

 The second option would be to discontinue the service at LWH and recommission it at the newly formed Liverpool University Hospitals trust, either at the Royal or the Aintree site. In this scenario, all relevant staff would transfer to LUH and out-patient, ward and theatre activity would follow suit. The work would be commissioned with LUH and LWH would simply refer patients with newly diagnosed gynaecological cancers into that service. This option has been excluded to date because an on-site presence would be required 24/7 from suitably skilled O&G trainees for the safe care of the patients.

 This would not be possible at present because a 20% rota gap rate is the norm for O&G trainees across Cheshire and Mersey. This would be negatively impacted by the introduction of an additional clinically active site.

The subspecialist Consultant Gynae Oncologists do not believe that either ANPs or trainees from a non-O&G specialty would have the knowledge and expertise required to provide safe care to the gynae cancer in-patient population, in place of cover from O&G trainees, on either the Royal or Aintree sites.

In both of the above options, the loss of Consultant Gynaecological Oncologists from the LWH workforce would have a significant detrimental effect upon the rest of the service. Specifically, massive postpartum haemorrhage is a key risk in the obstetric services and life-saving surgical rescue in the most extreme cases is provided primarily by the gynae oncology team.

 Caesarean hysterectomy is performed around six times per year at LWH in response to rapid, massive blood loss and the deterioration in on-site surgical expertise accompanying the repatriation of gynae oncology services would clearly increase the risk of exsanguination in these patients.

 The third option is for LWH to retain its gynaecological oncology services but to perform an increasing volume of work at neighbouring adult acute sites as describe above, both for women with advanced disease and for women with multiple medical or surgical co-morbidities.

 Of note, this third option could have a positive impact upon recruitment and retention although this remains to be tested.

None of the above options provides the same impact against safety as the relocation of LWH in its entirety onto an adult a

Gynaecological Oncology The gynaecological oncology service at the LWH is under significant pressure at the present time, with a high level of activity required yet a low number of consultants with subspecialist skills available to deliver the clinical work. Of the 6.0 WTE budgeted subspecialist consultant posts, the trust currently has 4.0 WTE in post and of these, one is currently on long term sick leave and one will be leaving the trust for Manchester within the next month.

In recent years, recruitment to these posts has proven to be extremely challenging. This has in part been due to the fact that there are more posts available across the UK than there are subspecialist trainees to fill them. LWH does not present itself as an attractive prospect to candidates, however, because of its isolated position on Crown Street. Modern gynaecological oncologists expect to work in a facility with full access to multidisciplinary care, access to robotic surgery and access to an ITU since these services are necessary for the best clinical outcomes to be achieved

 Partly as a consequence of senior staffing shortages, the trust is not currently meeting its 31 and 62 day referral to treatment cancer targets and activity is underperforming against plan. In mitigation, the job plans of the trust’s remaining gynaecological oncologists have been re-written with all benign gynaecological commitments now removed. In addition, a (non-subspecialist) consultant gynaecologist with an interest in oncology has been appointed, who is providing clinical support and who is helping to co-ordinate clinical activity. The drive to recruit subspecialists, however, continues.

 In order to make these senior posts more attractive to potential candidates and simultaneously to improve our clinical services, an increased level of access to operating lists at LUH has been achieved. These consist of one all day list at Aintree University Hospital each week and one extended (10 hour) all day list at The Royal Hospital each fortnight, each with colorectal support and access to the respective ITUs. Discussions about the future provision of surgery at LUH are on-going but the present aim is to achieve:

 · One all day list for open surgery at either The Royal or Aintree each week

· One all day list for robotic surgery at The Royal each week

· Each with access to critical care and ward accommodation for LWH patients · Protected multidisciplinary team working from all relevant specialties

· Formal pathways to be established around access to specialist pre-operative testing

 · Establishment of gynaecological nursing support on the LUH sites for LWH patients

 · Improved access to imaging and diagnostic services

· Improved access to therapies and support services

These matters are being pursued individually by the MD at LWH and DMD at LUH but they will also be formalised as part of the Partnership Board’s workstream once it has been established, described in more detail below.

Repatriating Gynaecological Oncology The option of repatriating the gynae oncology workload has been considered. There are three options. The first option would be to discontinue the service at LWH and recommission it at either Preston or Manchester, both of which are presently active in the field. This option has been excluded to date in part because of geographical constraints – the patients using the service live across the Cheshire and Mersey footprint but most live in Liverpool.

 Equally pertinent is the fact that it is highly unlikely that either Preston or Manchester would have the physical or operational capacity to deal with the increased volume of work that would accompany the change. The option remains under consideration but is presently seen as impractical.

 The second option would be to discontinue the service at LWH and recommission it at the newly formed Liverpool University Hospitals trust, either at the Royal or the Aintree site. In this scenario, all relevant staff would transfer to LUH and out-patient, ward and theatre activity would follow suit. The work would be commissioned with LUH and LWH would simply refer patients with newly diagnosed gynaecological cancers into that service. This option has been excluded to date because an on-site presence would be required 24/7 from suitably skilled O&G trainees for the safe care of the patients.

 This would not be possible at present because a 20% rota gap rate is the norm for O&G trainees across Cheshire and Mersey. This would be negatively impacted by the introduction of an additional clinically active site.

The subspecialist Consultant Gynae Oncologists do not believe that either ANPs or trainees from a non-O&G specialty would have the knowledge and expertise required to provide safe care to the gynae cancer in-patient population, in place of cover from O&G trainees, on either the Royal or Aintree sites.

In both of the above options, the loss of Consultant Gynaecological Oncologists from the LWH workforce would have a significant detrimental effect upon the rest of the service. Specifically, massive postpartum haemorrhage is a key risk in the obstetric services and life-saving surgical rescue in the most extreme cases is provided primarily by the gynae oncology team.

 Caesarean hysterectomy is performed around six times per year at LWH in response to rapid, massive blood loss and the deterioration in on-site surgical expertise accompanying the repatriation of gynae oncology services would clearly increase the risk of exsanguination in these patients.

 The third option is for LWH to retain its gynaecological oncology services but to perform an increasing volume of work at neighbouring adult acute sites as describe above, both for women with advanced disease and for women with multiple medical or surgical co-morbidities.

 Of note, this third option could have a positive impact upon recruitment and retention although this remains to be tested.

None of the above options provides the same impact against safety as the relocation of LWH in its entirety onto an adult acute site.

cute site.

Please read this inconjuction with the other linked posts. Your comments are very welcome.

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