1. The West Midlands IR Service Dr Paul Crowe Working in partnership with

2. IR The West Midlands IR Service Paul Crowe Consultant Interventional Radiologist Heart of England NHS Foundation Trust

4. Global Trends  Minimally invasive therapies  Shorter length of stay  Technological advances  More informed patients and public  Patient choice  Cost-effectiveness and financial accountability

5. Global Trends  Interventional Radiology as stand alone speciality  Interventional Radiologists as clinicians  OPD clinics, ward beds, direct GP access  Interventional Oncology  Hybrid specialists

6. Global Trends  IR as stand alone speciality  April 25 th 2009 EUMS (European Union of Medical Specialists) vote recognises IR as a distinct speciality  UK recognition as subspeciality

7. SHA Review  In response to ◦ National Imaging Board (NIB) – IR: Improving quality and outcomes for patients ◦ RCR ◦ NCEPOD report on trauma ◦ Healthcare Commission report into maternity deaths at Northwick Park Hospital  West Midlands SHA review of IR services  WMQRS Vascular Services Review

8. WMQRS Vascular Review  Strategic review of vascular services  VSS and BSIR representation  Criteria for status as a vascular centre  Based on optimum 800,000 catchment population  24 hour IR cover essential

9. IR Questionnaire Birmingham Children’s Hospital NHS FT- Birmingham Women’s NHS Foundation TrustY Burton Hospitals NHS FTY Dudley Group of Hospitals NHS FT- George Elliott Hospital NHS FTY Heart of England NHS FTY Hereford Hospitals NHS TrustY Mid Staffordshire NHS FTY Robert Jones & Agnes Hunt Orthopaedic Hospitals NHS FTY Royal Orthpoaedic Hospital NHS FTY Royal Wolverhampton Hospitals NHS FTY Sandwell & West Birmingham Hospitals NHS FTY Shrewsbury & Telford Hospital NHS TrustY South Warwickshire General Hospital NHS TruastY University Hospital Birmingham NHS FTY University Hospital of North Staffordshire NHS TrustY University Hospital Coventry & Warwickshire NHS Trust- Walsall Hospitals NHS TrustY Worcestershire Acute Hospital NHS Trust-

10. IR Questionnaire  Wide range of IR provision  From <10 drainages and 1-2 nephrostomies per month with no out of hours service to full range of tertiary IR services with 24/7 cover.  Only one centre with formal IR on-call rota separate from general radiology rota  Variable and ad hoc out of hours arrangements elsewhere

11. Service Delivery  Consultant delivered  Radiographer practitioner undertaking angiograms and angioplasties  Clinical nurse specialist doing Hickman line insertions  IR OPD clinics in two centres  IR admitting in one centre  Teaching and training  Endovascular surgeons performing vascular intervention

12. Issues Raised  Difficulties around IR nursing and radiographic cover  Access to OPD clinics, beds, day units  Low overall numbers in some smaller centres, ? Sufficient to maintain competencies (only 16 vascular interventions in one centre in 12 months)  Lack of formal SLAs and protocols for referral and transfer where in-house provision is lacking

13. Barriers to IR development  “Lack of dedicated nursing support”  “There is an unwillingness to invest in the necessary infrastructure”  “Business cases for nurses, out-patent sessions, theatre co- ordinators, etc. difficult to compile as there is no IR tariff and therefore no income stream”  “Inadequate number of IR consultants to ensure robust on call rota”  “Other demands on IR consultants time on average only 3PAs dedicated to IR in job plans”

14. Out of hours IR provision

15.  Only 15 acute Trusts in the UK delivered a formal 24/7 IR cover at the time, 6 of them in London  Only 8 of these offered all aspects of emergency IR treatment  175 Trusts taking major trauma

16. Out of hours IR provision  In the absence of IR patients will be placed at risk  Need for clarity about what IR services are available and when  Clear pathways for when IR not available  Out of hours IR must be subject to a formal rota  Recognition of resource implication  Onward referral pathways must be clear www.rcr.ac.uk

19. IR Questionnaire Birmingham Children’s Hospital NHS FT- Birmingham Women’s NHS Foundation TrustY Burton Hospitals NHS FTY Dudley Group of Hospitals NHS FT- George Elliott Hospital NHS FTY Heart of England NHS FTY Hereford Hospitals NHS TrustY Mid Staffordshire NHS FTY Robert Jones & Agnes Hunt Orthopaedic Hospitals NHS FTY Royal Orthpoaedic Hospital NHS FTY Royal Wolverhampton Hospitals NHS FTY Sandwell & West Birmingham Hospitals NHS FTY Shrewsbury & Telford Hospital NHS TrustY South Warwickshire General Hospital NHS TruastY University Hospital Birmingham NHS FTY University Hospital of North Staffordshire NHS TrustY University Hospital Coventry & Warwickshire NHS Trust- Walsall Hospitals NHS TrustY Worcestershire Acute Hospital NHS Trust-

20. IR Questionnaire – On call  Responses from 16 out of 19  No IR on call in two centres  Most provide partial or ad hoc cover  Drainages covered by general radiology on call rota in most centres  Full 24/7 IR cover with separate rota in one centre

21. UHB NHS FT  8 IR Consultants  1 IR Fellow  8 nurses & 8 radiographers on IR team  Separate diagnostic and neuro on call rotas

22. Heart of England FT  6 IR Consultants currently on general radiology rota  Full IR nurse and radiographer on call  Planned IR rota Spring 2011

23. Mitigating the impact  Extended working day in IR  Regular weekend IR sessions  Flexibility in early morning IR lists to accommodate overnight urgent cases, need to build in spare capacity  Consider shift and partial shift options

24. ‘Bleeding on call’ at UHB M. Malaki & A. Willis On behalf of the IR team WMIRG Spring 2010 Meeting

25. Aims To evaluate 20 months of emergency out of hours Interventional Radiology at UHB

26. Methods All IR cases 6pm - 8am and weekends September 2008 to May 2010 On call IR diary CRIS / PACS / IR theatre log

27. Results TOTAL N = 326 NON BLEEDING N = 260 BLEEDING N = 66

28. Results 66 6 10 138 5 5

29. Case distribution Total number = 326

30. Cases per month

31. Findings Significant workload Telephone consultations, 2 nd opinions Increasing numbers of cases Wide referral base

32. Issues highlighted Links with clinicians Additional workload UHB @ elsewhere Inappropriate referral Unsafe and delayed transfer

33. Conclusion  Current IR provision around the region is variable especially out of hours with informal onward referral arrangements.  IR becoming more high profile  Huge opportunity to improve patient experience and quality of outcomes  Equity of provision a challenge, especially out of hours  No one size fits all solution  With recognition come a responsibility to deliver!