Quality statement for vascular disease

Vascular diseases cover any condition that affects the network of the blood vessels known as the vascular or circulatory system. Diseased blood vessels may fur up and block resulting in tissue loss/gangrene, or they enlarge (aneurysm formation) and are at risk of rupture causing sudden death. The main aim of vascular services is to unblock or bypass blocked arteries to restore blood flow to limbs or organs or to reconstruct/replace enlarged vessels to prevent rupture and sudden death. These are often one-off procedures, mainly to reduce the risk of sudden death, prevent stroke, reduce the risk of amputation or improve function. Vascular services also provide support to patients with other problems such as kidney disease providing access for dialysis (renal replacement therapy), diabetes or major trauma.

Vascular diseases are common in the community and their incidence and severity increase with age. For example, peripheral arterial disease (PAD) affects about 20% of the population over the age of 60 in the UK and is associated with increased risk of death from heart attack and stroke. Approximately one quarter of affected individuals will develop symptoms which can lead to limb loss if untreated. Aneurysms of the abdominal aorta affect 1-3% of males aged 65 and over which may cause death from rupture if untreated. 

The increasing prevalence of diabetes and cardiovascular disease in our communities will result in more of the Welsh population suffering vascular pathology, including those with mild disease in the community through to those requiring specialist care. Currently, more than half of patients with vascular disease present urgently, or as an emergency. Patients with vascular disease are presenting older and with more associated co-morbidities. There is now more emphasis on the rigorous control of vascular risk factors to improve prognosis and outcomes. 

Vascular disease is caused by environmental factors and lifestyle choices, as well as genetic predisposition. Intervention earlier in life reduces the development of arterial narrowings, making it less likely the individual will develop the consequences of these conditions when they get older.

Vascular services have developed significantly during the last 20 years, with more complex open and minimally invasive/endovascular procedures used to manage patients who tend to be older and more comorbid than before. Vascular surgery in the UK has been recognised as a specialty in its own right since 2013. The increasingly specialised nature of vascular procedures has led to complex procedures being performed at fewer locations, in order to concentrate resources and expertise. Prior to the introduction of the National Vascular Registry (NVR), the UK did not compare well internationally for many vascular procedures. 

The challenge now is to develop national leadership, local engagement and collaboration with the third sector to deliver real improvements ensuring there is a long-term and consistent approach to improving outcomes as envisaged in the Wellbeing of Future Generations Act and demonstrated by international experience.

The introduction of quality statements were signalled in ‘A Healthier Wales’ and has been described in the National Clinical Framework as the next level of national planning for specific clinical services. Quality statements form part of the enhanced focus on quality and will be integral to the future planning and accountability arrangements for the NHS in Wales.

There is a need to ensure that equity of access is provided for those people who have faced inequality, such as, for example, ethnic minority communities and pathways will need incorporate more flexibility to deliver this. The Welsh Government’s 'More than just words' plan to strengthen Welsh language in health and care services through the ‘active offer’ principle should become an integral part of service provision. Service providers should build on current best practice and plan, commission and provide care based on this principle.

Although a person may present a particular set of symptoms, it is important their treatment considers their cardiovascular disease in general. This will include coronary artery disease, stroke, hypertension, hypercholesterolaemia, diabetes, chronic kidney disease, peripheral arterial disease, and vascular dementia. There is clear evidence that this secondary prevention plays a major role in reducing the morbidity and mortality.

The vision is to develop national pathways to provide the overarching framework for the delivery of vascular care from prevention to supporting people who require treatment for vascular conditions. The pathways will aim to drive system-wide improvement through a reduction in unwarranted variation of care and improved outcomes.

This approach aligns with the National Clinical Framework which places specific emphasis on the development of national clinical pathways and the Quality Safety Framework which emphasises the importance of systemic local use of the quality assurance cycle. 

It also enables a focus on cross-working with other groups to address areas such as prevention, rehabilitation, pain management, care for those who are critically ill or at end of life as well as collaboration with other conditions such as heart conditions, stroke, diabetes, kidney disease and major trauma.

Health boards – as integrated healthcare organisations – are responsible for the delivery of vascular services in line with professional standards and the quality attributes set out below.  They will respond to this Quality Statement through the integrated medium term planning (IMTP) process. The Wales Vascular Network in conjunction with the operational delivery networks (ODN) will support health boards to improve the quality, consistency, and value of healthcare delivery. A detailed service specification will be developed to support the commissioning and accountability arrangements including key metrics for delivering high quality and sustainable vascular services that meet the needs of the population. This will be set out in Annex A as it becomes available.
 

Equitable

1.    National approach led by the Welsh Vascular Network, supported by the operational delivery networks, to deliver service improvement with the NHS Executive. 

2.    National vascular pathways will ensure transparency, support equity of access, consistency in standards of care and address unwarranted variation.

3.    Services for people with vascular disease will be measured and held accountable using metrics, clinical audit, PROMs and peer review that reflect the quality of care and its outcomes. 

4.    Multidisciplinary vascular workforce is supported and developed, to address staff retention and ensure it is sustainable, equitably distributed, grown to meet increased demand with focus on key areas such as endovascular interventions including endovascular interventionalists and specialist nursing.

Safe

5.    A system-level focus on transforming pathways to further build in resilience by adopting the learning that was achieved throughout the pandemic. 

6.    Effective multi-disciplinary team working which enables appropriate, timely and constructive discussion with supportive collaboration and clinical decision making.

7.    Effective integrated care with appropriate MDT involvement, discharge planning (physiotherapy, community health and social care) including follow up and aftercare plans.

8.    Decisions relating to patient care are appropriately documented showing the decisions that were made and rationale behind them including appropriate consideration of the risk and benefits and potential prognosis.

9.    Evidenced patient safety improvement programmes are embedded utilising the all Wales incident reporting system to identify themes and share collective learning points.

Effective

10.    Nationally optimised evidence-based pathways for people who require vascular services are embedded in local service delivery to improve outcomes and survival, including access to diagnostics, local review of patients, clear referral, assessment, transfer/repatriation and rehabilitation pathways.

11.    Patients at risk of vascular disease or in the early stage of diagnosis are actively supported and involved in the management of their disease, including lifestyle modification support.

12.    A culture where all patients’ needs, not just vascular care are understood ensuring the right support is provided at the right time, utilising a whole system approach including other specialties such as cardiac, diabetes, renal, major trauma, pain management, care of the elderly, end of life care and services such a peer support provided by third sector.

13.    High quality research should be undertaken into methods of preventing and treating vascular disease to aid the delivery of improved outcomes, identification optimum treatments and evaluation of new therapies.

Efficient

14.    A national approach to informatics systems and vascular data that enables greater integration of care and provides relevant, high quality, standardised data to drive service improvement. 

15.    Building on new ways of working by using technology to free up more time to care such as the electronic patient records and prescribing enabling the safe and efficient management of patients.

Person centred

16.    Patients are communicated with effectively and compassionately, with active involvement in decision making processes regarding treatment of their vascular disease. 

17.    Patient’s wishes are listened to and respected that they are supported to understand the likely trajectory of their disease, treatment options and prognosis including, where appropriate, information and support about Advanced Care Plans to enable them to record how they would wish to be cared for at the end of life no matter which treatment option they choose.

18.    Collaborative approach to person-centred care is culturally embedded and supported by a common approach to diagnosis, treatment and care such as psychological support provided as locally as possible where appropriate.

19.    Improved insight into patient experience such as use of PROMS and PREMs to better understand care and service needs to aid service improvement and ensure people affected by vascular disease achieve the outcomes that matter to them, throughout the pathways that lead into vascular.

Timely

20.    Validated mechanisms for identifying people at risk of developing vascular disease and those at the early stages of disease to support primary care and ensure timely referral to secondary care.

21.    Appropriate mechanisms for ensuring timely access to vascular surgical opinion in secondary care hospitals without onsite vascular surgical services.

22.    Patients referred following identification by the Wales Abdominal Aortic Screening Programme are assessed and have appropriate interventions within the set standards.

23.    Opportunities to implement new medications proven to reduce the progression disease and associated cardiovascular disease or treatments which may improve outcomes are explored and implemented.

The Wales vascular network will a develop service specification for vascular services to inform accountability discussions and commissioning decisions. This will be added as it becomes available.