Vascular Services
Vascular services should be organised such that anyone with vascular disease in the UK and Ireland has equal access to specialist vascular care.
In reality geography plays a part, with a different model of provision needed in the most rural areas (i.e., Scottish Highlands, North Wales, Western Ireland, and Southwest England) from urban areas.
As people with vascular disease present to doctors from many specialities pathways of care are as important as staffing and facilities.
This is especially important for people living with
- Peripheral arterial disease
- Diabetic foot disease
- Venous disease
as management is initially in the community and under primary care.
Specialist vascular care
Vascular services in the UK have been transformed since the creation of a separate vascular surgery speciality in 2013.
These changes were driven both by workforce considerations and the recognition that patient outcomes are better for vascular surgery performed in high volume centres by specialist vascular multidisciplinary teams (MDTs).
It is recognised that not every vascular intervention can be safely and effectively delivered in every arterial centre. A patient should not be denied a choice simply because a procedure is not performed at their nearest arterial centre.
Some servicesonly offered by larger vascular centre:
Endovascular procedures
Thoracic aortic stent graft (TEVAR)
Fenestrated aortic stent graft (FEVAR)
Branched aortic stent graft (BEVAR)
Surgeon-modified or ‘chimney’ stent grafts
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Open surgical procedures
Open thoracic and thoraco-abdominal aortic surgery
Thoracic outlet syndromes
Carotid body tumour resection
Retroperitoneal tumour resection surgery
Renal access
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Other
Vascular anomalies services
Paediatric vascular surgery
Connective tissue disease
Exercise induced limb discomfort
Deep venous interventions
Spinal access
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Vascular networks
While high volume arterial centres give better outcomes for most interventions, it is essential that vascular services provided outside of the arterial centre are not neglected; “What can be done locally, should be done locally”. This has led to the creation of informal ‘vascular networks’ where designated arterial centre, delivering specialist inpatient vascular care, works with local non-arterial Trusts to provide outpatient services and inpatient reviews.
This is similar to the model adopted for major trauma care.
Networks need clear aims, leadership, robust governance, cross site MDT working, joined up clinical pathways, and robust governance to function well.
Whilst outpatient clinics and vascular diagnostic imaging should be offered in every network hospital, inpatient arterial surgery should be undertaken in a specialist ‘arterial centre’ except when delivered jointly with other services (i.e., trauma, cardiac or cancer).
This network model for vascular care delivery with a single arterial centre within each vascular network has four key benefits:
- Patient safety: body of evidence relating surgical volumes and outcomes.
- Workforce: 24/7 availability of the vascular MDT.
- Training: better training opportunities for both vascular surgery and interventional radiology trainees.
- Economic: avoiding replication of expensive technology and staff on multiple sites.
The centralisation of vascular services into arterial centres also carries risks:
- Increased travel times: potential harm in the emergency setting.
- Inequalities in access to care: peoples’ willingness, and ability, to travel to access specialist vascular care.
- Arterial centre is overwhelmed: unable to deliver safe, high-quality, care.
These factors are discussed more fully in the 2018 VS publication ‘Top Tips’ for Reconfiguring Vascular Services.
Network population size
800,000 people has become the established minimum population for UK vascular networks (an arbitrary figure from the AAA screening programme). Smaller vascular networks should align with a larger network; this includes agreeing pathways of care, holding a joint MDM, and for governance and quality improvement.
- Across most of the UK, a network population size of >1.2 million people is needed to provide the volume of aortic cases to drive better outcomes.
- At least 3 UK vascular networks serve populations of around 2 million people.
Arterial centres
Vascular inpatients should be cared for by a team of specialist clinical, nursing, and allied healthcare professionals, the vascular MDT. At weekends and overnight, the same level of service support for time-critical care should be available.
The recognised arterial centres in the UK and Ireland are shown in the interactive map on this website link.
Arterial centres should provide, as a minimum, the following:
- 24/7 Consultant vascular surgeon on call rota (maximum frequency 1 in 6).
- 24/7 Consultant interventional radiologist on call rota (maximum frequency 1 in 6).
- 24/7 Operating theatre, ‘hybrid’ theatre and interventional radiology room readily available, and appropriately staffed.
- Level 3 critical care beds ('Intensive Care Unit').
- Dedicated ward for vascular patients (GIRFT supports provision of monitored recovery beds on the vascular ward).
- Access to sessions in a second theatre (GIRFT recommend that this is 7 days of the week).
- Hybrid operating theatre compliant with MHRA guidance for performing aortic procedures.
- Dedicated interventional radiology suite with day care beds.
- Vascular laboratory (or equivalent).
- Blood transfusion laboratory
The following factors will increase the demand on inpatient beds:
- Poorly organised outpatient pathways for time-critical patient assessment.
- An older (or frailer) patient demographic in the population served.
- Serving areas with more socially deprived populations.
- If repatriation pathways are poorly conceived or delivered.
- When local rehabilitation and nursing home facilities are limited.