Lower Urinary Tract Symptoms (LUTS) Update June 2018

19 Jun 2018

Whittington Health Lower Urinary Tract Symptom Service (LUTS) Service is run at Hornsey Central Health Centre. The service has been closed to new patients since October 2015. The service continues to treat patients that were already patients of the clinic.

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The Lower Urinary Tract Symptom Service
 
Whittington Health Lower Urinary Tract Symptom Service (LUTS) Service is run at Hornsey Central Health Centre. The service has been closed to new patients since October 2015. The service continues to treat patients that were already patients of the clinic.
 
The service is currently led by Professor James Malone-Lee. Professor Malone-Lee retired from University College London (UCL) in September 2016, and since that time has been employed on a locum contract by the Trust to continue working part time to deliver the LUTS Service.
 
The LUTS service was subject to a Royal College of Physicians (RCP) Invited Service Review in May 2016. The RCP Invited Service Review Panel recommended that “until the future of the service has been determined by the Trust and commissioners, no new patient referrals should be accepted into the LUTS clinic”.
 
Re-opening the LUTS service
 
Following a meeting of the Joint Commissioning Committee (JCC) of North Central London CCGs and the Whittington Health NHS Trust Board, the LUTS clinic has re-opened to new patients.

In order to re-open the clinic the Islington Clinical Commissioning Group (CCG) and Whittington Health Trust Board has approved a Commissioning Service Specification, which meets the recommendations set out in the report from the Royal College of Physicians (RCP) Invited Review.

The RCP report says: “Based on all of the information considered by the review team it was concluded that significant changes need to be made to ensure the safety of patients currently being treated by the LUTS clinic.”
 
Since the service has re-opened there have been a number of queries about the service from the LUTS patient group, MPs and local councillors. In order that the wider stakeholder group is kept informed of the progress being made to secure the future of the LUTS service we have set out the responses to the queries that have been raised below.

The responses to the queries detail some of the changes that are being made to the way the LUTS clinic is being run in order that Commissioners and the Trust meet the recommendations set by the RCP.

1. Patients currently waiting to access the clinic are being seen in very limited numbers
 
The Royal College of Physicians (RCP) Invited Service Review Panel recommended that “until the future of the service has been determined by the Trust and commissioners, no new patient referrals should be accepted into the LUTS clinic”.  In line with this recommendation the clinic has remained open to existing patients, but the Trust has not accepted any new referrals since October 2015. Any clinician who wrote to make a referral during that time was advised that the referral would not be accepted and that they should refer their patient elsewhere. There is therefore no waiting list or backlog of patients for the Whittington Health LUTS clinic.
 
The LUTS clinic team has recently reviewed patient referrals that were made to the service in the last six months against the above criteria. They found that, of the referrals made, only 10 qualified as tertiary referrals, in the last six months.
 
The LUTS clinic team has been asked to write to the referring consultants for these 10 patients to enquire if they still need to be seen in the clinic. The reason for this is that the patient may have had treatment elsewhere, or their clinical condition may have changed, and they may no longer need to be seen in the service.
 
The RCP recommended in their report that: “The management of these patients, including the medication prescribed, its doses and durations, should be reviewed, discussed and agreed at properly constituted and well managed MDT [multi-disciplinary team] meetings.”
 
The Commissioners’ Service Specification responds to the RCP recommendation as follows:
“This Multi-Disciplinary Team (MDT) will meet monthly and consist of colleagues from both Whittington Health and UCLH (and or another tertiary provider). Included in its membership will be:
  • Consultant Urologist
  • Consultant Uro-gynaecologist
  • Consultant Microbiologists
And any other clinician relevant to the individual’s case.

An MDT coordinator will support the working of the MDT.
1. Every new patient will have their treatment discussed and agreed at the MDT
2. Any treatment outside of nationally agreed guidelines or local MDT agreed guidelines will be provided within the context of an ethically approved clinical trial”
 
The Trust has established a local MDT and this has expedited the re-opening of the LUTS clinic, while the Trust works with UCLH to establish tertiary MDTs.
 
This decision was brought to, and approved by, the Joint Commissioning Committee (JCC) of North Central London CCGs. The JCC debated whether the clinic should not re-open until the tertiary MDTs were in place and the substantive successor to Professor James Malone Lee was in post. Eventually the JCC agreed that it would be better to have a phased re-opening of the clinic to once again allow access for patients to the Whittington Health LUTS clinic, but only if referral management followed the Commissioners’ Service Specification.

The local MDT currently has capacity to review a minimum of two patients per week. Given that the LUTS team found that only 10 of the patient referrals made in the last 6 months qualified as tertiary referrals, we anticipate that there is sufficient capacity within the MDT to meet the demands for tertiary referrals. The Trust and the CCG will keep this under review and consider how we address any demand and capacity mismatch should this arise.
 
2. The Commissioner Specification stipulates that referrals must come from secondary care, so all patients currently waiting who have been referred by GPs now need to arrange to be seen by a consultant and then secure a second referral
 
In relation to the process for managing referrals to the clinic, the RCP Invited Service Review report commented as follows: “There are questions about whether local CCGs will wish to commission the service and whether a tertiary centre would be better placed to support a service like the LUTS clinic. The review team were of the view this could be achieved in a tertiary service such as UCLH that would have the necessary range of contributing specialties to manage complex patients”.
 
The RCP Report recommended: “The future of the clinic would be much safer and better regulated …in a tertiary centre such as UCLH that has a mix of appropriate specialties and could offer true multi-disciplinary working. Clinicians working in such an environment will safeguard care of patients by peer review, good teamwork and integration with Trust governance processes”.
 
The Commissioners Service Specification has outlined the referral process for the LUTS clinic as follows:
 
“The referral process to the service will be consultant to consultant. As a tertiary referral service, the clinical team would accept referrals from across the country directly from secondary care institutions. This will ensure the patients are not lost in the system and can access expertise in timely way. Patient’s currently under the care of the service will not need to be referred but will continue to be cared for.”
 
As a tertiary service the LUTS will not accept referrals directly from GPs. The service will accept referrals from across the country directly from secondary care clinicians.
 
Patients currently under the care of the Whittington Health LUTS clinic will not need to be re-referred.
 
Commissioners believe that in the longer-term alignment of the LUTS clinic with a broader tertiary service will be the best way to match demand and capacity.
 
3. There remains no referral route into the clinic for paediatric patients
 
In relation to the process for managing referrals to the clinic, the RCP Invited Service Review report commented as follows: “The existing restriction for a requirement of consultant paediatric input for paediatric patients should remain in place.”
 
Commissioners are following the recommendations of the Royal College of Physicians to ensure the LUTS service is a tertiary service and works within an academic research framework, to provide on-going evidence base for treatment.
 
The commissioned pathway for children is through the specialist paediatric centres within their areas. For those within North Central London the specialist hospital for referral is Great Ormond Street Hospital.
 
4. Recruitment for the replacement for Professor Malone-Lee
 
In relation to succession planning for Professor Malone-Lees replacement, now that he has retired, the RCP recommended:
- “The Trust should identify who can take over the management of the LUTS service”
- “Succession should focus on the development of MDT working to ensure resilience in the service, and to overcome the reliance on any one individual”
- “The Trust should engage in direct, high level dialogue with local clinical commissioning groups and with neighbouring tertiary centre to agree a strategy for the long term future of the LUTS clinic. This should include …..Whether the treatment to be offered would be part of a research framework”
 
Whittington Health is working with UCLH to agree a joint appointment of a consultant to provide leadership to the LUTS.
 
The Trust must gain approval for the Consultant Job Description from the Royal College.
 
It is our intention that we commence a new recruit into the Consultant post by September 2018.
 
5. Clinical Research
 
In relation to research the RCP Invited review said:
- “The fact that the LUTS clinic has not been able to carry out randomised controlled trials or high quality observational studies assessing clinical outcomes means it has not been able to provide verifiable evidence that its treatment is effective.”
- “Without reliable clinical research evidence it will be difficult for other clinicians to accept that these unorthodox treatments are sufficiently effective.”
 
To address these concerns the Commissioner Service Specification says:
“The patients within the service are often complex and have been treated in secondary care prior to referral. For these reasons some patients may not have responded to current national recognised guidance. For these reasons included in the specification planning is a need to include an academic research component to the service to develop evidence for treatment new treatments.”
 
The Trust and UCLH have discussed the academic research component of the tertiary service. The current proposal is to commence clinical research once the new Consultant appointment is in post and the tertiary MDTs are established.
 
6. The May MDT meeting was cancelled at only 24-hour notice
 
The Associate Medical Director at Whittington Health decided to cancel the MDT.
This was because of the following circumstances:
  • The new referrals were uploaded onto the Anglia ICE system that books the MDT list. However no clinical details about the patients were included, and the MDT could not review the patients in advance.
  • Of the core consultant members, only two were available to meet. The core members include a urologist, a microbiologist, a gynaecologist and Professor Malone-Lee.
  • The Associate Medical Director felt that as this was the first MDT meeting that would review new patient referrals, it was important that Professor Malone – Lee, and not a trainee doctor from the LUTS service, was present, to discuss each of the referred patient’s and the recommended treatment in detail, with a full complement of expertise available to review the patient clinical management.
All members of the MDT, including Professor Malone-Lee were informed of the cancellation of the MDT and the reasons by the MDT co-ordinator on 15 May 2018.
 
Conclusion
 
There were many actions and changes required following the RCP invite review. The Trust and Commissioners are implementing these changes.
 
The Trust and CCGs are working together to deliver a sustainable solution to the delivery of the LUTS service at Whittington Health.
 
The actions are being taken are fully in line with the RCP recommendations.

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