Inquiry into access to medical technologies in Wales

Evidence from Association of Coloproctology of Great Britain & Ireland – MT 9

The Association of Coloproctology of Great Britain and Ireland

Inquiry into access to medical technologies in Wales for the National Assembly for Wales' Health and Social Care Committee.

Report on behalf of: Association of Coloproctology of Great Britain & Ireland for South Wales

Report compiled by : Michael Davies, Consultant Colorectal Surgeon, University Hospital of Wales, Cardiff. CF14 4XW. Tel: 029 2074 3351. Email:Michael.Davies5@wales.nhs.uk

Introduction

To provide evidence for this report I have undertaken an email circulation of all Consultant Colorectal Surgeons who are members of the South Wales Chapter of the Association of Coloproctology of Great Britain & Ireland. I have circulated the information from the National Assembly for Wales' Health and Social Care Committee indicating that it is undertaking an inquiry into access to medical technologies in Wales. This report is therefore based on information obtained from 10 hospitals within the Hwyl Dda, ABM, Rhondda Cynon Taf, Cardiff & Vale University and Aneurin Bevan Health Boards. 36 specialist colorectal surgeons work in these units. (para 1)

There are 5 main areas within Colorectal Surgery where lack of access to Medical Technology is a significant problem: (para 2)

1) Laparoscopic Colorectal Surgery

2) Faecal Incontinence - Sacral Nerve Stimulation & Posterior Tibial Nerve Stimulation

3) Transanal Endoscopic Microsurgery.

4) Combined Laparoscopic and Colonoscopic Polyp Surgery

5) Biological Meshes

1) Laparoscopic Colorectal Surgery.

NICE Guidance (NICE, TA 105, 2006) recommends that all patients with colorectal cancer who are suitable are offered the opportunity to have their surgery performed with a laparoscopic approach. All hospitals in South Wales have colorectal surgeons who are trained to undertake laparoscopic colorectal surgery and it is the standard approach to surgery for colorectal cancer and benign conditions unless there are patient factors which preclude this. Feedback from my enquiry has indicated that many hospitals are well equipped for this type of surgery but has identified a number of hospitals where there is a lack of laparoscopic equipment due to funding, including: (para 3)

1) Princess of Wales Hospital, Bridgend - financial constraints have resulted in failure to replace reusable laparoscopic instruments which have broken. Several laparoscopic cases have been cancelled due to lack of equipment and old instruments have broken on more than one occasion during procedures.

2) Prince Charles Hospital, Merthyr - colorectal surgeons are struggling to undertake minimally invasive procedures due to lack of laparoscopic equipment stacks.

3) Royal Gwent Hospital, Newport - A laparoscopic power source (Ligasure), which increases the safety of laparoscopic surgery, has only just been ordered despite surgeons undertaking laparoscopic colorectal procedures for over 5 years. (para 4)

2) Faecal Incontinence

Faecal Incontinence is an embarrassing condition which can have a serious impact on quality of life. It may result from damage to the anal sphincter mechanism, weakening of the sphincter due to ageing and spinal injury or other neurological causes. In the UK major faecal incontinence affects an estimated 1.4% of the population over 40 years of age. Many patients can managed with relatively simple strategies but those with more severe faecal incontinence require interventional treatment. Previously many of these patients would have eventually undergone surgery to form a colostomy with significant effects on quality of life. More recently two minimally invasive / non invasive techniques have been developed (Sacral Nerve Stimulation (SNS) and Posterior Tibial Nerve Stimulation (PTNS)). These treatments are entirely dependent on new medical technology. They have provided a high percentage of patients with a significant improvement in their symptoms and quality life measures. Published studies for SNS have demonstrated that 41-75% of patients achieved complete faecal continence and 75-100% experienced an improvement of 50% or more in the number of faecal incontinence episodes. (para 5).

Published data for patients treated with PTNS have demonstrated significant improvement in continence in >50% of patients. Both of these techniques are NICE approved (Sacral Nerve Stimulation (NICE Guidance IPG 99, 2004), Posterior Tibial Nerve Stimulation (NICE Guidance IPG 395, 2011)) but despite this the evidence from this enquiry indicates that there is very limited availability of these treatments in South Wales due to funding constraints. (para 6)

Cardiff & Vale University Health Board is the only unit in South Wales in which there is a surgeon who has undertaken Sacral Nerve Stimulation procedures. Despite having a high efficacy and being NICE approved, Sacral Nerve Stimulation remains an unfunded service in Wales. There have been individual cases which have received exceptional individual funding over the last 10 years. As a result 12 patients have had stimulators implanted with very good results. Many others have been declined funding and have had stomas formed. The majority of patients that have been able to get funding have done so by involving their Welsh Assembly Member (AM). Patients continue to be referred for consideration for this technique and continue to be turned down due to lack of funding. There have been continuous attempts to get WHSCC to engage with this process and provide funding but this has not achieved any progress. (para 7)

The Colorectal Unit at Morriston Hospital Swansea is the only other unit in Wales undertaking treatment of this type. They have only been able to set up a PTNS service through charitable donation. (para 8)

3) Transanal Endoscopic Microsurgery

The Welsh Bowel Screening Programme has increased the detection of complex rectal polyps and early rectal cancers. These are frequently amenable to minimally invasive surgery with TEM (Transanal Endoscopic Microsurgery). This allows patients to undergo smaller procedures with less impact on quality of life compared with traditional removal by major bowel resection. This type of surgery has for more than 10 years only been available at the University Hospital of Wales in Cardiff which has provided a regional service for all units in South Wales. Despite this important service being focused in Cardiff the equipment used to perform the surgery is over 10 years old and requires a sterilisation process for which part of the equipment must be sent to Scotland. More modern equipment is needed but no funding is currently available for this newer technology (TEO - Stortz). (para 9)

TEO equipment has recently been purchased by Morriston Hospital but only using money obtained from charitable sources. Some TEM type surgery is now undertaken at Morriston Hospital in Swansea but the main centre for this surgery remains in Cardiff. (para10)

4) Combined Laparoscopic and Colonoscopic Polyp Surgery

The detection of complex polyps in the colon has also increased with bowel screening in Wales. Colonocoscopic removal of these is frequently performed but at times can be challenging. The alternative requires major bowel resection with its associated risks and effects on bowel function. A combined procedure has been developed where an operating surgeon undertaking a minimally invasive approach using laparoscopic equipment assists a colonoscopist to enable removal of more difficult complex colonic polyps. (para11)

This technique is undertaken at the University Hospital of Wales in Cardiff. Over the last 3 years more than 30 patients have undergone successful complex polyp removal with significantly shorter hospital stays, low morbidity and no impact on quality of life compared with major surgery and bowel resection which otherwise would have been required. (para12)

Initially it was only possible to undertake this work by loan of the endoscopic equipment and diathermy required because there is insufficient funding to purchase the equipment. After a considerable amount of effort by the clinicians the equipment has been leased but still not purchased. This adds to the difficulties with undertaking this important work since each time a procedure is undertaken the equipment has to be specially brought to the hospital and passed through relevant administrative and testing processes. (para13)

5) Biological Meshes

Meshes are commonly used in hernia repairs and abdominal wall reconstruction since there is clear evidence that hernia recurrence rates are significantly reduced. In cases where there are also bowel stomas or fistulae there is an increase risk of infection and it is accepted that a permanent mesh (such as a Proline mesh) should not be use due to the risk of a mesh infection which is extremely difficult to treat without removal of the mesh. In these cases biological type meshes are used. (para14)

There are a number of biological meshes which have been developed for use in surgery. Two main types of these are in use; Permacol (Covdien) and Strattice (KCI). They have different constructions and properties. Permacol forms a capsule which can become infected while Strattice becomes incorporated into the tissue with less risk of infection. (para16)

At the University Hospital of Wales in Cardiff abdominal reconstruction and surgery for stoma reversal or bowel fistula in patients are undertaken by the Colorectal Surgeons in combination with a Plastic Surgeon. The Plastic Surgeon uses Strattice as a preference for this work at Morriston Hospital where he also works. In Cardiff patient specific applications for funding for Strattice has been turned down by the Health Board and the cheaper alternative (Permacol) has had to used instead. (para 17)

Summary

Rationalisation of health care in Wales is a current reality due to the difficult financial times. Evidence given in this report obtained from different hospitals in South Wales indicates that this is having a significant impact in access to medical technologies for specialist colorectal surgeons treating patients in Wales. Surgical expertise is available but some treatments are directly prevented due to lack of funding. Many of the treatments with very limited or lack of provision of care, including SNS and PTNS, are NICE approved and offered on a consistent basis to patients in England. Bowel Screening in Wales is achieving success in detection of polyps and cancer but treatment for more complex lesions is affected by lack of funding which represents an incomplete service for participants. (para18)

In conclusion action is required to enable access to medical technologies by specialist colorectal surgeons in Wales to ensure that modern treatment is available to patients in Wales in an equitable way to those in other parts of the United Kingdom. (para 19)

Hospitals Included in Enquiry:

University Hospital of Wales, Cardiff (Cardiff & Vale University Health Board)

Morriston Hospital, Swansea (Abertawe Bro Morgannwg University Health Board)

Princess of Wales Hospital, Bridgend (Abertawe Bro Morgannwg University Health Board)

Withybush General Hospital, Haverford West (Hywel Dda Health Board)

West Wales General Hospital, Carmarthen, (Hywel Dda Health Board)

Bronglais Hospital, Aberystwyth (Hywel Dda Health Board)

Neville Hall General Hospital, Abergavenny (Aneurin Bevan Health Board)

Royal Gwent Hospital, Newport (Aneurin Bevan Health Board)

Royal Glamorgan Hospital, Llantrisant (Cwm Taf Health Board)

Prince Charles Hospital, Merthyr (Cwm Taf Health Board)