Which Way was Wrong? is a fact-checker. It provides a comparison between two crisis cancer situations with significant similarities. It provides evidence about the primary, underlying decision of Velindre in 2014 to eliminate (or ‘discount’) the world consensus model for new cancer centres. That model always places non-surgical treatments in co-location with surgical and other services at an acute hospital.
The original post last year exposed a deficiency in process for the current New Velindre programme. But now a Freedom of Information reply this January has come along to confirm and seal our verdict then (see the post Freedom of Information – but ‘where are the Velindre minutes?’)
How the case has grown
The disclosures of the FOI drove home our original conclusion that Velindre’s documents lacked evidence of formal peer consultation with partners and stakeholders. And it therefore also makes impossible any of those independent clinical reviews baselessly claimed by New Velindre.
What follows compares the landmark review of Mount Vernon and how it contrasts starkly with New Velindre. We could have made a similar comparison using the award-winning Clatterbridge Cancer Centre in Liverpool.
It was the ‘smoking gun’ left in the Nuffield Advice (Dec 1 2020) that inspired this updated investigation. The question now was whether or not a ‘large-scale options appraisal exercise’ existed to support New Velindre’s legitimacy.
Velindre has now pulled its own supporting online documents describing the narrative. But most of the relevant evidence remains in the Outline Business Case November 2020 and Co-locate Velindre holds the relevant screenshots.
What was done before full option appraisal was undertaken?
Extensive, independent external review, including the extensive gathering of views from interviewees formally and informally.
- This is all the information we have from Velindre: reference to a ‘number of clinical meetings and discussions’ (followed by Trust Board approval). No attendees, times and dates of this engagement or account of its deliberations (Strategic Outline Programme October 2014 137-138). And from the FOI result above, and Velindre’s admission in the press since, we have even less than this. For the supposed deliberations of those meetings and discussion left no minuting, notes or other formal records.
- No oversight or input external to Velindre appear in the account. No record for the period prior to selecting a clinical options list (3.9.3. ‘Estate Model Options’ non-financial, p.137) whether from clinicians or stakeholders.
How far was an independent body involved?
The Independent Clinical Advisory Panel led everything (commissioned by NHS England and ‘to be led by the East of England Specialised Commissioning Team’).
The FOI gives no evidence of any supervising external body, named or unnamed. In one press report Velindre mentions an unnamed facilitator, but we have no idea what they facilitated. Nor who discarded the usual ‘co-location’ from going forward to the options appraisal long-list. Nor when or how.
What depth of pre-options process?
Full Two-Day Programme of interviews (day, time and year dated), phone-calls, group engagement (Some names appear in more than one list).
- 32 consultants interviewed by phone ahead of the dedicated two days
- 39 senior clinicians and executives took part in personal interviews over two days of programmes (of whom only 3 were from the Mt Vernon Cancer Centre) along with 3 junior doctors
- 27 stakeholders interviews (of which only 10 were from Mt Vernon Cancer Centre). These represented hospitals, regions and cancer bodies.
- 21 propositions posed to consultants and stakeholders on: Clinical Delivery; Oversight and Leadership; Service Configurations; Capital & Estate; Sustainable Workforce; Research & Development; Development Opportunities.
In line with the FOI disclosure, inevitably no consultation with external clinicians appears in the Strategic Outline Programme. Neither the public nor stakeholders know anything today about dates, activities for the ‘meetings or the ‘discussions’.
What formal reporting from consultation?
As obvious above, the whole procedure was recorded in detail and became publicly available. Anonymous responses from all involved facilitated an honest ‘Consensus’ on 17 of the 21 propositions set out and a ‘Majority’ on the rest.
No pre-longlist, external peer consultation is described in the Strategic Outline Programme October 2014 with regard to ‘co-location’ or ‘stand-alone’.
How was the full options appraisal itself conducted?
- Carried out by the externally commissioned independent panel.
- Description of survey included.
- Full option appraisal included both ‘co-location’ and ‘stand-alone’ options.
- By consensus all ‘stand-alone’ models eventually excluded from the shortlist but only subsequent to interviews. It was ‘not considered clinically acceptable’, so leaving just two versions of co-location.
- The appraisal account describes only that part of the process decided already by undocumented deliberations. These ‘discussions’ discarded co-location well ahead of the preferred longlist. Yet everywhere else in the UK co-location was the dominant trend in cancer centre planning.
- No information appeared in the Strategic Outline Programme (SOP) concerning named participants nor any large-scale survey.
- Reasons for the exclusion of co-location got a listed, abbreviated appearance without reference to the deliberation process. The Nuffield Advice later directly contradicted some of the reasons offered for the decision (see below).
What outcomes flowed from the full options appraisal?
- Emphatic recommendations appear in the record, requiring a new build on an acute site and centralising main operations there, especially acute care, trials, research and training.
- This was to happen whether or not a scaled down form of the original cancer centre remained in situ.
- Measures emerged for safety and effectiveness required to be taken for the period of transition, similar to the holding actions recommended by the Nuffield Advice for Velindre.
Longlist and shortlist considerations from a selection of ‘stand-alone’ options only decisively influenced the emergence of one preference. No names appeared for those making these options decisions or for where the meetings came in the timeline.
New Velindre on co-location and Nuffield Advice
- Velindre’s account of why co-location was excluded includes three major explanations contradicted by Nuffield:‘The critical care /transfer system provides the required levels of safety and responsiveness to manage patients (SOP p.137).
Nuffield: ‘Safety – the management of acute illness can require immediate access to a range of clinical disciplines. Some of this can be provided by telephone or video but there are cases where it is necessary for an expert to examine the patient in person or perform a procedure… Trends in the toxicity and complexity of treatment and the growing number of patients with comorbidities and side effects from treatment mean that access to critical care and advanced support to deal with rapid deterioration is very important.’ (pp.47-48).
- ‘Research and development activities currently are multi-organisational and dispersed across Wales… the mantra must be about ‘relationships’ and not places’ (SOP 138).
Nuffield: It displays widespread agreement that the nature of the current and proposed services at the VCC make it unsuitable for some types of research due to the high levels of risk associated with the treatments carried out at the planned new centre. ‘The future delivery of Phase 1 trials in Wales will largely need to take place on a site where immediate escalation of care is possible, and also the provision of additional medical specialty support. This is not part of the new Velindre site plan and therefore Phase 1 trials will need to take place elsewhere.’
- ‘Co-locating Velindre Cancer Centre on an acute site would potentially weaken the culture of the organisation, its values and beliefs…’ (SOP 138).
Nuffield: ‘the specialist unit can still retain a distinct identity. It may have a separate building… or a physically distinct wing… In some cases the unit may even have a separate organisational form even though it is on the campus of a larger organisation…’ (p.49).
Welsh Government’s role
Welsh government has facilitated and approved this clinical decision for stand-alone without seeing any apparent deliberations behind the key decision. It seems still unconcerned about the lack of visible clinical consultation with partners and stakeholders, and so remains out of line with routine practice in the UK (see Nuffield Appendix 1).
Despite this most basic non-compliance from its flagship cancer project, Welsh Government from the start rewarded the programme with unprecedented NHS capital funding. This contrasts with its more recent snubbing of senior clinicians, calls from MP and MS for an external independent review and strong representation from its distinguished external advisory board. Welsh Government has opened itself up to censure for:
- approving more than once the Strategic Outline Programme of 2014 and the resulting Outline Business Case. Each of these begin with prior, undocumented exclusion of the dominant clinical model in the NHS UK for transforming cancer provision.
- influencing the options appraisal which should mainly be a clinical-led process. The 2017 Programme Business Case records a Welsh Government condition of funding: ‘the entire nVCC should be built in Whitchurch, Cardiff, and on land under the ownership of the Trust.’ (Velindre: Programme Business Case September 2017 page E4 of E43). This rule specifically ruled out relocation to an acute hospital site, the natural frontrunner.
- by refusing to countenance any independent reviews, because of its misplaced belief that Velindre’s leaders are the ‘expert providers’1 of cancer care, competent to decide ‘what the best model is to treat cancer’ (Letter 22 November 2020 to Ms Beverley Woods). This level of ignorance of cancer’s complexity was dispelled by Nuffield: ‘…the decision to site the new VCC on the Northern Meadows… is fundamentally about values and the choices that need to be assessed and taken by all involved.’ Wales is teeming with genuine cancer expertise from many contributors in varied fields.
It is easy to see in this uninformed claim why Welsh Government has earned so many enemies. There’s no record to show it ever took interest in an all-region consensus on cancer transformation or formally required a large-scale review. And in such statements, it is perceived as continuing to snub senior clinicians, independent expert reports and global expertise.
Links to documents:
Mount Vernon Cancer Centre
see also the start:
and the progress:
Velindre Cancer Centre
Illustrative Appendices for Mount Vernon Breadth of Consultation
Appendix 3 Clinical Advisory Panel Programme Participants (19/20 June) [p.29]
Name Position Jagdeep Kudhail Divisional Chair, Cancer Division
Dr Paul Mulholland Clinical Director, MVCC Sarah James Hospital Director, MVCC
Kelly McGovern Head of Nursing, Cancer Division, MVCC
Neel Bhuva Clinical Oncologist Maggie Fitzgerald Deputy Head of Nursing
Trisha Webbe Associate Director, Cancer Division
Sarah Morgan Matron, Out-patients
Dean Weston In-patient and Palliative Care Manager
Claire Dua In-patient Matron
Humaira Jamal Palliative Care Consultant
Suprotim Basu Consultant, in-patient lead
Zandie Chakunda Acute Oncology, Lead Nurse
Laura Morrison Junior Medical Staff
Jyotsna Bhudia Junior Medical Staff
Mohammed Abdul-Latif Junior Medical Staff
Dr David Miles Clinical Lead for Chemotherapy
Jo Demare Chemo, AOS, OPD and Medical records Service Manager
Michelle Orsmond Chemotherapy Matron
Vikash Dodhia Lead Pharmacist
Andrew Hood Chief Pharmacist
Amanda Webb Palliative Care CNS
Melanie Blyth Lung CNS
Helen Blyth Lung CNS
Helen Johnson Haematology CNS
Cathy Cale Medical Director, Hillingdon Hospital
Beverley Flower Accountable Officer, ENH CCG
Sharn Elton Clinical Lead, Cancer services, ENH CCG
Lizzy Bovill Director of Performance, NWL SRO for Cancer
Edward Bramley-Harker EDGE
Kim Fell NHS E/I
Roberto Alonzi Brachytherapy Consultant
Pete Ostler Breast, Urology and Brachytherapy Consultant
Suzy Mawdsley Head of School for Clinical Oncology, London
Daniel Megias Head of Radiotherapy
Karen Venebles Head of Radiotherapy, Physics and Bioengineering
Claire Strickland CEO, Paul Strickland Scanner Centre
Professor Padhani Consultant Radiologist,
Paul Strickland Cancer Centre
Suzanne Douglas Lead Clinical Scientist, Nuclear Medicine
Andrew Shah Head of Radiations Protection
Rachael Corser Director of Nursing, ENHT
Philip Smith Associate Director, research and Development
Paul Nathan Medical Oncologist
Marcia Hall Clinical Lead, R & D
Anita Holmes Trust Lead Research Nurse
Appendix 4 Clinical Advisory Panel Participants – telephone call interviews
Dr Roberto Alonzi Clinical Consultant Urology
Dr Nicola Anyamene Clinical Consultant Upper and Lower GI
Dr Neel Bhuva Clinical Consultant Upper and lower GI
Dr Kevin Chiu Clinical Consultant Head and Neck
Dr Shirley D’Sa Consultant Haemato-Oncologist Haematology
Dr Jeanette Dickson Clinical Consultant Lung
Dr Rob Glynne-Jones Clinical Consultant GI
Dr Amy Guppy Medical Consultant Breast
Dr Marcia Hall Medical Consultant Gynae
Dr Mark Harrison Clinical Consultant Upper and lower GI
Prof Peter Hoskin Clinical Consultant Urology
Dr Humaira Jamal Palliative Care consultant Palliative Care
Dr Jonathan Lambert Consultant Haemato-Oncologist Haematology
Dr Catherine Lemon Clinical Consultant Head and Neck
Dr Alan Makepeace Clinical Consultant Breast
Dr Andreas Makris Clinical Consultant Breast
Dr Suzi Mawdsley Clinical Consultant Upper and lower GI
Dr David Miles Medical Consultant Breast
Dr Paul Mulholland Medical Consultant Neuro
Dr Paul Nathan Medical Consultant Melanoma
Dr Peter Ostler Clinical Consultant Breast
Dr Andreas Polychronis Medical Consultant Upper and lower GI
Dr Nihal Shah Clinical Consultant Breast
Dr Anand Sharma Medical Consultant Germ cell
Dr Heather Shaw Medical Consultant Melanoma
Dr Narottam Thanvi Clinical Consultant Breast
Dr Ignacio Vazquez Medical Consultant Breast
Dr Anup Vinayan Clinical Consultant Breast
Dr Charlotte Westbury Medical Consultant Breast
Dr Kee Wong Clinical Consultant Head and Neck
Dr Hannah Tharmalingham Clinical Consultant Gynaecology
Appendix 7 Stakeholder Interviewees (p.34)
Caroline Blair NHSE
Christine Moss West Essex & Hertfordshire STP
Jane Brown Healthwatch Hertfordshire
Turkay Mahmoud Healthwatch Hillingdon
Jo Murfitt NHSE Michael Chilvers E&NH (Executive Team)
Laura Churchward UCLH
Cathy Cale Hillingdon Hospitals FT
Sarah James E&NH (MVCC)
Claire Strickland Paul Strickland Scanner Centre Jagdeep Kudhail E&NH (MVCC)
Kelly McGovern E&NH (MVCC)
Julie Smith E&NH (Executive Team)
Sue Douglas E&NH (MVCC) Dan Megias E&NH (MVCC)
Hannah Tharmalingam E&NH (MVCC) Paul Mulholland E&NH (MVCC)
Prof Hoskin E&NH (MVCC)
Harper Brown West Essex & Hertfordshire STP/East & North Herts CCG
Nicky Bannister Herts Valleys CCG
Rachael Corser E&NH (Executive Team)
Sarah Brierley E&NH (Executive Team)
Mandy Sanderson NHSE and I Nicola Hunt RM Partners West London Cancer Alliance
Naser Turabi North Central and East London Cancer Alliance/UCLH
Maggie Fitzgerald E&NH (MVCC)
Mohammed Abdul-Latif E&NH (MVCC)