Quality statement for vascular disease

Vascular disease is when vessels become narrowed or blocked, often due to a build-up of fatty deposits, compromising blood and potentially leading to tissue damage, gangrene, or even limb loss. Blood vessels may weaken and enlarge, forming aneurysms that can rupture without warning, potentially resulting in sudden death.

Vascular disease is common and becomes more prevalent with age. Peripheral arterial disease (PAD) affects approximately 20% of people over the age of 60 in the UK and is associated with an increased risk of heart attack and stroke. Around 25% of those with PAD develop symptoms, which, if left untreated, can progress to serious limb-threatening complications. Abdominal aortic aneurysms (AAAs) are also age-related, affecting 1 to 3% of men aged 65 and older.

With rising rates of diabetes and cardiovascular disease in Wales, vascular disease is becoming more prevalent. Patients are often older and have multiple conditions, and more than half of vascular cases are emergencies or urgent referrals. This has led to increased focus on early detection and managing risk factors such as smoking, hypertension, and cholesterol to improve long-term outcomes. Addressing these risks early can delay or prevent arterial disease and its effects.

The core activities of the vascular service include promoting cardiovascular health, facilitating communication and shared decision-making with patients and families, preventing limb loss from peripheral arterial disease and diabetes-related complications, reducing the risk of stroke due to carotid artery stenosis, preventing death from aortic diseases, and improving quality of life for individuals with venous disease. The vascular team also play a key role in managing acute diabetic foot problems, performing bypasses, debridements, and minor and major lower limb amputations. They also manage other conditions in close collaboration with other specialties, such as major trauma and nephrology.

Over the past two decades, vascular services have advanced significantly. Today, patients benefit from complex open surgery, minimally invasive endovascular techniques, or a combination of both. These improvements have enhanced safety and outcomes, particularly for older patients with multiple health conditions. As care complexity increased, vascular surgery has become a standalone specialty in the UK and services have centralised to specialist centres to concentrate expertise and resources. The National Vascular Registry has also improved standards and aligned UK outcomes with international benchmarks.

Although a person may present with 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. The NHS is developing national optimal pathways that provide an overarching framework for the delivery of vascular care, ranging from prevention to the management of those requiring treatment for vascular conditions. These pathways support system-wide improvements by reducing unwarranted variation in care and improved patient outcomes.

There is a clear need to ensure equity of access for individuals and communities who have historically faced inequality, including ethnic minority communities. To address this, the national optimal pathways are being designed with greater flexibility to accommodate diverse needs and remove barriers to access. This means embedding inclusive principles into planning, commissioning, and delivery processes to ensure that all individuals can access services that are responsive, culturally appropriate, and equitable.

Nationally comparable datasets, peer review, and national audits such as the National Vascular Registry are used to support continuous quality improvement, reduce unwarranted variation, and ensure equitable access to high-quality care across Wales. Service guidance is also available from the Vascular Society: Provision of Services for People with Vascular Disease.

This approach aligns with the National Clinical Framework which focuses on the development of national optimal pathways and the Quality Safety Framework which emphasises the importance of systemic local use of the quality assurance cycle. It also promotes collaboration other groups to address prevention, rehabilitation, pain management, end-of-life care, and related conditions like heart disease, 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 planning expectations set out below. They will respond to this Quality Statement through the integrated medium-term planning (IMTP) process. The NHS Wales Performance and Improvement Vascular Network, in collaboration with regional senior leadership groups, will support health boards to improve the quality, consistency, and value of healthcare delivery.

Equitable

1. Organisational leaders, clinical teams, and operational managers routinely collaborate at the national level through the NHS Wales Performance and Improvement Vascular Network to improve the quality and equity of locally delivered vascular services.
2. NHS Wales Performance and Improvement monitor vascular service data and peer review outputs to identify and escalate variation or fragility through formal accountability processes.
3. Health boards, with support from Health Education and Improvement Wales, use regional planning processes to ensure a sustainable service, with an equitably distributed vascular workforce.

Safe

4. Health boards configure vascular services to keep pace with defined clinical standards, to ensure consistent and sustainable delivery of high-quality care. This may involve reorganisation at a health board, regional or supra-regional level.
5. NHS Performance and Improvement reports evidence of harm or service fragility through the national Quality and Delivery Board for system-wide action.
6. Health boards ensure safe and timely access to urgent and emergency vascular services for key index conditions such as critical limb-threatening ischaemia, symptomatic carotid disease, and abdominal aortic aneurysms. This includes appropriate investment in workforce and infrastructure to maintain clinical competencies and service resilience.
7. Health boards support regular MDT meetings and embed protected time in consultant job plans to ensure timely and collaborative decision-making.
8. Health boards ensure clinical decisions are clearly documented, including rationale and risk-benefit considerations, particularly for high-risk vascular interventions.

Effective

9. Nationally optimised evidence-based pathways for vascular services are fully embedded in local service delivery, including timely access to diagnostics, specialist assessment, transfer, repatriation, and rehabilitation.
10. Health boards provide patients at risk of, or diagnosed with, vascular disease support to manage their condition through lifestyle advice, early intervention, and whole-system approaches that include relevant specialties such as diabetes, renal, cardiac, pain management, and palliative care.
11. The NHS Wales Performance and Improvement Vascular Network works with partners, including the Value Based Health and Care Academy, to develop new models of care that includes prevention strategies for high-risk individuals.
12. Health boards provide patients coordinated care based on clinical need, supported by cross-specialty collaboration, timely information sharing, and continuous service evaluation.

Efficient

13. Health boards apply nationally agreed vascular pathways and service specifications to reduce variation, support efficient service delivery, and improve patient outcomes.
14. Health boards roll out of electronic patient records and prescribing to support efficient vascular care delivery. 
15. Health board clinical staff working in vascular services are supported to work at the top of their license and are encouraged to participate in service innovation, research, and quality improvement activity to enhance value and efficiency.

Person centred

16. Health boards deliver care that is person-centred, respecting individuals’ values and preferences throughout the vascular pathway. Shared decision-making is supported at key points of care, including discussions on treatment options, prognosis and long-term outcomes.
17. Health boards assess holistic patient needs to identify what matters most to people living with vascular disease, and ensure timely access to appropriate physical, psychological, social, and peer support.
18. Health boards offer advance care planning, where appropriate, ensuring that patients with life-limiting vascular conditions can make informed choices about future care and avoid non-beneficial interventions.
19. Health boards signpost to voluntary sector and community resources, ensuring that support extends beyond clinical treatment and considers the wider impact of vascular disease.

Timely

20. Health boards provide validated processes to identify people at risk of, or living with, early-stage vascular disease to enable appropriate referral from primary to secondary care in a timely manner.
21. Health boards ensure timely access to specialist vascular surgical opinion, particularly in secondary care hospitals that do not have onsite vascular services.
22. Health boards assess and treat people referred through the Wales Abdominal Aortic Aneurysm Screening Programme in line with agreed national timeframes and standards.
23. Health boards review component waits across the vascular pathway to identify delays and support pathway redesign.

Vascular services are subject to a comprehensive set of national performance measures. The National Vascular Registry and the NHS Wales Performance and Improvement Vascular Network dashboard provides clinically-led benchmarking to drive improvement in quality and outcomes.

The NHS Wales Performance and Improvement Vascular Network conduct regular audits to assess service adherence against agreed service specifications. These include key indicators such as 24/7 access to emergency surgery, MDT activity, referral-to-treatment times, postoperative outcomes, and average length of stay.

Data from Patient Reported Outcome Measures (PROMs) and the newly developed Patient Reported Experience Measure (PREM) for vascular patients are used to monitor service quality from the patient perspective.

In partnership with Health Education and Improvement Wales, an annual Workforce and Infrastructure Report is published, detailing staffing, capacity, and service provision across the vascular networks. This report supports long-term service planning and investment in a sustainable and equitable workforce.