Hearts and Minds again

The Safe and Sustainable programme to reorganise child heart surgery just 19 years after the Eye broke the story of the Bristol heart scandal is running in to difficulties. There are currently around 30 consultant heart surgeons who operate on children spread across 11 surgical centres in England.  All signed up to a process that was likely to recommend a reduction in the number of centres so specialist expertise and resources can be concentrated in fewer, safer centres better equipped for training and expansion. This process was made all the more urgent by the Oxford scandal (Eye 30.7.2010) and a report last year that found that 76 ‘excess deaths’ had occurred in just four centres between 2000 and 2008 (Oxford, Leeds, Guys and St Thomas’s and Leicester). This was the same methodology used to count the excess deaths at Bristol.

The Children’s Heart Federation, which exposed the Oxford scandal, has now written to the Care Quality Commission asking them to urgently investigate the high number of reoperations that appear to be occurring in the Leeds unit, and any damage associated with them. Meanwhile, Yorkshire MPs have this week secured a Commons’ debate to try to halt the reorganisation and save their local unit. Alas they appear to have been swayed by egos in the hospital rather than the safety of patients.

The Bristol Inquiry also recommended a decade ago that services for children with very rare heart conditions such as Truncus Arteriosus (TA), in which a single vessel comes out the ventricles rather than two, ‘should only be performed in a maximum of two units, validated as such on the advice of experts.’ The latest figures, for 2009, show that Birmingham performed 14 TA operations, Leicester and Newcastle 3 each, Leeds, Great Ormond Street and Alder Hey 2 and Oxford, the Brompton, Guys and Bristol just 1 each. Southampton didn’t do any but had done two the year before. MD wouldn’t let his dog go to a surgeon who does ‘1 a year’ of anything, especially if there’s another who does 14 a year just up the road. Despite the recommendations of a hugely expensive and very traumatic public inquiry, child heart surgeons are still being allowed to dabble in rare complex cases.

Lest we forget, disgraced heart surgeon James Wisheart told Jim and Bronwen Stewart in 1994 that their son Ian had a 67% chance of surviving his TA repair and that the chance of brain damage was very remote. BBC Newsnight later revealed that, prior to Ian’s operation, Mr Wisheart had performed 11 TA operations with nine ‘early’ deaths. Ian survived, suffered profound brain damage but appeared in the surgical audit as a ‘success’ because he was still alive after 30 days. The Stewarts had to fight for years for compensation, never got justice and publically derided the GMC hearing and Public Inquiry as hollow shams that would change nothing.

And they may have a point. Some of the centres are now having cold feet about merging. The Royal Brompton hospital (RBH) and Great Ormond Street hospital (GOSH) had even agreed, in April 2009, to merge cardiac services at GOSH in the report of ‘A Proposal to Establish A National & International Service for Children with Heart & Lung Disease’. Now RBH is taking the Safe and Sustainable Review to Judicial Review, which will cost the tax payer millions, delay implementation by many months and allow smaller, inadequately resourced units to keep struggling on and surgeons to keep dabbling in the rare stuff.

The needs of Isle of Wight’s 145,000 residents were not factored into the whittling down process; an omission which worked against the survival of Southampton’s unit, which is one of the best and safest in the country. Had the Isle of Wight been included – as it undoubtedly should have been – Southampton should have been safer for geographical reasons. The review says there should be a maximum of 3 hours’ (4 for remote areas) travel time to the nearest specialist centre, based upon the same methods used for deciding paediatric intensive care provision. If the Isle of Wight is factored in – and Southampton’s unit closed – the travel times from its main hospital St Mary’s to either Bristol or the two London units are over the four hour ‘remote’ deadline. The review panel has now ‘developed scenarios that show it is possible for an ambulance from London or Bristol to reach the island in under 4 hours by road and ferry – but not all the time.’ So that’s all right then.

MD

CQC – Can’t Quite Cope

The Care Quality Commission’s failure to stop the torture of patients at Winterbourne View Private Hospital in Bristol, despite the repeated pleadings of a whistleblower, is yet more evidence that it isn’t fit for purpose. And the CQC knows it. Last month, the Health Service Journal published minutes of a recent CQC board meeting, which acknowledged it faced ‘three major areas of risk, all of which were likely to happen.’ ‘1. Failure to effectively identify or deal with non compliance leading to persistently poor quality care for users. 2. Lack of volume and/or type of resource to meet the demands placed on it, leading to unacceptable levels of performance. 3. Failure to operate in line with required standards of probity and value for money.’

A key issue is whether the CQC should be both an investigator and a regulator. As the Eye argued 12 years ago (Eye November 1999), the NHS needs a lean and fast independent inspection team in every region, staffed by experienced clinicians, rather than ex-policemen, that can go into any hospital or GP surgery after one unexpected death or serious injury, complaint or staff concern, rather than wait for a whole pile of bodies to mount up. Labour created a Commission for Health Improvement (CHI) that started off well, but their reports were so hard hitting and politically embarrassing they soon fell out of favour. CHI was replaced by a Healthcare Commission (HCC) which lost independence when its inspection standards were decided by the Department of Health. A National Patient Safety Agency was set up to monitor NHS errors, but wouldn’t share its information with the HCC. And yet another regulator, Monitor, was set up for Foundation Trusts and didn’t want anything to do with the HCC.

The HCC’s Annual Health Check for hospitals was just a simplistic check list of supposed standards that managers found it very easy to game, and told patients little about the quality and safety of their hospital. Dr Foster’s mortality rates should have blown the whistle on Mid Staffs but instead were dismissed by both the Trust and West Midlands Strategic Health Authority (chief exec Cynthia Bower, now chief exec of the CQC). The HCC had at least retained a proper investigative arm which belatedly went into Mid Staffs and unearthed appalling care and between 400 and 1200 avoidable deaths, which they passed onto the CQC. The CQC were so angry they gagged the lead investigator, Dr Heather Wood, until she was finally allowed to give her explosive evidence to the Mid Staffs inquiry. Dr Wood – one of the HCC’s best investigators – has no confidence that the CQC, in its current form, would have unearthed Mid Staffs.

The retrospective  ‘system management’ of regulatory bodies is incapable of picking up scandals until the body count is too big to ignore, which is why it’s vital to listen to staff brave enough to speak up. But this is not the first time the regulators have palmed off a whistleblower. Dr Pal identified serious shortcomings in the nursing and medical care of patients on Ward 87 of City General hospital, Stoke on Trent, when she started working there in August 1998 (Eye April 8, 2009). She complained to all three regulators – CHI, the HCC and the CQC. She found out from the CQC that the regulators didn’t even pass information on when they were closed down and opened up again with a different name. ‘As you can appreciate we had no knowledge or information about your concerns that you had raised with HCC or CHI in the past.’ A subsequent review in May 1999 by Mrs T Fenech from the Infectious Diseases Unit found ‘serious deficiencies in nursing practice’ and that ‘the level of care demonstrated for some patients on the ward at the time of my audit was nothing short of negligent’. But this failure, on the doorstep of Mid Staffs, did not warrant investigation by the regulator.

The CQC has neither the money, the methods nor the staff to competently inspect and regulate the whole of health and social, in both the NHS and the private sector. They failed to meet their own standards and timescales in registering dentists, and imposed inflexible paper-based policies and vast amounts of red tape that have merely succeeded in taking dentists away from teeth. Now they move on to GPs. The Health Bill should merge regulators – there aren’t the resources for both a functioning CQC and Monitor, and you can’t separate the money from the quality of care. More urgently, we need a truly independent inspectorate in every region that staff and the public trust,  that goes in hard and fast to investigate patient harm and publishes its findings in time to save lives.  MD