The Brompton Blues

Two consultants from the Royal Brompton hospital – cardiologist and intensivist  Susannah Price and anaesthetist Sarah Trenfield – are unimpressed with MD’s criticism of their hospital for it’s expensive legal challenge to the Safe and Sustainable review of child heart surgery (Eye last).  ‘The review will lead to the closure of one of the top three paediatric (and one of the most successful) cardiac centres in the country, jeopardising the largest paediatric cystic fibrosis unit in the UK, together with the biggest adult congenital heart disease unit in the country. Such centres comprising teams with world renowned expertise and outstanding results take decades to construct, and cannot be reconfigured piecemeal elsewhere without serious damage.’

MD is unmoved.  All eleven child heart surgery centres signed up to the review on the understanding that to continue to improve the service, and avoid future scandals, surgery should be concentrated in fewer, larger units with the appropriate staffing, expertise, throughput, resources, training and ability to expand.  This would not mean a cut in services, but some teams transferring to a different site, which in London would only be a short distance away.

During consultation,  75% of respondents supported the proposal that the number of surgical centres in London should be reduced from three to two.  Even in London,  47% of respondents supported the proposal for two centres. Great Ormond Street and the Evelina Hospital were  selected as the preferred London options for public consultation because they are dedicated children’s hospitals with all the necessary  facilities and services available on one site.  The Brompton is not a children’s hospital and does not have all necessary paediatric services on site. Clinicians from other hospitals assist with cardiac children when needed, and it does indeed get excellent results. However, the results and service could be even better and more sustainable if expertise was pooled on two sites.

In 2009 clinicians from the Brompton produced a paper with Great Ormond Street highlighting the advantages of centralising heart and lung services¹. And a panel of international respiratory experts dismissed the Brompton’s claims about the impact  of  moving cardiac surgery to cystic fibrosis services. ²    The litigation launched by the Brompton proved even more costly to the NHS due to the extreme claim that “all” respiratory services would be rendered “unviable”. The independent panel disagreed.  And although the poisonous claims of impropriety made against three eminent clinicians involved in the review were dismissed by the judge at the judicial review and then three appeal court judges, they don’t bode well for a harmonious merging of services.

It’s clear that pooling of expertise requires experts to work constructively together. The review, however well intentioned and supported initially, could fall to pieces if there are simmering resentments about where the surgery is taking place. Half of children with congenital heart disease don’t need surgery at all. Most care occurs close to home. Of those who do need surgery, over 80% only need it once – and it’s crucial to get it spot on first time round. Surgeons maintain and develop skills by operating on sufficient numbers of children, and evidence suggests that higher-volume surgical units have better clinical outcomes (Eyes passim). In the current financial crisis, no hospital likes losing business and it’s understandable that a surgical team performing very well is reluctant to move. But as surgery gets more complex, and the training gets tougher, the specialty can only survive in future if the staff  agree to work in fewer, larger, centres of excellence. The reorganisation of stroke services in London   – against strong political opposition – has vastly improved care for patients. Twenty years after the Eye broke the Bristol heart scandal, it’s high time paediatric cardiac surgery grew up and followed suit. The final decision on the 6 or 7 surgical centres will be made on July 4.

MD

1 http://www.specialisedservices.nhs.uk/document/improving-children-s-congenital-heart-services-in-london

2 http://www.specialisedservices.nhs.uk/document/report-independent-panel-on-relationship-interdependencies-at-royal-brompton-hospital/search:true

Unhappy Anniversary

It’s now twenty years since the Eye broke the story of the Bristol heart scandal (Eye May 8, 1992). It took seven years to get a public inquiry which, in 2001, declared that 30-35 more children under one year died from open heart surgery in Bristol between 1984 and 1995 than at other comparable units. A similar number were left severely brain damaged. The overriding conclusion was that to make the service safe, complex child heart surgery has to be concentrated into fewer, larger units with the appropriate staffing, expertise, resources, audit and training – and the crucial ability to expand. Twenty years later, we’re still waiting.

We have, however, had a further scandal in a small unit (Oxford), an estimation of another 78 ‘excess deaths’ spread over four units in eight years, two expert reviews calling for a reduction in the number of centres and the clinical director of the NHS – Sir Bruce Keogh (himself a cardiac surgeon) –declaring that ‘failure to reconfigure child heart surgery will be a stain on the soul of the specialty and will compromise the treatment of the most vulnerable members of the next generation.’ (Eye 20.1.10)

So why the delay? Politicians rarely show strategic leadership in the NHS, particularly when it necessitates the closure or down-grading of a specialist unit in their constituency. There are currently around 30 consultant heart surgeons who operate on children spread across 11 surgical centres in England. The latest review, Safe and Sustainable, is overseen by a Department of Health-mandated organisation called the Joint Committee of Primary Care Trusts (JCPCT). It managed to get all 11 centres to sign up to a process that was highly likely to recommend a reduction in the number of centres. After the most exhaustive and transparent consultation in NHS history, options were proposed for future centres which the Royal Brompton and Harefield trust didn’t like. Last year, it derailed the review by getting the process of choosing centres quashed, with the judge ruling the assessment had not taken proper account of the London hospital’s research strengths.

For good measure, the Brompton also threw in allegations of bias and impropriety against specialist advisers to the JCPCT who are connected with Great Ormond Street Hospital, the Evelina Children’s Hospital and Southampton General Hospital. The JCPCT appealed against the judicial review finding, and on April 19^th three Court of Appeal judges ruled that the Safe and Sustainable process for the public consultation was fair, lawful and proper, and dismissed as unfounded all of the allegations raised by the Royal Brompton Hospital. In the meantime, the Brompton has blown at least £1.5 million on legal fees that should have gone on patient care, and the process of making child heart surgery safe has been delayed for another year.

Stephen Bolsin, the cardiac anaesthetist who sacrificed his NHS career by blowing the whistle in Bristol, would doubtless be horrified that the culture of infighting, commercial interest and misguided institutional loyalty that blighted Bristol twenty years ago is still prevalent in the NHS now, and that babies undergoing complex heart surgery are still suffering ad a result. Professor Bolsin is flying in from Australia speak to the Patient Safety Congress on May 29^th in Birmingham. As Professor Bolsin puts it: ‘Improved ethical behaviour in health and social care is mandated by professional and managerial failings such as Bristol, Mid Staffs, North Staffs and ‘Baby P’. The benefit is a significant quantifiable cost saving amounting to billions of pounds each year.’ As the Royal Brompton has proved, litigation is a very expensive and harmful substitute for proper consultation.

MD