Eye success

In 1997, the Eye first exposed the wide variation in quality of care in the UK for the treatment of children with cleft lip and palate, with large numbers of centres doing relatively few operations with poor cosmetic results. A North West of England audit had found that 48% of children required major and often multiple reconstructive surgery, largely because of failure of the original surgery. In addition, Royal College of Surgeons guidelines were being flouted and a petty turf war was being fought out by plastic surgeons and maxillo-facial surgeons to the detriment of patients (Eye 937). Four months’ later, the Clinical Standards Advisory Group of the Department of Health (CSAG) echoed the Eye’s warnings. After investigating 297 children aged 5 and 277 aged 12 who had all undergone cleft repair in Britain, they found that 40% had poor dental bite, less than a third had a good lip appearance at the age of 12 and under half could speak with normal intelligibility at that age.

The CSAG stated that of the 57 centres carrying out the operation, only 6-8 provided good to
excellent care and the overall results were 5-12 times poorer than in the six European centres examined. And the key factor causing poor training and poor results from “specialists” (sic) doing one or two operations a year was “competition between plastic and maxillo-facial surgeons.” This report found that not only are many surgeons continuing to perform operations they are not competent to do, but they were failing to keep adequate records or perform proper audit. A further factor in this incompetence was the financial pressure from trust managers to do the operations locally, cheaply, occasionally and badly, rather than refer to a more expensive specialist centre.

CSCAG recommended that the number of centres undertaking cleft work should be reduced from 57 to between 8 & 15 “so that expertise and resources are concentrated”. Fast forward 15 years and the thousand children born each year with cleft lip and/or palate all now get operated on in one of just 11 centres of excellence. Complication rates have more than halved and success rates for alveolar bone grafting have risen from 58% to 85%. The standard of audit has improved dramatically and centralisation has enabled coordinated research that will further improve treatment in the UK and worldwide¹. The long overdue centralisation of child heart surgery should reap similar benefits.

Another Eye success

Following the exposure of shocking failures in the treatment of breast cancer patient Debbie Westwick, who now has metastatic disease, (Eye March 2012) the GMC finally got around to judging  that oncologist  Howard Smedley was guilty of serious misconduct. A Fitness to Practice Panel found ‘Dr Smedley’s misconduct involved a significant failure to follow establish guidelines in relation to the treatment of breast cancer. He has the opportunity to reflect on the appropriateness of his treatment plan but failed to do so. In failing to obtain DW’s properly informed consent Dr Smedley breached the guidelines of Good Medical Practice and Seeking Patient’s consent, and this is, in the Panel’s judgement, serious misconduct in the circumstances of the case.’

The GMC did not explain why it took three years from Debbie’s first complaint to pronounce, nor why they didn’t act sooner to protect patients. Unbeknown to Debbie, Smedley was subject to ‘supervision undertakings’  imposed by the GMC when she was originally referred in 2006, for reasons that they refuse to reveal. Four fundamental errors occurred whilst he was under GMC supervision but weren’t flagged up.  Her surgeon, Mr Jackson, was then suspended in the middle of her treatment, subsequently sacked and referred to the GMC. The CQC and local cancer network also don’t seem to have acted swiftly to protect patients for harm. But at least Debbie now has a measure of justice. And Dr Smedley has voluntarily removed himself from the medical register.

1 British Dental Journal 212, 525 (2012)

Lansley Vs Nicholson Round 12

Any health secretary hoping to force untested free-market health reforms on a resistant NHS needs a chief executive with a similar ideology to push them through. Unfortunately for Andrew Lansley, he’s got David Nicholson, a command and control former member of the Communist party. At this year’s Patient Safety Congress, MD asked Nicholson whether he supported Lansley’s reforms. He said: ‘I lack the imagination to have come up with them.’ Even more damning was that not a single one of 700 delegates thought the Health and Social Care Act would make the NHS safer for patients, and a majority thought it would make it less safe.

Massive structural change at a time of massive debt creates a perfect storm in the NHS for Mid Staffs type disasters, as staff take their eyes off patients to balance the books whilst endlessly reorganising. In August 2009, David Cameron promised : ‘We will not persist with the top-down re-structures and reorganisations that have dominated the last decade in the NHS.’  In government he has done the opposite, implementing reforms that Nicholson says ‘are so big, you can see them from space.’

Nicholson remains in office to oversee the NHS debt crisis – £20 billion must be saved over 5 years – but it’s given him a golden opportunity to scupper Lansley’s reforms. Lansley promised GPs they could organise themselves into groups of any size and reshape the NHS by innovating, closing down unprofitable hospitals and developing services closer to patients. Bullish GP consortia of all shapes and sizes popped up with corporate brands like Bexley Clinical Cabinet, the Red House, the Fortis Group, Cumbria Clinical Senate and Principia.

Fast forward 2 years and these clinical commissioning groups (CCGs) have been rounded up by Nicholson and forced to merge until they’re the same size as the Primary Care Trusts (PCTs) they replaced. They have been given a measly running cost allowance that will minimise their chances of commissioning locally. The new National Commissioning Board is starting to enforce top down financial targets and micro manage GPs, just as the Department of Health currently does. The GPs have been forced to accept centralised commissioning support advice from new organizations that are almost identical in size and personnel to the Strategic Health Authorities they replaced. And the CCGs have been ordered to abandon their lovingly chosen names to become identikit PCTs. So Principia will become NHS Rushcliffe CCG.

The battle between Lansley and Nicholson has ensured vast amounts of time, money, stress and anxiety have been expended dismantling organizations to rebuild them under another name. Clearly one of them has to go, but who? Both could both be undone by the Mid Staff’s inquiry report, due in the autumn. Its recommendations could strongly contradict Lansley’s reforms. Nicholson has his fingerprints on Mid Staffs – he was chief executive of Shropshire and Staffordshire SHA – and has overseen an NHS culture where whistleblowers have been repeatedly suspended, sacked and silenced, senior NHS managers protected and bad news buried under a pile of legal threats. (See Shoot the Messenger).  Two of the Eye’s ‘cussed quartet’ – Dr Jayne Collins, chief executive of Great Ormond Street and Cynthia Bowyer, chief executive of the CQC, have now resigned from their jobs and DH director of commissioning Barbara Hakin might have to follow suit if the Health Select Committee takes evidence from the gagged former Lincolnshire chief executive Gary Walker.

The noose is tightening on Sir David Nicholson but he’s sure to leave with a gold-plated pension. Meanwhile, Lansley can only bully doctors into ill-advised industrial action over theirs, and hope that when he leaves office he’ll be rewarded with some lucrative directorships and consultancies for opening up the NHS market. Back on earth, the proportion of patients waiting more than four hours in A&E has increased by more than a quarter over the last year, reaching its highest level since 2004.

Shoot the Messenger has been shortlisted for the Martha Gellhorn Prize for Investigative Journalism

Time to investigate Alder Hey?

What has been done to properly investigate allegations of avoidable death, suboptimal care and lack of informed consent at Alder Hey Children’s Hospital?  Back in 2007, it was alleged that a baby died hours after surgery despite the explicit advanced warning of a specialist surgeon not to operate at that stage. An excellent outcome would normally be expected in the overwhelming majority of such cases. The whistleblowing surgeon raised his concerns with the then Clinical Director, who did not investigate but instead made his life difficult through withholding on-call work, job plans and travel payments. The whistleblower was then suspended on the trumped up charge of being a ‘self-harm risk’.

In 2010, another baby allegedly suffered avoidable bowel damage during routine surgery at Alder Hey. No incident form was completed. X-ray evidence suggested a leak from the bowel and the child died a few days later. Another surgical whistleblower tried to get both cases properly investigated but thus far without success.

A subsequent Royal College of Surgeons (RCS) visit registered ‘incomprehensible failure’ at the lack of proper investigation, but this was excised from the publicized report along with anonymous cases of suboptimal care. The RCS found medical notes to be confused, or to have disappeared. They did not look at the nursing records. In one case, a senior surgeon struggling with stress and ‘failing eyesight’ was allegedly responsible for a child who was seriously harmed during routine day case surgery. He requested that discussion of this case not be minuted in light of legal action, but vast compensation was apparently paid out. In other cases, parents are allegedly still unaware of the true extent of the harm. In one case an accident in theatre went unreported despite the clear national guidance and the child later died in unusual circumstances yet without post-mortem or adequate investigation.

Prior to 2011, the department was not recording and circulating minuted reviews of children’s deaths such that learning was not shared and errors recurred. This meant in over 60% of surgical deaths, Alder Hey failed to provide notes for review by the National Confidential Enquiry into Perioperative Deaths (At Birmingham Children’s Hospital the figure is less than 2%). Similarly the RCS highlighted problems with consent.  It is further alleged that one surgeon did unorthodox anti-reflux surgery on children that had no evidence of benefit in that role and that he repeatedly refused to publish his results or risks of harm.  Inexplicably the RCS did not require him to declare his results or inform parents they had consented to riskier non-beneficial, non-standard procedures.

The surgical colleagues of the whistleblowers now refuse to work with them. One of the surgeons allegedly has a severe tremor that worsens with stress. He was criticized in the RCS report over an appendicectomy that took over ten hours.  Another surgeon allegedly returned from extended stress-related leave tied off the wrong arteries during a routine surgery and failed to recognize this in time to save the child. In a statement, Alder Hey hospital said: ‘The surgical service referred to in this report was reviewed independently by the Royal College of Surgeons in 2011 and was found to be “safe”. In March 2012, the Care Quality Commission made an unannounced inspection of the Trust and concluded that “patients have safe, appropriate care, treatment and support”. Both reports are in the public domain. Alder Hey has full confidence in its surgical team and is extremely disappointed that they, along with our parents, continue to be targeted in this way.’

The key question is whether the RCS and CQC got to the bottom of these serious allegations, and whether the whistleblowers were given the support and protection they needed. The GMC has apparently been made aware of the allegations but it is unclear whether it will investigate. Meanwhile, patients are left in the dark.

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