Open heart surgery

For more than 60 years, the NHS has pretended it can provide high quality care across the board from cradle to grave and close to home. Politicians, managers and clinical staff have colluded to hide the dangers and inadequacies of an endemically patchy service, and although the massive injection of money under Labour has resulted in improved outcomes for many diseases, no health secretary has had the balls to push through unpopular reorganisations of services that can only be safely and sustainably delivered in fewer, larger units.

So two cheers for NHS Specialised Services and the latest attempt to reduce the number of hospitals providing children’s heart surgery from eleven to six or seven. The Eye has been campaigning for this since breaking the story of the Bristol heart scandal in 1992, the subsequent public inquiry recommended it a decade ago, as did a review of services in 2003. The Labour government, alas, was ‘minded not to agree’, preferring small units to fly by the seat of their pants rather than risk the political fallout from closing them.

Labour hid behind the statistics, claiming that all of the units were performing well, but the figures were too small to provide meaningful comparisons and besides, it’s the process of delivering such specialised care that matters as much as the outcome. As the recent scandal in Oxford showed, a truly gifted individual workaholic surgeon can just about keep a service afloat but when he takes his first holiday in three years and hands over to an unsupervised new recruit, it all falls to pieces.

It’s hard to believe that such a skeleton service could be tolerated in the NHS twenty years after the Eye exposed another, but in the interim, no quality standards have been implemented to ensure all units doing the most complex surgery on hearts the size of a plum have the resources and staffing levels to do it safely. As one eminent surgeon put it: ‘People often joke that if surgeons were like pilots, and we died with our patients, we might take a bit more care. But no pilot would be forced to take off with the tank on empty and half a wing missing. In the NHS, that happens all the time.’

The latest, and hopefully final, review of child heart surgery deserves huge credit not just for finally defining these standards and arguing strongly for a reduction in the number of centres in order to achieve them, but in the transparent manner in which it has visited all of the units, meeting staff, parents, carers and patients. When the case for reform is understood, it’s a no brainer. Larger centres get better and more statistically comparable outcomes, can provide urgent care around the clock, have room to expand as technology advances, allow staff to support and mentor each other (and go on holiday) and will allow the UK to train its own child heart surgeons rather than import them.

A 4 month public consultation starts this week1 before the final outcome is announced. Health Secretary Andrew Lansley has thus far been true to his word and devolved the decision to a panel with an expert knowledge of child heart surgery. Their public meeting, on February 16, was the rarest of occasions when the NHS admitted openly and honestly that it has been winging it for years and it can’t go on pretending to provide safe, high quality specialist care everywhere.

There will doubtless be public demonstrations to protect threatened units, but Lansley must resist the temptation to interfere. All those involved in the delivery of child heart surgery have bought into these reforms, they now have to debate them with the public and reach a final conclusion without the knee jerk posturing of politicians. If it works, it’ll be a huge step forward for child heart surgery and a template for NHS reorganisation. If it doesn’t, I’ll set light to myself outside the department of health.

MD 1 www.specialisedservices.nhs.uk/safeandsustainable