Will cutting children’s heart surgery units improve care?

It’s been confirmed that paediatric heart surgery at the Glenfield Hospital in Leicester, the Leeds General Infirmary and the Royal Brompton in west London is to cease, reducing from 10 to 7 the number of specialist units in England carrying out such procedures on children.

Operations are expected to continue at least throughout 2013 at the three hospitals earmarked for closure today, as the plans to streamline the service are still being drawn up.

Few medical procedures are more emotive, and when an inquiry found that between 30 and 35 children died after heart surgery in Bristol because of sub-standard care, the NHS and Department of Health were adamant that it could not happen again.

That was back in 2001. Fast forward over 10 years, and the review of children’s heart surgery services, launched by the Joint Committee of Primary Care Trusts (JCPCT) of England as part of a national review aimed at streamlining services, is finally coming to a conclusion.

The Safe and Sustainable review decided Wednesday afternoon that eight of the country’s 11 specialist heart surgery centres would remain open.

There is a difficult trade-off to be made between local access, and on the other hand, being willing to travel a bit further to a hospital which has fewer deaths and better care. Chris Ham, the King’s Fund

The recommendations to emerge from the consultation process proposed concentrating available treatment within fewer, but better equipped centres. That has been bitterly contested by charities and hospitals threatened with closure, who say that getting rid of cardiac services will force patients and their families to travel further for treatment at a significant cost.

The Royal Brompton in west London took its fight to the court of appeal earlier this year, but it lost a legal battle against the recommendation for its paediatric cardiac centre’s closure.

As well as the Royal Brompton, London hospitals whose departments were threatened with closure were the Evelina Hospital, which is part of Guy’s and St Thomas’ Hospital Trust, and Great Ormond Street, however both of these are now included in each of the final recommendations.

Practice makes perfect

The principle behind closing some centres is that the more paediatric heart operations that surgeons carry out, the better they will become. This advice is not new, and dates back to the 1980s when a report advised surgeons undertake at least 50 cardiac surgeries a year to ensure good practice.

Expertise is spread too thinly within the current organisation of children’s heart surgery, says Chris Ham, chief executive of the health care think tank, the King’s Fund: “We know that in children’s heart surgery, as well as in other areas, practice makes perfect.”

The review could see just six cardiac units for children in England, meaning that many patients and their families will be forced to travel much further to receive life-saving treatment. But that is part of the compromise for better treatment, Mr Ham told Channel 4 News. “There is a difficult trade-off to be made between local access and, on the other hand, being willing to travel a bit further to a hospital which has fewer deaths and better care.

“It sounds harsh, but if a surgeon’s mortality rate is lower, that’s a trade-off most people are willing to make.”

Timeline
2001: Bristol Inquiry finds that between 30 to 35 children who had heart surgery at the hospital died because of sub-standard care.
2003: Professor James Munro reviews services and suggests closures and reorganisation of provision..
2007: Parents can for the first time access detail about survival rates at specialist hospitals online.
2008: Sir Bruce Keogh, head of cardiothoracic surgeons warns the department of health that some units are understaffed and requests review of children’s heart surgery provision.
2009: Sir Bruce heads up a steering group to review services and provision.
2012: Safe and Sustainable finalises its recommendations following a consultation process launched by the JCPCT.

Knock-on effect on hospitals

Leading the charge against the proposed closures is the Royal Brompton Hospital in Chelsea, west London. It argues that not only will the closure affect the hospital’s cardiac patients, but those who come to the hospital for complex respiratory care.

Around a third of children receiving respiratory treatment at the heart and lung hospital also require specialist cardiac treatment for their complex needs, and many are supported by anaesthetic care – both of which will be unavailable if the cardiac unit is closed.

For us, it’s a very difficult thing to have to turn round to our patients and say – we can no longer see you here, and we don’t know where you’re going to fit in. Dr Claire Hogg, Royal Brompton hospital

The hospital’s specialist departments work inter-dependently, and staff feel that the JCPCT has not taken this into account during the consultation, says Consultant Respiratory Paediatrician Claire Hogg.

“We don’t disagree that reviews should be ongoing for any service we provide in the NHS,” she told Channel 4 News. “But if we take away our cardiac surgery for children here, we would loose our intensive care facilities and anaesthetic specialist care. Our real concern is that in this entire process, none of the NHS management that involved in the JCPCT has really taken that into account.”

The Royal Brompton takes in a lot of patients from surrounding hospitals for specialist care, and its respiratory centre is the largest in Europe. “For us, it’s a very difficult thing to have to turn round to our patients and say – we can no longer see you here, and we don’t know where you’re going to fit in,” Dr Hogg told Channel 4 News.

“A lot are too sick to undergo diagnostic procedures or surgery without that level of expertise in the areas that we may lose.”

Responding to the announcement that specialist childrens heart surgery is to end at the Royal Brompton, the hospital’s director of children’s services Dr Duncan Macrae said: “Our leading children’s lung disease service and its world class research programme will in my view be fatally wounded. How can this NHS reorganisation be an improvement, if services such as these are destroyed in the process?”

A Safe and Sustainable representative told Channel 4 News an independent panel concluded in November 2011 that “children’s respiratory services, including cystic fibrosis services and asthma services, would remain viable at the Royal Brompton if children’s heart surgery services were moved”.

However the Royal Brompton responded with a quote from the independent panel’s report: “the removal of paediatric cardiac surgical services from the RBH site would render the PICU (Paediatric Intensive Care Unit) unviable. The panel further agrees that anaesthesia provision is essential to maintain paediatric respiratory services, and that a reduction in paediatric surgical activity would affect the ability of the RBH to provide anaesthesia services for children in their current form”.