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.