Medicine Balls: Lessons from Leeds
First the good news. Data just released shows that survival rates for child heart surgery in the UK are as good as anywhere in the world, if not better. What’s more, no unit in the UK has a significantly higher death rate that the others. So why is the NHS in England considering cutting the number of units from ten to seven? Why all the fuss about Leeds? And why are we not praising and celebrating child heart surgery teams for the incredibly difficult work they do under enormous pressure and scrutiny?
The answers are all related. The most recent data is all the more miraculous in that some of the smaller units have only 2 or 3 permanent surgeons who work ridiculous hours and are heavily reliant on locums, mostly overseas, to cover leave and sickness. The low death rates are as much to do with the pre and postoperative care as the surgery itself. This requires adequate numbers of skilled staff such as cardiologists, anaesthetists and specialist nurses, and highly sophisticated imaging equipment. At present, many units operate with a bare minimum of staff and suboptimal equipment, and sometimes operations are cancelled because there are unsafe staffing levels. Staff are under so much stress that turnover of nurses is high and paediatric surgery is not seen as a popular career option. At least two talented consultant heart surgeons left the UK in the last year.
The reorganization into fewer, larger, better staffed and equipped units is vital to reduce the stress on staff, make the training of future surgeons viable and make the outcomes even better (Eyes passim ad nauseum). Unlike adult heart surgery, where the range of operations is limited, child heart surgery is so varied and complex that a newly qualified consultant needs the supervision and wisdom of a senior colleague at hand for the first 5 years to master the full range of procedures required. In the current system, with too few experienced surgeons per unit, training is suffering, hence the reliance on overseas locums to plug the gaps. And money is so tight in the NHS that units are not given the resources to have their data independently collected, completed and verified in a timely way, particularly as the specialty has been in limbo for so long, awaiting the results of the review. Corners are being cut in the name of safety.
Everyone who works in paediatric cardiac surgery knows this, every unit signed up to a reduction in the overall number but when specific units were outlined for closure, some have backtracked and the Safe and Sustainable process has been derailed by its own incompetence and by internecine fighting between units and their supporters (relatives, MPs and the press). Supporters in Leeds won a High Court case to have the closure of the unit reconsidered because the Safe and Sustainable review team failed to submit all its data to the public consultation. Shortly afterwards surgery at Leeds was suspended ironically, as it turned out, because Leeds itself had submitted incomplete data.
Could the Leeds circus have been handled better? The stress on staff has been
enormous, with some in tears. Hardly conducive to a safe operating culture now that surgery has resumed. In a safety culture, a ‘no blame’ suspension of services is entirely appropriate given the concerns raised not just by the data but by clinicians and parents. This should be happening all the time in the NHS, but not as a big media circus to very publically show how the NHS has toughened up since Mid Staffs and Bristol.
In a safe culture, heart surgery units would be obliged to submit all their data or simply not be commissioned. They would be fully aware of how the data was being analysed to reflect the complexity and risks of different procedures, and they would know and accept precisely what investigations would automatically ensue, in a calm measured way, should the data trigger an alarm. The report and its conclusions would then be put into the public domain.
Bruce Keogh, the Clinical Director of NHS England, has argued that this is exactly what he did on hearing that provisional data showed Leeds had double the mortality of other units. In a unit treating 350 babies and children, there would be an average of 10 deaths a year. If there really has been 20 deaths a year in Leeds for the last few years, Keogh – a heart surgeon – should have known about it long before. It was always more likely that the problem was incomplete data, but in being seen to have put safety first so publically, Keogh has conveniently holed Leeds below the waterline before the final decision on closures is made.
Perhaps, with the derailing of the Safe and Sustainable review, this was the only way to get the specialty to see sense and force through the centralisation of surgery. Keogh will swat away the calls to step down by Leeds MPs, but the lack of trust in NHS England under David Nicholson remains. Keogh has pledged his loyalty to Nicholson, despite his role in the Mid Staffs scandal, and has now said he would allow his own child to have heart surgery in Leeds. Meanwhile, Professor Sir Roger Boyle, director of the National Institute for Clinical Outcomes Research, has said he would not. Keogh called on Boyle to resign, and he has. NHS England is already committed to publishing outcomes for individual consultants in ten surgical specialties by the end of the summer. NHS staff are not convinced this will be done fairly, and without risk of media crucifixion. Such sensitive data data needs to be explained to the public and staff by gifted communicators who are trusted. Nicholson is beyond repair, and Keogh has much work to do.
Listen to my interview on Radio 4’s PM programme, 13.4.13