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Archive - Tag: paediatric cardiac surgery

March 2, 2011

Medicine Balls, Private Eye Issue 1283
Filed under: Private Eye — Tags: , — Dr. Phil @ 10:24 am

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

February 1, 2010

Dr Phil’s Private Eye Column, Issue 1254, January 24, 2010
Filed under: Private Eye — Tags: , , , — Dr. Phil @ 5:29 pm

Bristol Update

 ‘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.’ So says NHS Medical Director and cardiac surgeon Sir Bruce Keogh, just 18 years after the Bristol heart scandal was exposed in Private Eye. The Public Inquiry a decade ago found that as many as 35 babies had died unnecessarily, and a review in 2003 recommended the concentration of scarce expertise and equipment in fewer centres. Alas, Labour ignored it for fear of the political ramifications. Keogh admits there has ‘frankly been little progress’ since the inquiry and he can’t at present guarantee that ‘another Bristol’ won’t happen. The job of fixing it has now been handed to the National Specialised Commissioning Group (NSCG), which since 2007 has been responsible for making sure the treatment for all rare and complex conditions is ‘safe and sustainable.’ As Keogh puts it: ‘The NSCG has to flex its muscles. Politicians have to accept their recommendations and clinicians have to put aside personal conflict and institutional self interest.’ And patients and parents have to accept they may have to travel further to get the best treatment. We shall see. The battle to safely reconfigure specialist services is also at the heart of the current Bristol pathology inquiry, which MD is due to give evidence to next month. The Royal College of Pathologists (RCPath) describes pathology as ‘the hidden science at the heart of modern medicine’ but it’s high time it was flushed out into the open. As medicine becomes increasingly technical and individualised, there is an urgent demand for specialist pathologists with the experience to spot the complex nuances in tissue samples and advise on treatment. Alas, specialist pathologists are in short supply and the temptation, to save money and hold onto business, is to let those with insufficient expertise report on complex slides. This is the allegation made against pathologists at University Hospital Bristol, with evidence submitted of serious reporting errors for complex gynaecology, respiratory, dermatology, breast and paediatric tissue samples. There is also evidence that, as with the heart scandal, a lot of senior NHS managers, consultants and the royal college have known concerns about UHB’s pathology department for some time. So there are powerful vested interests in not having another scandal. UHB ordered the external inquiry, chaired by Jane Mishcon, but only after the Eye went public with the allegations. The Trust was initially overseeing the inquiry, but this clearly lacked independence and it has now transferred to London under the management of Verita. However, the inquiry panel has no control over the analysis of samples. The alleged errors reported to MD have occurred between 2000 and 2009, and all in specialist areas. Whereas the inquiry is looking at a random sample of 3,500 adult slides taken across a single year and including all the ‘bread and butter’ reporting, so complex mistakes can be buried and the overall error rate will look small. This is precisely the tactic used in defence of the heart surgeons. The inquiry needs to focus its attention on specialist areas and specific cases. Against this background, local cancer services are in the process of being reconfigured to make them ‘safe and sustainable’. All are highly dependent on co-operation between hospitals and developing specialist pathology services but whether Bristol’s clinicians and managers can work together and share expertise remains to be seen. Oh, and UHBs chief executive Graham Rich has just resigned.

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