16 September 2011
Report suggests downgrading of leading heart and lung centre
The report of the independent panel, which assessed the knock-on effects of the removal of children’s cardiac surgery from Royal Brompton, has confirmed that “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”. The report identifies that, due to patient safety concerns:
- “The potential impact on the services provided by the anaesthetic department at the RBH is therefore significant.”
- Complex bronchoscopies needing intensive care support would have to be referred elsewhere.
- Complex cystic fibrosis cases ”may have to go elsewhere for specific aspects of their management”.
- Bronchoscopy for patients with severe asthma would need to be undertaken elsewhere, in a centre that has a PICU.
- The current long-term ventilation service could not continue to be delivered at the RBH site: “The panel acknowledges that it would not be feasible to deliver weaning services or manage acute respiratory decompensation on the RBH site.”
- Removing on-site anaesthesia and intensive care for children “may affect the motivation of personnel working in these changed circumstances and could also have implications for the successful research programme”.
The report states that children with rare lung disorders who require PICU for diagnosis or management, do not warrant “material consideration” as numbers are small.
A number of compromises are suggested in the report to try and mitigate these safety issues. These include referring the most challenging cases to other centres, and seconding staff between different hospitals, so anaesthetists and theatre staff at non-specialists neighbouring hospitals can “broaden” their “skill base”, and Royal Brompton clinicians can “sustain specialist skills” at tertiary centres.
Commenting on the report, Professor Tim Evans, medical director at Royal Brompton & Harefield NHS Foundation Trust, said: “While pleased that the panel recognises the severe knock-on effects on respiratory patients of removing heart surgery from our children’s unit, this report shows a complete failure to grasp the fundamental issue at the heart of this debate – the role of Royal Brompton as a specialist centre. It is astonishing to read phrases such as ‘it is commonplace nationwide,’ when referring to our clinical practice. Our purpose in providing services for children has always been to offer exactly the opposite of ‘commonplace’ – expert, specialist care that is not available at other centres.
“By their very nature the cases we see are ‘rare’ but in bringing them together at Royal Brompton we have developed clinical and research expertise that is unmatched; a fact recognised by the panel and also the national bodies that support us (such as Asthma UK and the Cystic Fibrosis Trust). We are astonished that the panel thinks that children who come to us with rare lung disease ‘constitute a very small caseload each year’ and therefore do not warrant consideration – we know our expertise saves their lives. It is also worth noting that it is, in part, the skills gained treating our adult patients with the same rare respiratory diseases that provide our paediatric experts with their unique skills.
“Our paediatric respiratory services have been built up over nearly 50 years. This report, assembled in five days, suggests dismantling a successful service using an untested model based on compromise; and seems to rely on people being on continuous secondment elsewhere to maintain their competence. This seems extraordinary and should the report’s suggestions be introduced, staff would undoubtedly be demotivated and deskilled. What internationally recognised expert would wish to work under such conditions in the long-term? It is highly improbable that we would keep our current clinical teams if we introduced such strange working practices: removing the specialist aspect of our work with the corresponding “implications for the successful research programme,” would change the nature of what we do beyond recognition.”
Dr Andrea Kelleher, director of anaesthesia at Royal Brompton Hospital, added: “The difference between the nine anaesthetic consultants who work here and the typical general paediatric anaesthetist comes from the experience we have, as well as the different training that we had as juniors.
“We simply deal with a different cohort of patients. It is very rare for a general paediatric anaesthetist to be asked to manage a patient whose respiratory system gives major cause for concern and it would take considerable time to be competent and confident enough to deal with such cases. However, it is not unusual for us to deal with patients who have a significant disease that poses a constant threat to their life.”
Dr Ian Balfour-Lynn, consultant in paediatric respiratory medicine and honorary senior lecturer at the National Heart & Lung Institute of Imperial College, School of Medicine, commented: “We welcome the fact that the report acknowledged we are a ‘world-class respiratory service with an impressive respiratory research programme,’ but it is inconceivable to me that NHS officials are trying to make it unsafe by removing our on-site paediatric intensive care and specialist anaesthesia. I told the panel who visited that in order to function safely and effectively, a world- class paediatric respiratory unit cannot exist without on-site paediatric anaesthesia. We could certainly bring in general paediatric anaesthetists to carry out some of the lower risk procedures, but there is all the difference in the world between that sort of service and the highly specialist work that we provide for children with complex airway and respiratory disease.
“I also explained to the panel that a world-class children’s respiratory unit should not exist without on-site paediatric intensive care. I was challenged to agree that there are plenty of district general hospitals that deal with respiratory disease without these facilities. I had to point out that there is no recognised specialist paediatric respiratory unit in the UK that works under those conditions, and I am not aware of one elsewhere in the world either.”
Dr Gillian Halley, consultant in paediatric intensive care and director of children’s long term ventilation, said: “I was in no doubt that the clinicians on the panel recognised that our work would be quite impossible without PICU, so felt confident that they would report back accordingly. To see that they did recognise this, but have suggested that we downgrade the care we offer, is frankly shocking. The alternative they propose may not even meet the minimum requirements of safe clinical standards, never mind best practice. Royal Brompton’s medical staff are unanimous in standing by the rights of patients to receive nothing short of excellence. We will not compromise our standards.”
Mr Bob Bell, chief executive of Royal Brompton & Harefield NHS Foundation Trust, added:
“This report abuses the idea of clinical collaboration. The work we spearheaded with Great Ormond Street in 2008/9 is a much fairer representation of how effective collaboration should work. The fundamental driver behind that joint report was a shared clinical vision that would build on and improve current services for patients without disrupting the integrity of existing teams and expertise. An important component of this concept was the introduction of a structured and phased change, with strong governance processes, that could be controlled and managed over a timeframe that was realistic. This was considered an important factor in minimising the risk to patients.
“The key themes of this new report are compromise, untested models of care without any evidence to back them up, and without a shadow of a doubt, a vastly inferior quality of care for children. We will, of course, not be adopting any such approach.”
“When we discovered flaws in the Safe and Sustainable consultation process we approached Sir Neil McKay twice in order to meet and discuss them. When our approaches were rejected, we had no other option than to launch legal action for the sake of our patients. The decision by Mr Justice Burnett on July 15 to grant permission for a judicial review on all grounds advanced by the Trust, clearly reflects the credibility of our case.
“This ‘Pollitt’ report supports our firm beliefs that specialist respiratory work at Royal Brompton cannot continue in its present form without intensive care and specialist anaesthesia, and it is extremely helpful to see its publication in advance of the court case. It is worth pointing out however, that the Safe and Sustainable review’s failure to properly assess the knock-on effects on other Trust services and research programmes of the removal of children’s heart surgery, is just one of a number of flaws in the consultation process. The same consultation process did not include Royal Brompton in any of its four recommended options, in each one two other London centres were recommended – so it is hardly a surprise that most people who responded to the public consultation followed the guidance provided.”
“In conclusion, this report is disturbing for four reasons: it concedes that the Safe and Sustainable proposals for paediatric cardiac surgery would require radical changes to other services that were not revealed to the public when the proposals went out to consultation; it recognises that some respiratory services are provided in hospitals across the country that do not have the sort of expertise Royal Brompton enjoys and proposes that Royal Brompton be down graded; it suggests that the complex and specialist services that Royal Brompton presently provides to some of the sickest children in the country should be transferred to other hospitals but does not consider whether these other hospitals have the capacity to take on such services or the capability to develop the skills that Royal Brompton clinicians have developed over 50 years; and it makes no proposals to protect and advance the enormous programmes of translational research that are carried out at Royal Brompton in partnership with the National Heart and Lung Institute. It looks like a desperate attempt by the Safe and Sustainable team to propose another set of ill-conceived clinical changes, to the absolute detriment of patient care.”
Notes to editors:
1. Royal Brompton’s respiratory care for children is recognised throughout the world. Trust experts treat more children and adults with severe asthma – unresponsive to standard inhalers, and requiring frequent hospital treatment – than anywhere else in the country, and the hospital hosts the largest cystic fibrosis centre in Europe. Royal Brompton’s long-term ventilation programme, E-vent, is an award-winning initiative enabling children who need long-term ventilation to get home more quickly.
In January, Earl Howe, Parliamentary Under Secretary of State for Health, commented: “This is a very, very impressive initiative and I think it is important for others in the NHS to hear more about it.
“I was particularly interested to see that a project developed in one specialist trust, which offers patients and their families a much-improved service, also benefits so many other organisations in the health and social care systems.”
2. ‘Failure’ to raise the knock-on effects of the removal of children’s heart surgery: over the last two years, through numerous warnings given by our managers and senior clinicians to commissioners, and through three formal written submissions (to a senior London commissioner sitting on the Safe and Sustainable steering group, to the Kennedy panel, and to Sir Neil McKay, chair of the JCPCT) the Trust has consistently pointed out the wide-ranging impact on our services if children’s heart surgery is withdrawn, not only on paediatric respiratory and anaesthetic services but also on a wider set of paediatric electrophysiology and inherited cardiac disease services, children’s thoracic surgery, adult congenital heart disease and pulmonary hypertension services. The relevant sections on knock-on impacts within our submission to the ‘Pollitt’ panel were redacted by the Safe and Sustainable team before panel members could read them.
3. In August 2011, the quality of Trust research was recognised in a £20 million government grant. The award supports the two Biomedical Research Units (BRUs), which opened in 2010 and are run jointly by Royal Brompton & Harefield NHS Foundation Trust and Imperial College, to continue pioneering research into the most challenging heart and lung conditions affecting patients around the world.
For more information:
Director of Communications
Royal Brompton & Harefield NHS Foundation Trust
0207 351 8850
Read the views of international clinical leaders who are shocked by recommendations to withdraw paediatric heart surgery.
The Trust’s formal response to the Safe and Sustainable consultation
The Trust’s consultants give their views on the likely impact on patient care, if the Safe and Sustainable proposals go ahead.