At a public consultation event last night (7 March), NHS England’s national clinical director for heart disease, Professor Huon Gray, admitted there was “no scientific evidence” to back the decision to withdraw congenital heart disease services from Royal Brompton Hospital.
The ‘Question Time’ consultation event was the first NHS England have held on their proposals to decommission congenital heart services from a number of NHS centres, including Royal Brompton & Harefield NHS Foundation Trust.
‘Co-location’ of services not supported by evidence
Professor Gray’s admission was in relation to a new ‘co-location’ standard for congenital heart disease services which NHS England claim Royal Brompton does not meet. There are around 470 other new standards and no centre in the country meets them all.
The co-location standard requires certain paediatric services, such as gastroenterology and general surgery, to be ‘co-located’ in the same building as the CHD service. As a specialist heart and lung hospital, Royal Brompton delivers a co-located paediatric service in partnership with neighbouring Chelsea and Westminster hospital, just a few minutes’ walk away.
Clinicians are jointly appointed between the two trusts and part of their contract (job plan) is allocated to Royal Brompton work. They attend weekly joint clinical meetings, joint ward rounds, use shared systems and some nursing staff take part in shared staff rotations. The co-located service has a 100 per cent record of providing emergency care (within 30 minutes) to the 1 per cent of patients who need it, day or night.
NHS England have stated that there are no issues either with the quality of care delivered at Royal Brompton, or the nature of the partnership with Chelsea and Westminster, but claim they are ‘future-proofing’ congenital heart disease treatment.
Prof Gray described a ‘consensus’ of opinion behind the decision to introduce a co-location standard but repeatedly agreed that the decision was not based on evidence that showed it would improve patient care in any way. Currently, there is no impact on patient outcomes of having the nominated services in the same building.
No consensus
Responding to the suggestion that the decision to introduce the new standard was the result of wide consultation, Caroline Mutton, the mother of a young Royal Brompton patient, said: “As a member of the patient and public group present throughout, I remember significant conversations about the definitions of co-location ……at no point was it made clear that this ‘on site’ co-location requirement was on the cards or necessary. This discussion did not take place in those patient meetings to this degree, so how are you claiming patients support this?”
Her comments were echoed by Dr Duncan Macrae, consultant paediatric intensivist at Royal Brompton, who said: “I think it’s disingenuous to imply that two years of discussion around the current definition of co-location is actually the fact. The fact was that the clinical reference group – in actually recommending the standards to NHS England – defined co-location as response time within 30 minutes and it was only at the very last minute that a very small group… changed it to absolute co-location on the same physical site. So it’s not true that the vast majority of clinicians recommending the standards actually agreed absolute co-location.”
Dr Rodney Franklin, consultant paediatric cardiologist, agreed with Dr Macrae.
Parent, Wai Ho, told the panel: “I have had a child who has gone through multiple heart surgeries, he’s nine years old…. He was an inpatient for seven months and I never had any problems whatsoever with the speed at which the doctors from Chelsea and Westminster came to his bed.”
Robert Craig, chief operating officer, re-iterated: “It’s not just about how quickly a clinician can get from Chelsea and Westminster to the bedside at Royal Brompton, although that matters. It’s the fact that they’re a single team and they work together on the paediatric intensive care unit, on the ward, they’re members of the multi-disciplinary team.
“If we need them to be there every day, they’re there every day, if we need them to be there once a week, they’re there once a week. So the characteristics of a co-located service that have been described are exactly what you would find at Royal Brompton.”
Impact on children’s respiratory services
The impact on children’s specialist respiratory services, of withdrawing congenital heart disease services from Royal Brompton, was also discussed at the event.
Royal Brompton’s children’s intensive care unit is also part of the closure plan and, without intensive care, a number of other vital children’s heart and lung services would have to be withdrawn, forcing children with conditions like cystic fibrosis and difficult asthma to find care elsewhere. NHS England have not yet explained what they have planned to ensure these patients continue to receive the care they need.
Fiona Copeland runs a family support group for patients with a rare respiratory condition, and has two children who have been treated at Royal Brompton for 16 years. She asked about the plans for respiratory patients who will no longer be able to be treated at the hospital if NHS England’s plans go ahead.
Responding, Will Huxter, regional director of specialised commissioning at NHS England, admitted that no risk assessment had been carried out for those patients: “We haven’t at this stage done the detailed assessment about what re-provision of any other services, apart from CHD, would look like but we have acknowledged that’s one of the pieces of work we would need to do before we were able to start implementing overall.”
Robert Craig responded by saying: “That suggests the views of respiratory patients and their families will not really be taken into account in the consultation responses because they’ll have to wait and see what the decisions are, before they get a view of what [NHS England] think the impact on their services will be… That seems to fly in the face of the requirement that all of the knock-on impacts are taken into account in making proposals about the future of these services.”
Further issues
Other issues discussed at the event include:
- The irrationality of withdrawing a service from 8,000 adult patients on the basis of one new paediatric standard that affects 1% of children treated at the hospital
- The logic of spending millions of pounds recreating capacity at other centres when it already exists at Royal Brompton, especially when NHS finances are so challenged
- The risk that many of the clinical staff and academics who come to Royal Brompton from around the world to work in the congenital heart unit, will return to their country of origin if the unit closes, fragmenting research teams and losing expertise from the wider NHS
- The irrationality of closing a unit rather than helping it work towards achieving the new standard.
As the event came to a close, Jim Hedge, the parent of a young Royal Brompton patient, asked the panel from NHS England “You’re tearing up a very good unit, scaring a lot people, destabilising a whole load of lives, for something that you ‘have no robust evidence for’. With the NHS in the state that it’s in, is there nothing better you could be doing?”
Spend a day on our children’s ward and paediatric intensive care unit by visiting a Guardian ‘live blog’ from earlier this month.