Health: Congenital Heart Disease

Lord Darzi of Denham Excerpts

Thursday 20th July 2017 Lords Chamber

[Lord Darzi of Denham (Lab)]

My Lords, I thank the noble Baroness, Lady Boothroyd, for calling this debate. I declare an interest: I am a surgeon working in the NHS, the chair of surgery at Imperial College London and a consultant surgeon at Imperial College and the Royal Marsden NHS trusts. I am also a non-executive director of NHS Improvement.

I have always been a passionate champion of change in the NHS, so long as that change is for the right reasons. Healthcare exists at the limits of science, which is why high-quality care is a constantly moving target—by definition, to stand still is to fall back. Sometimes that means taking very difficult decisions to make far-reaching changes to services that are cherished by NHS staff and patients alike.

As some in this House may recall, in 2007 I led a review of London’s health services. One of the most significant findings was that care for people who had experienced a stroke was very poor. Across the capital, just four hospitals were providing the high-quality care that all patients should expect. This meant that many Londoners were dying needlessly and many others were left with life-altering disabilities that could have been avoided. The changes that I proposed, consolidating stroke services into a smaller number of sites, were implemented by the NHS in London in the years that followed. More than 200 lives a year have been saved and many thousands more have been improved. Those changes were incredibly difficult to implement but were done in the right way and for the right reasons.

The first and most important principle of changes in the NHS is that they should be to the benefit of patients. Quality of care should be the organising principle of the health service, as I set out in my 2008 NHS review, High Quality Care for All, published for the 60th anniversary of the National Health Service. This means that changes must be supported by clinical evidence and after broad and meaningful engagements with both patients and members of the wider public, which brings me to the specifics of today’s debate.

Let us be clear about the starting point. The Royal Brompton Hospital is a specialist NHS trust. It is the largest provider of care for adults with congenital heart disease and the second-largest provider of care for children with congenital heart disease in this country. In partnership with Imperial College London, the trust is a leading centre for research, education and training. It produces highly cited publications in heart and lung disease—more than any other trust in this country. Last year alone, the Royal Brompton, together with Imperial College, published 742 papers. I remind your Lordships that more than 50% of London’s coronary heart disease specialists are trained at the Royal Brompton.

More than any of that, its services achieve the highest-quality outcomes in every dimension that we could choose to measure. The proposals we are debating today are to dismantle the highest-quality service in England. I must be honest and say that I find it utterly astonishing that it should even be a question for discussion.

The justification for the changes revolves primarily around two sets of standards. The first is about the number of cases undertaken by individual surgeons and by the unit as a whole in any year. Like anything in life, practice makes perfect; the same is as true for playing the piano as it is for complex surgery. But the minimum number of cases for congenital heart surgery has simply been plucked from the sky, with a completely random figure of 125 cases per surgeon. I have seen zero clinical evidence to support this number anywhere.

Indeed, in my specialty, cancer surgery, the minimum volume for me is 25 cases a year; in the United States, the minimum volume for congenital heart defect surgery in children is 75 cases. I have no idea where we got the figure of 125 in this country. My diagnosis is of an acute case of policy-based evidence-making rather than evidence-based policy-making. We have seen more of that in recent years. The Brompton actually exceeds that target, with the second-largest number of cases in the country—522 in the last year of published data—but the point remains that the so-called standards create little confidence when they are decoupled from meaningful clinical evidence or outcomes.

The second set of standards are about co-location of services. These are what are driving the changes at the Brompton at the moment. The consultation demands that paediatric congenital heart surgery is provided only in settings where a wide range of other specialist services are located on the same site, as we have heard. The co-location standard requires certain paediatric services, such as gastroenterology and general surgery, to be co-located in the same building as the congenital heart disease service, as these services are needed by around 1% of patients each year.

As a specialist heart and lung hospital, the Royal Brompton delivers a co-located paediatric service in partnership with neighbouring Chelsea and Westminster Hospital and the Royal Marsden Hospital, both just a few minutes’ walk away—I do it, as I work at the Royal Marsden. This partnership has existed for many years, and a wealth of support is available between these sites. Specialists can go from Chelsea or the Marsden to the Brompton within a five-minute walk. It takes the same amount of time to get from my operating theatre to the pharmacy department at St Mary’s Hospital. There are no recorded cases of problems accessing emergency care under this arrangement.

It is, therefore, painfully obvious that the standards on co-location have been defined in such a way as to deliberately result in the dismantling of the services at the Brompton. Indeed, NHS Improvement estimates the cost of shifting services to Guy’s and St Thomas’ Hospital to be in the region of £800 million—an enormous sum at a time of financial difficulty, and with no meaningful clinical evidence. More than that, it has absolutely no regard for the patients or the public of north-west London.

[Baroness Goldie (Con)]

My Lords, I know that this is a very important contribution but this is a time-limited debate with Bank-Bench speaking slots of six minutes. Might I respectfully remind the noble Lord of that?

[Lord Darzi of Denham]

My apologies, my Lords. Just to finish, I strongly believe that this debate is based on complete fallacy in terms of the evidence supporting it and I urge the Government not to dismantle the most important hospital contributing to the treatment of congenital and non-congenital heart disease in this country.

--- Later in debate ---

[Baroness Chisholm of Owlpen (Con)]

I thank the noble Baroness, Lady Boothroyd, for tabling this debate, and I pay tribute to her for her tireless work in this matter. I do feel quite lonely in here today—but, luckily, I have my noble friend Lady Sugg beside me, so I have one mate.

The future of congenital heart disease services is of utmost importance and I understand why, for many people, it is a concern. I am of course happy to facilitate a meeting with the noble Baroness, Lady Boothroyd, and anybody else who would like to join us, alongside NHS England. That could be an important thing to do.

With this review, NHS England is asking how we can take the good service we have across the country and turn it into a truly great service for the long term—a service fit for the 21st century. This is not about closing the Royal Brompton Hospital or stopping it providing CHD services. NHS England is proposing instead to continue to commission specialist medical services, which make up much of the care required by people with congenital heart disease. The proposal is that NHS England ceases level 1 children’s surgical services from the Royal Brompton Hospital. NHS England has also asked the Royal Brompton to consider providing an adult level 1-only surgical service.

Heart surgery is becoming ever more complex and technically demanding. Surgeons now operate on babies who may be only hours old. They will in future be able to operate on babies before they are born. This demands a highly skilled and experienced team of doctors and nurses able to operate on sufficient numbers of patients to maintain and improve their skills, as well as access to the very latest technology. The noble Lord, Lord Darzi, mentioned that the number of procedures is arbitrary—but 125 is not an arbitrary number. That number of operations was agreed by CHD surgeons as the minimum required to maintain a certain level of competence in the operating theatre.

NHS England’s approach to commissioning these very specialised services is proactive and future-focused. If the proposed changes are implemented, patients and their families can be confident that they will be able to access the very best CHD services in the world, regardless of where they live. It is worth emphasising that the consultation which closed on Monday considers the implementation of an agreed set of common standards, developed more than two years ago by clinicians, other experts and patients, which were subject to full public consultation and which the Royal Brompton, along with other centres, helped to develop.

The standards include the requirement that specialist children’s cardiac services are delivered only in settings where other children’s services are collocated on the same site. There are several reasons why collocation is essential for a world-class service. Managing the complex needs of very sick children demands close co-operation between many specialist doctors, nurses and other experts. Collocation allows much closer working relationships to develop between paediatric cardiology specialists and other paediatric teams. The interaction between these teams on a daily basis, when collocated, is considered by NHS England’s clinical advisers to be of significant benefit to patients. Follow-up and rehabilitation for recovering children often require intermittent access to a wide range of specialists, which is far easier to provide at a centre supporting a full range of services.

The noble Baroness, Lady Boothroyd, and the noble Lord, Lord Darzi, talked about collocation, and I would like to read a couple of quotes. Professor Michael Birch, head of clinical service, cardiology, at GOSH, said:

“Paediatric collocalisation is crucial to provide optimal clinical care at the specialist children’s surgical centre. In the UK early post-operative mortality has reduced, but morbidity remains a concern. The co-dependencies are essential, not only to maintain results with regard to mortality, but also with regard to morbidity”.

[Lord Darzi of Denham]

I suggest that the last person I will ask about their experience is the person who is conflicted.

[Baroness Chisholm of Owlpen]

I understand, but this is a time-limited debate. I have only 12 minutes to speak and if interrupted, I cannot. I am very sorry. I shall continue the quote:

“In … one year, a formal transfer of care was required to 18 different specialties … These specialties included urology, renal medicine, metabolic medicine, general surgery, respiratory medicine, plastics, neurosurgery, neurology and haematology”


Having those all in one location obviously makes a huge difference. This way of working brings paediatric cardiac care into line with expectations in other specialist children’s services. Collocation of specialist children’s services is the accepted international norm, and this is why the standard requires collocation on the same hospital site.