Health: Congenital Heart Disease

Baroness Walmsley Excerpts

Thursday 20th July 2017 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I congratulate the noble Baroness, Lady Boothroyd, on her tour de force and many other noble Lords on their very authoritative speeches. I feel a bit sorry for the Minister, who might be feeling a bit lonely.

In decisions such as the closure of a highly successful and reputable unit such as the CHD unit at the Royal Brompton, the key driver must be to maintain and improve the quality of patient care. Any merger or closure decision must be made on the clinical evidence and not on cost saving, although, in this case, the costs of the change could well be greater than the existing provision.

The Brompton is a highly experienced unit, as the noble Baroness, Lady Finlay, told us. It performed 512 congenital heart disease operations and 554 catheter procedures on children and adults in 2014-15, more than any of the 12 other NHS trusts performing such work. As the noble Lord, Lord Patel, mentioned, its adult CHD research team is responsible for publishing more cited research papers than any other CHD centre in the world. It is at the cutting edge of innovation. Despite the severity of the health problems experienced by its patients, as we have heard, survival rates and the quality of care are very high.

However, NHS England’s concerns about the Brompton focus on two issues. First, Standard B10 requires there to be four CHD surgeons, each of whom has presided over at least 125 operations per year. At the Brompton, I am told, three out of the five surgeons fall short of 125 cases–an arbitrary figure, according to the noble Lord, Lord Darzi. I listened to him very carefully.

Secondly, NHS England is concerned that a number of linked paediatric services are not collocated in the same hospital but are provided by the Chelsea and Westminster and St Mary’s hospitals, both easily within 30 minutes of a child’s bedside. It is worth nothing that 30 minutes is the time limit proposed by the standards even when the services are collocated. This partnership is very close, with joint rotas, ward rounds and meetings and shared IT systems. This high level of communication is essential to the working of such a partnership.

To comply with the rapid availability of paediatric cardiology, ICU, anaesthesia, gastroenterology and other services, the Brompton has formed joint teams with the Chelsea and Westminster, which is five to 15 minutes’ walk away, depending on how fast you walk. You can be more than 10 minutes’ walk away from another department in the same hospital on a large site such as my own local hospital—I have done such a walk many times. The main thing is that you can get there in time. The Brompton has proved that it can do this by its claim that, for the 1% of paediatric CHD patients who have needed these services, it has a 100% record of providing them in time, in an emergency, day or night.

Given that there are many downsides to closing the unit, NHS England should apply the standards a little more flexibly when it comes to how they are complied with, as long as the standard of patient care is not compromised. The issue of collocation seems to have been appropriately dealt with by the partnership arrangements. The issue of the number of cases presided over by each surgeon could surely be addressed in the interest of saving the large amount of money that would need to be spent on closing the unit. I understand that the cost of redundancy payments alone amounts to £13.5 million, let alone the cost of increasing the number of beds elsewhere. Last December, my noble friend Lord Sharkey told the House that closure of the unit would remove a quarter of paediatric CHD beds in London. Can the Minister say what the plans are and what the cost would be of recreating beds for these 12,000 patients elsewhere? Where is the cost-benefit analysis? At a time when the NHS is struggling so hard financially, it seems highly risky to take the proposed line.

There are other, considerable risks to closing the unit. Take staffing: how do we know that existing staff are prepared to relocate? Experienced UK staff and those coming from abroad are attracted by the Royal Brompton’s reputation and, especially in the uncertain climate of Brexit, we cannot be certain that they will still come. Already, almost 90% of children’s units express concerns over how they will cope with staff shortages over the coming months. Already, one in five vacancies for junior children’s doctors is unfilled, on a rising trend. Now is not the time to upset an already wobbly apple cart.

As we have heard from the noble Baroness, Lady Morgan, then there is the effect on other departments that would be threatened with closure because of volume reductions. The hospital claims that, without child CHD services, its children’s intensive care unit would become unsustainable because of the reduction in volume. Consequently, its paediatric respiratory unit and paediatric cystic fibrosis and asthma services would also have to close, and other services would be under threat. NHS England admits that it has not done a detailed assessment of the knock-on impact of closing CHD surgery on other departments at the Royal Brompton. Can the Minister say when this will be done?

Talking of unintended consequences, will the Minister look carefully at the funding models for surgery to ensure that there is no barrier to the hospital taking a holistic approach to the patient’s disease? For example, I understand that the range of a consultant heart surgeon’s practice has been limited by the funding model, since, although heart patients may well also have other diseases, the heart consultant will never deal with them, yet it is all part of the same syndrome.

As the noble Lord, Lord Darzi, mentioned, there are examples of where centralisation of services can improve patient outcomes, which is what we all want, and I congratulate and support them. High among those is stroke and trauma services in London. However, we must not assume that one size fits all. It really depends on where you are starting from and in the case of the Brompton we are starting from a very high base. We have to look at the scope for doing even better and consider all the options for improvement. While this debate has been very supportive of the Royal Brompton, it also raises challenges for the trust, and I am sure it will rise to them. Surely there is a way of addressing some of the issues that NHS England has mentioned without closing the unit, with all the attendant downsides.

I agree with the noble Baroness, Lady Masham, that “if it ain’t broke, don’t fix it” is a very good motto. In reflecting that this debate has had contributions from nine women and five men, I wish all hard-working noble Lords a very happy summer holiday.