Congenital Cardiac Services for Children

Simon Burns Excerpts

Thursday 23rd June 2011 Commons Chamber

[Greg Hands (Chelsea and Fulham) (Con)]

I very much support the principle that lies behind the review—that we need larger, more sustainable centres with the same overall number of specialists throughout the country. That is why charity and campaign groups, such as the Children’s Heart Federation and Little Hearts Matter, back the change.

I recognise that people will have to travel further as a consequence, and that will sometimes be extremely difficult, for families in particular, but the choice is between people travelling further and getting the best outcome for their child, and people having a shorter distance to travel but perhaps compromising the outcomes that can be achieved. The clinical evidence is unambiguous: travelling further means that some children will live who would otherwise die. On that basis—the whole basis behind the review—we have to bite the bullet and make change.

I support the principle of fewer, larger units, but the experience of Royal Brompton hospital in my constituency has made me question the process that is being used to make individual decisions. As my hon. Friend the Member for Pudsey (Stuart Andrew) pointed out, the matter needs to be depoliticised from the outset. The review is taking place at arm’s length from the Government. Indeed, as the right hon. Member for Newcastle upon Tyne East (Mr Brown) said, it was set up under the previous Government and is being administered by a body called the joint committee of primary care trusts, which I assume is up for abolition.

Phase 1 of the assessment process involved ranking all the existing units on core standards, sustainability, facilities and so on. Great care was taken, and that makes the next phases all the more mystifying. Out of the 11 units ranked, the Royal Brompton came joint fourth, on 464 points. Of the 11 units assessed, only two had the maximum number of four surgeons—the Royal Brompton and Great Ormond Street. In terms of the number of procedures undertaken each year, the Royal Brompton came fourth highest of all. In each of the three objective criteria, the Royal Brompton was in the top four nationally. I therefore asked the joint committee of PCTs this question: why bother to rank all the units only then to stipulate that one of the top four has to close whatever else happens? That is the consequence of the decision arbitrarily to rule out keeping three centres open in London. One of the top four units in the country is to be axed, no matter its size and no matter its quality, due merely to its location. That flies in the face of the starting point of the review—that it was all about clinical outcomes, not geography.

The Royal Brompton has four specialist surgeons who perform 520 operations, including 453 children’s heart operations, per year. It has a fantastic safety record, with an aggregate mortality rate of 0.94 of 1%—less than half the national average of 2%. Why, then, when it is already a model example of what the review wants to create, does the consultation, in all the options available, decree that it must close? The joint committee of PCTs is claiming that it has an open mind, but in reality it is consulting on four options, all of which would shut the unit at the Royal Brompton.

The knock-on effects on services elsewhere in the trust would be considerable, especially on children with cystic fibrosis, of whom there are 300 in the country. The future of provision for those children would be extremely unclear. It is also unclear what capacity the remaining two hospitals in London would have to take on—

[The Minister of State, Department of Health (Mr Simon Burns)]

I will speak with great care because—my hon. Friend is as aware of this as I am—of the possible judicial review with regard to the Royal Brompton. I would like to say, though, as I think it may help him, that no decisions have yet been made. The consultation literature specifically asks consultees for their views on how many centres it is best to have in London—two or three. If they agree that two is optimal, they are asked to state which two they prefer, including the Royal Brompton. Even though it is not included in any of the pillars, people who are taking part in the consultation process can argue its case, and it will be considered because the JCPCT is taking a flexible approach to the consultation process.

[Greg Hands]

I welcome that intervention from the Minister. He is right that it is open to the consultation to consider it, as it says on the last page of the consultation document, but the document was contradictory on this point in the first place. On page 84, it says:

“London requires at least 2 centres due to the size of the population it covers”,

but in a footnote on page 93 it still imposes the arbitrary limit of two centres at most.

The joint committee has belatedly recognised a problem. Under pressure, it announced at the beginning of May that an expert panel would be established to review the wider impact on other services if cardiac paediatrics were to close. That was welcome, but it has continued to press ahead with the original consultation and names for the new panel were not proposed until this week. By the time the new panel reports in August, the consultation will have closed. What happens if its response reflects the serious concerns about a whole series of national services? Having consulted on options A, B, C and D, it can hardly go for an option E that no one was asked about. It would then probably have to re-consult.

I became the MP for the Royal Brompton in May last year, although, as the neighbouring MP previously, I have been very familiar with its work for many years. Its previous MP, my right hon. and learned Friend the Member for Kensington (Sir Malcolm Rifkind), also strongly supports its campaign to fight the proposal. I have visited the hospital three times in the past year. The proposal to end its cardiac paediatrics has been brought to the attention of parliamentary colleagues across all parties and across large parts of London, the south-east and East Anglia. A huge petition has been gathered, signed by more than 30,000 people, and tomorrow we are delivering it to No. 10. I have written at length and in detail to the Secretary of State on the matter, and he helpfully replied—I think this was confirmed by the Minister—that

“no decisions have yet been made”,

including on the number of units to be located in London. That is a cause for encouragement.

I repeat that I support the aims of the review, but the consultation has been badly flawed. Three units in London, perhaps restructured, should have been an option, and the knock-on effects of closing services should have been considered. The case must now be re-examined. The Royal Brompton is good enough, large enough and loved enough to survive.

--- Later in debate ---

[Pat Glass]

I am not going to give way, no matter how much the hon. Gentleman hassles me. I can see that that is what he plans to do.

Many local campaigns have been mounted, and they have been supported by local MPs fighting for their own units or fighting to delay decisions. I absolutely understand that, but the decisions have been put off before for many reasons, which I believe is to the detriment of patients.

The decision should not be made on a political basis. Few of us in the House are qualified to judge the quality, sustainability and deliverability of clinical outcomes in children’s heart provision. On 7 June, when I questioned the Minister of State, Department of Health, the right hon. Member for Chelmsford (Mr Burns), on the matter, he gave me a categorical assurance that decisions would be

“based on clinical outcomes, not political considerations.”—[Official Report, 7 June 2011; Vol. 529, c. 12.]

I hope that he will keep his nerve in the face of sustained political lobbying.

[The Minister of State, Department of Health (Mr Simon Burns)]

If it encourages or reassures the hon. Lady, I will give her that commitment again today.

[Pat Glass]

I thank the Minister.

The Children’s Heart Foundation has advised me that the closer we get to a decision, the more difficult the political battle will become. In a bid to save surgery facilities in their areas, some parents and clinicians are asking MPs to stall progress towards a decision. Parents have been told that some units will close, when in fact even if surgery is centred elsewhere, local units will continue to provide specialist medical treatment on a “hubs and spokes” model. I believe that parents have been misled on some matters.

These decisions are crucial to the future clinical outcomes and life chances of our children. The Minister has again today categorically assured me that they will be based on clinical outcomes only, and I thank him for that.

--- Later in debate ---

[The Minister of State, Department of Health (Mr Simon Burns)]

I congratulate my hon. Friend the Member for Pudsey (Stuart Andrew) on securing this debate on the review of children’s heart surgery services. He has a strong record of campaigning on this issue and of bringing the concerns of his constituents to the attention of the House. I also congratulate him and the other hon. Members on the motion they tabled. The Government and I wholeheartedly support its contents, and I urge other hon. Members to do so as well.

I should also like to take this opportunity to pay tribute to the dedicated NHS staff who work in children’s heart services in my hon. Friend’s constituency and across the country. They do a tremendous job, for which we are all incredibly grateful, more often than not in complex and difficult circumstances.

I should like to confirm that the review is totally independent of the Government, and that it is clinically led. It is not driven by me, by other Ministers or by the Department of Health. It is therefore not appropriate for me to comment on the specific hospitals consulted during process. I do not wish to act, or to be seen to act, in a way that could influence or prejudice the process that is going on. As many hon. Members have said, this is a highly emotive issue, particularly for those whose children’s lives have been saved by the services under review. It is worth reminding ourselves why the review was conceived and planned and is now being carried out.

This is not a new issue. The provision of children’s heart surgery has been a cause for concern since the Bristol Royal infirmary inquiry in the late 1990s. Understandably, there has been considerable pressure from national parents groups and professionals to ensure that children receive the best treatment, and the sole purpose of the Safe and Sustainable review is to ensure that children with congenital heart problems receive the best possible care now and long into the future. To do that, we must be certain that the centres in which surgery takes place are as good as they can be.

[Mr David Davis (Haltemprice and Howden) (Con)]

The Minister will not be surprised to hear that my constituents, like all the others in Yorkshire, are in favour of Leeds, but I do not want to draw him on that. I would like him to help us in our argument by telling us what the clinical outcomes for Leeds are and how they compare with other centres. In particular, will he confirm that they are all safe?

[Mr Burns]

I am grateful to my right hon. Friend for that intervention. With regard to Leeds teaching hospital, he will know that this is a complex issue. There are 36 different surgical procedures listed on the central cardiac audit database, but the three most relevant ones in the context of his question are those that deal with atrioventricular septal defect, arterial switch and Fallot’s tetralogy. Over the past six years, 304 operations have taken place involving those three specialties. Sadly, the number of patients who died within 30 days was 12, and 18 died within one year. The results of surgery in all units are good, with no significant divergence. The issue, however, is the future. We need to prepare for units that can deal with these highly complex procedures and the intense technology needed, and provide the qualified doctors and nurses involved, in order to keep up with professional and public expectations of the high quality of care required. This is not so much about today’s figures as about how we meet the challenges of the future to provide the finest and safest possible care in this deeply complex area of medical treatment.

The consensus among professional associations is that there should be no fewer than four congenital surgeons in a centre, each performing between 100 and 125 procedures every year, for a centre to be optimally staffed. Over the past few years, the outcomes for the services have remained good, as the figures that I have just given to my right hon. Friend illustrate, but there have been several warning signs that the current arrangements are fragile. For many years, professionals and national children’s charities, including the Children’s Heart Federation and the British Heart Foundation, have urged the NHS to review services for children with congenital heart disease. They have consistently raised serious concerns about the risks posed by the unsustainable and sub-optimal nature of smaller surgical centres.

Many of the 150 types of operation undertaken by these dedicated teams are among the most complex, challenging and technically demanding areas of surgery. Success requires intricate surgery on hearts often no bigger than a walnut, coupled with finely balanced judgments drawn from a combination of advancing science, personal experience and compassion. It involves a range of highly trained individual team members—before, during and after the operation.

The risks posed by the complex nature of heart surgery include not just possible death after surgery, but lifelong complications such as brain damage and other disabilities. The judgments of any expert medical team caring for a particular child therefore have a direct and long-lasting impact not only the future of each vulnerable child, but on that of their families.

There is also the issue of recruitment. The fact is that smaller centres have problems with recruiting and retaining the very best surgeons. There is a risk that those working in smaller centres will find themselves working in isolation and in units that are not as up-to-date with techniques and clinical practice as the larger ones are.

[Greg Mulholland]

We all understand the premise of the review about the need to move to larger centres, but does the Minister not understand—I am not trying to draw him—the real concern when Leeds is performing 370 procedures a year and Newcastle, a smaller unit, performed only 255 last year, yet Newcastle is in all four options and Leeds only in one?

[Mr Burns]

I fully appreciate the hon. Gentleman’s point, but I hope that he will appreciate that he is now trying to draw me into a discussion on the merits of Leeds as against Newcastle. As I said earlier, it is inappropriate for me as a Minister to do that. However, it is a point that the hon. Gentleman, my hon. Friend the Member for Pudsey and others can make more than adequately to the joint committee, which will be able to determine the merits of the argument prior to reaching a decision. I urge the hon. Gentleman to understand how inappropriate it would be for me to go down the route of arguing the merits or demerits of one area or another.

Smaller centres struggle to train and mentor junior surgeons, making these units less attractive to the senior surgeons of tomorrow and making it difficult to provide a safe 24-hour service. We must ensure that our surgeons and their teams are well supported. They need opportunities to develop their experience as they become increasingly expert in these intricate and complex procedures. We must ensure that all the hospitals that provide heart surgery for children can also provide care within safe medical rotas.

No parent would wish the care of their child to be entrusted to a surgeon who, though an excellent doctor, is overly tired because they have had to work around the clock without any peer support. This means that to reduce the risk of surgery in sick children and to improve their long-term outcomes, we must focus our surgical expertise in larger centres. The need has become ever more pressing with the increasing complexity of treatment.

As hon. Members will know, the national review is known as the Safe and Sustainable review. Its aim is to ensure that children’s heart services deliver the very highest standard of care. The NHS must use its skills and resources collectively to gain the best outcomes for patients. As I stated at the beginning of my speech, in line with the Government’s entire approach to the NHS, this review is both independent and clinically led. May I reassure hon. Members that the objective of the review is not to close children’s heart centres? Far from it. While surgery may cease in some centres, they will continue to provide specialist, non-interventional services for their local population.

Indeed, the review proposes to extend local care further, supported by the professional associations that support the increased clinical expertise across England. This wider support is crucial. Surgery is usually a single, short episode in what is often a lifelong relationship with specialist congenital heart services. The aim is to improve those services as a whole and to ensure that as much non-surgical care as possible is delivered as close to the child’s home as possible through the development of local congenital heart networks. These will enable children to be safely and expertly cared for nearer to home in the longer term.

Given the complexity of the issues for consideration, the NHS has held a four-month, rather than the usual three-month, consultation. Hon. Members should be reassured that the consultation process has been impressive in its scope, inclusiveness and transparency.

[Julian Smith]

Will the Minister give way?

[Mr Burns]

I will, but it will be for the last time.

[Julian Smith]

I thank the Minister. Will he comment on the lack of translation of certain consultation documents, which has affected many communities, particularly in and around the Leeds area?

[Mr Burns]

I am grateful to my hon. Friend for raising that issue, and I will address it later in my speech.

No decision has yet been made about which centres should continue to undertake surgery. That decision will be made only after the responses to the consultation have been properly and fully considered. The chair of the joint committee of primary care trusts, Sir Neil McKay, has made it clear that it is a genuine consultation and that all viable proposals will be considered, and I agree with that. There has been no pre-determination of the number of centres that will be selected. Rather, the review remains flexible and open-minded as to the final number and is happy to listen to all options that would produce the excellent clinical outcomes for our children that we desire.

As I have said however, this review is being driven by a powerful clinical imperative. The trend in children’s heart care is towards increasingly complex surgery on ever-smaller babies. That requires surgical teams that are large enough to provide sufficient exposure to complex cases, so that surgeons and their teams can maintain and develop their specialist skills. Larger teams also provide the capacity to train and mentor the next generation of surgeons. In recent years, other countries have recognised the clinical necessity of larger surgical units and have reconfigured their services along the lines proposed by the Safe and Sustainable proposals. Here in the United Kingdom, there are successful precedents for centralisation. In the past 15 years, the congenital cardiac services in Cardiff and Edinburgh have ceased heart surgery on children, as they recognised that their centres were just too small to be sustainable.

I also want to reassure Members about the integrity of the process that was followed in developing the options for consultation. In the past, concerns have been put to me in this House about mistakes in the assessment process, particularly relating to the Leeds service, and Members have referred to that again today. I understand that since our last debate in February or March of this year the chair of the joint committee, Sir Neil McKay, has written to the chief executive of the trust in Leeds to explain why mistakes have not been made in relation to the Leeds centre.

Members, including my hon. Friend the Member for Skipton and Ripon (Julian Smith) in his recent intervention, have also raised the issue of documents not being made available in a sufficiently wide range of languages, thereby excluding those who speak those languages from the consultation process. The relevant documents have for several weeks been available in 10 different languages, including Urdu, Arabic, Farsi and Punjabi. [Interruption.] The hon. Member for Leicester West (Liz Kendall) shakes her head, but I assure her that they have been available for several weeks, although I accept that they were not available from the first day of the review. That may be the point the hon. Lady was seeking to make, and I agree with her if she thinks they should have been from the first day. We cannot change the fact that they were not available from then, however, but they have been available from, I believe, 20 May, and the consultation process runs until 1 July, which gives sufficient time for people who need to access the documents in those languages to do so and to be able to input their views.

I hope to be able to reassure my hon. Friend the Member for Isle of Wight (Mr Turner) on retrieval times and access times from the Isle of Wight, given its unique geographical situation. It is my understanding that the joint committee of primary care trusts has agreed that Southampton University Hospitals NHS Trust has provided evidence on this issue that requires further consideration and has invited the trust to develop a detailed case regarding retrievals from the Isle of Wight, which the committee will consider as part of the evidence to determine the optimum reconfiguration.

Several Members raised the issue of the inclusion of black and minority ethnic communities in the consultation process. There have been a number of workshops and focus groups, many of which have been aimed specifically at the BME communities. Almost 2,000 community groups and organisations that have an interest in BME issues have been contacted and invited to take part in the proceedings. Public meetings have been arranged, particularly in Leeds, specifically for the Asian population of Yorkshire in partnership with representatives of local BME groups. The Leeds meeting is on 29 June, there is a meeting planned for Bradford on 30 June and a further meeting is planned for Kirklees. I hope that hon. Members who represent parts of Yorkshire and the surrounding catchment areas will be assured by that.

To abide by your rules, Mr Deputy Speaker, I will now conclude by saying that I am confident about the consultation. Everyone will accept that all consultations of this nature can be difficult, when tough decisions have to be taken. The decisions have to be taken for the right reasons, based on clinical evidence about the best way to improve and enhance care and the quality of care for patients. That is particularly true in this case because more often than not the patients are very young children with very complex needs—that is what makes this issue so difficult.

Let me reiterate that no decisions have been taken or will be taken until the joint committee has had an opportunity to consider the independent analysis of the consultation responses, reports from any local overview and scrutiny committees and a health impact assessment. Throughout, it will remain open-minded and flexible as to the number of centres. The only important consideration will be the sustainability of clinical excellence at the centres chosen. I doubt whether this is the case, but if any hon. Members have not taken part in the consultation I urge them to do so. I also urge them to ensure that their constituents and organisations in their constituencies with an interest in this matter take part in the consultation if they have not already done so, so that the committee can have the widest range of views, information and opinion before reaching what will, in any circumstances, be difficult decisions.