Health Service Focus

Safe and sustainable?

NHE speaks to Anne Keatley-Clarke, chief executive of the Children’s Heart Federation, about the implementation of the Safe and Sustainable proposals to centralise paediatric heart surgery, and a recent CQC inspection that uncovered problems at one of the earmarked units at Bristol.

There has been yet another delay in the drive to centralise children’s heart surgery in fewer centres of excellence, based on the standards and recommendations set out by the Safe and Sustainable process, as health secretary Jeremy Hunt chose to have that process reviewed by the IRP following a number of political and legal challenges from campaign groups backing the units set to close.

The Independent Reconfiguration Panel (IRP), the independent expert on NHS service change, will carry out an independent review into whether the Safe and Sustainable proposals for children’s congenital heart services will enable the provision of safe, sustainable and accessible services, following referrals from the Health Scrutiny Committee for Lincolnshire and the Leicester, Leicestershire and Rutland Joint Health and Overview Scrutiny Committee.

It is due to make recommendations to Hunt by 28 February 2013, after which he will make a final decision.

Soon after that decision was announced, a CQC inspection of a ward at Bristol Children’s Hospital showed that staff shortages are having a “major impact” on patients, with not enough checks or observations, and too many medication errors, equipment failures and generally “unsafe staffing levels”.

The hospital – one of the seven where paediatric heart surgery is being centralised following the Safe and Sustainable review – has been forced to restrict the number of operations being carried out there until its high dependency unit is in place.

The unannounced CQC inspection, on September 5, was prompted by complaints from families of children who died there following heart surgery. The CQC report says: “We found that ward 32 admitted children from the paediatric intensive care unit who were in need of high dependency care. We observed during our visit that this was not reflected in the actual staffing level. Ward 32 was staffed as a paediatric general ward and not as high dependency care.”

University Hospitals Bristol NHS Foundation Trust has now cut the number of heart operations being carried out at the hospital, until it has set up a dedicated high dependency unit.

Chief executive Robert Woolley said: “I am deeply concerned that some families believe that we have let them down and will continue to ensure that we address their concerns and bring forward our plans to develop a high dependency unit.”

Anne Keatley-Clarke, chief executive of the Children’s Heart Federation, a parentled charity, said the issues at Bristol “are symptomatic of a wider problem in children’s heart care services across the country”.

Speaking to NHE, she said: “Because of the Safe and Sustainable review that’s been going on for some time, the hospitals are waiting. When there are changes in personnel, changes in staffing arrangements and so on, when people leave, they are reluctant to replace or invest in that service until they are absolutely certain that they are going to continue with heart surgery. So we’re finding – and this isn’t just with surgeons, but all the support workers and specialist nurses and so on who support children in those units – they are not being replaced, and certainly not being increased.

“It’s leaving a hole. At the same time, cardiologists who make the referrals to surgery are conscious there are likely to be changes, so some of them are already pre-empting that and saying that since they don’t think this unit or that unit is going to continue to offer surgery, and the child is going to be looking at surgery perhaps over the next 10 years, they are making more referrals to those units they think are ‘safe’. That is building up pressure points.”

Keatley-Clarke backs the standards and was part of the group looking into them (though she wasn’t part of the final decision-making process), and represents parents who are members of protest groups.

She also spent 10 years a non-executive director at a Strategic Health Authority, which means she has seen the debate from all perspectives. We asked her whether she was dismayed at the further delays to the reconfiguration of children’s heart surgery, or whether she accepted it as inevitable.

She said: “There was a feeling that we knew there would continue to be challenges, but we had hoped that after the Brompton judicial review, which although obviously was linked to what was happening in London, actually gave it quite a good going over and did look at all the processes.

“From a patient’s perspective, of course I recognise that parents of children who have been treated at particular units and those they feel are at risk, or that have been earmarked to not continue with surgery, of course they have a right to fight for it.

“But I think now everybody recognises that the development of the standards were the right thing: they were clinician-led, not management-led, and it was inevitable that certain units were going to close down – really, can we just get on and do it now.”

The Safe and Sustainable review included a requirement that each surgical unit has four surgeons conducting between 400 and 500 operations per year. Keatley-Clarke said: “Parents, national charities and professional associations involved all agree that the changes planned are necessary to improve the quality of care and outcomes for children.”

The CHF has also criticised a potential delay to the judicial review of the heart unit changes, following rumours that the ‘Save our Surgery’ campaign group is planning to “deliberately” halt its challenge to further delay planned changes to children’s heart services.

The Save Our Surgery campaign was set up to oppose the unit closure in Leeds and has applied for a judicial review of that decision. The Safe and Sustainable review also recommended the closure of the units at Leicestershire and the Royal Brompton in London.

The conclusions have been met with severe opposition in the areas set to lose their units, and campaign groups in each area are fi ghting for a reversal of the decisions.

Keatley-Clarke said: “Parents have contacted us concerned over suggestions that the Save our Surgery campaign group have instructed their lawyers to delay their judicial review challenge to the proposed improvements and reconfi guration of children’s heart surgery.

“It’s been suggested by some that they are playing politics with people’s services across the whole country. Parents are concerned and worried over the possibility of even more months of delays. “We are already seeing planning blight in services. There are serious worries over deterioration and the impact this will have to the care on offer. While uncertainty continues, much needed staff are not being recruited, investment in services is not taking place as managers wait to be certain their unit will continue to provide surgery.

“No-one should be using legal challenges in this way, it is almost playing with the future of children and their parents. Of course if people want to use legitimate campaigns and legal challenges they are perfectly entitled to do so, but they should proceed with the legal challenge as they initially planned, not delay it for maximum disruption and delay to this process. In seeking to postpone a challenge until after the Independent Reconfiguration Panel reports they may be hoping to add many more months of hold-ups in a bid to stop these changes completely.

“Put simply, if Save our Surgery feel they have a strong case, they should surely want it to be heard as soon as possible. I hope they will clarify their position and guarantee that they will not cause such a delay; giving reassurance to parents up and down the country.

“If these challenges are to take place, we hope that they will be conducted as quickly as possible to reduce distress and uncertainty to families and staff. Parents have been waiting for years and years for these improvements and yet again news about even more setbacks will be extremely disappointing and worrying for them”.

Save our Surgery said there are misconceptions in the CHF statement, and a spokeswoman told NHE: “Save our Surgery is asking for a stay of proceedings in our judicial review case against the Joint Committee of Primary Care Trusts (JCPCT) whereby our legal representatives will request that the action be put on hold until after the Independent Reconfi guration Panel’s review is complete at the end of February. This follows the health secretary’s decision to put the review process on hold until 28 February 2013 after Leicester’s Joint Health and Overview and Scrutiny Committee referral to the IRP. Save our Surgery had no involvement in this referral.

“Save our Surgery is asking the Court to wait until the health secretary’s decision has been made as it is hoped the IRP will deal with the points raised by the judicial review challenge. This is the appropriate and right action to take in light of these circumstances and the fact that the health secretary has decided that the children’s heart surgery provision review process needs to be re-examined.

“We have always made it clear that seeking a judicial review was our last resort option and we would rather avoid court action and the costs associated with it if we can. At the time that we initiated legal proceedings the IRP referral had not taken place – now that it has, we need to see what the panel decides before proceeding.

“We have waited ten years for the review of children’s heart surgery services to be completed. We must now make sure that the outcome is right for children and the safest option for patients. We have grave concerns about this process and the recent Care Quality Commission (CQC) fi ndings at Bristol have only added to the evidence that the decisions regarding which units remain open is highly questionable. We will continue to challenge this decision, whether through government referrals or legal action, until we believe that the right decision has been made for patients and future generations.”