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New heart surgery plans to leave behind closure controversy

NHS England has launched a new consultation paper on the future of children’s and adults’ congenital heart disease (CHD) services, in an attempt to move forward after a decade of debate over which hospitals’ surgical units should stay open and which should shut. 

The ‘Safe and Sustainable’ review said three centres providing children’s heart surgery should close – those at Leicester’s Glenfield Hospital, Leeds General Infirmary and the Royal Brompton in London – but that review was scrapped following a judicial review, which said the consultation was flawed. 

The new NHS England approach is to outline a set of minimum standards, rather than insist that some units close. At the core of the new proposed standard in the consultation is for each specialist unit to have four consultant congenital surgeons performing 125 procedures a year, and 24-hour clinical cover. 

The consultation notes that “if work was spread evenly across the existing 10 Specialist Surgical Centres, it would be close to the level of activity required to meet proposed standards at every centre”. NHS England expects activity in this area to rise in the next few years. 

NHS England’s Specialised Commissioning Oversight Group said in a recent update on the CHD review: “‘Safe and Sustainable’ took four years and had a net cost of £6m, but in the end the conclusions were not implemented because of concerns about the process. We are mindful of this and – despite the clamour for a quick solution – have resisted the temptation to take short-cuts in our process, our engagement or in our own internal assurance.” 

Ensuring patients get the same high-quality service wherever they live 

In a policy area that has been controversial for almost a decade, following repeated reviews and investigation, the new standards aim to ensure that patients receive the same high-quality screening wherever they live and will receive the support, care, and information they need if an anomaly is suspected. 

CHD refers to birth defects that affect the normal workings of the heart. These range from severe life-threatening conditions that need immediate surgery, at or even before birth, to minor conditions that may not need treatment. CHD surgery for children is carried out in 10 hospitals in England with three other centres offering specialist paediatric cardiology. Twenty-five hospitals in England provide most of the surgical procedures and interventional cardiology for CHD in adults. 

Since June 2013, NHS England has worked closely with stakeholders to develop the children’s and adult standards on which it is currently consulting, and with the congenital heart services clinical reference group who have developed the draft service specifications.  

Within the new consultation proposal it was stated that NHS England has heard that it is important that each surgeon does enough operations on a regular basis to maintain their surgical skills. Therefore, it has been proposed that hospitals providing care for CHD must work as part of three-level networks that bring together fetal, children’s and adult services. 

Additionally, patients being considered for surgery or intervention must be discussed by a multidisciplinary team and these procedures must only be undertaken at a Specialist Surgical Centre. 

Minimum standards and clinical cover 

There are also proposals for CHD teams to have at least four consultant congenital surgeons – to enable centres to provide a concentration of expertise ensuring a team approach can be taken to managing clinical problems in a team with a greater range of skills; to be more resilient to the loss of one surgeon (for example, in the event of illness); and to provide 24-hour clinical cover all year round while avoiding the risk of fatigued surgeons. 

In total, the standards cover 13 areas including: communication with patients and their families; staff and skills needed in teams; transition for children moving between child and adult services; working with other healthcare services patients might need; and support for patients and their families when their disease is not responsive to treatment. 

Dr Jackie Cornish, national clinical director for Children, Young People and Transition to Adulthood at NHS England, said: “CHD services in this country already provide good, safe care, with high survival rates after surgery.  

“But we know there are areas for improvement, and we want consistent services of the highest quality for all our patients throughout their lives, wherever they live. We know this is what patients want, and it is what they deserve. Our aim is to ensure a high standard of service is sustainable for future generations of children.” 

Dr Mike Knapton, associate medical director at the British Heart Foundation, who sits on NHE’s editorial board, said: “We want to see the best possible services and outcomes for children and adults with CHD and this consultation is intended to achieve that. Patients and families affected by CHD should have access to high standards of expertise when they need it, regardless of where they live. 

“This means that NHS services have the right staffing and skills, and work closely together and with other relevant services, as well as with patients, to ensure that every congenital heart patient receives an optimal standard of care.” 

The consultation 

A roadshow of drop-in events will be held across the country, where people will be able to find out more about the draft standards and can complete a consultation response if they wish. Following consultation and agreement of the final standards, they will be written into service specifications. These set out requirements of a service and form the basis of contractual arrangements between NHS England and hospitals providing care. 

The consultation is more extensive than usual, “reflecting the higher than usual interest in this area”. 

A Department of Health spokesperson told NHE that the priority is to ensure children and adults with CHD get the best care possible. 

“In cooperation with leading clinicians, NHS England has developed and is now consulting on standards, so we have consistent, high-quality heart services across the country,” he said. “Everyone with an interest should contribute their views.” 

The closing date for the consultation is 5pm on 8 December 2014. The consultation drop-in events will be open for anyone to attend and will take place on: 

• 14 October 2014:              London
• 16 October 2014:              Newcastle
• 22 October 2014:              Birmingham
• 24 October 2014:              Leicester
• 3 November 2014:           Leeds
• 4 November 2014:           Liverpool
• 5 November 2014:           Manchester
• 6 November 2014:           Cambridge
• 10 November 2014:         Oxford
• 11 November 2014:         Cardiff
• 12 November 2014:         Bristol
• 13 November 2014:         Southampton 

(Image: c. Anna Gowthorpe/PA Wire) 

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