Closing cardiac units might be right, but it won’t be easy

Yesterday, Health Secretary Andrew Lansley reported to MPs on the state of the NHS. The state of the NHS, you’ll be relieved to know, is good, or at least it is in Mr Lansley’s estimation. Budgets are in surplus, waiting lists are down and, unless you are very unlucky, you won’t have to hang around for more than four hours in A&E before they see you. One thing, however, that the Health Secretary didn’t volunteer – curiously, since it was the biggest NHS news of the day – was the reorganisation of heart care for children, and the closure of three specialist surgery centres in England. This is probably just as well, for the man who is the ultimate source of what was announced yesterday is now in charge of MPs‘ expenses, and our legislators probably don’t want too much reminding of Sir Ian Kennedy’s existence.

It says on IPSA’s website that Sir Ian, its Chairman, is best known as the man who led the public inquiry into the deaths over a ten year period of several children and babies undergoing heart surgery at the Bristol Royal Infirmary. In the political world, it is probably a toss up between that, the expenses and being the friend whom Alastair Campbell phoned when he appeared on Celebrity Who Wants to be a Millionaire. On planet NHS, however, there is no doubt that the Kennedy Report, published in 2001, had the impact of a fairly substantial meteor. As well as addressing the specific issues in Bristol, Sir Ian ranged widely (as his terms of reference permitted) over how the standards and safety of clinical care delivered through the NHS should be upheld. This was a time when the medical professions’ self-regulation monopoly was already under serious attack. Kennedy added to the momentum of what is called ‘clinical governance’ – the idea that there should be a systematic, existential approach to improving standards and keeping patients safe.  Out of this came a quango, the Healthcare Commission – chaired naturally enough by Ian Kennedy – and this approach, subject to the odd label change, still exists today.

It might seem odd that it wasn’t until the turn of the 21st century that ‘quality’ actually became something the NHS sat back and thought about. No stranger, I suppose, than that Kennedy should title one of the sections of his report ‘patients are entitled to care that is safe’, as if such an obvious truism needs to be handed down to us by a lawyer steeped in medical ethics. Yet when it comes to the specific matters that the Kennedy Report was addressing – i.e. a specialised children’s unit where children were dying – it has taken even longer to respond. Here we are, 11 years on from Kennedy, and it has only now finally been decided that, for safety’s sake, some children’s heart surgery centres need to close, and which ones those should be. 

Partly the delay resulted from a legal challenge to the process by the Royal Brompton Hospital, the highest profile of the units earmarked for closure. But it is hard to blame just that for the fact that it has taken over a decade to get to where we are now. It was not until 2008 – seven years and three Secretaries of State for Health later  – that the NHS Medical Director commissioned a formal review of children’s congenital heart services. This delay has not meant that the unpalatable consequences of the review are any easier to stomach.

The idea that very specialised health services, like children’s heart surgery, should be concentrated in fewer places, where there can be more people who know what they are doing and the very best equipment, shouldn’t strike one as particularly controversial. In the abstract at least, it commands universal clinical consensus. It is where this logic takes you that is the problem. Parents who have had their children’s lives saved in one of the closing units are easily, and understandably, swept up in the horror that it is going to be taken away. Doctors on the other hand are in a more compromised position, and tend to sit on both sides of the argument. They are confident that the evidence-base supports rationalisation, right up until the point that it is their unit that falls out on the wrong side of the analysis. Announcing the outcome yesterday, Sir Neil McKay, who chaired the committee that took the decisions, made a pointed remark that ‘the needs of children, not the vested interests of hospitals, have been at the heart of this review’. The uncompromising way in which the Royal Brompton has set about trying to defend its patch has, in particular, upset a number of people in the process.

There will be more of this – much more – to come. The same team that has been reviewing children’s congenital cardiac services is also carrying out an examination of paediatric neurological care. Up and down the country there are local reviews of hospital services and proposals for change and once all the comforting sounding jargon about clinically-led change and public consultation has been swept away, this will mean actual units and actual hospitals boarding up. It may be right. It may be evidence-based. It may be about quality and safety, not about money. But it won’t be easy.