Agenda item

A review of paediatric cardiac surgical services in England began in 2008 in response to long-standing concerns around the sustainability of the current service configuration for paediatric cardiac services. It was planned that proposals for change should go to public consultation in 2011. However, in October 2010 it was announced that the Joint Committee of Primary Care Trusts (JCPCT) would be advised that eventual options for reconfiguration to be put out for public consultation would not include the children’s heart surgery service at the John Radcliffe Hospital.

The Oxfordshire Joint Health Overview and Scrutiny Committee first considered this matter at the January meeting. Members agreed that that they would wish to consider the overall proposals for service change during the formal consultation period. The consultation started on March 1^st and will finish at the end of June.

The formal consultation document issued by the Safe and Sustainable programme includes a number of options for the future configuration of services. The options would see the number of centres providing paediatric cardiac surgical services reduced from the present 11 to 6 or 7. The consultation is focussed on the following areas;

·                          new national standards that have been developed

·                          suggested new approach in providing children’s congenital heart services

·                          proposed options for reconfiguration

·                          new systems for measuring quality

Members of the HOSC will consider the proposals and decide which, if any of them, they would wish to support.

Speakers will include:

Professor Edward Baker, Medical Director Oxford Radcliffe Hospitals Trust

Simon Jupp, Director, and Teresa Warr, Head of Service Development, South Central Specialised Services Commissioning Group

Jude Stevenson and Caroline Langridge, Young Hearts Parents Support Group

Dr Paul Roblin, Chief Executive, Berks, Bucks and Oxon Local Medical Committee

The following are attached:

A briefing note from the South Central Specialised Commissioning Group (JHO6a)

A briefing note dated March 2011 from the Young Hearts Group (JHO6b)

A further submission from the Young Hearts Group (JHO6c)

A briefing note from the Oxford Radcliffe Hospitals Trust (JHO6d)

Slides from a presentation from the Oxford Radcliffe Hospitals Trust (JHO6e)

The formal consultation document has been circulated to members of the HOSC prior to the meeting. Spare copies (234 pages) will be available at the meeting.

The discussion was opened by Simon Jupp and Teresa Warre from the South Central Specialised Commissioning Group. Teresa Warre summarised the proposals in the Safe and Sustainable (S&S) consultation document. Simon Jupp went on to commend the work that has been done by the Oxford Radcliffe Hospitals NHS Trust (ORH) and the Southampton University Hospital NHS Trust (SUHT) in creating the South of England Congenital Heart Network. He also recognised the work done by parent groups in highlighting a number of concerns and questions left unanswered by the consultation document. He pointed out that some questions might only be able to be answered at the national level.

Professor Ted Baker then spoke on behalf of the ORH. He expressed concern that S&S had concentrated on congenital heart disease to the exclusion of those children who had other forms of heart problems.  The ORH is worried that the wider picture is being forgotten and that the whole range of services provided in Oxford could be put at risk by the S&S proposals. For example, there is no reference to emergency access in the consultation document and that relates to many children who do not have congenital problems.

Professor Baker accepted that the ORH on its own does not have sufficient mass to provide a cardiac surgery service. By working with Southampton and the wider network however, sufficient mass has been developed. The network being developed provides not only the cardiac service but also the necessary support to maintain the other critical services in the children’s hospital.

The S&S document refers to networks but does not develop the theme. Oxford and Southampton are building a wide network and are already attracting additional work.

Generally the consultation document leaves many unanswered questions and it is the view of Oxford clinicians that Option B, provided it includes the network and not Southampton on its own, is the only option in the consultation document that would serve the needs of patients in Oxfordshire and the surrounding area. 

Dr Paul Roblin supported Professor Baker’s comments. The consultation should, he stated, look at the overall service and not just at one specific aspect as this one does.

For Young Hearts Caroline Langridge stated that they considered the consultation to be flawed due to the exclusion of Oxford from the consultation and the lack of a question such as, “Do you agree to cardiac surgery in Oxford being closed own”. By not asking the questions S&S appears to be creating a de facto acceptance of the situation.

Young Hearts considers that the assessment by Professor Kennedy of the JR is biased and the fact that the effects on other services is ignored calls into question the seriousness of the consultation.

Young Hearts accepts that Oxford would struggle to match the requirement for 400 cases a year. However the network would provide the required numbers, safeguard all other services at Oxford and lead to a better service overall.

Ms Langridge finished by stating that Young Hearts:

1)     Objects to the closure of paediatric cardiac surgery at Oxford.

2)     Objects to the decision to exclude Oxford from the consultation.

3)     Supports the Southampton/Oxford network.

There then followed a number of statements by parents of children who had received care, and continued to need care, at the John Radcliffe. They made the following points:

The consultation meeting held at the Kassam Stadium was inadequate with many questions going unanswered.

Children with congenital heart problems usually continue to require treatment as an adult. The transition from children’s services to those for adults is best managed on one site or between medical teams from the same hospital. Relationships between patients and clinicians can then be developed over time. The proposed reconfiguration risks jeopardising those relationships. Relationship building is particularly important for children with learning difficulties.

It is also very important for a mother whose baby is born with a heart problem to be able to stay with their baby. That would be made much more difficult by some of the configurations suggested in the consultation document.

Patient choice has been ignored and no consideration appears to have been given to the additional costs and difficulties that would be experienced by parents/carers if the Oxford set up were to close. Only parents who are on benefits would receive help with increased transport costs. The support of the family is vital to the young patients and parents, carers and other family members go back and forth to hospitals and some would need accommodation. In most cases no help would be provided towards the additional costs. This despite the fact that the estimated cost of the S&S proposals is £60m.

There are concerns that diminishing the service at Oxford would lead to doctors leaving  and the effects that would have on the wider service.

Parents whose children have been treated by Oxford physicians working in Southampton have provided glowing reports on the way that the service works.

The consultation document provides no evidence to suggest that services would be better and that more lives would be saved. In fact it might be that the lives of children who require emergency care might be put at greater risk if the closure of cardiac surgery leads to the run down of other services.

Further questions, answers and comments to emerge from the discussion:

Q. What are the likely unintended consequences of cardiac surgery being removed entirely from the JR, i.e. option B not being chosen? Would there be a risk to training status and junior staff employment?

A. (from Professor Baker) S&S gives no indication of what a non-surgical set up might be but catheters cannot be fitted without surgeons and general anaesthetics could be lost with consequent knock-on to intensive care, general paediatric cardiac treatment and training.

Children’s services cannot be run one at a time. A combination of Oxford and Southampton would ensure that expertise would be maintained.

Q. Is the reorganisation about improving a flawed service, saving money or for the sake of reorganisation?

A. (from Simon Jupp) It is not about cost cutting and it will in fact go ahead despite added costs. It is about quality, however it has to be accepted that no evidence has been produced on how making the proposed changes would improve quality. 400 cases is deemed to be the minimum number per year but there is no evidence where that figure came from. Having said that, critical mass is important and there should be enough surgeons to run a sustainable service 24/7, i.e. 4 surgeons as a minimum.

According to S&S none of the 11 centres, including Oxford, is unsafe. None of the deaths at Oxford were due to poor clinical performance.

Q. What guarantees could be given in terms of clinical safety if (i) surgery remained at Oxford; (ii) the network was to be maintained and developed.

A. (from Professor Baker) In the long-term, linking with another centre would always be the preferred clinical option as it would provide the necessary mass to ensure that surgeons maintained their skills and that training would be available for junior staff. Oxford would probably have gone down the network route without the impetus of closure. The network would provide the necessary resilience.

Q. How would the network work – would Southampton team come to Oxford?

A. (from Professor Baker) Details are still being worked through and individuals cases would be different and have to have individual responses. Some cases are very complicated and it may be that those would be dealt with at Southampton with more common cases dealt with at Oxford.

Mrs Anne Wlikinson then spoke about a visit she had made to Southampton to see the set-up there. She had found an excellent service with dedicated staff in a lovely environment. There were major concerns that if option B were not chosen then highly trained and experienced surgeons would leave the NHS.

In summing up the Chairman reminded the meeting of what the HOSC looks for in every change of service. That change should lead to: equity of access; equity of outcome and improvement of service.  He suggested that the proposals would not lead to an improvement in any of those and in fact access would inevitably be worsened.

Everybody would like to see surgery retained at Oxford but clinical advice was clear that most sustainable way forward would be the network solution that Option B could provide.

The Committee agreed that an interim response should be sent to Safe and Sustainable pending further consultation on the outcome of this initial consultation. The response should comment on the lack of detail and information in the consultation and state a preference for Option B provided that it contained Oxford in the network configuration.

The Chairman then thanked everybody for their contributions to the discussion.