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Open Heart Surgery (Aberdeen)

Volume 978: debated on Friday 15 February 1980

The text on this page has been created from Hansard archive content, it may contain typographical errors.

Motion made, and Question proposed, That this House do now adjourn.—[ Mr. Brooke.]

2.32 pm

I am grateful for the opportunity to discuss a matter of serious concern in my constituency and in the constituencies of other hon. Members from the Grampian area.

When it was publicly announced that open heart valve replacement surgery had been stopped by the Grampian health board, a shock wave reverberated through not only the city of Aberdeen but the whole area served by the Grampian health board.

I wish to make it clear at the outset that I have no criticism of either the administrators or the members of the Grampian health board. They were placed in an invidious and impossible position when they learnt that operations were being carried out without their knowledge or authority. If there be criticism, it must be made against those surgeons who quite deliberately carried out heart valve replacement surgery without advising the board. This was an attempt to present the board with a fait accompli in the hope that once it became known that such surgery was being carried out there would be no alternative but to sanction its continuance.

This criticism must be tempered by the knowledge that the surgeons concerned had, and still have, the interests of their patients at the forefront of their minds and by the fact that between March and November last year 12 patients underwent successful surgery. This is an achievement that cannot be set aside and must be taken into account in our discussions of the future. It is a compelling reason to authorise the restarting of this particular surgery and for the Minister to provide the additional finance required by the Grampian health board.

This brings me to the determination of priorities within the National Health Service. I do not take the view that because surgical or medical treatment of any particular specialty is available in one part of the country it must necessarily be made available in every part. For example, if we discuss heart transplants, I would certainly not support the case for such operations to be done in Aberdeen.

But we are not discussing an operation on the frontiers of medicine. We are discussing a well-tried and successful operation carried out in many parts of the country and in Aberdeen itself.

Priority for finance and expansion of services must be judged primarily on the needs of patients, the capacity of the hospital to do the operation with safety, and the availability of finance. Locally, at health board level, there are clear and well-defined channels of communication between medical staff and the health board, which has the ultimate responsibility for sanctioning either the establishment of some new medical specialty or the expansion of an existing specialty within the finance allocated by the Secretary of State for Scotland. The options open to the health board are circumscribed by the money allocated. There is no independent revenue-raising mechanism. The board is wholly and entirely dependent on the Secretary of State for Scotland for its funding.

As the frontiers of medical technology expand, the exceptional techniques become normal and obviously the demand increases to save the lives of patients. I must emphasise here that we are discussing surgery that saves lives. This brings me to the1977 Kay report, which sought to establish the need in Scotland for cardiac surgery of different kinds and to determine how the interests of the patients might be met. In our correspondence and public exchanges, the Under-Secretary has relied heavily on that report—master-minded by the late Professor Kay—as a defence, I believe, for his own inaction. He has not investigated the changed circumstances since 1977.

In his letter of 18 January, the Under-Secretary placed the responsibility on the health board to approach him requesting that the 1977 arangements should be revised. I do not think that this is an adequate response to the serious position in the Grampian area. I hope to argue later, if I have time, that he has a statutory responsibility to take the initiative rather than adopt a passive and negative attitude.

The 1977 report provided for the total Scottish need of between 1,600 and 2,000 adults and 400 pediatric heart operations a year to be met by the establishment of two major centres in Glasgow and one in Edinburgh. In recognition of Aberdeen's special position, it was finally agreed that coronary artery bypass surgery should be continued in Aberdeen on the scale of about one operation a week. It was decided that no operation should be carried out in Aberdeen for heart valve replacement. The report concluded with a recognition that there was a need for a continuous review.

I should emphasise that I am advised that there is no basic difference between valvular surgery and coronary artery surgery and that, in fact, the latter is often more demanding than the former. How have the projected aims and objectives of the 1977 report been matched by performance? Sadly and tragically, they have been matched badly. Instead of of the 1,600 to 2,000 cases per year, only about 800 have been dealt with. Glasgow's work load has been static for the last three years at about 450 per annum. Edinburgh's work load has remained at about 350 cases per annum. As a result, waiting times of 12 months to 18 months have occurred. Aberdeen patients have had to be referred to London and some patients have died because of the delay.

The delay caused by the inability of Glasgow and Edinburgh to cope has led to patients on their lists being sent to London and Leeds. Therefore, the three centres are not coping with their own areas, never mind with patients from outside. The demand in the Grampian area for valve replacement is constant at 30 to 40 cases per annum. The waiting time for surgery in Glasgow and London is between nine and 12 months. There is also a demand for coronary artery bypass surgery of about 60 to 70 cases per annum. That is slowly increasing and leading to a waiting list of six to nine months for surgery.

In addition to seeking the authorisation for valvular surgery, an increase from one case to three cases per week in coronary bypass surgery is sought. I hope that the Minister will confirm those figures in his reply. I believe that they are accurate because they come from an authoritative source. I have no wish to add to the stress on patients awaiting surgery or to contribute to the worry of their relatives by dramatising the position. Nevertheless, patients have died. Five or seven patients might still have been alive today. I believe that a compelling and unanswerable case has been made for lifting the ban on the ground of need. Furthermore, the team of surgeons and anaesthetists claim, with firm conviction, that they can operate with safety within the capacity of the existing staff numbers and that no extra staff or back-up facilities are required. Indeed, I believe that they have demonstrated that.

The additional cost involved is said to be about £550 for the replacement valve and associated equipment. With a demand of 30 to 40 cases per annum, we are speaking in terms of £22,000 per annum. I accept that if the demand for valvular surgery were to increase or if there were a greater demand for coronary bypass surgery, there would be additional costs. However, I understand that the existing staff and facilities would not need to be expanded. How is that £22,000 to be found? One thing is clear. It cannot be found from the existing revenue allocated to the Grampian health board. The board is just about at its wit's end trying to determine how to keep existing services going with its current budget, bearing in mind the inflationary costs that it will face this year.

I note from last night's Aberdeen Evening Express that Mr. Cockburn, a senior cardiac surgeon, has said that if the lifting of the ban is prejudiced for pure financial reasons, consideration should be given to the launching of a public appeal to raise the required money. I cast no doubt on Mr. Cockburn's sincerity or desire to serve his patients. However, the thought that the lives of patients at risk should be in the balance and dependent on public subscription is appalling. It demonstrates far more vividly than I can describe how far public expenditure restrictions have affected the National Health Service.

The finance can and must be found by a direct injection of additional funds from the Government to the Grampian health board. There is no time for delay. I trust that the Minister will make clear that the lifting of the ban will not be prohibited by the unwillingness of the Government to act and provide the money involved. I have time to explore briefly the Minister's responsibility which he seeks to avoid. In his letter to me of 18 January he said:
"You must be well aware as a previous holder of the Ministerial post which I now occupy that the responsibility for managing the Health Service in the Grampian Area is statutorily invested in the Health Board, and that it is not appropriate for me to intervene in the day-to-day administration of the Service."
I call attention to section 2 of the National Health Service (Scotland) Act 1972, which, in subsection (1), provides:
"It shall be the duty of the Secretary of State to provide throughout Scotland, to such extent as he considers necessary to meet all reasonable requirements, accommodation and services of the following descriptions—
(c) medical, nursing and other services, whether in such accommodation or premises, in the home of the patient or elsewhere."
The Minister might quote back at me section 13 of that Act, now consolidated with section 2 of the National Health Service (Scotland) Act 1978, which gives him the power by order to constitute health boards and to make regulations requiring health boards to submit a scheme for the exercise of his functions and their functions in relation to him.

No such regulations have been made. Indeed, I am advised that no such regulations are contemplated in the near future since the whole question of the management of the health boards is in the melting pot following the issue of the consultative document "Structure and Management of the NHS in Scotland."

However, I rest my case not on a technical nicety, but on the paramount duty of the Secretary of State as laid down by section 1(1) of the Act, which reads:
"It shall be the duty of the Secretary of State so to exercise the powers and perform the duties conferred and imposed on him by the Health Service Acts as to provide or secure the effective provision of an integrated service in Scotland."
I believe that it is the Minister's duty to take the initiative in matters of this kind and that he cannot shirk his responsibility to provide the finance required.

I submit that the argument is clearly demonstrated and irrefutable. Frist, there is a need to lift the ban on valvular surgery for patients not only of the city of Aberdeen but of the whole of the Grampion area. Secondly, surgery can be carried out safely by the cardiac team. Thirdly, the additional finance is not by any stretch of imagination an exorbitant demand on the Exchequer. Fourhtly, the objectives of the 1977 report have not been met. Finally, the matter is urgent.

I appeal to the Minister to take action without delay. It is his responsibility. He must have as his first priority the care, safety, welfare and health of patients in the Health Service, whether in the Grampian area or in any other part of Scotland.

2.48 pm

I think that we ought to look first to the origin of this debate. It stems from 19 December 1979—little time ago—when, in answer to a routine question about when I would next be meeting the chairmen of health boards in Scotland, the hon. Member for Aberdeen, North (Mr. Hughes), in his supplementary question, asked:

"Will the hon. Gentleman have an urgent meeting with the chairman of the Grampian health board in order to investigate the report that the health board has had to stop open-heart surgery? Otherwise, many emergency patients will have to go to Glasgow or to London to have their operations. Is it not totally unfair that the board should bear the opprobrium of having to stop that kind of surgery, since that responsibility belongs to his Department? If anyone dies, it will be the hon. Gentleman's responsibility."—[Official Report, 19 December 1979; Vol. 976, c. 601.]
That is emotive, dramatic stuff. What is the inference behind it? It is that current cuts are causing this situaton.

The hon. Gentleman knows full well that whilst there have been cuts in other parts of our public work, the Health Service in Scotland, as elsewhere in the United Kingdom, has had no cuts this year. He knows that next year in Scotland alone there will be a 2·6 per cent. increase in spending, in real terms, on the Health Service. Therefore, I suggest that the whole background to this Adjournment debate is spurious, hypocritical, cynical and politically motivated and that these are the reasons for it.

The debate is not primarily concerned with the allocation of resources, nor with levels of public expenditure in the Health Service, despite the references to cutbacks in cardiac surgery in Aberdeen. The main issue is the medical question—I repeat, the medical question—of how we can best organise cardiac surgery in Scotland to ensure that all Scottish patients have access to the benefits that can now be conferred by that rapidly developing surgical specialty. On that question, we are fortunate to have the advice of a national body of the highest professional standing, the cardiac surgery programme planning group, chaired by Professor Sir Andrew Kay and composed almost entirely of cardiac surgeons, cardiologists, radiologists and anaesthetists, which reported in September 1977.

That body, which included two members from the Grampian area—Professor Gillanders and Dr. Short, who both practice in the Aberdeen area—stressed that in the developing specialty of cardiac surgery the best results have come from large centres to which selected patients have been referred. If time permits, I shall quote from certain conclusions in their report.

The group accordingly recommended that there should be three cardiac centres in Scotland, two in Glasgow and one in Edinburgh, providing facilities that would be capable in due course of catering for the future estimated need of up to 2,000 operations on adults per year and 400 operations on children. The majority of those operations, possibly 1,500 in respect of adults and 250 in respect of children, would entail open-heart surgery. It may be helpful if I were to define that expression as surgery requiring cardio-pulmonary bypass or, in layman's language, requiring the action of the heart to be stopped and the use of an external machine to circulate the blood while surgery takes place within the heart itself. It is with that form of cardiac surgery that we are particularly concerned in this debate and not with surgery that does not require the heart to be opened—for example, surgery to deal with disease in the coronary arteries outside the heart.

The recommendations of the cardiac surgery programme planning group were accepted by the Government of the day, of which the hon. Member for Aberdeen, North was at one time a member, occupying the ministerial post that I now have the honour to hold. The hon. Gentleman's colleagues in Government at the time accepted that the report of the programme planning group presented convincing arguments for the restriction of cardiac surgery to a limited number of designated centres—

—and that it was in the best interests of cardiac surgery for Scotland as a whole that there should be only three cardiac surgery units, as recommended by the group. A circular to that effect was sent to Scottish health boards on 14 September 1977. It is surprising, to say the least, that the hon. Member for Aberdeen, North should now be seeking, for purely political motives, to undermine the recommendations of such an eminent professional body which were fully accepted by his own colleagues in Government as recently as two and a half years ago.

In pursuing this matter, the hon. Gentleman has done no service to the interests of cardiac surgery or, indeed, to the best interests of patients awaiting cardiac surgery in his own area. I have in my hand a letter dated 11 February 1980 to the chief medical officer of the Scottish Home and Health Department signed by the president of the Royal College of Physicians and Surgeons of Glasgow, the president of the Royal College of Surgeons of Edinburgh and the president of the Royal College of Physicians of Edinburgh—these are, of course, national bodies—drawing attention to the serious concern of their joint cardiology committee at the possible development of open-heart surgery in Aberdeen against the express recommendations of the Kay programme planning group. They stress that this report provided clear advice on open-heart surgery in Scotland indicating that this should be limited to centres in Edinburgh and Glasgow. The presidents of the three Royal colleges wish to reaffirm their full endorsement of the recommendations of the Kay report.

They have asked the chief medical officer to confirm that these will be implemented and that the development of open-heart surgery in Aberdeen is not the policy of the Scottish Home and Health Department. I deal with the sedentary interjection from the hon. Gentleman. Of course, the endorsement is not for ever. The report was produced in 1977 and we are now in 1980. These are highly technical medical conditions and provisions that we are discussing. It is not necessarily for ever, but it applies for the time being.

I am happy to give the Government's confirmation that the recommendations of the Kay report will be implemented, as proposed by our predecessors in office, and that the development of open-heart surgery in Aberdeen is not the policy of the Department.

There are other matters with which I should like to deal, but in the interests of time I shall push on with certain other matters.

I noted from a press report earlier this week that one of the Aberdeen cardiac surgeons has said that the only additional cost for the replacement of a valve by open-heart surgery in Aberdeen is the cost of the valve itself, at £500. That may be his view of the level of additional expenditure required, but it is certainly very far removed from the Kay report on the matter.

I have been informed this week by a consultant heart surgeon in Edinburgh royal infirmary, who took the trouble to get in touch with me on the matter, that claims that the Edinburgh cardiac surgery unit has such a long waiting list that it cannot cope with patients from Grampian are without foundation. All emergency cases referred to the unit are operated on within a matter of days, while serious, non-urgent cases are dealt with in a matter of weeks. There is no reason to believe that the three centres will not be able in due course to meet the full level of demand indicated by the cardiac surgery programme planning group.

The Kay report did not take up a defensive position. I have mentioned the two eminent gentlemen from Aberdeen who contributed to the report. The report was produced in the best interests of cardiac sufferers in Scotland.

I have no need to take up a defensive position. It is a great pity that the truth has not been offered properly to the Scottish media. I hope that as a result of the debate we shall have a full and frank report of the true position in Scotland.

The hon. Gentleman advanced certain medical arguments. With due respect to his knowledge of medicine, I suggest that they were technically incorrect. The issue of Aberdeen patients going to London is irrelevant and a red herring as basically they go to Glasgow or Edinburgh.

The reference to £550 per operation is so far from the real position that it does not warrant further comment. There is no question of my giving the money to lift the ban. Eminent medical men have stated where this high-quality, high-technology surgery should take place. Their reasons are based on what is best for patient care in Scotland and not on financial considerations.

I have about three minutes in which to finish my speech and I should like to return to the quotes from the report of the body of which the two Aberdeen doctors were members. It concluded:
"If the benefits of the rapid advances which are taking place are to be fully exploited, it will be more appropriate in future for the cardiac disciplines to be developed as opportunity presents in designated cardiac centres providing integrated medical and surgical care. Such an arrangement would ensure the most efficient deployment and use of scarce professional staff, expensive equipment and other resources, would be essential if the substantial teaching commitments are to be met, would provide the best opportunity for cardiac research and for the development of the services and, above all, would provide the best clinical environment for patient care at its highest level."
It went on:
"the number of cardiac centres should be limited so that each would be sufficiently large to handle a workload which would justify the provision of a full range of investigative, diagnostic and treatment services on an economic basis, provide sufficient experience on which to build and maintain the highest level of expertise and attract and retain staff of the highest professional and technical competence."
I hope that what I have said will rebut the inaccurate reports, to which the hon. Member has lent the authority of his support, that the prohibition of open-heart surgery in Aberdeen was a decision by politicians and administrators, rather than by clinical experts. The decision that cardiac surgery, and, in particular, open-heart surgery, should be undertaken only in three special centres in Glasgow and Edinburgh arose from the recommendations of a body composed almost entirely of professional experts, including two from the Grampian area.

It was a decision supported by the hon. Gentleman's colleagues in Government and one that the present Government are happy to endorse. The Department has had to wait since December to clear up, at best, the misunderstandings and, at worst, the misrepresentations on this matter.

I only hope that the media will give complete coverage to the reasons why open-heart surgery is not taking place in Aberdeen, so that the correct medical and clinical reasons are under- stood. The Government confirm their position, which is exactly the same as that of the previous Government

Question put and agreed to.

Adjourned accordingly at two minutes past Three o'clock.