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Upper Gastrointestinal Surgery

Volume 502: debated on Wednesday 9 December 2009

Motion made, and Question proposed, That this House do now adjourn.—(Mr. Mudie.)

It is probably about two years ago that Devon primary care trust informed us, through their then chief executive, Dr. Kevin Snee, that it had been proposed that the upper gastrointestinal unit at Wonford hospital in Exeter be moved to and merge with the unit in Derriford hospital in Plymouth. In principle, I have no objections to proposals, including this one, that aim to create centres of excellence where surgeons can deal with a much wider range of patients and a much larger catchment area to improve their expertise in what is a very difficult area of surgery. Indeed, I support the call for centres of excellence.

In the discussions that I had with the then chief executive, it became clear to me that the facilities at Exeter would be moved to Plymouth and that, from that, the centre would grow. However, the upper GI unit at Wonford hospital in Exeter has developed as a national centre of excellence, using keyhole surgery to perform what are known as minimally invasive oesophagectomies—in other words, the removal of the oesophagus, a serious operation, usually required because of cancer, and one that surgeons need a great deal of experience to perform. To be able to carry out MIOs—which are much easier to say—it was promised that the excellence that had been developed in the centre at Exeter would be moved with the unit to Derriford hospital.

Under normal circumstances, the operation requires major open surgery, with the surgeon opening not only the chest cavity of the thorax, in order to access the oesophagus, but the abdomen. As one can imagine, that is a very large operation indeed. The surgical removal of the oesophagus has large implications for quality of life and recovery after surgery. However, as they have been developed over the years, it has been demonstrated and proven at Exeter that MIOs, where the thorax and the abdomen are entered using keyhole surgery, have a most beneficial effect on both post-operative recovery and quality of life, particularly where there are later reoccurrences of the carcinoma.

Since 2004, two surgeons at Exeter, Mr. Richard Berrisford and Mr. Saj Wajed, have done that operation in preference to open surgery. The Exeter MIO unit has submitted many papers to MIGOCS, the minimally invasive gastrooesophageal cancer study, which is run by the Oxford university medical school. The Exeter MIO unit is the only established UK unit that has published its data, published a safety algorithm and proven that its techniques result in the rapid restoration of quality of life, and it is also undertaking further research. Exeter is the UK’s largest contributor to that national study, as a result of the work done in the MIO unit. Therefore, although I and my hon. Friend the Member for East Devon (Mr. Swire), who has raised the matter with Ministers in the past, have an interest in Devon and the wider west country, the unit is also of national importance, which is why I am raising the issue on the Floor of the House.

I was first alerted to the problems that have arisen with the removal of the MIO unit from Exeter to Derriford only recently, by Hannah Foster, the Conservative prospective parliamentary candidate for Exeter, who was in touch with the local patients group. Patients, who included my constituents, were concerned that they would be denied MIO treatment and that the MIO surgeons, who were meant to have helped establish the MIO unit at Plymouth by last September following the move from Exeter, had not been able to do so.

I congratulate my hon. Friend and neighbour on achieving this debate. I raised the issue in Parliament more than two years ago and have continued to do so since. She referred to the move and the culture of secrecy surrounding it. Does she agree with my constituent Mr. David Hamilton of Sidmouth, who is currently undergoing treatment, and others who have raised the issue, who say that people are not allowed to talk to politicians? A culture of secrecy seems to have been created, with a rather sinister air of intimidation surrounding the entire proposal to relocate—a proposal that I do not believe adds anything to the argument, but which makes us in this place rather suspicious about the motives behind it all. Does my hon. Friend agree with me that the proposal is not benefiting anybody?

I do agree with my hon. Friend. There is already a unit in Plymouth, at Derriford hospital, and it might well claim that it does keyhole surgery. However, the procedure that it carries out is not the same as that carried out at Exeter. The procedure at Plymouth tends to be either keyhole surgery in the thorax with open surgery in the abdomen, or vice versa. In other words, it is hybrid in nature.

The fact that everyone had been informed that the move from Exeter to Plymouth would have taken place by September of this year—so that, under the supervision of the Exeter surgeons, the unit would ideally have been up and running in Plymouth by early 2010—is a matter of great concern. I shall turn in a moment to the subject that my hon. Friend has just raised. Patients are worried, and doctors do not know where they stand, and we face the potential loss of a groundbreaking unit, not only in the west country but in the rest of the country.

The hon. Lady is making some important points. May I first apologise to the Minister, because I might not be able to stay in the Chamber to hear his closing remarks? The hon. Lady has raised an important issue that also affects Cornwall. It involves the whole issue of planning for upper gastrointestinal cancer surgery. I entirely accept the view of the Devon and Cornwall peninsula cancer network that patient safety must be paramount in the planning of these services, but does she agree that, rather than taking decisions about sub-specialty surgical interventions for cancer in a piecemeal manner, as is the case at the moment, we need to take a broader, more strategic view of how all these interventions are managed across the whole peninsula?

I am not sure that I have understood the hon. Gentleman correctly. I said earlier, however, that if I needed treatment for oesophageal cancer, I would want that operation to be done by a person who was doing many such operations, and I would be prepared to travel to do that. Patient safety is important, and some procedures, including this one, are of such a specialised nature that they should not be left to generalist surgeons, who do not see or treat enough patients who require such a procedure in the course of a year to develop sufficient expertise. So I might be disagreeing with the hon. Gentleman on that.

I agree with my hon. Friend the Member for East Devon, however, when he says that the way in which the primary care trust has gone about all this looks extremely sinister. The Exeter surgeons should have been in the Derriford unit by last September, as promised, and working as a team. Teamwork is important in building up the necessary expertise. We have seen examples in other parts of the country of units not making such a transition smoothly. The result is that the consultants do not have enough time to build up their expertise before starting to carry out these procedures. The consequences of that will be obvious to everyone.

Plymouth has not yet carried out a full MIO of the type done at Exeter. Nor has it yet filed any papers with the Oxford study that I mentioned, to which Exeter has contributed more than any other organisation in the country. It has not registered its patients on the national register database in Oxford. I therefore believe that, in the interests of patient safety, Derriford should not be expected to replicate what is being done at Exeter without the proper transitional arrangements in place which are seen to work. That has not happened yet, and I would be very concerned if such procedures were to take place without those transitional arrangements. The health scrutiny committee of Devon county council has referred the case to the Minister, because it is so worried about it.

A further concern is that patients who are now presenting to the surgeons in Exeter are being told that the unit will not offer them operations after the new year. I received a phone call earlier from one of my constituents who was told by phone only this morning—I do not know whether that was connected to our holding this debate—that an exception would be made, and that he would receive his surgery in the MIO unit in Exeter in February. That makes it sound as if it is a one-off case and it does not look as though it will solve the whole problem that I have brought before the House tonight. The Minister is involved and there should be some national intervention in this case, not least because of the research at the Exeter MIO unit.

The research is known as the LOGIC programme; I am sorry about all the acronyms. The laparoscopic gastric ischaemic conditioning trial is approved by the Devon and Torbay ethics committee, has been running since April and has so far recruited 15 patients. It requires a total of 44 to complete the study. If there is a break in the established MIO service, there will not be a sufficient number of patients to allow the research to be completed. It is a very important piece of research. It is so important that one of our local cancer charities based in Exeter, FORCE—Friends of the oncology and radiotherapy centre—has donated £20,000 to the research project. People locally have put their firm commitment behind the research.

Will the Minister confirm tonight that the MIO unit in Exeter will continue until such time that it is safely—and I mean safely—established in Plymouth? If not, why is this being done against the clear recommendations of the health scrutiny committee and contrary to what was promised personally to surgeons, patients and MPs by the primary care trust? Why has Plymouth failed to develop a total MIO, despite giving the reassurance that it would develop it in September 2009, by which time we would have hoped that it would be well on the way to being established?

Will patients in Devon now have to accept the choice of open surgery, which they do not want—those who have seen what is done at Exeter clearly opt for the minimally invasive surgery—or will they be faced with the very real risks of a learning curve in developing a new highly complex operation in a unit not familiar with this procedure? As I have mentioned, there have been disastrous parallels in previous examples of centralisation. I will not name them, but I am happy to tell the Minister privately where we have seen the procedure bomb as a result of the transition not being implemented properly and surgeons not having sufficient time or a team built around them to carry out the transition properly.

A final aspect of the problem is that people come from far and wide for the procedure in Exeter—not just from the south-west but from all parts of the country, because the procedure is unique. If the MIO unit closes in Exeter and is not reopened in Plymouth, a private patient could opt to have the MIO procedure and all the associated benefits if they are prepared to pay for it. NHS patients, however, who until now have had the choice and the benefits of the procedure, will be denied it. I really do not understand why something so groundbreaking and so important to our constituents, as well as being in the national interest, should be denied to the NHS. Something has gone seriously wrong with the way in which the process has been carried out, and I would like the Minister to investigate what it is and put it right.

I congratulate the hon. Member for Tiverton and Honiton (Angela Browning) on securing the debate.

The fast and effective treatment of cancer is one of the national health service’s highest priorities. As a result of massive and sustained investment in the NHS and in cancer services by this Government, paying for more consultants, more nurses, more National Institute for Health and Clinical Excellence-approved drugs and far better facilities, there are now almost 9,000 fewer deaths every year than there were before 1997.

In 2000, we published the NHS cancer plan, setting out how we would improve cancer treatment and ensure high-quality services for patients. The plan committed the NHS to implementing the latest authoritative guidance available on all aspects of NHS cancer care. However, I can assure the hon. Lady that decisions about exactly where and how care will be provided are local decisions. It is a matter for the local NHS, working with cancer networks, clinicians, patients and other stakeholders; it is not for Ministers to decide that in Whitehall.

The Department, supported by the national cancer action team, has been monitoring progress in the context of local plans. Although I understand the concern expressed by the hon. Lady, I am sure she will appreciate that if further improvements are to be made in cancer surgery and if better outcomes are to be delivered for patients, local clinicians must be able to secure local solutions to the various issues that are raised. In 2008-09, a total of 3,668 major oesophagogastric procedures took place in England. I understand that about 50 patients currently undergo surgery for oesophagogastric cancer each year at Derriford hospital in Plymouth, some of whom are from Cornwall. About 47 patients undergo surgery at Royal Devon and Exeter hospital in Exeter, and about 20 undergo surgery at Royal Cornwall hospital in Truro.

I understand that Devon primary care trust, working with the South West strategic health authority and the peninsula cancer network, has considered the improving outcomes guidance recommendations for upper gastrointestinal cancers, and that discussion took place with local people. The proposal is that from 1 January next year the oesophagogastric surgical unit at Plymouth Hospitals NHS Trust will expand to become the centralised specialist surgical unit for patients from Devon and Cornwall with oesophageal and gastric cancer.

As part of its commitment to placing patients and the public at the centre of health services, the Government have established an independent scrutiny and review process for local change. I will deal with that shortly, and will deal in particular with the views of the overview and scrutiny committee, which were raised by the hon. Lady. The proposed change is intended to start from 1 January, which is fairly soon. The local NHS has finalised implementation plans, and patients in the south-west peninsula requiring specialist upper gastrointestinal cancer surgery will be given their surgical treatment in Plymouth from that date. The surgical element of their treatment will no longer be provided by Royal Cornwall hospital in Truro or by Royal Devon and Exeter NHS Foundation Trust. I recognise that there is a specific case of which I was not aware. I shall establish further information about it and report to the hon. Lady on whether it indicates any sort of precedent, because at present I simply do not know.

The peninsula cancer network has told my Department that the whole surgical team is experienced and properly trained in both open and minimally invasive techniques for oesophageal and gastric cancer surgery.

If the hon. Lady allows me to say a little more, she may understand my point.

There is no nationally recognised definition of MIO, although this is a national issue. In Plymouth, the plan is to investigate both the role and the definition of minimally invasive techniques for oesophageal cancer as part of a multi-centre study.

I said I was aware that keyhole surgery had been performed at Plymouth. So far, however, a single case has not involved keyhole surgery throughout the procedure. Only hybrid operations have been performed at Derriford. I believe that this is an urgent matter involving the safety of patients. If what the Minister is telling me is accurate, either those at Derriford are going to replicate what is done at Exeter—they have not done that to date, which that means that they would practise on the first few patients, and that would worry me—or they will drop the full MIO procedure.

I will make further inquiries about the hon. Lady’s point. I will say, however, that the intention is for the internationally recognised research on MIO at Exeter to be supported and developed at Plymouth. Once the clinical service has been established, it is intended to support and pursue the research programme currently under way in Exeter and to develop further projects. It is also the case that, following the publication of the review carried out by Professor Mike Griffin and Mr. Bill Allum, a period of public engagement was carried out, with various local meetings.

I understand the concerns that have been raised, and we have looked into some of those raised by the Devon OSC. The PCN has confirmed that equipment to undertake open and minimally invasive procedures is in place in Plymouth. Additional equipment has been ordered, after discussion with a senior surgeon at the Royal Devon and Exeter, and it will be delivered shortly. This will not impact on the delivery of the service from 1 January.

I hear what the Minister says about the equipment being ready at Derriford. However, if I wanted to climb Everest, I could order the equipment over the internet and have it all ready, but although I might be a bit of a mountaineer, that would not make me ready to climb Everest. Experience and practice are required to go with that kit, and an experienced team as well.

The hon. Lady puts her case very eloquently, but I have to say that the PCN has confirmed that the whole surgical team is experienced and properly trained in both open and minimally invasive techniques for oesophageal and gastric cancer surgery. As was described in the AUGIS—Association of Upper Gastrointestinal Surgeons of Great Britain—consensus statement of 2008, there will be two consultant surgeons operating on each case, which will allow for the incorporation of skills from around the peninsula and the appropriate supervision and mentorship model for minimally invasive surgery. As also described in the AUGIS consensus statement, there is no recognised definition of MIO, and these matters will need to be looked at.

I am concerned by what the hon. Lady says and I will make some further inquiries, but we have been given reassurances, and, essentially, this is a local matter. We therefore have to rely on local clinicians to say whether they can do this. At present, they are coming back to us, through the appropriate procedures they have, and saying, “Yes, we can do this.” She is saying that she believes the qualifications and experience are not in place. I will look again, and we will go back to the local clinicians, but she says something different from what they are currently telling us. I am not an expert clinician, and no more is she, and neither of us knows whether those skills are in place. All she can do is report what is being said to her, and all I can do is report back what I am being told. This is, however, a matter to be resolved locally, rather than nationally.

That brings me on to the hon. Lady’s point about the local health OSC. I am concerned about that, of course, because such committees can refer proposals to the Secretary of State for Health, which he can then pass on to the independent reconfiguration panel for consideration and independent advice. On 20 November 2009, the Devon OSC informed the Department of Health that it would refer the proposals to the Secretary of State. A letter from the committee providing the grounds for its referral was received by the Department on 4 December. However, I now understand from the local NHS that the committee has said it will be writing again to the Secretary of State, seeking to “clarify” its position on its original referral. We await that letter, to discover what the clarification is, and whether or not it is referring, and if so, what exactly it is referring. I initially thought the letter was clear, but it now appears that it is not and that it needs further clarification. As the hon. Lady will appreciate, it is not appropriate for me to comment in detail on the issue at this stage, and certainly not before the Secretary of State has had the opportunity to consider the additional letter from the OSC. I understand that the local NHS is continuing to ensure that there will be full implementation of upper GI surgery at Plymouth on 1 January. That is the current situation.

All patients affected by planned changes will be given support with transport and accommodation. As I stated earlier, the local organisation of health care services is dictated not by Ministers or civil servants in Whitehall, but by the local health care professionals on the ground. The criteria by which any changes should be introduced are that they are clinically-led, that they are focused on the best outcomes for patients and, of course, that they meet the highest levels of patient safety. I urge MPs who have concerns about the proposals coming from their local health service to contact their primary care trust. I understand from NHS Devon that the hon. Lady has not, as yet, been engaging with it and that it would appreciate it were she to do so. I also made inquiries as to whether Hannah Foster, a prospective Conservative parliamentary candidate who was quoted in the local media, had been in contact with NHS Devon. Sadly, she has apparently not raised issues with NHS Devon, other than by attending an engagement meeting. If she wants to do something that is to be taken seriously, engaging with NHS Devon would be an appropriate course for her to take, rather than just dealing with the media.

With local leadership and national guidelines based on the latest evidence, we are continuing to seek to ensure that cancer care is delivered in centres of excellence, which ensure that people get the best quality treatment. The hon. Lady has raised a number of concerns. I shall go back to NHS Devon to make inquiries about some of the points that she has raised and then write to her or meet her, if she wishes me to do so. I aim to ensure that in so far as she or I can be satisfied, given that neither of us are clinicians, such reassurances as can be given will be given. It is important that people know that they are receiving safe treatment at a centre of excellence and that such an important operation is being delivered at a place where they can rely on that excellence being delivered to them.

Question put and agreed to.

House adjourned.