Question for Short Debate
My Lords, I hope this debate will persuade the Government to end the current crisis that threatens the future of the Royal Brompton Hospital. I hope also that it will convince NHS England, which funds Britain’s largest centre for the treatment of congenital heart and lung diseases, that its plans to decommission the hospital’s key services are mistaken and should be withdrawn. There is no justification for them. The NHS trust which runs the Royal Brompton is wholly opposed to them; on any rational basis, it is the last hospital one would expect to be treated in the way it has been by the national board of NHS England.
I deplore this crisis. It was entirely avoidable. Unless it is resolved in a way that benefits patients, it will have appalling consequences. It has already eroded the good faith that ought to exist between the hospital’s trust and NHS England, which appears to be determined to get its own way.
To make matters worse, the dispute between them is over a problem that actually does not exist. Perhaps the Minister will explain why it has been allowed to escalate in the way it has. I know that the Minister has strong feelings and will disagree with me, but I am delighted to be able to put my views in print, and I hope she will relay our dismay and alarm to her colleagues in senior government positions. If it ends in legal action, which has been talked about, the High Court will want to know a lot more about the way NHS England has behaved.
I declare an interest as a grateful long-term cardiac and respiratory patient at Brompton. From the information I have received, the national board has been high-handed, devious and secretive. It has constantly misunderstood and misrepresented the hospital’s position and dismissed its representations without proper consultation. In my opinion, which is shared by others, it has not behaved fairly, in the way its executive functions require and British justice expects.
Why, for example, did it demand the trust’s response within three days to its warning last year that it was minded to decommission Brompton’s procedures for treating congenital heart disease?
Why did it reject the hospital’s submission out of hand without explanation and announce the very next day that it was minded to cut Brompton’s funding? That was a breach of natural justice if ever I saw one.
Why was a small group of its advisers allowed at the last minute to overturn an independent review that had approved the way the Brompton worked in harmonious partnership with its near neighbour, Chelsea and Westminster Hospital? Other questions arise from its arbitrary decision to accept that U-turn.
How and where will Brompton’s 12,000 displaced patients be relocated? We all know that hospitals in London and the south-east are absolutely chock-a-block. What evidence do NHS England and the Minister have that the relocating of patients—whose interests must come first, or at least ought to—will lead to improved patient outcomes? Where is the evidence? That is the question that has to be answered today. A spokesman for NHS England told a public consultation recently that removing patients to other hospitals in London would be a formidable challenge. A patients’ representative asked, “Have you nothing better you could be doing?”. Evidently not. I say this to NHS England and to the Government too: I am minded to conclude that you are out of touch with public opinion and you have lost your way on this issue.
Is the Royal Brompton a failing hospital? No, its excellent performance ratings show otherwise. Is there some scandal we do not know about, like the 29 infant deaths from congenital heart disease in Bristol Royal Infirmary 20 years ago? No, there is not. So what is the problem? NHS England has changed tack on this. In June last year, it claimed that Brompton had failed to comply with seven of the board’s 14 requirements. NHS England dropped that charge when Brompton disproved it, but still rejected its submission out of hand. Its attitude throughout has been imperious.
No less a figure than Sir Magdi Yacoub, one of our surgeons of international repute, who performed Britain’s first heart and lung transplant and still oversees research work at the Heart Science Centre, which the Royal Brompton Trust runs, calls the effect of the plans to disrupt Brompton’s services “a crime”—a crime. Sir Magdi said:
“What are you doing? Why are you killing a centre of excellence? To me, it’s a crime”.
I want to know that too, as do many Members in both Houses of Parliament and several thousand families outside this House. We want Jeremy Hunt, the Secretary of State for Health, to stop this madness. He did so four years ago when the Brompton’s services were under threat; he should do so again and lose no more time and precious resources. Professional staff will move abroad.
Brompton’s fame and uniqueness stems from the results it achieves and the progressive treatments it generates. Its dedicated staff care for 8,000 adult patients and 4,500 children per year. Its out-patients receive lifelong care in a seamless stream from infant to senior citizen. It is the nation’s centre for treating babies and children from all around the UK with severe forms of cystic fibrosis, asthma, muscular dystrophies and other respiratory illnesses. Its research papers are widely published and students and academics study there, but that appears not to be good enough. It has to be decommissioned.
The controversy that threatens Brompton’s patients stems from NHS England’s regulation that from 2019 every hospital’s doctors should work under the same roof. This runs counter to Brompton’s agreement with its near neighbour Chelsea and Westminster, which is a different form of co-proximity but works just as well. If the Brompton needs a specialist with a differing discipline, Chelsea and Westminster provides one within half an hour, which used to be the national rule. I have personal experience of that procedure. Moreover, no patient has ever been put at risk. It has been 100% successful.
What does it take to convince the powers that be that the Brompton is an exceptional hospital and should be treated in a way that suits its patients best and not bureaucracy? NHS England talks about “future-proofing” congenital heart disease treatment, which the Brompton does every day. It alleges that the hospital has rejected an alternative proposal, which the hospital says has never been made.
The Brompton meets 469 out of NHS England’s 470 requirements. Even so, that is deemed not to be enough. Imagine any organisation being failed on a score of 469 out of 470. Parliament would have to shut up shop. What does it take to persuade the NHS moneybags that wrecking the Brompton risks more than they realise? This approach is not only unfair, it is quite unreasonable. NHS England demands optimal performance but only on its own terms. The Brompton’s performance is already optimal and risk-free.
The dire consequences of a forced relocation are already apparent. Brompton would lose 28% of its NHS income. The redundancies would cost more in professional and financial terms. The hospital’s respiratory services for asthma sufferers could not be sustained. I ask the Minister whether NHS England has forgotten the first principle of the Hippocratic oath that doctors must do nothing to harm their patients? It has certainly ignored the guidelines in its own Five Year Forward View published in 2014. It said then that,
“England is too diverse for a ‘one size fits all’ … model”.
Henceforth, it said, regulations were to be applied with “meaningful local flexibility” and it would back “diverse … and local leadership”. That seminal document went on to say:
“One of the great strengths of this country is that we have an NHS that—at its best—is ‘of the people, by the people and for the people’”.
There would be no more “factory models” of care and repair, with little engagement with the wider community and short-sighted attitudes to partnerships.
Is that not what is happening at the Brompton right now? If NHS England presses ahead and the Government do nothing to stop it, the health service will be the poorer, so will our country and others further afield. It would be a disaster if it succumbs to the diktat of bureaucracy.
The Royal Brompton must be allowed to get on with the job at which it excels.
My Lords, I am glad to be here today and to be able to contribute to the debate secured by the noble Baroness, Lady Boothroyd, on this important subject. I certainly support her aim of ensuring the continuation of children’s services for the treatment of congenital heart conditions at the Brompton.
My connection with the Brompton dates back to my 16 years’ board membership of the National Heart and Royal Brompton hospitals, from 1979 to 1990. The Brompton Hospital was established in 1878 and the “Royal” came later. It is world-renowned. The year 1947 saw a major development, with the first cardiac operations. The Brompton was the first to use closure devices as an alternative to surgery for children born with a hole in their heart.
Those who say that the Brompton does not have the necessary availability of children’s services fail to understand the very special relationship, which the noble Baroness, Lady Boothroyd, brought out, between the Brompton and the Chelsea and Westminster hospitals. Under this unique system, the paediatric consultants at the Chelsea and Westminster have hours built into their contracts to be worked at the Brompton. The two hospitals are close together geographically and, when needed, a paediatric consultant can be at the Brompton within 20 to 30 minutes. These are reliable, audited facts, not just aims or wishes, and the system works well. Why spend millions recreating the capacity at other centres when it already exists and is doing very well?
Any woman who has been diagnosed at the Chelsea and Westminster as carrying a baby with a congenital heart disease can be treated at the Brompton. Many Members of your Lordships’ House will know one of our number who has had two sons treated at the hospital for congenital heart conditions. He is away and unable to participate in the debate today, but I know how appreciative he is of the first-class treatment that they had and I would like to place that fact on record.
The number of international researchers and academics who come to the Brompton from all around the world to work in the congenital heart disease unit will fall, and we will lose research and expertise from the UK. That will be a very serious loss. It is important that the decision is made to retain congenital heart treatment at the Brompton, and I ask the Government to do so.
My Lords, I thank the noble Baroness, Lady Boothroyd, for calling this debate. I declare an interest: I am a surgeon working in the NHS, the chair of surgery at Imperial College London and a consultant surgeon at Imperial College and the Royal Marsden NHS trusts. I am also a non-executive director of NHS Improvement.
I have always been a passionate champion of change in the NHS, so long as that change is for the right reasons. Healthcare exists at the limits of science, which is why high-quality care is a constantly moving target—by definition, to stand still is to fall back. Sometimes that means taking very difficult decisions to make far-reaching changes to services that are cherished by NHS staff and patients alike.
As some in this House may recall, in 2007 I led a review of London’s health services. One of the most significant findings was that care for people who had experienced a stroke was very poor. Across the capital, just four hospitals were providing the high-quality care that all patients should expect. This meant that many Londoners were dying needlessly and many others were left with life-altering disabilities that could have been avoided. The changes that I proposed, consolidating stroke services into a smaller number of sites, were implemented by the NHS in London in the years that followed. More than 200 lives a year have been saved and many thousands more have been improved. Those changes were incredibly difficult to implement but were done in the right way and for the right reasons.
The first and most important principle of changes in the NHS is that they should be to the benefit of patients. Quality of care should be the organising principle of the health service, as I set out in my 2008 NHS review, High Quality Care for All, published for the 60th anniversary of the National Health Service. This means that changes must be supported by clinical evidence and after broad and meaningful engagements with both patients and members of the wider public, which brings me to the specifics of today’s debate.
Let us be clear about the starting point. The Royal Brompton Hospital is a specialist NHS trust. It is the largest provider of care for adults with congenital heart disease and the second-largest provider of care for children with congenital heart disease in this country. In partnership with Imperial College London, the trust is a leading centre for research, education and training. It produces highly cited publications in heart and lung disease—more than any other trust in this country. Last year alone, the Royal Brompton, together with Imperial College, published 742 papers. I remind your Lordships that more than 50% of London’s coronary heart disease specialists are trained at the Royal Brompton.
More than any of that, its services achieve the highest-quality outcomes in every dimension that we could choose to measure. The proposals we are debating today are to dismantle the highest-quality service in England. I must be honest and say that I find it utterly astonishing that it should even be a question for discussion.
The justification for the changes revolves primarily around two sets of standards. The first is about the number of cases undertaken by individual surgeons and by the unit as a whole in any year. Like anything in life, practice makes perfect; the same is as true for playing the piano as it is for complex surgery. But the minimum number of cases for congenital heart surgery has simply been plucked from the sky, with a completely random figure of 125 cases per surgeon. I have seen zero clinical evidence to support this number anywhere.
Indeed, in my specialty, cancer surgery, the minimum volume for me is 25 cases a year; in the United States, the minimum volume for congenital heart defect surgery in children is 75 cases. I have no idea where we got the figure of 125 in this country. My diagnosis is of an acute case of policy-based evidence-making rather than evidence-based policy-making. We have seen more of that in recent years. The Brompton actually exceeds that target, with the second-largest number of cases in the country—522 in the last year of published data—but the point remains that the so-called standards create little confidence when they are decoupled from meaningful clinical evidence or outcomes.
The second set of standards are about co-location of services. These are what are driving the changes at the Brompton at the moment. The consultation demands that paediatric congenital heart surgery is provided only in settings where a wide range of other specialist services are located on the same site, as we have heard. The co-location standard requires certain paediatric services, such as gastroenterology and general surgery, to be co-located in the same building as the congenital heart disease service, as these services are needed by around 1% of patients each year.
As a specialist heart and lung hospital, the Royal Brompton delivers a co-located paediatric service in partnership with neighbouring Chelsea and Westminster Hospital and the Royal Marsden Hospital, both just a few minutes’ walk away—I do it, as I work at the Royal Marsden. This partnership has existed for many years, and a wealth of support is available between these sites. Specialists can go from Chelsea or the Marsden to the Brompton within a five-minute walk. It takes the same amount of time to get from my operating theatre to the pharmacy department at St Mary’s Hospital. There are no recorded cases of problems accessing emergency care under this arrangement.
It is, therefore, painfully obvious that the standards on co-location have been defined in such a way as to deliberately result in the dismantling of the services at the Brompton. Indeed, NHS Improvement estimates the cost of shifting services to Guy’s and St Thomas’ Hospital to be in the region of £800 million—an enormous sum at a time of financial difficulty, and with no meaningful clinical evidence. More than that, it has absolutely no regard for the patients or the public of north-west London.
My apologies, my Lords. Just to finish, I strongly believe that this debate is based on complete fallacy in terms of the evidence supporting it and I urge the Government not to dismantle the most important hospital contributing to the treatment of congenital and non-congenital heart disease in this country.
My Lords, I start by congratulating the noble Baroness, Lady Boothroyd, on securing this debate, even at the last minute before the summer starts. She ended her brilliant speech by presenting the evidence why the Brompton is so important and should not be closed. The Brompton’s international reputation derives from its eminence as an innovator in care and its reputation in international research, which is what I will refer to.
To give an example of the hospital as an innovator in care, I mention the case of Chloe Narbonne, a 13 year-old girl from Worcester who had been diagnosed with cardiomyopathy at the age of four weeks, and required a heart transplant. Her second heart transplant failed, meaning that she faced death because she would have to wait some time for another heart to be available. At that time, the doctors at the Brompton decided to implant an artificial heart. It was the first artificial heart implanted in a child in the whole of Europe. Since then, the surgeon involved, André Simon, has conducted 13 implantations of an artificial heart. That kind of cutting-edge innovation occurs only in an institution of very high standing, where highly skilled doctors and nurses practise. This is an example of a hospital that innovates care.
I have two examples of how important this institution is to research. The first is a report by the National Institute for Health Research about the hospital’s performance as an academic institution in 2016-17, which says that the trust achieved 104% of its overall recruitment target; 17 non-commercial studies that closed last year recruited in time and on target; and the trust increased its participation in the commercial portfolio, recruiting to 38 commercial studies—an increase from the previous year. Despite respiratory recruitment falling since 2015-16 in the Brompton, it remained the highest recruiting trust in the country in the NIHR respiratory portfolio, and contributed 8% of the national portfolio—a huge number. Some 75% of non-commercial cardiovascular studies and 80% of commercial cardiovascular studies closed on time and on target—a remarkable achievement for an academic institution.
An analysis from the RAND Corporation shows that the Royal Brompton publishes more highly cited papers on both respiratory and cardiovascular medicine than any other NHS trust in the United Kingdom—in scientific work, how many times your papers are cited is a mark of your original contribution to science. The trust is the UK’s flagship centre for research on adult CHD and is widely recognised as the world’s leading institution in CHD research. The hospital is funded by bodies including the National Institute for Health Research and the British Heart Foundation. In fact, the British Heart Foundation funds one of the only full-time academics working in CHD research in the country.
The combination of factors that makes the trust so prolific and influential—the lifelong rather than separate paediatric and adult patient care; the large patient populations; the multidisciplinary expert teams; and the culture of vision and drive that has been cultivated over many years—cannot be replaced if people move elsewhere, as NHS England suggests. Teams get broken up. It takes years to build research teams, particularly in academic medicine, so for the NHS to suggest that this proposal will not have any effect is fundamentally and absolutely wrong.
Last August, the Secretary of State for BEIS vowed that:
“The government’s commitment to our world-leading science and research base remains steadfast”.
The Minister of State for science and research commented in the same month that,
“it’s more important than ever that we support the brightest and best researchers and innovators”.
I hope that the new Government will take the opportunity to prove that their enthusiasm for and commitment to British research remain steadfast and undiminished. I suggest that that could be achieved by the Government forcing the NHS to change its mind about closing the Brompton.
My Lords, I join others in thanking the noble Baroness, Lady Boothroyd, for securing this debate. My contribution will be fairly brief. I start by congratulating everyone involved on understanding the need for a set of standards for congenital heart disease, and NHS England on organising two separate groups—one for children, the other for adults—to agree those standards. We should not forget that our NHS congenital heart disease service is a remarkable success, given that being born with this condition in the 1960s suggested a survival rate to the age of 16 of only 15%, whereas those born with the condition today have a survival rate of nearer 90%.
The Somerville Foundation, of which I have recently become a patron, is the UK patient support group for adults with congenital heart disease. It had been calling for a set of standards for adults for more than 10 years and is convinced that these standards will further raise the quality of the service for these patients across the country. It also points out that, for the first time ever, the number of adults with congenital heart disease is higher than the number of children with it, and this number continues to rise.
The Royal Brompton Hospital achieves all the standards for adult congenital heart disease and the Somerville Foundation is extremely concerned about the impact that this proposal will have on adult patients. There is no suggestion that the Brompton does not provide a world-class service for congenital heart disease. It is recognised around the world for its care, technology, clinicians and research.
We are now at the stage where the public consultation on congenital heart disease surgical services has ended. Therefore, only now can the difference between the cold interpretation of the standards and the outcomes of implementing them be fully considered. NHS England was right to consult, as it had to measure services against the standards it was given. The Brompton, it is suggested, fails one of the children’s standards. Of course, it would be best if this was not the case, and it was able to comply in some way. However, the proposals would have such an impact on the adult service that the cost would be greater than the gain. Already around the country, including in London, the demand for adult congenital heart services outstrips the supply and, as I have already said, the demand is getting larger due to better survival rates.
The other two London specialist centres, Bart’s and St Thomas’, are already fully stretched in providing the specialist care for these patients. While the long-term aim of having fewer, larger centres is understandable, it would be better achieved by combining centres. It is difficult to understand how the transfer of thousands of patients within an already stretched service in London can provide improved patient experience. Once the responses of the public consultation have been considered, as well as the impact of the proposed change at the Brompton, I am sure that the only conclusion can be that the Brompton must retain its adult congenital heart service.
My Lords, I thank my noble friend Lady Boothroyd for successfully securing this vital debate. My noble friend has first-hand experience of the Royal Brompton, having been a patient, and I consider the patient’s voice essential in assessing the standards of any hospital in which they have been treated. Some years ago, I was a member of the Yorkshire regional health authority, and I realised that there was great competition within health service specialties and that one had to fight hardest for children’s services. That challenge does not seem to have changed, even now when there is an increased demand on the NHS and also a baby boom. Children’s safety is paramount.
While traveling to your Lordships’ House in a taxi, I was asked by the driver what we were discussing, and I told him that it was the proposed closure of the congenital heart disease unit at the Royal Brompton Hospital. He was totally shocked—in fact, he was gobsmacked. He said, “They can’t shut a world-famous hospital like that! I take many patients and families to the Brompton from all over the world”. He said it was the first time he had heard of this worrying proposal.
The Royal Brompton team is not only the largest and best resourced adult congenital heart disease team in the country; it is also the leading centre of research into adult congenital heart disease in the world. Royal Brompton’s teams have developed an international reputation for tailoring a seamless transition from paediatric to adult care. That approach will be lost if the Royal Brompton’s unit is closed. Does the Minister not think that continuity of care is important?
With the insecurity of everything at present—and Brexit, which does not help—there is already evidence that many of the clinicians and academics who come to the Royal Brompton from around the world to work in the CHD unit will return to their country of origin if their unit closes, fragmenting research teams and losing expertise from the UK. Does the Minister realise that if the unit closes, those expert staff will be lapped up by other countries only too eager to employ staff from a hospital with the success rate of the Royal Brompton?
There is a serious staff shortage in the NHS, and specialist units across the country do not have enough slack in the system. Where will the patients go if the unit closes? The Royal Brompton is the national centre for treating babies and children from around the UK with some of the most severe forms of cystic fibrosis, asthma, muscular dystrophies and other respiratory illnesses. Without the back-up of intensive care, which would be lost with the closure of CHD services, the hospital says that it will be unsafe to undertake the more complex specialist respiratory treatments and they will have to stop. These sick children need the very best expert treatment, which the Royal Brompton has provided. Surely, this is a case of, “if it ain’t broke, don’t fix it”.
My Lords, I am proud to declare my interest in this debate as chairman of the Royal Brompton and Harefield NHS Trust. I am also immensely grateful to the noble Baroness, Lady Boothroyd, for obtaining this debate and introducing it so brilliantly. I hope that the Minister realises what a formidable force she is and, importantly, that she understands that she stands at the head of a large, articulate, informed and angry group of patients, parents of patients, charities, local politicians and MPs of all parties—and that is before we talk about clinicians, academics and educators connected to our trust but also around the UK and globally. As you would expect, there is a lot of emotion, but crucially there is also a great deal of expert opinion and experience. I hope that the Minister has not just been supplied with a file that says, “The standards have been carefully drawn up and the consultation results will be reviewed diligently”. We need more than that.
The trust board would not stand in the way of change backed by strong clinical evidence, nor do we resist all change. We focus hard on patient outcomes and experience. Our opposition is neither nimbyism nor the result of closed minds. We are aware of the need to reconfigure and strengthen a range of services nationally in the medium and longer term. However, any such decisions at any point must be transparently discussed, clinically led and must put patient outcomes and care at the centre. So let us use these benchmarks in relation to CHD.
The services at the Brompton are world-renowned. Babies born with CHD live with often very complicated medical conditions all their lives. The Brompton manages the transition from child to adult care flexibly and brilliantly. The transition age can meet the needs of the individual patient rather than the patient being fitted into the structure. Remember that these patients often have complex special needs. The Brompton treats 12,500 patients, including 4,500 children. We performed almost 1,300 clinical procedures in 2015-6. Crucially, our 30-day patient outcomes are among the very best in the country and our “family and friends” recommendation rate is over 98%. I fully understand the history of the Bristol scandal but completely fail to understand the relevance of that history for services today at the Brompton.
The hospital is situated in Chelsea but truly is a national specialist hospital. For example, the main foetal referrals are from Queen Charlotte’s, St George’s and Chelsea and Westminster Hospitals, but there are formal outreach relationships with 23 trusts where over 8,000 babies are reviewed, with many babies coming to the Brompton for further investigation and/or treatment. Over a quarter of hospital admissions are from north-west London, a quarter are from other parts of London, a quarter are from the wider south-east, and the rest are from anywhere else in the country. There are dynamic relationships with a wide range of clinicians at a significant number of hospital trusts, which is as it should be for a specialist tertiary provider.
The Royal Brompton and Harefield Trust is internationally known for its education and training as well as its research, as we have already heard today. This is evidenced by the letter sent to the Secretary of State recently by 198 leading professionals from around the world, including Gary Webb from Cincinnati Children’s Hospital; Professor Khairy from Montreal Heart Institute; Professor Ju Le Tan from the National Heart Centre Singapore; Professor Diller from Münster, Germany; Professor Shah, cardiac director at the Geneva University Hospitals: Professor Geva from Boston Children’s Hospital and Harvard; and many other eminent professors from Brazil, Israel, France, Italy, Greece, India, Spain, Belgium, the Netherlands, Egypt, China, Sweden, Japan, Australia and Denmark. I could go on. In their letter they say that,
“by any measure the Royal Brompton’s CHD service is the largest in the UK with excellent outcomes. The Trust’s research team is the most influential in the world”.
They say that the plan will have “devastating consequences”. Similarly, the Joint Royal Colleges of Physicians Training Board has written to NHS England to express its deep concern about the future training of paediatric cardiologists.
Of course, bizarrely, none of this is disputed by the NHS England board. The trust meets 469 of its 470 care standards. Until a recent addition to the standards—a very specific designation of collocation—safe and sustainable specialised paediatric services were governed by the Baker review. This was detailed and thorough work led by a clinical advisory group. It was produced in collaboration with, among others, the Royal College of Paediatricians and Child Health and the Royal College of Surgeons.
Prof Mike Richards commented on Baker:
“This framework is a unique piece of work with clinical credibility and I commend it to commissioners”.
It gave clear advice on collocation of services as being either on the same hospital site or in neighbouring hospitals if specialist opinion and intervention were available in the same parameters, as though the services were on the same site. I shall tell the House what that means for the Brompton, which, as we have heard, delivers in partnership with Chelsea and Westminster Hospital, which is round the corner. It means service level agreements 24/7, 365 days a year; joint ward rounds; multidisciplinary meetings; integrated patient pathways; senior and junior staff rotation; shared imaging and digital systems; joint teaching programmes; and a gastro and general surgery portal.
However, suddenly there was a new heart disease review and a new definition of collocation, which meant more instability. No scientific or clinical evidence is given for this change. There is no suggestion that the current model provided by the Brompton does not and will not provide excellent care. Only 1% of children with CHD have needed non-cardiac emergency care, which has been delivered 100% of the time within 30 minutes.
Frankly, the consultative meetings have been insulting. I attended the one with staff at the Brompton where highly trained practitioners were treated to a parroting of the consultation documents. There was no serious engagement. No medical professional was sent to face the detailed, knowledgeable, evidenced questions of our staff. I was livid on their behalf, and frankly I was embarrassed on behalf of those sent to do the parroting.
What would the knock-on effects be? It would be a devastating blow, first, to the viability of the trust—that is, to two leading hospitals, the Brompton and Harefield—and, secondly, to paediatric intensive care; our intensive care unit would be non-viable. Thirdly, closure of the ICU would have a damaging effect on the intense treatment of cystic fibrosis and asthma, and a number of charities have talked about the many other services that would go. The body of highly skilled UK and international staff would be split, and people here know far better than I do the importance of that. Our staff have stayed but they are clearly anxious. The assumption in the consultation document is that people are like widgets that can be moved around.
Finally, I ask the Minister, first, whether she can produce the clinical and scientific evidence on which the proposals are based, not the minutes of the committee meeting that produced them. Secondly, will she commit to publish the submissions that have been received and the independent review of those submissions? Thirdly, will she explain to us what consideration has been given to the knock-on effects of this proposal?
My Lords, I thank my noble friend Lady Boothroyd for calling this debate and I want to add some of my own thoughts to those that have largely been expressed by other noble Lords.
Currently in London, paediatric heart disease services are provided at Great Ormond Street, Guy’s and the Royal Brompton. The proposal is to reduce this provision to two centres. What evidence is there that this approach will improve services for patients? There are, I understand, 15 specialist paediatric intensive care beds at the Brompton. The ITU service is staffed by highly skilled and trained doctors, nurses and other clinical team members. Such staff are expensive to train and often very difficult to retain. What reassurance can the Minister give that all these staff will be given opportunities to continue working in their chosen field at their current grade in London or elsewhere in the NHS? Will TUPE apply? There must surely be a risk that these staff, unless given suitable employment choices within the NHS, will leave and possibly, as my noble friend Lady Masham stated, go to work overseas—where, make no mistake, they will be welcomed not only with open arms but with generous employment packages.
I understand that the 15 ITU children’s beds are key to providing training opportunities for student nurses from three different universities. Can the Minister assure the House that, if these beds are not fully re-provided, similar clinical placements will be found to prepare the next generation of nurses with paediatric intensive care skills?
In London recently there has been a range of large-scale emergency challenges due both to the two recent terrorist attacks and the tragic fire at Grenfell Tower. The health service and hospitals generally quickly responded, with both adult and paediatric ITU beds being utilised to their maximum capacity. While I appreciate that the ITU beds at the Brompton are predominantly used for children’s cardiac work, is it possible that the reduction of 15 paediatric ITU beds in what is, effectively, west London may affect the ability to provide sufficient services in any future large-scale emergency?
I understand that the decision to keep four trauma centres around London was partly provided on accessibility. Will the Minister seriously consider the possible consequences of reducing the paediatric coronary service ITU beds from three to two; and is it simply a considered response to the chronic financial challenges in the NHS rather than an attempt to enhance potential clinical outcomes? I more than many in this House want to see new investment in child and adolescent mental health services—a manifesto commitment—but is the NHS envelope simply too small a proportion of GDP, pushing NHS policymakers to close some services in order to develop others?
Finally, it has been argued by other noble Lords that research will suffer at the Brompton and its academic partners as a result of this proposal. I ask the Minister, is this the time, with Brexit on the horizon, to adversely affect research in a centre of international excellence and to risk losing not only expert clinical doctors and nurses but also research teams?
I sincerely trust that the issues raised in this House will be carefully considered, not only by the Minister this afternoon but also by those policymakers who are considering how best to provide the excellent-quality services for patients with congenital heart disease currently provided at the Royal Brompton Hospital.
My Lords, this important debate, secured by my noble friend Lady Boothroyd, has raised an issue much wider than simply the hospital, and that is the role of standards. They are a means to an end, and that is what patients want—good outcomes.
The services at the Royal Brompton care for 12,500 patients and undertook 1,288 congenital heart disease procedures in 2015-16, of which 814 were paediatric surgical and interventional catheter procedures. For such interventions, the well-established and skilled multidisciplinary teams have a 30-day survival rate of 98.3%, against a predicted survival rate of 97.7%. The data from 2012 to 2015 suggest that Brompton ranked third in the UK in its outcomes. That is what patients want—good outcomes.
What is the evidence for closure? We have heard about the Chelsea and Westminster hospital being located five minutes away on foot. In 2016, an audit of the arrangement showed that 100% of emergency attendances occurred within the agreed response times and no patient has ever been known to suffer because of the current locations of the general paediatric services, and there seems no evidence from anywhere around the world that this standard of same-site co-location will provide better outcomes for patients.
Apart from this single standard, all other standards are more than met by the Royal Brompton. NHS England does not dispute this. So where is NHS England’s transition plan for this proposal? If the services were closed, the patients would be scattered, as we have heard, between Great Ormond Street, Bart’s, Guy’s and St Thomas’ for surgery and other procedures. Up to 100 healthcare professionals currently can be involved in any one patient at the Royal Brompton. These teams will be broken up, compromising continuity of patient care and, more importantly, compromising future patient care because it takes years to build them up again.
The NHS’s own assessment shows that, if the proposals are implemented, there will be a significantly detrimental impact on the paediatric intensive care unit, known as PICU. That is because congenital heart disease accounts for 86% of admissions to PICU at the Royal Brompton so it is dependent on providing these services. Without them, the unit would be forced to close, resulting in a reduction of PICU in London of one-sixth or possibly more. Children requiring PICU services are already being sent out of London because there are not enough PICU beds. On 1 December last year, a lack of such beds meant that three children had to be sent far away for care. That is not good for clinical outcomes, and it is certainly disastrous for them and their families psychologically, even if they survive the experience.
Closure of the Brompton PICU would result in a cascade of loss of skills. The absence of PICU and on-site anaesthetists will further jeopardise complex specialist treatments such as cardiac extracorporeal membrane oxygenation, known as assisted ventilation, for children, as well as cardiac and respiratory ECMO for adults.
An independent review published in 2013 in the International Journal of Cardiology rated the Royal Brompton as the most influential research unit in the world, with a cumulative research impact factor that was 50% higher than any other centre in London. The research facilities provide advanced cardiac magnetic imaging, echocardiographic work and a catheter laboratory. Its genetics laboratory is looking at new genes linked to congenital heart disease, with diagnostic and prognostic markers for disease and surgery outcomes. Novel right ventricular assist devices and valve replacement procedures are currently being trialled, along with new treatment modalities for pulmonary arterial hypertension. Closure of the clinical congenital heart disease services will have a destructive effect on this world-leading research facility. Again, these services have taken decades to build up. This is not something that can be replicated overnight.
The holistic approach taken in the care of sick children and their families means that every child with complex needs, particularly in palliative care when it is clear that they are not going to survive, is dealt with by a team with its own lead nurse and consultant helping parents to participate fully in care and with a staff focus on quality of life for the child and their family. The hospital has a unique feature of integrating paediatric and adult services so that teenagers can transition seamlessly and learn how to look after themselves. They are given help in planning their future careers and guidance on healthy living, including knowing who to contact if there is a problem.
Closure of services at the Brompton goes against the interests of patients and their families. It will disrupt vital research, and I would suggest that it also seems to have no evidence base behind it.
My Lords, I too would like to congratulate the noble Baroness, Lady Boothroyd, on initiating this debate and for her marvellous, fiery speech. I need to declare an interest in that I have been associated with the Royal Brompton Hospital for many years. In addition, one of my daughters has been under its expert care for all of her 50 years and I am grateful for the superb service that she has had and is still receiving. For her and many others, closure of the adult congenital heart disease unit would be a disaster.
Of course I realise that it is often attractive for administrators to tidy up what they regard as “loose ends” by closing smaller units and incorporating them into much larger hospitals. But of course as has been said already, it takes years to develop the expertise, customs and procedures that provide a really good clinical service for patients, but which can be destroyed overnight when moved elsewhere. The adult congenital heart disease unit is a case in point. It has been going for years and provides a unique service for so many people.
How exactly would this service be lost? Let me give noble Lords some details. My daughter was born with a heart defect. She has had scores of emergency admissions to the unit and several major and dangerous heart operations because the defect she was born with meant that there was no direct flow of blood from the heart to the lungs. The operations that she has had create new channels through the chest wall. On one occasion when she was acutely ill, there was no bed available at the hospital, and she was sent to a general hospital. There they started to do potentially lethal manoeuvres, such as draining fluid off the lungs, which are routine in normal patients but not in these cardiac patients. They did not seem to know that, although it is all right for a normal patient to have a few bubbles in a vein, for these people that can be lethal.
These are complicated problems which require real expertise and experience, which are often not available elsewhere. My daughter and many other patients whom she has met there, if they have an acute problem with their heart, can text the consultant and get immediate advice and, if necessary, treatment. It would be a tragedy if this unit were closed. I hope very much that ways will be found to keep this unit going for many years to come.
My Lords, there is no time for congratulations. I declare an interest. I am having a procedure in the Royal Brompton on Monday, and I thought I had better find out what state this organisation was in. I am not reassured. I have to tell my noble friend that I have heard what seems to me an irrefragable and irrefutable case against what is being proposed by the National Health Service England.
I hope to be reassured by what she tells me, but I have to warn her also, having sat in that seat for a short time for the Department of Health, that there are three sorts of political emergency you can face in her position. One is a coalition of experts who disagree with you; one is a body of public opinion which disagrees with you. Each of these is manageable. But when they agree with each other and disagree with you, you are in real trouble.
The barometer in this case is the taxi driver quoted by the noble Baroness, Lady Masham, who makes it clear that, even under the umbrella of August, this is going to go sour unless it is put right.
My Lords, I congratulate the noble Baroness, Lady Boothroyd, on her tour de force and many other noble Lords on their very authoritative speeches. I feel a bit sorry for the Minister, who might be feeling a bit lonely.
In decisions such as the closure of a highly successful and reputable unit such as the CHD unit at the Royal Brompton, the key driver must be to maintain and improve the quality of patient care. Any merger or closure decision must be made on the clinical evidence and not on cost saving, although, in this case, the costs of the change could well be greater than the existing provision.
The Brompton is a highly experienced unit, as the noble Baroness, Lady Finlay, told us. It performed 512 congenital heart disease operations and 554 catheter procedures on children and adults in 2014-15, more than any of the 12 other NHS trusts performing such work. As the noble Lord, Lord Patel, mentioned, its adult CHD research team is responsible for publishing more cited research papers than any other CHD centre in the world. It is at the cutting edge of innovation. Despite the severity of the health problems experienced by its patients, as we have heard, survival rates and the quality of care are very high.
However, NHS England’s concerns about the Brompton focus on two issues. First, Standard B10 requires there to be four CHD surgeons, each of whom has presided over at least 125 operations per year. At the Brompton, I am told, three out of the five surgeons fall short of 125 cases–an arbitrary figure, according to the noble Lord, Lord Darzi. I listened to him very carefully.
Secondly, NHS England is concerned that a number of linked paediatric services are not collocated in the same hospital but are provided by the Chelsea and Westminster and St Mary’s hospitals, both easily within 30 minutes of a child’s bedside. It is worth nothing that 30 minutes is the time limit proposed by the standards even when the services are collocated. This partnership is very close, with joint rotas, ward rounds and meetings and shared IT systems. This high level of communication is essential to the working of such a partnership.
To comply with the rapid availability of paediatric cardiology, ICU, anaesthesia, gastroenterology and other services, the Brompton has formed joint teams with the Chelsea and Westminster, which is five to 15 minutes’ walk away, depending on how fast you walk. You can be more than 10 minutes’ walk away from another department in the same hospital on a large site such as my own local hospital—I have done such a walk many times. The main thing is that you can get there in time. The Brompton has proved that it can do this by its claim that, for the 1% of paediatric CHD patients who have needed these services, it has a 100% record of providing them in time, in an emergency, day or night.
Given that there are many downsides to closing the unit, NHS England should apply the standards a little more flexibly when it comes to how they are complied with, as long as the standard of patient care is not compromised. The issue of collocation seems to have been appropriately dealt with by the partnership arrangements. The issue of the number of cases presided over by each surgeon could surely be addressed in the interest of saving the large amount of money that would need to be spent on closing the unit. I understand that the cost of redundancy payments alone amounts to £13.5 million, let alone the cost of increasing the number of beds elsewhere. Last December, my noble friend Lord Sharkey told the House that closure of the unit would remove a quarter of paediatric CHD beds in London. Can the Minister say what the plans are and what the cost would be of recreating beds for these 12,000 patients elsewhere? Where is the cost-benefit analysis? At a time when the NHS is struggling so hard financially, it seems highly risky to take the proposed line.
There are other, considerable risks to closing the unit. Take staffing: how do we know that existing staff are prepared to relocate? Experienced UK staff and those coming from abroad are attracted by the Royal Brompton’s reputation and, especially in the uncertain climate of Brexit, we cannot be certain that they will still come. Already, almost 90% of children’s units express concerns over how they will cope with staff shortages over the coming months. Already, one in five vacancies for junior children’s doctors is unfilled, on a rising trend. Now is not the time to upset an already wobbly apple cart.
As we have heard from the noble Baroness, Lady Morgan, then there is the effect on other departments that would be threatened with closure because of volume reductions. The hospital claims that, without child CHD services, its children’s intensive care unit would become unsustainable because of the reduction in volume. Consequently, its paediatric respiratory unit and paediatric cystic fibrosis and asthma services would also have to close, and other services would be under threat. NHS England admits that it has not done a detailed assessment of the knock-on impact of closing CHD surgery on other departments at the Royal Brompton. Can the Minister say when this will be done?
Talking of unintended consequences, will the Minister look carefully at the funding models for surgery to ensure that there is no barrier to the hospital taking a holistic approach to the patient’s disease? For example, I understand that the range of a consultant heart surgeon’s practice has been limited by the funding model, since, although heart patients may well also have other diseases, the heart consultant will never deal with them, yet it is all part of the same syndrome.
As the noble Lord, Lord Darzi, mentioned, there are examples of where centralisation of services can improve patient outcomes, which is what we all want, and I congratulate and support them. High among those is stroke and trauma services in London. However, we must not assume that one size fits all. It really depends on where you are starting from and in the case of the Brompton we are starting from a very high base. We have to look at the scope for doing even better and consider all the options for improvement. While this debate has been very supportive of the Royal Brompton, it also raises challenges for the trust, and I am sure it will rise to them. Surely there is a way of addressing some of the issues that NHS England has mentioned without closing the unit, with all the attendant downsides.
I agree with the noble Baroness, Lady Masham, that “if it ain’t broke, don’t fix it” is a very good motto. In reflecting that this debate has had contributions from nine women and five men, I wish all hard-working noble Lords a very happy summer holiday.
My Lords, I, too, congratulate the noble Baroness, Lady Boothroyd, on instituting what has been an excellent debate. Of course, these proposals have had a long gestation. They really go back to Ian Kennedy’s review of the tragic events at Bristol in relation to cardiac surgery for children. I well remember as a Minister receiving his report and discussing with him and Alan Milburn what action needed to be taken, not just in Bristol but more generally in the NHS as a whole. That really started the review of the number of hospitals considered safe and appropriate to provide for children receiving complex cardiac surgery.
As the Minister will know, no one should underestimate the difficulties of such a debate or the tensions between the expert view, coming generally from the centre, and the view locally of clinicians, parents and the NHS of the impact of closing those services, not just on children because of the distances that then must be travelled, but also on the institutions where those services are provided. We heard eloquent contributions about the consequences of closing one service at Brompton and the domino impact it would have on many other of its services.
I read very carefully the review document prepared by NHS England. It makes the point, with which I agree, that we have had far too many reviews and there has been too much uncertainty, now going back 17 years, about the future of many of these centres. Fortunately, outcomes generally in relation to CHD surgery and interventionist procedures have improved across the NHS and compare well with other countries. However, the NHSE paper argues that our outcomes could be better if the standards it sets out were implemented more generally. It is also worthy of note that the review, which looks at the importance of hospitals having the right staffing and skill mix, improved resilience and the elimination of isolated and occasional practice, is accompanied by a warning that it will be difficult for all hospitals approved to go forward to meet these standards immediately.
We then have the specific question of the Brompton and the argument in the paper that it should cease to provide surgery and interventional cardiology for children and adults, principally because it does not have enough of the required paediatric services on site and is stated not to support an adult level 1 service on its own. On the other hand, we heard from every noble Lord here, led by the noble Baroness, Lady Boothroyd, and had a briefing paper from the Brompton itself, arguing that there is no evidence from NHS England to support its contention that the collocation of children’s services improved patient outcomes. It also argues that NHS England is inconsistent on the issue of collocation and that no cost-benefit analysis of its proposals has been produced. It is also clear from what we heard from the Brompton that there is real concern that the closure of its level 1 service would have a wider and destructive impact on its research and respiratory medicine treatments. My noble friend Lord Darzi and the noble Lord, Lord Patel, spoke about the impact on the Brompton’s teaching, service excellence and research.
I do not envy the Minister in coming to her conclusions. I just suggest two things to her. First, it would be fair to say that the noble Baroness, Lady Boothroyd, was not entirely complimentary about NHS England, which is not exactly a visible presence in Parliament. It is sometimes difficult to understand how its accountability is discharged. NHS England owes it to the noble Baroness, Lady Boothroyd, and parliamentarians to arrange a meeting and briefing between them, and those who have taken part in this debate, to discuss these issues further before they come to a conclusion. I hope the Minister might be able to facilitate that.
The principal point I want to put to the noble Baroness, Lady Chisholm, is that these issues have been debated and there have now been endless reviews going back 17 years. It is of course possible that NHS England will come to a conclusion shortly and propose the closure of certain units in the report it produced, which concerns other units including those in Manchester, Leicester and other parts of the country. My supposition is that when it does that, whichever centre is fingered for closure, there will be an outcry. My second guess—if it is a guess—is that Ministers will then try to find another reason for a further review, to delay making the decision.
It is becoming pretty clear that Ministers find this situation very difficult and are simply not prepared to accept a decision for closure. But they want to put it in the long grass because they cannot face up to the fact that someone at some point has to say, “These are the units we’re going with and we’re going to do everything we can to make sure they’re up to standard. But we’re not going to have further reviews”. The one thing I would say about the NHS England paper is that it points out the problem of managing a unit where uncertainty continues over many years.
In the end, the public are owed a decision, which would either be to go ahead with the recommendations of NHS England or to say, “We’re not going down that route at all but we will keep the units and do what we can to improve them”. I am afraid that I expect there to be another review and that the noble Baroness, Lady Boothroyd, will be instituting a debate in three years’ time. However, I hope that will not be the case.
I thank the noble Baroness, Lady Boothroyd, for tabling this debate, and I pay tribute to her for her tireless work in this matter. I do feel quite lonely in here today—but, luckily, I have my noble friend Lady Sugg beside me, so I have one mate.
The future of congenital heart disease services is of utmost importance and I understand why, for many people, it is a concern. I am of course happy to facilitate a meeting with the noble Baroness, Lady Boothroyd, and anybody else who would like to join us, alongside NHS England. That could be an important thing to do.
With this review, NHS England is asking how we can take the good service we have across the country and turn it into a truly great service for the long term—a service fit for the 21st century. This is not about closing the Royal Brompton Hospital or stopping it providing CHD services. NHS England is proposing instead to continue to commission specialist medical services, which make up much of the care required by people with congenital heart disease. The proposal is that NHS England ceases level 1 children’s surgical services from the Royal Brompton Hospital. NHS England has also asked the Royal Brompton to consider providing an adult level 1-only surgical service.
Heart surgery is becoming ever more complex and technically demanding. Surgeons now operate on babies who may be only hours old. They will in future be able to operate on babies before they are born. This demands a highly skilled and experienced team of doctors and nurses able to operate on sufficient numbers of patients to maintain and improve their skills, as well as access to the very latest technology. The noble Lord, Lord Darzi, mentioned that the number of procedures is arbitrary—but 125 is not an arbitrary number. That number of operations was agreed by CHD surgeons as the minimum required to maintain a certain level of competence in the operating theatre.
NHS England’s approach to commissioning these very specialised services is proactive and future-focused. If the proposed changes are implemented, patients and their families can be confident that they will be able to access the very best CHD services in the world, regardless of where they live. It is worth emphasising that the consultation which closed on Monday considers the implementation of an agreed set of common standards, developed more than two years ago by clinicians, other experts and patients, which were subject to full public consultation and which the Royal Brompton, along with other centres, helped to develop.
The standards include the requirement that specialist children’s cardiac services are delivered only in settings where other children’s services are collocated on the same site. There are several reasons why collocation is essential for a world-class service. Managing the complex needs of very sick children demands close co-operation between many specialist doctors, nurses and other experts. Collocation allows much closer working relationships to develop between paediatric cardiology specialists and other paediatric teams. The interaction between these teams on a daily basis, when collocated, is considered by NHS England’s clinical advisers to be of significant benefit to patients. Follow-up and rehabilitation for recovering children often require intermittent access to a wide range of specialists, which is far easier to provide at a centre supporting a full range of services.
The noble Baroness, Lady Boothroyd, and the noble Lord, Lord Darzi, talked about collocation, and I would like to read a couple of quotes. Professor Michael Birch, head of clinical service, cardiology, at GOSH, said:
“Paediatric collocalisation is crucial to provide optimal clinical care at the specialist children’s surgical centre. In the UK early post-operative mortality has reduced, but morbidity remains a concern. The co-dependencies are essential, not only to maintain results with regard to mortality, but also with regard to morbidity”.
I understand, but this is a time-limited debate. I have only 12 minutes to speak and if interrupted, I cannot. I am very sorry. I shall continue the quote:
“In … one year, a formal transfer of care was required to 18 different specialties … These specialties included urology, renal medicine, metabolic medicine, general surgery, respiratory medicine, plastics, neurosurgery, neurology and haematology”
Having those all in one location obviously makes a huge difference. This way of working brings paediatric cardiac care into line with expectations in other specialist children’s services. Collocation of specialist children’s services is the accepted international norm, and this is why the standard requires collocation on the same hospital site.
The decision has not been taken. I am explaining why collocation is the accepted international norm. I am not saying the decision has been made. I am just putting forward the reasons why we hope we will be able to do this, but the consultation will come out later in the year, we hope.
The noble Baroness, Lady Masham, asked about continuity of care. Collocation would encourage that. It not just about the ability to get to the bedside within 30 minutes of the call. The aim is to have immediate access to a full range of specialists, operating theatres and intensive care for the sickest children. Experience shows that once families have used a collocated service, they do not go back.
No final decisions have been made yet, and we need to wait to see what comes out of the next stage of the process. Responses to the consultation will now be carefully considered, and NHS England expects its board to reach a decision by the end of this calendar year. Any change to CHD services would be implemented at the correct pace. I want to be quite clear: this is not a cost-cutting exercise and funding is not the issue. The recent protest march, which featured the noble Baroness, shows how passionately people feel about these issues and their strong desire to defend their local services. I would gently suggest that in celebrating and cherishing the incredible achievements of our current services, we do not lose sight of the obligation we owe to future patients and their families.
This is about ensuring that all patients receive the best care from providers that meet agreed national standards, now in and the future, regardless of where those patients live. I hope that providers and other stakeholders will support these aims and work with NHS England going forward to ensure that sound decisions for the future are taken and, once taken, are implemented effectively and efficiently.
I will just respond to a few issues that were raised during the various speeches. My noble friend Lady Pidding talked about the effect on respiratory services. NHS England’s impact assessments acknowledged that there would be an impact on paediatric respiratory services at the Royal Brompton. A panel that includes respiratory clinicians from outside of London and representatives from other patient and public groups has been set up to assess the potential impact on these services. The panel’s findings will be taken into account by the NHS England board before it takes any decisions concerning these proposals.
The noble Baronesses, Lady Watkins and Lady Finlay, both mentioned the impact on patients and beds. We acknowledge this concern. One of the main reasons for carrying out the consultation is to better understand the impact the proposals might have on the paediatric patients from the Royal Brompton who will go the Great Ormond Street Hospital or the Evelina. The hospitals that will be taking on additional patients have confirmed that they will be able to manage the increase in activity.
The noble Baronesses, Lady Masham and Lady Watkins, mentioned Brexit and immigration. The Government continue to want the brightest and best from the EU and around the world to work on research in the NHS. Government and charities invest £4 billion a year to support world-class research in the UK and will invest more in the coming years.
The noble Baroness, Lady Morgan, talked about the publication of consultation responses. NHS England will publish the independent report on the consultation responses and the relevant NHS England board papers.
Finally, let us remember that the strength of the NHS does not reside within any individual institution. NHS England has a responsibility to ensure that these services deliver the very highest standard of care, regardless of where patients live or which hospital provides that care. We must strive for an objective focus on the actual needs of sick children and their families in this debate. I thank all your Lordships for attending this debate. I realise that people have very strong feelings about what is going to happen to their hospital.
House adjourned at 5.12 pm.