Hospital medical staff raise serious concerns about children’s cardiac service proposals

By Niall McCracken

A GROUP representing medical staff and clinicians working at the Royal Belfast Hospital for Sick Children has said that the safety of children’s heart services is at risk of being “sacrificed on the altar of potential un-sustainability.”

The cardiac services are the focus of a consultation which will determine if paediatric cardiac surgery will close in Belfast. Among the alternative options put forward are for the service to be commissioned primarily from Belfast or Dublin or from providers within Great Britain.

A letter from the hospital’s Medical Staff Committee claims that without immediate surgical cover in Belfast, local children in need of emergency cardiac procedures could have “an unlikely chance of survival” because of the inevitable delays caused by transfer times and finding suitable intensive care accommodation.

Consultation response documents released to a member of the public under Freedom of Information (FOI) and seen by The Detail, show that the overwhelming majority of clinicians who responded favour retaining some form of hybrid cardiac surgical service in Belfast through developing links with Dublin.

This is at odds with correspondence from the Belfast Trust’s chief executive who claims the Belfast site does not have the capacity to function as a “stand-alone centre.” The trust’s preferred option is to have all paediatric cardiac surgical procedures carried out in Dublin.

However, according to the senior health professionals within the Belfast Trust, there will be huge “psychological, social, financial and physical implications” for families here if Northern Ireland’s Children’s Cardiac Service loses its surgical provision.

In December 2012 Health Minister Edwin Poots said he was committed to finding a “network solution” between the two services in Belfast and Dublin and that he would take the advice of clinicians on this issue.

Speaking to The Detail, Sarah Quinlan from the Children’s Heartbeat Trust said the clinicians have made it clear that they think the development of an all island network with cardiac surgery taking place in Belfast and Dublin should be the way forward.

THE CONSULTATION

In July 2012 the service based at the Children’s Hospital in Belfast was evaluated against the “safe and sustainable guidelines” used to assess units in England and Wales. It concluded that with two surgeons performing around 90 operations in Belfast a year the surgical element of the service was not sustainable.

However the consultation response documents reveal that medical staff at the Royal Belfast Hospital for Sick Children have “significant concerns” about how this review was carried out.

Following the publication of the review into children’s cardiac services in Northern Ireland, a separate consultation was launched by The Health and Social Care Board in September 2012 to look at how best to cater for children here.

The focus of the consultation was on the development of an appropriate framework which could be used to determine a preferred option. The main options include paediatric cardiac surgery and Interventional cardiology commissioned primarily from Belfast or Dublin or from provider(s) within GB.

Last week the findings of the HSCB’s consultation were published. Unlike the majority of other consultation processes, the HSC Board was not consulting on a preferred option.

However, the document stated: “A significant proportion of those who responded indicated a preferred model of service provision, namely one which retained surgical services in Belfast. A number of clinicians in responding to the consultation expressed concerns about the potential impact on patient care if surgical services were removed from Belfast.

“This was noted and acknowledged by the working group but could not be taken further at this stage which is focused on developing a framework for the commissioning of paediatric cardiac surgery and interventional cardiology.”

The document also outlined two further consultation options that would see paediatric cardiac surgery commissioned from Belfast with:

(i) Clinical teams from elsewhere in GB and ROI.

(ii) An increase in the number of procedures in Belfast achieved by bringing children t from elsewhere to make the local service sustainable.

“SIGNIFICANT CONCERNS”

The new information released by the HSCB through a Freedom of Information request and passed on to The Detail reveals the responses of a number of senior clinicians and healthcare professions from within the Belfast Trust and across Northern Ireland.

Of the 647 submissions received by the HSCB, 25 responses fall within the definition of either being received from a ‘clinician or groups of clinicians’ or ‘health care professionals.’

In their joint response document the Medical Staff Committee of the Royal Belfast Hospital for Sick Children raise “significant concerns” regarding the Safe and Sustainable Review process that had previously been carried out. Previously the review did not identify any immediate safety concerns with the current arrangements for pediatric cardiac surgery but concluded that the surgical element of the service was not sustainable.

However in their latest response, the committee outline that the Belfast Trust were only given five working days’ notice to supply the relevant documentation to the team prior to the visit whereas in similar reviews in England and Wales each trust was given a three month period to complete their submission.

The committee also claims that it was “very clear from the report that the review team did not give adequate consideration to the geographical isolation of Belfast”. It also claims that existing network arrangements with Dublin was inadequately explored with no visit to Our Lady’s Hospital in Crumlin.

In October 2012 the Safe and Sustainable Review team’s proposals for England and Wales were called into question by the Health Minister in London, Jeremy Hunt, who ordered a full review of the proposals.

In February this year it emerged that the “safe and sustainable guidelines” used to assess units in England and Wales had not been endorsed by all the relevant professional medical bodies in the UK, with some organisations believing that Northern Ireland was being treated as a separate case.

The Medical Staff Committee state in their response letter that the review team failed to recognise the “potential difficulties of not having any paediatric cardiac surgery delivered in Belfast.”

Members of the committee point out that if Northern Ireland had no immediate surgical cover it would cause problems for how emergency surgical procedures could be carried out. They highlighted that “patients would have to be initially stabilised, an intensive care bed would have to be found in a surgical centre and transport arranged with an unlikely chance of survival due to the time delay prior to intervention.”

They also raised issues around difficulties for families having to travel and relocate, often for “significant periods of time.” They say that air travel may be difficult for mothers, particularly after delivery or post caesarean section and the fact that the relocation of parents removes them from the support of the wider family in “an already stressful situation.”

The committee’s preferred option is to maintain the delivery of paediatric cardiac surgery in Belfast as part of a wider network with our Lady’s Hospital in Crumlin.

The committee concludes its letter by stating:“ As eloquently described by one of our members, it would appear that for paediatric cardiac surgery the safety and accessibility of the existing service are to be sacrificed on the altar of potential un-sustainability and this could then become a template for many other similar paediatric specialities.”

The FOI documents contain further letters from medical professionals outlining similar viewpoints.

Dr Andrew Sands, a consultant paediatric cardiologist based in the Belfast Trust, stated that he had a “real concern that infants requiring surgical/catheter intervention will be placed at higher risk if there is no surgical presence in Belfast.”

While Lorraine Davidson, a cardiac clinical physiologist within the Belfast Trust, claimed in her response that the removal of a cardiac surgery from Belfast would have a negative impact on the “adult congenital heart disease population, as the removal of surgical cover from Belfast would mean that it would be removed for this specialised group of patients also.”

The documents show that similar views are held by groups of consultants in fetal medicine, consultant neonatologists, consultant paediatric neurologists and consultant cardiologists. All of these groups are based within the Belfast Trust and they argue in their submissions that surgical expertise needs to be retained within the Belfast site.

Sarah Quinlan from the Children’s Heartbeat Trust says the clinicians have sent a strong message through their consultation responses.

She said: “Clinicians have made it clear that the development of an all island networked paediatric congenital cardiac surgical service with surgery taking place in Belfast and Dublin is the way forward to ensure the continued safety of all babies, children, teenagers and adults with congenital heart defects in Northern Ireland.

“Children treated in Belfast enjoy extremely high standards of care, endorsed by a Royal College of Surgeons report only last July and managed by clinicians and experts who work closely with colleagues in Dublin and Britain. These links should be strengthened and enhanced with agreed protocols, safeguarding the service for the future.”

Only two of the responses from health professionals raise some concerns around benchmarking standards of care and of medical practices in the Republic of Ireland, as well as the cost implications of retaining surgery in Belfast with primary commissioning based there and another larger centre.

In a letter contained in the FOI documents, Colm Donaghy, Chief Executive of the Belfast Trust, said that the Children’s Hospital does not have “the service capacity to function as a stand-alone centre and currently sends approximately 40 highly complex children to Our Lady’s Hospital, Dublin and to the Birmingham Children’s Hospital each year.”

On that basis the trust’s preferred option is for the development of a network arrangement with our Lady’s Hospital in Dublin where “surgery, interventional and diagnostic catherisations are undertaken in Dublin for Belfast patients by Belfast and Dublin clinical staff.”

He said there was a need to ensure “maximum reliability and availability” of the transportation arrangements.

In a statement the Belfast Trust told The Detail it would “await the outcome of the public consultation.”

In December 2012 Health Minister Edwin Poots said he was committed to finding a “network solution” between the two services in Belfast and Dublin and that he would take the advice of clinicians on this issue.

A spokesperson for The Department of Health said: “The Minister is fully committed to the delivery of paediatric cardiac services which are safe and sustainable and which deliver the best outcomes for children.

“He aims to make a final decision on the future arrangements for this service within the coming months.”