Representatives from UHL will attend the meeting to present their current view on the proposals. A copy of presentation is attached.
The Chair welcomed the following representatives of University Hospitals of Leicester NHS Trust (UHL) to the meeting:-
John Adler, Chief Executive.
Dr Aidan Bolger, Consultant Cardiologist & Honorary Senior Lecturer and Head of Service East Midlands Congenital Heart Centre.
Mark Wightman, Director of Communications Integration and Engagement.
Alison Poole, Senior Manager Special Projects.
John Alder thanked the Committee for the opportunity to address the Committee. He stated that UHL were opposed to the proposals in NHS England’s Consultation Documents for the Congenital Heart Disease (CHD) Review; particularly as the Trust had made good progress in meeting the standards required and NHS England had formally acknowledged that the only point of issue was the standard for each surgeon to perform 125 procedures a year. The Trust had submitted a Growth Plan to NHS England, at their request, in May 2017 which had clear and robust plans to meet the target standard specified in standard B10 (L1) and demonstrated that the Trust had already begun to put this plan into place to meet the required target. It was understood that NHS England had been considering the growth plan since it was submitted and had promised a meeting with UHL during the consultation period to discuss it. However, no formal response had been received from NHS England.
Dr Bolger gave a presentation on their current view of the proposals and a copy of the presentation is attached to these minutes.
During the presentation the following points were noted:-
a) The announcement that NHS England were minded to decommission Level 1 services in Leicester was made in July 2016. It was not until February 2017 that the public consultation was launched and in may not be until 2018 that the outcomes will be known. This was having a destabilising effect on those centres put forward for decommissioning.
b) This destabilising effect had already impacted upon Level 1 services in Manchester as the unit had recently closed prematurely at short notice. This was the result of senior staff leaving because of the uncertainty over its future and, as the Trust could no longer provide Level 1 congenital heart services. NHS England has had to form a crisis team to manage the situation externally, calling on other Level 1 providers in the North of England and Queen Elizabeth Hospital in Birmingham to provide care for Manchester’s patients. It was of concern that this had been allowed to happen, particularly as NHS England did not have a contingency plan in place for this eventuality during the consultation process. This uncertainty remained and there was still a danger that other centres, such as UHL, could be susceptible to the same pressures. If UHL was forced to close prematurely then patients would be at risk as there were no plans in place to absorb their caseload at short notice.
c) The national picture in relation to CHD services has transformed immensely since the concerns associated with Bristol in the 1980’s and 1990’s. At that time, Bristol had a 30 day post-operation mortality rate of 28% in those under a year of age compared to the national average of 14% and Leicester’s 13%. In 2015-16, the national mortality rate was 2% for all children’s heart surgery compared to Leicester’s 0.6%. The number of CHD centres in the UK had reduced from 17 in 1991 to the current 12 centres and there was now far more regulation, governance and audit in place to monitor safety and outcomes than in 1991, when there was very little overview.
d) After a self-assessment exercise in early 2016, UHL were informed that they were non-compliant with 8 out of 14 “core standards”. NHS England’s “minded” decision was based on this analysis. After UHL challenged this position, further discussions took place with NHS England, after which NHS England revised UHL’s compliance to 13 out of 14. Despite this, it didn’t alter NHS England’s “minded” decision to decommission Level Services from UHL. According to NHS England, UHL failed to achieve the surgical activity standard by April 1st 2016. The standard refers to a centre having a team of three surgeons undertaking 125 operations per year (i.e. 375), averaged over three years. UHL objected to NHS England’s retrospective application of this standard. They pointed to the fact that this was never agreed by the working group of stakeholders who proposed the standards, to the fact that current surgical activity was now significantly higher than the historical data NHS England used and to the fact that the rate of increase in surgical activity will mean that for the current year, (2016-17), 375 operations would be undertaken. UHL also submitted a robust growth plan to NHS England in May 2017 that described how the network would grow in order to reach the 2021 standard of four surgeons/500 cases per year. Despite UHL providing them with a detailed growth plan that described how the 500 cases per year would be achieved, and agreeing to meet them to discuss that plan, NHS England had failed to reply to enquiries from UHL about when, or even if, those discussions would take place.
e) UHL had demonstrated unequivocally to NHS England that 500 operations per year are undertaken on patients from this region already with many having to travel outside the region to receive specialist care. NHS England had undertaken its own analysis of activity in the region and agreed with UHL’s conclusions. UHL, therefore, stated that the issue was not one of a centre situated in a small geographical area with a small population of patients, as is found elsewhere in the country where there is no threat of decommissioning, but one of improving access to care for a large and populous region.
f) In addition to activity growth from existing network partners, UHL had been working with Chesterfield, Peterborough and Northampton hospitals who had expressed clear support for the continuance of CHD services in Leicester and the desire to explore network relationships in the future. These new referral pathways would accelerate the surgical activity in Leicester so that the target of 500 operations per year by 2021 would be comfortably achieved. However, critically, the fact that it was now a year since NHS England had announced that it was minded to decommission Level 1 services in Leicester and the fact that NHS England had still not decided when it would finally make a decision on future commissioning had created such instability and uncertainty that providers up and down the country were struggling to move forward with developing care pathways for paediatric and adult congenital heart services.
g) UHL had also held informal discussions with clinicians in Milton Keynes and Warwickshire Hospitals who were currently outside Leicester’s Network but which were geographically close and had short journey times. There was interest in exploring network membership further. Any referrals from these centres had not been included in the UHL’s Growth Plan adding further confidence to UHL’s firm belief that they will reach the required target for operations in the required time.
h) UHL felt that there should be much more consistency with respect to the approach NHS England was taking. For example, UHL had asked NHS England to consider its world leading ECMO programme in the same light as the cardiac transplant service in Newcastle. NHS England had stated that ECMO was subject to a separate review as it was not in the terms of reference for the congenital heart review and yet heart transplantation was not in the terms of reference for the congenital review but was given due consideration. That included an open-ended derogation on achieving the surgical activity target and co-location of paediatric cardiac services with all other children’s services with respect to the Newcastle service. As another example, UHL had been required to submit a detailed Growth Plan to NHS England to demonstrate their ability to reach 500 operations per year by 2021. Other centres for whom this target is equally challenging, but who were not earmarked for decommissioning, had not been asked to provide anywhere near this level of detail. Through Freedom of Information requests, UHL was aware that at least one other centre had stated in its impact assessment that they would achieve the 500 target only by other centres closing. This was felt to be inequitable. Many patients would have to travel further than their nearest centre for this to be achieved, something highlighted by the Independent Reconfiguration Panel (IRP) that reviewed the Safe and Sustainable decision as being highly undesirable.
i) UHL had demonstrated the largest sustained percentage growth in operations for CHD services over the last 8 years compared to other Level 1 centres where the number of operations has remained static or declined in the same period.
j) UHL’s provision of regional and local PICU and regional and national ECMO services should have received equal consideration to Newcastle’s heart transplant services. The PICU and ECMO provision should have been part of the CHD Services Review from the outset as had been recommended by the IRP in their report to the Secretary of State for Health in 2013 on the matter of the Safe and Sustainable Review.
k) UHL questioned the ability of other centres to cope with the additional workload that would result from decommissioning in Leicester. Consideration seemed to have only been given to cardiac surgery whereas PICU capacity, catheter interventions (“key hole” procedures), non-cardiac surgery, ECMO, obstetric cardiology (the care of expectant mums with heart conditions), education, training and research seemed to have been given far too little attention; if any at all. The point was made that many of the complex patients need outpatient review in the Level 1 centres and the NHS England model that describes outpatient review in a Level 1 centre only on a single occasion before surgery and a single occasion after surgery just was not accurate. UHL expressed concern that waiting lists in other Level 1 centres were already under pressure and moving patients out of the East Midlands would make this worse. Patients from the East Midlands were therefore likely to have to wait longer for operations and catheter procedures than they do now and by default so would patients in the receiving centres. This must be seen as a risk to implementing the current proposals. UHL also stated that the surgical activity data sent to other Level 1 centres to test their capacity expansion plans was years out of date, again adding significant and unnecessary risks to implementation.
l) UHL raised the prospect of a shortage in human resources, particularly PICU nurses as a serious concern with respect to the transfer of surgical services to another centre. Indeed it was highlighted that Birmingham Children’s Hospital had already expressed their concerns over recruiting sufficient staff to accommodate the increase workload in the event of UHL ceasing to provide Level 1 services. It was stated that the issue at hand was not whether other centres could build a hospital big enough to accommodate all the patients from the East Midlands with congenital heart conditions but whether they should.
The Chair thanked UHL for their presentation and commented that this was a regional issue and not just a local issue to Leicester. There was a great deal of concern across the East Midlands about the current proposals.
The Chair offered the representatives of NHS England the opportunity to comment upon the points raised by UHL. The representatives indicated that they did not wish to comment as they were attending the meeting to hear the views put forward by the public and stakeholders.
The Chair then asked Members to refrain from asking questions until the Committee had heard the representations and submissions from patients and stakeholders as there may be some duplication of questions arising from UHL’s presentation and representations and submissions still to be heard.