Minutes:
Mr Jim Birrell, Interim Chief Executive and Mr Aidan Bolger, Head of Service for Cardiology, attended the meeting to present evidence on the outcome of the UHL review of the JCPCT’s decision in relation to securing legal advice and a clinical review of the recommendations. A report that was submitted to the UHL Trust Board Meeting on 30 August had previously been circulated to Members.
Mr Birrell in presenting his evidence to the Committee made the following comments:-
Ø That, having considered Counsel’s advice, the Board had concluded that challenging the decision of the JCPCT on legal issues was not likely to achieve a beneficial outcome and this route would not be pursued.
Ø The Board had considered that it had a convincing case to question the JCPCT’s decision on clinical grounds based around quality, capacity and risk issues.
Ø Representatives of UHL had met with Sir Neil Makay last week and had presented their case to him. He had taken the case away to assess it and had subsequently written to the Secretary of State to suggest that the evidence now submitted should be looked at in detail.
Ø The Board believed that the only route to question the JCPCT’s decision was through a formal referral by the Committee.
Ø The UHL supported the Safe and Sustainable process and felt it was a good model to secure the safest and best quality services and recognised the philosophy of concentrating the best skills in a smaller number of units to achieve this.
Ø The UHL had also put forward a further option to create a modified midlands unit based on two sites at Birmingham and Glenfield to be subject to single audit, reporting and research processes.
Mr Bolger stated that :-
Ø The capacity for the proposed midlands’ network did not take account of the fact that demands for the services exceeded the capacity at the Birmingham Children’s Hospital. The risks of the JCPCT’s proposal had been underestimated and there were local, regional and national implications of closing the Paediatric Intensive Care Unit.
Ø The Safe and Sustainable Committee had commissioned work to predict demand up to 2025 for Paediatric Cardiac Surgery. The only data available to them was surgical data for 2006/07. At that time there were 4,750 operations and a flat growth of operations were predicted. Data now available up to 2010 indicated a rapid increase in the number of operations to 5,452, an increase of 700 operations per year. This data was not available to the JCPCT at the time it made its decision but UHL felt that it would be negligent to ignore this now. Reference was made to the data on pages 8 and 9 of the UHL report (Appendix C7).
Ø If the data in the graph on page 9 of Appendix C7 was extrapolated, it showed a marked increase in the predicted number of operations nationally in the future.
Ø This had implications for the proposed midlands network as the predicted population growth for Age 0-4 years for the period 2010-2015 was 10% for the East Midlands and 9% for the West Midlands compared to national growth rate of 5%. The figures for 2010-2025 showed an increase of 11% for the East Midlands and 8% for the West Midlands. These increases above the national average were not considered as part of the JCPCT’s consideration when it decided to move the services from Glenfield to Birmingham.
Ø The midlands network covered 14 post code areas and the data on page 18 of Appendix C7 showed that the current demand was 611 operations per year, rising to 651 operations in 2015 and 719 operations in 2025.
Ø In addition to the figures above, there would also be further demands from patients transferring in from other areas. Initial feedback from the Sheffield area indicated that most potential patients would prefer transferring to Birmingham rather than Newcastle, thus putting extra pressure on the services provided at Birmingham. It was predicted that the 611 operations per year would be nearer 900-1000 operations per year and this had not been accounted for in the Safe and Sustainable modelling process.
Ø It was considered that it was not possible to sustain 1,000 operations per year; given that it required 7 nurses per day to maintain 1 Intensive Care bed and 13 nurses per day to support 1 ECMO bed. It was felt that this was too much for one single centre to cope with, especially as this level of service would be unprecedented in the UK and it was questioned whether a unit operating on this scale could be found within Europe. There were also concerns that a unit trying to provide services for 1,000 operations per year would become prone to unavoidable inefficiencies.
Ø The Glenfield survival rates for ECMO treatment were far superior to the national and international figures currently available.
Ø The JCPCT were not aware of the ECMO data and unless the new unit at Birmingham provided the same quality of service as Glenfield then the mortality rate would increase and, based upon past data, this could translate into an additional 50 children per year dying.
Ø The JCPCT’s decision had a major impact on the Paediatric Intensive Care Unit (PICU) provision. There was already a national shortage in this area and in 2010 Glenfield had taken 87 patients from the West Midlands. This would mean that the gap in under provision would get bigger if Birmingham were required to take up the extra capacity in the future.
Ø 40% of PICU cases at Glenfield were related to ECMO and cardiac services compared to 29% at Southampton and whilst the loss of the PICU at Southampton had been recognised by the JCPCT the same principles had not been applied to Glenfield in the review.
Ø If the PICU closed at Glenfield, it would leave the East Midlands short of PICU beds, since the only other unit would be at Nottingham; and they were stretched to capacity already.
Members of the Committee raised a number of questions in relation to comments made by Mr Birrell and Mr Bolger and in response they stated that:-
Ø It was considered that the JCPCT had not been negligent in making their decision, they had been faced with making a difficult decision and had made that decision on the data available to them at the time in the interests of securing the safest and sustainable services in the future. The data now available presented a challenge to the basic premise of the decision.
Ø The UHL were assured by Sir Neil McKay that the additional data presented to him would be looked at in detail and, although he had indicated that the JCPCT had concluded its representations to the Secretary of State, things could be reconfigured differently if the Independent Reconfiguration Panel made recommendations to the Secretary of State.
Ø The population data now provided strong evidence that the capacity for the future has been underestimated. This had been brought to the attention of Sir Neil and it will now be considered.
Ø The cost of implementation was one factor in the decision making process for selecting the current preferred options. It was felt that driving force behind the exercise was not primarily to save money; as it was likely that the future service provisions would cost more than currently. The main driver and focus had been on providing high quality expertise and services at fewer centres.
Ø The UHL did not consider that they had ruled out a legal challenge too lightly or too early. They were satisfied that, based upon the advice they had received, a challenge on legal grounds would only have resulted in the same decision being reached. The clinical case provided a stronger method of challenge.
Ø Generally, the increase in the number of operations required would match the growth in population rates as 1 in 200 babies were born with a congenital heart defect. In addition, advances in techniques and technology meant that it was now possible to provide a more comprehensive level of service. The success rate for children surviving after the first operation was higher than ever before and 25% of children receiving surgery required further operations. This all added to further pressures in increasing the number of operations required in the future.
Ø Given the number of staff required to support and ECMO bed, it was questionable that sufficient staff could be recruited in sufficient numbers locally to replace the loss of the current staff at Glenfield and the increased pressures on the service in the future. The clear message from the staff survey at Glenfield was that it would be wrong to assume that staff in the ECMO unit at Glenfield would transfer to Birmingham.
Ø It had not been possible to undertake a feasibility study on the proposal to create one unit on two sites as dialogue only started last week. The proposal envisaged both sites scaling up to deal with the projected future demand that was now envisaged. A feasibility study could be concluded, however, in the timescale envisaged. It was felt that the option was a sensible approach as it did not compromise the integrity of the safe and sustainable exercise or its principles.
Ø If the suggested option was taken up, it was envisaged that the ECMO unit would be retained at Glenfield along with paediatric cardiac surgery.
Ø The National Specialist Commission Group provided the budget for the paediatric cardiac surgery at Glenfield which was in the region of £2.5m. The impact of losing the paediatric cardiac surgery was more significant and had a potentially bigger impact upon the services provided at the hospital than the impact of the transfer of the current budget to Birmingham.
Ø The JCPCT had not been convinced by the UHL arguments that there was instant access between the two sites in Leicester and Glenfield. As a result of that, the UHL had addressed the issues last October and transferred some Ear Nose and Throat (ENT) staff to Glenfield to provide a 24 hour service at Glenfield.
Ø There was a typographical error in the table on page 7 of Appendix C7 figure. The figure for the validated CCAD data for ‘infant’ for 2010 should be 1,770 and not 1,170 as printed.
Ø UHL were surprised that the Glenfield only received a score of 2 (Poor) for Innovation and Research Capacity. (Page 156 of the JCPCT’s Decision Making Business Case) It was noted that the initial request for information had been a ‘dry’ process and whilst the documentation requested had been supplied, Glenfield appeared to have been underscored in some areas compared to other centres. Glenfield had been marked down for sustainability despite increasing the number of beds from 8 to 12. The generic process of information gathering had not been scoped to include the national service provision of ECMO.
Ø It was felt that the impact of transferring the ECMO unit had been underestimated by the JCPCT and it was encouraging that Sir Neil Mckay had expressed surprise at the evidence now provided in relation to the evidence given to the JCPCT and the fact that the advice of the ECMO world expert had been ignored. Furthermore, the JCPCT did not have the data relating to the survival rate at Glenfield up to 2010 when they had made their decision.
The Committee thanked Mr Birrell and Mr Bolger for their contribution to the meeting.