5.3.4 It is remarkable that Imperial College, at which the NHLI is located and the Royal Brompton provide the cardiological component, was found to have more cardiology researchers doing 4* work, that is work of
Quality that is world-leading in terms of originality,
significance and rigour"
than any other two Centres in England put together. It is astonishing that the Panel should have ignored this when reaching a radically different view. To reject such an authoritative conclusion reached after such an exhaustive process looks brave if not idiosyncratic; to fail to refer to the HEFCE’s RAE when doing so looks ill-informed.
5.3.5 At the same time as HEFCE was recognising the pre-eminence of Imperial College’s academic research, the NHS National Institute of Health Research (NIHR) had to decide where to site two of its Biomedical Research Units in cardiovascular and respiratory medicine. This is the Department of Health’s equivalent recognition of excellence and two were placed in the Royal Brompton Hospital. It is only a small component of the research being carried out at the Brompton and the NHLI – but as a recognition of excellence in research by the NHS it is unequalled. Here at least the S&S team did recognise the presence of the BRU, but they disregarded it on the basis that:
"The Trust has a good track record with clinical research however
the panel felt this has recently slipped and the research
undertaken by the two BRUs at the Trust is not relevant to
paediatric cardiac surgery…The panel did not feel that there were
explicit plans for research undertaken by the BRUs to include
research relevant paediatric cardiac surgery" 
This sort of value-judgement is hard to counter but the breadth and volume of publications undertaken by Royal Brompton is hard to reconcile with such a proposition (http://www.rbht.nhs.uk/research/projects/publications/
and http://www.rbht.nhs.uk/research/projects/). More cogently HEFCE found that the scale of the work being done here dwarfs that at other centres.
5.3.6 It is true that one of the two BRUs is less likely to be directly relevant to cardiac surgery since it is concerned with respiratory medicine. However even here we may note that primary ciliary dyskinesia, a respiratory condition, is also associated with complex congenital heart disease (an association first described at this institution) and there are ongoing joint projects which might sit in either BRU. The same is true of acute lung injury after cardiac surgery, in which Dr Nazima Pathan is leading an important project.
5.3.7 Nevertheless, we do accept that the majority of research work in cardiovascular medicine undertaken by the NIHR and the majority of work undertaken by the cardiovascular BRU do not deal with the subject of paediatric cardiac surgery narrowly defined. But what S&S overlooked, inexplicably, is:
220.127.116.11 The BRU means that the DoH NIHR, in its way as
respected as HEFCE, although not setting out to do the same thing, has
given Royal Brompton a similar vote of confidence in the quality of its
18.104.22.168 That the future best interests of patients suffering from
these diseases will be served by supporting a broad base of research
into cardiovascular science, not by concentrating narrowly on surgical
research. The damage that will be done to research as a result of this
decision will impact on future generations.
5.3.8 In fact research being carried on here over the next five years will pioneer new treatments for heart disease using gene therapy, stem cells, tissue engineering and mechanical and electrical devices. We are also working on cardiovascular genetics in close synergy with advanced cardiac imaging and cardiac positron emission tomography (PET). We expect that this will lead to a stream of discoveries about new mechanisms of heart disease and new treatment modalities for them. The imaging technologies will also be used to develop new techniques for delivering novel treatments, such as stem cells. It may be that the Panel decided to ignore work being done at the NHLI on the grounds that it is not taking place in the Trust, if so this is difficult to understand.
5.3.9 Work being carried on at Royal Brompton which is not being carried out by cardiac surgeons includes studies of the following:
The incidence and nature of specific congenital diseases in this country and abroad which have elicited risk factors for poor outcome from surgery.
An enormous research study into the association of assisted conception and congenital heart disease.
The use of clopidogrel to prevent post operative thrombotic disease in paediatric surgery.
The use of Ivabradine which slows the heart rate in patients with congenital heart disease.
Studies of connexins, which are proteins composing the junctions between heart muscle cells and may be responsible for impaired cell to cell communication and hence the development of congenital cardiac abnormalities.
World-leading work is being carried out at Royal Brompton Hospital into cardiac electrophysiology and cardiac morphology studying the structure of the heart will help to reduce the dangers of surgery.
We are unique in having two Readers in Fetal Cardiology and their present projects, in addition to the description of structural defects at a time when the fetal heart is tiny include
- Studying fetal ECGs and arrhythmias,
- Studying perinatal adaptation of the fetus with CHD
- Investigating biochemical markers in CHD and 3D-fetal
- The development of normative data.
The contribution of the Brompton to the clinical care of the fetus with CHD, like its work in teaching sonographers and other professionals to recognise f-CHD with the aim of improving prenatal detection rates does not appear to have been taken into account at any point when S&S ‘graded’ the Royal Brompton against other centres in the UK.
5.3.10 None of this is research into paediatric cardiac surgery per se, but, crucially, these are studies are likely to benefit the service offered to such patients over the next 10 years and they are crucially dependent on the clinical work with patients going on around them. The proposition that Royal Brompton is not an outstanding international centre of research simply does not stand comparison with the objective evidence, and the proposition that none of this will benefit patients with CHD is similarly unsupportable.
5.4 The flawed approach to quality
It is very difficult to understand how S&S has reached its conclusion in assessing the quality element of different Centres. The view that was reached does not stand comparison with the objective data which shows for example that Royal Brompton’s mortality data stands comparison with other speciality centres elsewhere. Certainly none of the documentation that we have seen enables us to understand what the Panel mean by quality or the respects in which the other London centres were found to be better than Royal Brompton.
5.5 At the moment we are quite unable to understand how the Panel have reached their assessment of Quality. We have requested an explanation repeatedly but as of June 28 2011, we have met with obstinate resistance. We have called for the raw data relating to the assessments of the other centres and hope that when these are forthcoming, as of course they will eventually have to be through the Freedom of Information Act and the process of disclosure in our application for Judicial Review, they will be taken into consideration as part of this consultation.
5.6 The misunderstood co-location
5.6.1 The strongest argument of those who believe in a horizontal approach is that any other specialist services that a child might need will be available on site from a dedicated team already there. Great Ormond Street Hospital (GOSH) understandably believes that it has unequalled strength in this direction. Evelina Children’s Hospital believes that it combines the best of both worlds since it has adult medicine available from the adjacent Guy’s & St Thomas’ Hospital whilst having a large range of paediatric specialists available within the Evelina Children’s Hospital itself. In fact there are good grounds for concluding that all three hospitals have to make compromises and that the compromises made by the Royal Brompton are no less advantageous to patients than those made elsewhere.
5.6.2 First, the importance of respiratory medicine to these children cannot be over stated. A significant proportion of children being treated for cardiac disease also need the attention of respiratory physicians and vice versa. Royal Brompton has the strongest respiratory team in London led by Professor Andrew Bush and indeed that team is relied upon by the Evelina Children’s Hospital to assist with some of their cardiac surgical cases.
5.6.3 By contrast, Royal Brompton enjoys an advantageous relationship with the Chelsea & Westminster Hospital (“C&W”) in the form of fixed Service Level Agreements (SLAs). C&W is 10 minutes’ walk from Royal Brompton, less time than it takes to cross the campus at many a larger hospital and certainly less time than it takes to reach, for example, the Evelina from Guy’s or Lewisham Hospital, the Freeman Hospital from the Royal Victoria Infirmary in Newcastle or Leeds General Infirmary from St James’s Hospital in Leeds. All of these intra-Trust journeys are far longer than the distance between C&W and the Brompton. Furthermore, Royal Brompton has two priceless advantages arising from its SLA with C&W. The first is that the attending doctor is always a Consultant and second, once they have reached Royal Brompton it is a matter of moments to reach the relevant ward and obtain whatever support is needed.
5.6.4 Where such compromises have to be made, a fair assessment will inevitably revert to the standards for co-location laid down by the Baker Report. There is no question but that our arrangements mean that we meet those requirements handsomely.
22 A Collaboration Between Royal Brompton & Harefield NHS Trust and Great Ormond Steet Children’s Heart and Lung Services – A Proposal to Establish a National and International Service for Children with Heart and Lung Disease 3 April 2009
23 Ibid, page 14
24 Ibid page 51
27 Ibid page 11
28 Report of Sir Ian Kennedy’s expert Panel 2010