Dr Simon Finney – consultant in adult intensive care and anaesthesia
As a doctor who cares only for adult patients, it might be expected that the outcome of the Safe and Sustainable review has little impact upon me.
This is incorrect.
I rely on the breadth and richness of clinical knowledge, skills, and experience at Royal Brompton to help me care for my patients. Cardiovascular disease is not defined solely by age – more the prevailing anatomy and physiology. Comprehensive care of any patient, child or adult, may need skills found outside traditional groupings of doctors. For example, closure of an ischaemic ventricular septal defect in an adult may be best undertaken by a paediatric cardiologist for whom similar procedures are routine. Alternatively, a child with a coronary artery anomaly may be best assisted by a surgeon with a primarily adult practice that focuses on coronary artery disease.
Moreover, during the winters of 2009 and 2010, the adult intensive care unit provided a national ECMO service for patients with severe pandemic H1N1 influenza. The excellent outcomes were, in part, dependent on the skills gained from paediatric clinical perfusion and paediatric ECMO.
All these synergies between departments will be lost if the paediatric cardiac surgery unit is closed. This will be detrimental to adult patients.
I also feel obliged to comment on a process that I am concerned will be detrimental to patients other than my own, namely children with heart disease.
While doctors, nurses and therapists can move geographically, I believe the results produced by a team are more than their collective skills. The bricks and mortar matter – they define an organisational culture that focuses on governance and quality, and aspires to achieve the best outcomes when judged nationally and internationally. I believe Safe and Sustainable places too much emphasis on the number of cases performed each year (which Royal Brompton achieves) and focuses less on other equally valuable considerations such as organisational culture, collective professionalism, and the desire to train the next generation of doctors and nurses.
Cardiac services should be flexible. The care of patients transitioning between paediatric and adult services need not occur at a specific age. Individual patients differ as to when their transition should occur; early or late, quickly or slowly. The co-location of adult and paediatric services facilitates doctors, nurses and therapists in caring jointly for each patient during transition.
I am also concerned about the rigour of the process. The decisions reached by Safe and Sustainable will influence clinical practice and patient outcomes. Therefore, the methodology, the analysis, and the publicity should be undertaken and independently reviewed to the same scientific, ethical and publication standards we would expect of a clinical trial. For example, previously defined and publicised methodology, independent review, and statistical robustness.
If I were making the decision, I would maintain all three centres across London believing this maximises patient choice and acknowledges all three centres provide excellent care. The centres should be mandated to act collaboratively to share experience, data, undertake research, and provide rapid access for patients.
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