Annex A > Chapter 11 - Referrals > Referrals to other centres by Bristol cardiologists and surgeons

Referrals to other centres by Bristol cardiologists and surgeons

Referral procedure and reasons for referral

205 The Inquiry heard evidence from the Bristol cardiologists and surgeons about the nature and extent of referrals to centres other than Bristol.

206 Dr Joffe explained the procedure once a child had been investigated by the Bristol cardiologists:

`If the cardiologist considers that surgery may be indicated, the results of investigative procedures are reviewed at a joint cardiology/cardiac surgical/radiological meeting.' [217]

He told the Inquiry: [218]

`It was, and still is, up to the paediatric cardiologists and cardiac surgeons together to determine the best course of action for each individual child.'

207 Dr Jordan told the Inquiry that he referred patients elsewhere:

`... usually for one or more of the following main reasons:

• `There was a surgeon able to offer an operation that was not available in Bristol. This included, at different times, the Rastelli operation, arterial switch (Magdi Yacoub), Fontan operation (Brompton and GOS), autograft aortic valve replacement (Donald Ross) and heart or heart-lung transplantation (Harefield Hospital).
• `A surgeon or a team had shown a particular interest in the management of an unusual condition such as ventricular septal defect with prolapsing aortic valve cusp (Donald Ross and Jane Somerville at the National Heart Hospital).
• `Parents requested such a referral either because it was more convenient (e.g. they had relatives with whom they could stay in London) or had some other association, such as a relative or godparent who was a cardiac surgeon.
• `I or my colleagues were uncertain about the actual diagnosis, such as differentiating aorto-left ventricular tunnel from sinus of valsava aneurysm.
• `I or my colleagues were uncertain as to the correct procedure and we wanted a "second opinion".
• `Parents requested a "second opinion", usually because they were uncertain as to the need for surgery or were unhappy with the risk that they had been given by the surgeon.
• `Parents where a previous child had been operated on in Bristol and had died, in which case I always offered to send the child elsewhere.
• `When surgery had previously been carried out by another surgeon and the patient had moved into the area (or we had taken over an area formerly served by another unit). Not all parents wished to be referred back to the original surgeon.' [219]

208 Asked on what basis a unit would be chosen for a referral, Dr Joffe said:

`A variety of reasons, including a personal connection between someone who had trained, let us say, at the Brompton, knew the surgeon and knew he did an operation particularly well; the overall perception that cardiologists, as a group, would have of a particular unit's performance on another condition. The relationship between one surgeon and another, because these cases would be referred either by the cardiologists or after our joint meetings, by a cardiac surgeon, with whoever he or she, in this case he, was referring that patient to. So it is a variety of reasons, but I think, as you will see at that time, it was mostly Great Ormond Street, sometimes the Brompton, but later on Birmingham.' [220]

209 Dr Jordan acknowledged the comparatively short waiting list at Southampton, but explained why he would not have referred patients from Bristol there. His evidence included this exchange:

`Q. Southampton, if I have understood it correctly, had no or very short waiting lists compared to Bristol?

`A. The information I was given by the paediatricians in Plymouth was if a patient was seen by one of their paediatric cardiologists in outpatients, requiring a catheter and presumably an operation, they will be admitted within about three weeks for the catheter and they will have their operation next week. That is what they described to me as being a typical situation. Whether, you know, it always quite worked like that, I cannot say, but that was the information given to me.

`Q. And that was about this sort of time, three years or thereabouts before your retirement?

`A. Yes. We had this discussion on odd occasions, but, yes, I mean, there was certainly a discussion about 1989/90, something like that.

`Q. So were the Bristol children who were facing the long waiting list at Bristol referred to Southampton where there were very short waiting lists?

`A. ... No, they were not.

`Q. Would that not have been a more sensible way of proceeding?

`A. It is like all of these things: it is sensible in that it deals with the immediate problem. What then happens when Southampton builds up a waiting list because they have been sent twice as many patients as they can cope with?

`Q. What would be the bars, the disincentives for you and Dr Joffe in sending a patient to Southampton, say?

`A. Can I say, I have absolutely no criticisms of the surgery in Southampton, so let us get that out of the way. That is not a bar. Firstly, it would almost inevitably mean a longer journey for the patients and their parents. Secondly, there would then be problems of communication between the surgeons there and the patients: where do they follow them up? If it was a patient who came from Haverfordwest in South Wales, they would not want to be sending one of their teams out to Haverfordwest just to see one or two patients. There were those sort of logistic problems, basically, that it seemed to us desirable to avoid, if they could be avoided. Having said that, I did refer patients not to Southampton but to other hospitals for specific reasons, and obviously we had to make the best that we could of those particular objections.' [221]

210 Mr Dhasmana and Mr Wisheart gave evidence to the Inquiry about the circumstances in which a child might be referred to another centre for surgery. They identified Great Ormond Street, Harefield, the National Heart Hospital, the Royal Brompton Hospital and Birmingham as centres for such referrals. Mr Dhasmana told the Inquiry that such decisions were made in conjunction with the cardiologists and others, usually in joint meetings held on Mondays at the BRHSC. Mr Wisheart acknowledged that there might have been referrals elsewhere by the cardiologists about which he had not been told.

211 Mr Dhasmana said that a record of these referrals would usually be kept at the BRHSC with the cardiologists, and provided a list [222] produced by Dr Joffe illustrating referrals to other centres between 1992 and 1994. Mr Dhasmana added: `There were similar patterns of referrals before 1992.'

212 Mr Wisheart told the Inquiry:

`There were always a small number of referrals away from Bristol to other centres, such as Great Ormond Street, the Brompton, the National Heart Hospital or in recent years to Birmingham. In many instances the decision to refer elsewhere was a joint one between the surgeons and the cardiologists. It is impossible for me to say whether or how many were referred elsewhere by the cardiologists without consulting the surgeons.' [223]

He added:

`I would now find it very difficult to indicate the extent of these referrals, other than to say that apart from [the neonatal Arterial Switch], it was relatively uncommon.' [224]

213 Mr Dhasmana told the Inquiry [225] that the reasons for such referrals included:

• `Patients for consideration for heart or heart and lung transplantation;
• `surgical treatment not available at Bristol i.e. patients with hypoplastic left heart requiring Norwood Procedure and Neonatal Switches after October 1993;
• `for second opinions, when the risk of surgery was considered very high or surgical options were not clearly defined;
• `I recall an instance when parents asked me for referral to Mr Yacoub at Harefield for a second opinion, before returning to me for surgery on their child;
• `there were instances when patients were transferred to other centres, for example when an urgent surgery could not be provided at Bristol, for the lack of a bed.'

214 Mr Wisheart told the Inquiry [226] that reasons for such referrals would include:

• `At the beginning of the period, before Mr Dhasmana was appointed, an urgent patient who presented when I was on leave would have had to be sent elsewhere.
• `Patients with conditions whose rarity and/or complexity placed them outside our experience would have presented from time to time, and referral elsewhere would have been considered.
• `There were patients about whom it was difficult to be confident as to what was the appropriate advice and therefore from time to time we would have consulted with colleagues elsewhere, most commonly with Great Ormond Street. In the light of their advice, there were some occasions when we asked the surgeons at Great Ormond Street to undertake a surgical procedure they had recommended. On other occasions we undertook the surgical procedure in Bristol.
• `After we stopped the neonatal arterial switch programme, children with simple transposition who were suitable for an arterial switch operation in the neonatal period were sent elsewhere, mainly to Birmingham.'

215 Mr Watson commented on referrals from Bristol to other centres. He said that this:

`... would occur where the unit would be unable to deal with the specific patient and a more specialist referral would be needed. This is a separate issue to the waiting list issue which was one of capacity and does not fall within the meaning of what is normally understood by "tertiary referral".' [227]

216 In relation to the waiting lists, Mr Watson explained:

`... there are often waiting list initiatives in hospitals because waiting lists are always of concern ... The waiting list initiative was not in any way limited to paediatric cardiology but was across the board.' [228]

217 He referred in particular to an arrangement with the Royal Brompton Hospital. In October 1987 he wrote to Dr Roylance. [229] Of the letter he said:

`... [It] advised of my concerns about not hitting our targets of 50 patients for onward transfer to the Brompton Hospital for cardiac surgery. There was a question over whether the patients were reluctant to go to London, and this was potentially more so with paediatrics as a local hospital would be favoured by the visiting family ... The issue in October 1987 was that a deal had been struck with the Brompton to take a certain number of cases under the waiting list initiative and the BRI was not referring as agreed.' [230]

218 He wrote to Dr Roylance:

`I have discussed the situation covering the next few months with the three cardiac surgeons concerned. Dr [sic] Dhasmana informs me that he would expect to be able to send a further 15 patients, although he may be able to increase this number if he was more forceful in not giving referred patients a choice between London and Bristol. Mr Keen informs me that he has a waiting list of only about 6 weeks at the moment and would not envisage the need to refer patients to the Brompton. Mr Wisheart has contacted all of the patients on his waiting list informing them that they can receive treatment more quickly at the Brompton and so far hardly any have found this possibility acceptable. He does feel, however, that it may be possible to refer on new patients as they come onto the waiting list ... it would appear that if the trend continues as at present, we will not meet the number of 50 which was originally proposed, mainly because of a considerable number of patients who would rather wait to have their operations in Bristol.' [231]

It should be noted that this letter refers not only to paediatric cardiac surgery but also to adult heart surgery.

219 Mr Watson told the Inquiry:

`In all such situations there is a continual balancing act by those who allocate budgets. One inevitably has to consider looking to constrain this service, for example by restricting the number of incoming cases (as was the case with the Welsh referral of paediatric cardiology cases). The only options are to either get more resources or to take on fewer cases.' [232]

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Footnotes

[217] WIT 0097 0164 Dr Joffe

[218] WIT 0097 0292 Dr Joffe

[219] WIT 0099 0037 Dr Jordan

[220] T90 p.52 Dr Joffe

[221] T79 p.89-91 Dr Jordan

[222] WIT 0084 0064 - 0065 Mr Dhasmana

[223] WIT 0120 0119 Mr Wisheart

[224] WIT 0120 0120 Mr Wisheart

[225] WIT 0084 0062 Mr Dhasmana. See Chapter 3 for an explanation of these clinical terms

[226] WIT 0120 0119 - 0120 Mr Wisheart

[227] WIT 0298 0017 Mr Watson

[228] WIT 0298 0014 Mr Watson

[229] HAA 0119 0051 - 0052 ; letter dated 6 October 1987

[230] WIT 0298 0014 - 0015 Mr Watson

[231] HAA 0119 0051; letter of 6 October 1987

[232] WIT 0298 0015 Mr Watson