Annex A > Chapter 7 - Supra Regional Services > Developments in Wales until the designation of NICS as a supra regional service > The `Working Party Report' of 1981

The `Working Party Report' of 1981

73 The Working Party reported in 1981. This was, of course, prior to the establishment of NICS as an SRS. The `Report of the Working Party on Cardiothoracic Services in Wales' (the `Working Party Report') described the paediatric cardiac needs in Wales at that time as follows:

`Estimates of paediatric cardiac surgical need are broadly agreed in all major reports. These may be extrapolated to the All-Wales population as an annual need for 48 infant operations (24 of which would be open heart), and an additional 123 older paediatric operations after infancy (95 of which would be open heart), totalling 171. The corresponding figures for Wales excluding Clwyd and Gwynedd are 38 (19) and 97 (75), totalling 134 (94). The number of catheterisations required is identified as about double the number of operations, or a total of c. 350 for All-Wales (270 for Wales excluding Clwyd and Gwynedd).' [59]

74 The 1981 `Working Party Report' summarised the recommendations of the Joint Royal Colleges' second report on Combined Cardiac Centres in relation to suitable throughput and projected staffing of a paediatric cardiac surgical unit thus:

`The Joint Colleges' Report recognises that a paediatric surgeon should carry out at least 50 neonatal operations per year to retain the special expertise required for neonatal surgery, that two such surgeons are needed in the centre to provide cover, and thus that there should be a limited number (perhaps 10 in England and Wales) of supra regional centres specialising in neonatal surgery, but not divorced from the adult centres. A supra regional neonatal centre should have 2 or 3 paediatric cardiologists, and be closely associated with a Children's Department and an integral part of an adult cardiac or cardiothoracic unit.' [60]

75 The Working Party stated:

`It would appear likely that one such supra regional unit would in future be sited in Cardiff or in Bristol. However, it is unlikely to be developed in the near future. When it is developed, the choice of site will be influenced by the relative amount of paediatric work then being undertaken in each centre. The choice is thus unlikely to be Cardiff ... It is the view of the Working Group that the diversion elsewhere of paediatric cardiac services for Welsh children would be to the detriment of cardiac services as a whole in Wales. A paediatric unit should thus be developed in Wales.' [61]

76 To the extent that this recommendation was intended to embrace neonatal and infant work, it is inconsistent with the Royal Colleges' recommendations on throughput, since the need, in Wales, for open-heart infant operations, quoted above, was (at 24) [62] less than half the number recommended by the Royal Colleges.

77 The `Working Party Report' appeared to accept that the development of a neonatal service in Wales was desirable, although possibly a long-term aspiration. The Report stated:

`The need for some 150 post-infancy operations per year clearly justifies the provision of a paediatric cardiac service in the regional centre in Wales, even if complex neonatal problems continue to be referred elsewhere (e.g. to London) until a neonatal centre is established, and even if the needs of Clwyd and Gwynedd continue to be served as now by Liverpool. The need is clear and a paediatric unit is necessary in Wales now.' [63]

78 The Working Party concluded:

`For Wales a modest unit would require 2 surgeons with paediatric expertise, [64] and 2 paediatric cardiologists together with paediatric supporting staff. From the point of view of sharing expertise and resources it would best be part of the regional cardiac centre and closely associated with a paediatric department such as that of the University Hospital with other specialised paediatric services. Training in paediatric cardiology is recommended for all paediatric senior registrars and also for all cardiology senior registrars. A paediatric cardiac unit is therefore a highly desirable development for professional training. Continuing liaison between paediatric cardiologists and general paediatricians throughout the region is called for since most screening for heart disease will be carried out by general paediatricians. This would be better co-ordinated by locally based paediatric cardiologists than by paediatric cardiologists visiting from different regions (e.g. London) as at present.' [65]

79 The Working Party was urging that development occur swiftly, so that the prospects of securing a supra regional centre in Wales would be maximised. The Working Party ended its section on paediatric cardiac services thus:

`A PAEDIATRIC CARDIAC SERVICE IS NEEDED IN WALES NOW. THE OPTION OF DEVELOPING THIS INTO THE SUPRA REGIONAL NEONATAL SERVICE SHOULD NOT BE LOST.' [66]

80 The Working Party expanded on this need for such a service in Wales later in the Report:

`The paediatric cardiac surgical needs for Wales are for some 170 operations per year, or 134 if Clwyd and Gwynedd are excluded as being served by Liverpool as at present (cf. 40 at present undertaken in Cardiff). There is an urgent need to develop a paediatric cardiac unit as part of the cardiothoracic centre, though complex neonatal surgery will continue to be referred where possible to specialised units in London. It will then be possible to co-ordinate the paediatric services at least in South Wales (at present partly being served by a visiting consultant from London). A paediatric unit requires 2 cardiac surgeons with paediatric expertise and 2 paediatric cardiologists, with junior staff in rotation with paediatrics and cardiology. It must be on the same site as other paediatric specialties. This development also keeps open the otherwise endangered option of developing further into the supra regional neonatal cardiac centre which is likely to be sited in either Cardiff or Bristol.' [67]

81 In the event, Bristol was designated as a supra regional centre (SRC) for NICS, with effect from April 1984. There was no SRC for this service located in Wales at any time during the years of the Inquiry's Terms of Reference.

82 The actual numbers of open-heart operations performed on the under-1s at Bristol is shown in the following table, taken from a table of surgery for congenital heart disease, provided by the DoH:

83 It was put to Sir Terence that Dr Halliday had indicated to the Inquiry that he felt that there was nothing that the SRSAG could do in relation to increasing the numbers of operations in Bristol and that encouragement was entirely a matter for the Royal Colleges. Sir Terence's original response was:

`I do not think that there was anything that the two colleges of physicians and surgeons could do, other than to draw attention to the problem.' [68]

He expanded on this answer in oral evidence to say:

`I do not think that there was any specific encouragement which either the Royal College of Physicians or the Royal College of Surgeons could have given to the BRI at that time to increase their throughput in paediatric neonatal and infant cardiac surgery.' [69]

84 Accordingly, the Inquiry explored this difference of view, and considered the operation of the SRS, and what mechanisms there were by which the SRSAG could and did monitor the position of Bristol, in order to see both if the numbers of operations conducted increased to the necessary extent, and if the outcomes improved such that Bristol could properly be regarded as a centre of excellence and thus appropriate for supra regional designation.

85 The consequence of Bristol not developing as had been hoped might be thought to have been that it would cease to be designated. On this, there was a difference of emphasis between Sir Michael Carlisle, Chairman of SRSAG from April 1989 to October 1994, and Dr Halliday:

`Q. Sir Michael, can I deal now with the issue of Bristol's continued designation throughout the time that you were Chairman, until it became, with other units, de-designated? Can I ask you, please, to have on the screen, DOH 0002 0022? This goes right back to the start of the supra regional services, HN(83)(36) ... that appears to say that every year one of the duties for the group to advise the Secretary of State about is whether the service should continue to be designated; is that correct?

`A. That is correct.

`Q. It also appears to say that once it has reached the decision that the service should be designated, it has each year to make a fresh decision as to whether each unit providing the service should be designated to provide it; is that correct?

`A. I would take issue with that. I think "each unit should be designated" is incorrect. I think the service should continue to be designated, yes. [70]

86 Dr. Halliday, however, said:

`A. ... The procedure was that the Department each year would invite regional health authorities to submit bids for any service that they thought might warrant designation ... We had before us the reports of the various professional groups ...

`These bids were all then submitted to the Royal Colleges for their opinion as to which of the units should be selected. So Bristol was one of the units which the Royal College thought was a suitable unit for designation.

`Q. The Supra Regional Services Advisory Group had to agree of course?

`A. Would have to agree?

`Q. Well, they had to agree before there was any designation?

`A. Yes, of course.

`Q. Because it was not the Royal Colleges' decision?

`A. Of course not.

`Q. It was the Secretary of State's ultimately, and he would do it on the Advisory Group's advice?

`A. Yes.

`Q. And the Advisory Group would take their input from the Royal Colleges fed through you?

`A. Yes.' [71]

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Footnotes

[59] WO 0001 0044; `Working Party Report ', 1981

[60] WO 0001 0044; `Working Party Report', 1981

[61] WO 0001 0044;`Working Party Report', 1981 (emphasis added)

[62] WO 0001 0044; `Working Party Report', 1981

[63] WO 0001 0044; `Working Party Report', 1981

[64] This does not appear to envisage that the surgeons would be dedicated solely to operating on children

[65] WO 0001 0045; `Working Party Report', 1981

[66] WO 0001 0045;`Working Party Report', 1981 (upper case in original)

[67] WO 0001 0053; `Working Party Report' , 1981

[68] T17 p.97 Sir Terence English

[69] T17 p.99 Sir Terence English

[70] T15 p.45-6 Sir Michael Carlisle

[71] T13 p.20-1 Dr Halliday