Final Report > Chapter 8: Paediatric Cardiac Surgical Services > The de-designation of neonatal and infant cardiac surgery as a supra regional service
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The de-designation of neonatal and infant cardiac surgery as a supra regional service
34 The PCS service for children under the age of 1 was de-designated as an SRS in July 1992, although funding was maintained until the end of March 1994. It was taken out of the protected funding system because the proliferation of centres around the country providing the service became steadily more obvious. While the SRS system had, in part, been designed to control proliferation, the DoH did not in fact have the power to prevent centres which were not within the supra regional funding arrangement from offering the relevant services. Throughout the period that Bristol was designated, other centres which were not designated and, therefore, were not funded under the SRS system, began to carry out PCS on children under 1. For example, by September 1990 Cardiff, Oxford and Leicester were all performing NICS. [27]
35 Indeed, Dr Halliday agreed that designating PCS for children under 1 as an SRS was `doomed from the start', [28] in that the decision to limit the service to the under-1s was arbitrary, there was already an existing and established service in centres other than those designated, and that the criteria for SRSs did not appear ever to be met, at least in some of the designated SRCs. Moreover, the proliferation of centres made it inevitable that if there were too many centres, the criterion based on volume of cases could not be met. Given that the incidence of congenital heart disease was a constant 6-8 per 1000, there would not be enough throughput in at least some of the centres.
36 There were discussions about the continued designation of SRCs for NICS, and about the continued designation of particular centres, from at least 1988. These discussions, however, were focused on the number of units providing the service, rather than on any consideration of the quality of the service provided in any particular unit.
37 The possibility of de-designating NICS as an SRS was first raised as early as 1988 in a paper prepared for the SRSAG. [29] Sir Terence English told us that, subsequently, the de-designation of particular units, identified as `non-viable' and operating at `sub-optimal' levels, was discussed at a meeting of the SRSAG in September 1989. However, at a meeting of the SRSAG in July 1990, Sir Terence reported that he considered that NICS should remain a designated service, but with no more than nine units. [30]
38 In October 1990 the SRSAG stated that NICS should `ideally be concentrated in no more than 6 or 7 centres, and that proliferation occurred to the detriment of patients'. [31] The difficulty which the SRSAG identified was that, whilst the generally accepted view was that there should be a reduced number of designated centres, no clinicians were willing for their particular centre to be the one to be de-designated. Nor, it seems, was the SRSAG prepared to make the decision and earmark one or two units for de-designation. Dr Halliday told us:
`... almost from day 1 we were facing a situation where we might have to de-designate this service, or units within the service. The problem was that however much we tried, and however much advice we got from the various medical organisations, no-one recommended de-designating particular units, so we were faced with the situation where the only option was to de-designate the service. That is why we talk about the importance of geography, the problems about de-designating on expertise, or referral problems. Unless someone could provide us with the evidence which would allow us to take that decision, we had no alternative but to de-designate the service.' [32]
In addition, as we have said, the DoH had no power to prevent centres outside the SRS system from providing an NICS service. Indeed, as we have seen, by 1990 the SRSAG was aware that three centres outside the SRS system, Cardiff, Oxford and Leicester, were also performing NICS. [33]
39 In February 1992 the SRSAG considered a report entitled `Designation Issues. Neonatal and Infant Cardiac Surgery', which recorded that there were by that time 13 units in England undertaking NICS, whereas the epidemiological evidence suggested that the number of units required to provide the service was no more than seven and probably nearer five. The report considered and rejected the possibility of de-designating Bristol:
`Members accepted the conclusions set out in the paper SRS(90)15 that in general terms, all other factors being equal, there is a strong case for Bristol and Newcastle in terms of geographical spread. They agreed that it would be difficult if not invidious to de-designate the centres in question on the basis of surgical expertise, and doubted whether it was possible to do so on the basis of referral pattern.' [34]
40 In the event, the entire NICS service was de-designated in 1992. Its funding, however, was protected for a further two years until March 1994 under a funding arrangement with Regional General Managers. [35] The SRSAG stated that the decision to de-designate the whole of the NICS SRS, rather than just certain units, was: `a fairer decision in terms of medical and surgical rights of patients than to restrict designation to a few surgical units.' [36]
41 Funding for cardiac surgery on the over-1s and on adults had continued throughout the period in the normal way. After protected funding came to an end, it was then a matter for the DHAs, under the purchasing arrangements already in place, to purchase PCS services for the under-1s along with the existing cardiac services. None of the centres which had been designated ceased to provide PCS after this change in funding arrangements.
42 Sir Michael Carlisle, the then Chair of the SRSAG, told the Inquiry that he found the reason given by the SRSAG for de-designation of NICS, namely that it was `a fairer decision in terms of medical and surgical rights of patients', to be `slightly ambiguous'. [37] The advice previously had been that it was in a patient's best interests that there should be a designated service. Similarly, Sir Terence English commented that he was unable to understand the logic of the reference to `fairer in terms of medical and surgical rights' of patients. [38] Sir Michael said that, had the Working Group recommended a greater reduction in the number of designated centres, it was highly likely that the SRSAG would have continued to designate the service, and that the real cause of de-designation of the service was proliferation. [39]
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Footnotes
[27] SCS 0004 0026; minutes of meeting on 20 September 1990
[29] DOH 0002 0242; Paper SRS(88)2
[30] DOH 0002 0196; minutes of meeting on 26 July 1990
[31] DOH 0002 0168; minutes of meeting on 3 October 1990
[33] SCS 0004 0026; minute dated 20 September 1990
[34] DOH 0002 0044; Report on Designation of NICS, SRS(92)2
[35] T89 p.170 Dr Halliday; DOH 0002 0156; minutes of a meeting on 29 September 1992
[36] DOH 0002 0099; minutes of a meeting on 28 July 1992
[37] T15 p.78-9 Sir Michael Carlisle