Final Report > Chapter 8: Paediatric Cardiac Surgical Services > The planning and funding of paediatric cardiac surgery for children under 1 year of age (neonatal and infant cardiac surgery) > Paediatric cardiac surgery for the under-1s as a supra regional service

Paediatric cardiac surgery for the under-1s as a supra regional service

10 PCS service for children under 1 year of age (NICS) was selected for inclusion in the SRS system from the start of the financial year 1984/85.

11 Guidance on the selection of specialised services which were to be funded supra-regionally had been issued by the DHSS in a Health Notice dated December 1983. [4] The criteria to be followed were:

• the service should be an established clinical service, not a research or development activity (for which alternative sources of funding existed);
• there should be a clearly defined group of patients having a clinical need for the service;
• the benefits of the service should be sufficient to justify its cost when set against alternative uses of NHS funds;
• the cost should be high enough to make the service a significant burden for the providing regions;
• supra regional funding, as opposed to regional or sub-regional development, should be clearly justified either (a) by the small number of potential patients in relation to the minimal viable workload for a centre, or (b) by the economic or service benefits of concentrating the service in fewer and larger units shared between regions, or (c) as an interim measure by the scarcity of the relevant expertise and/or facilities; and
• the units to be designated should be capable of meeting the total national caseload for England and Wales.

12 The decision to designate NICS as an SRS was taken following years of discussion among healthcare professionals. In 1967 the Joint Cardiology Committee (JCC) of the Royal College of Physicians of London (RCP) and the Royal College of Surgeons of England (RCSE) prepared a report on the need for special cardiac centres for diagnosis, treatment and research. [5] In the same year, the British Paediatric Association (BPA) argued that operations to remedy congenital heart defects in young children should only be carried out in a limited number of centres. In 1979 the BPA followed up its 1967 report with the recommendation that six centres for NICS (including one in the South West) should be established. [6] In 1980 the London Health Planning Consortium recommended that three centres be established in London. [7]

13 It was with this background that, in 1980, the second report of the JCC of the RCP and the RCSE was published. Amongst other things, that report indicated that: the size of a centre should depend on the population served; there should be a close connection between where diagnosis and treatment were carried out; it was to be expected that the greater the number of operations performed the lower the rate of mortality; the number of units should be `certainly under ten'; and the selection of SRCs should be based on present workload, geographic location and quality of work. [8] In 1982 the regional medical officers suggested nine centres (being exactly those that were subsequently designated in 1984). [9]

14 The recommendation of the JCC in 1980 in relation to PCS that the selection of SRCs should be based, in part, on geographic location was not reflected in the criteria set out in 1983. Nor does it appear to have been endorsed by the SRSAG in their further guidance issued in September 1988. [10] This stated that certain quantitative criteria were being used in handling bids for designation of a service as an SRS, namely:

• that the rarity of the condition to be treated must be such that the population served by each unit (emphasis added) is a minimum of 5 million and the total national caseload should normally be capable of being treated in fewer than ten units; and
• that the cost [should] be high enough to make the service a significant burden for the providing regions had been taken as being at least £250,000 per unit.

15 The September 1988 guidance also stated that the units providing all SRS would be those which not only fell within the definition of a `centre of excellence', but also met all of the criteria set out in the December 1983 DHSS Health Notice. [11]

16 The professional view, accepted and endorsed by the SRSAG, was that the provision of NICS should be concentrated into relatively few centres so as to ensure a high standard of diagnosis and treatment. It was also noted that there were too many small units receiving funding that would be better directed towards developing the larger and more efficient ones.

17 NICS was designated as an SRS and the following centres were designated for its provision during 1984/85:

• The Freeman Hospital Newcastle;
• The Royal Liverpool Children's Hospital;
• Killingbeck Hospital, Leeds;
• Southampton General Hospital;
• Birmingham Children's Hospital;
• Brompton Hospital, London;
• Great Ormond Street Hospital for Sick Children, London;
• Guy's Hospital, London; and
• the BRHSC/BRI in Bristol.

18 Supra regional funding of PCS related only to neonates and infants. The PCS service for children over 1 was not within the SRS system. Thus, throughout the period of the Inquiry's Terms of Reference, the arrangements for organising and funding cardiac surgery for older children were the same as those which applied to children's and adults' acute healthcare services generally.

19 The SRSAG drew a distinction between children under and over 1 in designating NICS as an SRS in order to meet the criteria of low volume and high cost. Since PCS was carried out on children up to their teens, the overall volume of PCS could not be categorised as low. Only by restricting PCS to the under-1s was this criterion met.

20 Dr Halliday accepted that the drawing of a distinction between under-1s and over-1s, with the former included but the latter excluded in the SRS arrangements, was `somewhat artificial'. [12]

Footnotes

[4] HN (83) 36 and DOH 0002 0022 - 0023

[5] `British Heart Journal' 1968; 40:864-8

[6] BPCA 0001 0014; BPA report, 1967

[7] ES 0002 0007; London Health Planning Consortium report, 1980

[8] RCSE 0003 0017 - 0025; second report of JCC, 1980

[9] ES 0002 0007; minutes of a meeting of representatives of the designated SRCs, 5 December 1984

[10] Centres of excellence and supra regional units (DOH 0002 0025)

[11] HN (83) 36 and DOH 0002 0022 - 0023

[12] WIT 0049 0015 Dr Halliday