We're in danger of driving out our finest surgeons

Despite the scares, this is probably the safest time in history for children to have heart surgery
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The Independent Culture
IF YOU are thinking of flying and are concerned about safety there is really only one airline to choose - Swissair. After the disaster off Nova Scotia, Canada, last September, in which 229 people died, there is no better guarantee that aircraft flown by Europe's tidiest nation will arrive at their destinations as they left their departure points - in one piece.

As with airlines, so with medicine. There is nothing like a disaster for concentrating minds. If I had a child with a serious heart defect, I know where I would want to send him or her for surgery - to Bristol. The disaster which hit that city's Royal Infirmary, involving the deaths of too many children after heart operations, led to two doctors being struck off and one suspended. It also triggered the biggest public inquiry in the NHS's history, which is expected to conclude next year. But under the direction of its new paediatric cardiac surgeon, Ashe Pawade, who now operates at the Bristol Children's Hospital, the city has a record second to none.

This is probably the safest time in history for children to undergo heart surgery. Since the Bristol disaster came to national attention in October 1997, at the start of the General Medical Council's hearing, Britain's 14 specialist units for paediatric cardiac surgery have been engaged in a collective bout of naval- gazing. Everyone is now assessing risks, auditing performance and monitoring death rates among the patients of individual surgeons in a manner unmatched by their surgical colleagues in other specialties. But that is small comfort to the bereaved parents demanding a public inquiry into the latest allegations of poor practice and discrimination - against London's premier heart hospital, the Royal Brompton.

The allegations were made in an anonymous letter sent in June to Brian Langstaff, independent counsel to the Bristol Royal Infirmary public inquiry, and to the magazine Private Eye. The letter alleged that the hospital's death rate for heart surgery on children was higher than elsewhere and that the hospital was not explaining the risks fully to parents.

The letter was passed to Mark Taylor, chief executive of the Royal Brompton and Harefield NHS Trust, who immediately ordered an investigation. According to the Trust, the anonymous letter "did not mention any individual doctor, case or patient". It did contain some crude data on the success rates for three Brompton surgeons performing one type of operation - a hole in the heart repair technique - but these appear, at first glance, to be no worse than figures from elsewhere.

This is all that has emerged in the public domain. Allegations have been made and they are being investigated, as they should be. No one has been suspended, because the allegations, besides not naming individuals, were not judged serious enough to warrant immediate suspension. Suspending a surgeon means seriously ill children may have to wait longer for life- saving operations. More may die on the waiting list than on the operating table.

The Trust's response is not, however, good enough for Ken Livingstone. The outspoken Labour MP and candidate for London's mayor arranged a press conference this week, attended by seven of the affected families, at which he demanded a full public inquiry and accused the Trust of a cover-up. Several of the parents were in tears as they described what had happened to their children, and demanded "justice" and "accountability".

The impression given is that the allegations made at the Royal Brompton are a rare occurrence which demand, as in Bristol, an exceptional response. But they aren't, and they don't. Heart surgeons are the most closely scrutinised of any medical specialty. According to the Society of Cardiothoracic Surgeons, one in 10 of the 200 operating in Britain has been investigated after questions about safety were raised.

The NHS has been overwhelmed by a blizzard of official inquiries in recent years, and managers are starting to question whether the huge resources they consume are delivering value for money. It has become the standard response to any expression of concern - to set up an inquiry and call in outside experts. At the local level it may be the only safeguard patients have that standards of service are being maintained, albeit a cumbersome and expensive one.

But when those who conduct the inquiries are accused, as by Mr Livingstone, of covering up for other doctors, we are in deep water. The investigation of allegations of unsafe practice must not be allowed to develop into a witch hunt. Complex medical issues require the judgement of experienced medical experts - it is difficult to see who else could examine them.

There is a serious risk that if the clamour for someone to blame each time a child dies after high-risk heart surgery is not curbed, those highly- skilled trainees that the specialty needs will be put off (there is anecdotal evidence that they already are). Then cardiac surgery in Britain could go the way as in parts of the US - with restricted availability of the most difficult operations as surgeons "cream-skim" the easier patients to boost their success rates.

No one can predict the outcome of the inquiry at the Royal Brompton in advance of its findings. But the general issue of standards in paediatric cardiac surgery is being comprehensively investigated by the pounds 15m public inquiry in Bristol. Establishing a parallel inquiry at the Royal Brompton would be unwise, unnecessary and a waste of resources which the NHS can ill afford. The Bristol inquiry, under its chairman Professor Ian Kennedy, is in any case planning to visit and take evidence from other centres next year.

Children's heart surgery is one of the most demanding specialties for surgeons, requiring immense resources of skill, dexterity and speed. Its achievements are undeniable. Until the invention of the heart-lung machine 40 years ago, no open-heart operations were possible and these babies, who now survive into adulthood, would have died. Today, it is estimated that eight out of 10 babies with congenital heart defects would die without treatment.

Parents now have huge expectations of what can be achieved by modern medicine, with the consequence that death is seen not as a natural outcome of serious illness but as somebody's error. Doctors are not always good at dealing with parental grief, and the potential for misunderstanding the risks is high. But the interests of bereaved parents at the Brompton and elsewhere will not be served by turning their sorrow to indignation.

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