Concentrating resources on fewer centres would make complex operations safer, Leslie Hamilton says
A leading heart surgeon has spoken of the intense pressures and responsibilities that drove him to quit operating on babies and children because he no longer had the confidence to perform the complex, life-saving operations.
"I'd be sitting in meetings and I'd suddenly get an anxiety attack," Leslie Hamilton said of the stresses. Since 2007, he has operated only on adults.
"At home the phone would go and you'd get a tachycardia [a racing heartbeat]. You'd be woken in the night and wouldn't be able to get back to sleep. It built up. It was just beginning to affect my health."
Hamilton is a key supporter of proposals to amalgamate children's heart surgery into fewer, bigger units, which experts say will help surgeons become more experienced, operate more safely and support each other better.
A range of options for reducing the 11 NHS units to six or seven are undergoing public consultation and have caused controversy in areas where a hospital is under threat. Hamilton sits on the steering group of the NHS Safe and Sustainable committee which made the proposals, although he was not one of the decision-makers.
Hamilton, who led children's heart surgery at the Freeman hospital in Newcastle from 1991, believes all children's heart surgeons suffer high levels of stress. "But you are not allowed to admit that. People don't like to admit weakness."
After 18 months working on his own in Newcastle, Hamilton was joined by a second children's heart surgeon, Asif Hasan. With two surgeons sharing a relatively small volume of cases, "there would be times when you hadn't done things for a while and you were just that little bit more nervous about it. I found that pressure began to tell over the years.
"Then you have a case that maybe doesn't go so well and it knocks your confidence. And it's quite difficult to get that back again. I think that's what happened to me and it was time to stop."
That happened at the end of 2006. "It wasn't a particularly difficult operation, but there were issues just getting started. I was having real problems with something I had done thousands of times ? putting the tubes in for the bypass machine."
There is always fear that a baby will die, Hamilton said. "I suspect all children's heart surgeons will admit to waking up in the middle of the night going over the operation in their head they are about to do the next day, because it might well be different from the last one you did."
The death rate in children's heart surgery is about 4%. "Every surgeon has deaths from time to time and that's difficult to cope with. Even though you do the technical job well, how children respond, how their body copes with the stress of the operation, will vary."
The operations are longer ? children's surgery can last for eight hours, compared with two to three for an adult ? and afterwards the surgeon is far more involved with intensive care. "To my mind," said Hamilton, who had finished an adult heart transplant operation at 4am that morning after a full day at work, "children's heart surgery is the most demanding and stressful."
Hamilton spoke out as a number of hospitals stepped up their campaigns to keep their own children's heart surgery units, ahead of Friday's deadline for the public consultation.
The Royal Brompton in London, which under the proposals would lose its surgery to Great Ormond Street and the Evelina children's hospital, has launched a judicial review, saying the consultation was flawed.
One Royal Brompton patient, 12-year-old Greg Shipley, from Wandsworth, south-west London, has written to David Cameron. Shipley, who suffers from a complex heart problem wrote: "One of the reasons I got sent to Royal Brompton is that my condition in children is very rare and needs treatment by adult facilities as well as children's. Most children's hospitals will not have the right equipment or staff to treat me."
MPs from Leeds, who are arguing to keep the children's heart unit at the general infirmary, last week debated the matter in the Commons.
Greg Mulholland, the Lib Dem MP for Leeds North West has written to Cameron with concerns about the "impartiality, the accuracy and the consistency" of the consultation process. He wrote that there were no representatives from Yorkshire on the panel that decided which units would be closed.
Hamilton says nobody ? from surgeons to medical royal colleges to patient organisations ? disputes the need for fewer, larger centres. They just don't want their own unit to close.
Terence Stephenson, president of the Royal College of Paediatrics and Child Health, agrees that even London needs fewer centres. "Because England needs only six to seven centres to guarantee safe cardiac surgery for children, London needs two not three surgical centres.
"Expertise does not reside in bricks and mortar; the expertise resides in the very talented doctors, nurses and other clinicians. London has a unique opportunity to pool its clinical expertise and provide even better results for children in the future.
"The ideal model is where you have fewer but highly specialised larger centres delivering the really complex and difficult operations," he said.
Since the Kennedy inquiry, published a decade ago, into the Bristol babies disaster ? the unnecessary deaths of babies with congenital heart defects at the hands of surgeons who were not good enough at the procedures they were carrying out ? it has been accepted that bigger centres are safer.
"Looking back over Bristol, I don't know how the guys managed," Hamilton said. "They must have been having nightmares and yet the atmosphere of the time was you had to cope and you weren't allowed not to cope. An argument for having bigger centres is you are working as a team and you can support each other a lot more and take the pressures off for a time. Had I been in a bigger centre with more colleagues and they could have shared the workload a bit more maybe it would have been easier."
Hamilton said the reorganisation of children's heart surgery was being closely watched all over the world, adding that while it was always hard to close any medical centre, reconfiguration was vital if the the NHS was to meet the changing health needs.
Last time there was a review, submitted by Professor James Monro and submitted in 2003, the then health minister Stephen Ladyman said there was no evidence for closures, which most thought meant it was just too politically sensitive.
This time, technically, it will be doctors rather than politicians making the decision ? unless, that is, the potato once more becomes too hot for ministers to handle.
Source: http://www.guardian.co.uk/society/2011/jun/30/heart-surgeon-system-children-change
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