HC Deb 31 January 2001 vol 362 cc128-36WH 1.30 pm
Mr. Richard Allan (Sheffield, Hallam)

I am pleased to have been able to secure this debate, as it provides an opportunity for the Government to make a statement on the record about an issue of serious concern to all those involved with the transplant service at the Northern General hospital, Sheffield. That includes the hon. Member for Barnsley, Central (Mr. Illsley), and other local Members, all of whom have been concerned about the service, which covers quite a wide area.

I intend to cover three main areas in the debate, and I hope that the Minister will be able to respond to each of them at the appropriate time. First, I will examine the rationale behind any move to reduce the number of transplant centres in the UK as a whole. Secondly, I will talk about the service in Sheffield in particular, and the valuable role that it plays within the NHS. Thirdly, it is important to discuss how decisions about service changes in the NHS are made, as that has been a source of complaint from many of the people who have contacted me on the issue.

There has been an underlying assumption behind the review of cardiothoracic transplant surgery that the national specialist commissioning advisory group—NSCAG—has been carrying out for the Department of Health that there are too many cardiothoracic transplant centres, and some should be closed. I understand that that is the brief to which it has been working. However, I suggest to the Minister that to accept such a strategy of fewer units, which are by definition further apart, may be selling the NHS short.

My vision for the NHS, which I hope that the Government share, is that it should continue to be one of the best health services in the world. In my view, it would be disastrous for the NHS to end up as some kind of safety net service that withdraws from the more complex and expensive procedures that some people will always need. In that respect, I can see the need for the skills of transplant centres growing rather than reducing over the coming years.

Mr. Steve McCabe (Birmingham, Hall Green)

Is it not the case that at the very time when we are trying to expand the number of organ donors, it makes no sense to reduce the number of centres? If anything, there may be a need for some rebalancing of the geographical areas for harvesting donors. We should concentrate on that, to get the best distribution throughout the country, rather than concentrating on resources in the south-east.

Mr. Allan

That intervention helps to move us on to the issue of the shortage of organ donors, which has been one of the driving forces behind the strategy that has been set out. My presumption is that the shortage of organ donors is a problem that we could overcome. We should be tackling that, rather than closing the centres that could actually do the operations if the donations were occurring. I agree that there is currently a shortage of organ donations. The answer is not to give up but to campaign actively to increase the number. The Northern General itself ran a successful campaign in Sheffield before Christmas, using the local media and getting thousands of people to sign up for donor cards.

I am interested in schemes such as the credit card scheme, as it seems that the vast majority of people these days carry a credit card. If that were also a donor card, that would be an immediate and straightforward way of identifying someone as a donor. We are only beginning the process of expanding donation. It is true that the effort to expand the number of donors may be set back by current events surrounding organ removal without consent, but the Government could and should make a clear distinction between those unfortunate events and consensual organ donation to save lives. There are some good examples of how consensual organ donation works. I hope that the Government will be clear about not allowing that to be dragged into a debate about non-consensual removal of organs, which all of us would quite rightly condemn.

The Sheffield Heart and Lung Transplant Society has put it to me that a review of the donor zones mentioned by the hon. Member for Birmingham, Hall Green (Mr. McCabe), which decide which units receive which organs, would create a more efficient service and possibly make the existing transplant centres more effective. We are also witnessing the advance of new technologies that may expand the possibilities for medical intervention. We have recently debated the advances in stem cell research, which could create new ways to regenerate organs. There are advances in mechanical devices all the time. Those new techniques will require the skills necessary to prevent rejection, and to work with new tissue or implanted mechanical devices, that have been developed in transplant centres throughout the country.

What a travesty it would be if new technical solutions came on stream but there were no medical staff with the experience to use them. The present transplant staff have been trained all over the world for 15 years to achieve the skills necessary even to begin some of the procedures. They work in close-knit teams and achieve great successes. They, in turn, train future medical staff in these highly specialised skills.

The closure of units will disrupt that pattern and risk the NHS losing skilled people, and the global market for staff with transplant skills cannot be ignored. In any reconfiguration, there is the potential to lose people with vital skills who will train the next generation of staff in the new techniques. I ask the Minister to consider whether it is not incredibly short-sighted in the long run to risk the loss of skills when major medical advances are anticipated that will create a need for more, not fewer, staff with these specialisms.

Most importantly, a reduction in the network may have a damaging effect on patient care. The seriousness of the matter was underlined by a submission from members of the Sheffield patients group. They told me that the typical procedure for a patient undergoing a cardiothoracic transplant begins with an assessment of the suitability of the patient for a transplant, which involves a four-day stay in hospital. There is then a two-year wait, with various episodes of in-patient and out-patient treatment. The transplant surgery itself requires an in-patient stay of about three weeks. After being discharged, the patient must attend hospital for a minimum of four hours a week for the first four weeks, fortnightly for the next four weeks, monthly for the next six months, quarterly for the next year and every six months thereafter. In such an intensive period of attendance at the hospital, its geographical location is much more significant than it would be if a patient went in and out of hospital only once.

With such an intensive treatment schedule, any increase in the distance travelled is a major burden for the patient, not only in time, money and so on, but in health terms, as patients are very frail when their operations take place. At present, patients from areas such as Hull, Grantham and Nottingham have to travel for up to two hours each way to the Northern General hospital in Sheffield. If they had to go to Manchester or Newcastle—the alternatives if the unit were to close—that would increase to between three and five hours' travelling time each way. On present figures, that would mean that 100 post-operative patients in the area, including those in Barnsley, Sheffield, north Lincolnshire, Nottinghamshire and Derbyshire would have to travel for six to 10 hours a day. If closure goes ahead, a group of existing patients will have to start travelling those excessive distances immediately.

In addition to the problems for patients and their families who may wish to visit them, closure could significantly increase NHS costs, especially if out-patient appointments had to be changed to include overnight stays because the travelling distance was too burdensome for a two-way journey. That expensive option would, however, have to be considered.

I said that I would refer to the case for the Sheffield unit. In doing so, I am not trying to talk down the other transplant units, as this is not a beauty contest between them. However, I want to place on record comments about the qualities of the Sheffield unit that have been passed to me by patients and others.

The transplant programme started at the Northern General hospital more than 10 years ago, since when it has provided more than 230 patients with successful transplants. The facility was much improved recently with the opening two years ago of the £20 million Chesterman wing, which has some of the best facilities in the country. The team now operating at the Northern General has a tremendous reputation. A study carried out by the Royal College of Surgeons showed that it was one of the most successful in the country. There is an active support group for the unit.

Graham Earle, chairman of the Sheffield Heart and Lung Transplant Patients Society, told the local newspaper, The Star: Sheffield has the best records for post transplant survival, the shortest waiting time for pre-transplant assessment and an excellent after-care service. How they can think of shutting it is beyond belief. We have a first-class unit in a modern building, opened in this Government's term of office, providing a service that is much valued by patients. I am sure that other units are similarly valued by their local groups. An additional factor is important in considering the Sheffield unit: need. There is an acknowledged link between high rates of coronary heart disease and areas of high social deprivation. Similarly, the incidence of lung diseases is higher in areas of certain industrial activities such as mining.

The area served by the Northern General has a very high level of such problems. In the former coalfields of Yorkshire, Derbyshire and Nottinghamshire, people have suffered from years of poor health caused by poverty and the legacy of the former industrial activities. Barnsley and South Yorkshire have the highest heart disease rate in England. Those local factors are reflected in the high demand for cardiothoracic transplants at the unit. That is reflected in an extensive waiting list, which already, sadly, means that some people die before they can be treated. The loss of the Northern General unit would be likely to worsen the situation and leave that high-need population travelling much longer distances for their treatment, increasing their stress, at further cost to their health.

I am worried about the lack of public consultation. I want to leave the Minister in no doubt about the unacceptable nature of the decision-making process in this case. The main source for information has been the local newspaper, The Star. It has done an effective job in putting information into the public domain and has acted as a responsible local watchdog, but it is unfortunate that the Department's process does not appear to have included any more formal system for making the public aware of what is being considered and seeking their views on possible changes. The perception is that the results of the review were to be presented as a fait accompli to the users of the service.

I accept that people making decisions about the reconfiguration of services will always be criticised for not consulting properly by those who feel that they are losing out. Where my political colleagues are in power in local government they have had to deal with exactly that situation. In this case, there does not even seem to have been an attempt at public consultation. That is particularly serious given the nature of the service in question.

Cardiothoracic transplant units, by their nature, create long-term on-going relationships with their patients. I referred to the typical schedule as set out by the patients group in Sheffield when I talked about the need for a good geographical spread of centres. There are already hundreds of patients in the Northern General catchment who are at various stages of treatment and have an expectation of working with the hospital over several years to come. As one of them put it to me, they are very much stakeholders in their own treatment. In that context, the failure to make clear, authoritative public statements about the reorganisation to date has been a serious failing. I hope that the Minister will be willing to do something to remedy that today.

I have one last general point about NHS openness. The Secretary of State was very forthright about that in another context this week. The situation is not exactly comparable to decisions about the treatment that someone has received, but there are similar questions to be answered about the relationship between the NHS and the citizens of this country. We feel a tremendous sense of ownership of our health service and pride in its achievements. I was very conscious of that during the five years that I spent working in the NHS. NHS staff will often go that extra mile because it is for the public benefit. However, the decision-making processes in the NHS have often been remote from the people it serves. I believe that ordinary people can understand the concepts surrounding decisions about NHS service delivery. Those who hold power should not be defensive and seek to restrict information but should go out and involve people in the decisions that affect their lives.

The Government came into power with a commitment to save the NHS. I am sure that we will have the partisan debates about how successful they have been ad nauseam over the coming months. I ask the Minister today to consider seriously one aspect of the NHS debate, which would not cost a lot of money: the democratisation of the service. The alternative is to continue to have the NHS damaged by the perception that its users are being treated simply as patients having things done to them and not as full participants who both use the service and have a say in how and where it is delivered.

Ordinary people such as the users of the Northern General transplant centre should be entrusted with the information that they need to be involved in the decision-making process. I hope that the Minister will be able to give a commitment to doing that, and to publishing a full range of information on this particular decision. I hope that she will be able to explain clearly how public consultation will take place, and to set out a detailed timetable for the decisions on the review that will have to be made. I hope that at the end of the process she will be able to announce that the centre of excellence that is the Northern General transplant centre will continue to provide its valuable service within the NHS.

1.45 pm
The Parliamentary Under-Secretary of State for Health (Ms Gisela Stuart)

I congratulate the hon. Member for Sheffield, Hallam (Mr. Allan) on securing this debate. I do not disagree with any of his comments on what we expect of the NHS, its openness and its consultation with patients, but I hope that I can make clearer what has been happening in terms of organ transplants.

I would also like to make it clear that, as one of the transplant units under consideration is in Birmingham and is located in my constituency, it is important that I state publicly that, despite taking this debate here in Westminster Hall, I will play no part in the decision-making process to identify the units that will be consolidated. It is also a sign of the strong feelings of the hon. Members who represent the three constituencies in which the units are located that they are here. I am grateful to my hon. Friend the Member for Birmingham, Hall Green (Mr. McCabe) for his intervention, as he is correct when he says that we should do everything that we can to increase the number of organ donations. I went through the background briefing and was struck by the number of letters that we had received from various Members. This issue goes across all parties, and people feel very strongly about it.

In terms of organ transplants, we are in a good position in this country. Over the past 30 years, organ transplantation has become established as the best treatment for people suffering complete failure of vital organs. In the case of liver transplant and cardiothoracic transplant, that is heart, heart-lung and lung transplants, the procedure is literally life-saving. In the case of kidney failure, renal dialysis can sustain people while they wait for a suitable organ to become available, but to put that into context, currently we have approximately 3,000 transplant operations, with organs from 900 donors, and there are more than 6,000 people on the transplant waiting list. More than 8 million people have joined the NHS organ donor register, but one of the difficulties is that only a very small percentage of those dying are suitable as organ donors. The main source of organs is from people who have died from sudden brain injury such as a stroke or resulting from a road accident, and there was an assumption in the early 1990s that the numbers would continually increase, and while I of course welcome the reduction in road accidents, it does have some consequences.

Last February, there was a review in response to a number of important issues that had arisen concerning organ transplantation, including a report on the future of organ transplant services by the Royal College of Surgeons of England. My noble Friend Lord Hunt of Kings Heath announced measures that, taken together, provided a comprehensive strategy for the development and reorganisation of transplant services in this country. He accepted the RCS's recommendations on minimum levels of staffing for transplant units. The recommendation was that, because so much organ transplantation takes place at night or over the weekend, surgeons would work no more than a one in four on-call rota. That would require a minimum team of five surgeons. Currently, very few organ transplant units meet that requirement.

The hon. Member for Hallam raises the issue of training, but unless the unit and the programme itself are of a sufficient size, training cannot take place. He mentions future technologies, but those are very likely to require different skills that are already being developed in a number of the non-transplant units. While the renal transplant service is affected by these issues, work to address them is at a much earlier stage, so I will concentrate, as he has, on the cardiothoracic services.

Our national cardiothoracic transplant service is recognised as being among the best in the world, and we are rightly proud of it. Following its designation as a national service in 1986, it has been restricted to relatively few centres, preventing the proliferation of a large number of cardiac centres, as happened in some other countries, in the belief that the number of organs would continue to increase. Four new adult cardiothoracic transplant centres were designated, so that by 1991 there were seven adult centres in England.

I am worried that there may be confusion. Just because there is a greater concentration of cardiothoracic transplant services, would not in any way affect what we expect from the expansion of cardiac surgery, which would happen in many places. The hon. Gentleman correctly referred to the very high incidence of heart disease in his area. There will be a continued expansion of the service, so it is not "instead of" but "as well as".

Mr. Graham Brady (Altrincham and Sale, West)

The Minister has quite rightly drawn attention to the importance of specialisation. I wonder whether she would care to pay tribute to the work of New Heart, New Start at Wythenshawe hospital, in Manchester, which has raised £1. 8 million for the construction of a dedicated heart transplant ward, which will give Wythenshawe the only fully comprehensive heart transplant unit in the whole of western Europe.

Ms Stuart

This is the kind of thing that could get me into trouble. I would not wish not to pay tribute to extraordinary local fundraising, but my paying tribute to those activities should not be seen as indication that I take sides in the very close race between Sheffield, Manchester and Birmingham. I welcome the fact that the hon. Gentleman has such an active local organisation, but the decision is still open.

I return to what has happened in the Northern General hospital in Sheffield, because it is one of the new centres. The others were St. George's hospital in London, the Queen Elizabeth hospital in Birmingham and Wythenshawe hospital in Manchester. The three original centres were Papworth hospital in Cambridge, the Freeman hospital in Newcastle and, perhaps the best-known of all, the Harefield hospital in Middlesex. Hon. Members may be aware that the programme at St. George's has now been suspended following an unusual run of poor results last year, and the Commission for Health Improvement will be investigating that.

The early promise of expansion of cardiothoracic transplantation has not been fulfilled. Our assumption, in the early 1990s, that the number of available organs would expand has proved wrong, as a result of improvements in road safety and the prevention of strokes in younger people. Those are important health gains, which of course we all welcome, but they have had consequential effects.

For example, between 1990 and 1999, deaths from road traffic accidents in people aged 16 to 59, the usual age for adult heart and lung donors, fell by nearly 40 per cent. from 2,893 to 1,820. That is clearly very good news, but it has had an inevitable effect on the supply of organ donors. In the past five years, the number of organ donors under 60 has fallen by 15 per cent. The fall could have been greater had it not been for the dedication of intensive care units and the efforts of transplant co-ordinators and transplant teams in identifying donors, alongside our continuing efforts to increase organ donation, such as running major campaigns with credit card companies, which the hon. Gentleman mentioned. There is also the Boots initiative to persuade people to join the register. I think that he is absolutely right when he refers to the mood of the time.

We are having this debate after Alder Hey, and we face a significant challenge in re-establishing trust. It was interesting that many of the Alder Hey parents said that they would have given permission if only they had been asked properly. We will drive the issue of informed consent throughout the NHS. I know that in some areas extremely valuable work is going on with ethnic minorities to improve rates of organ donation.

We recognise that, however successful we are in arranging organ procurement, the supply of hearts and lungs, which come only from younger donors, will remain severely limited. Despite all our efforts, the impact on the cardiothoracic transplant programme has been considerable. Adult cardiothoracic transplant operations—heart, heart-lung and lung transplants—performed by the centres fell from 423 in 1995 to only 290 last year. During the same period, heart transplants performed in the seven centres in England fell from 262 to only 172.

We are committed to maintaining excellence, but a difficult decision must be made on the number of centres so that the coverage of the surgical teams can be maintained. We have accepted the advice of the Royal College of Surgeons in its 1999 report on minimum levels of staffing. It will be evident to hon. Members that, with such complex treatment, if the number of transplants falls below a certain level, the members of the transplant team will begin to lose their skills and standards may fall. We must ensure that each transplant team is well staffed with access to all the support that it needs. It must perform enough operations to maintain a high level of skill in all the members of the team, and it is essential to ensure that the service remains of the highest possible quality for the sake of patients.

The national specialist commissioning advisory group is responsible for advising on which services should be provided nationally. The group considered the impact of the various factors and recommended last year that the national programme should be delivered from four centres in England. That would allow each unit the optimum infrastructure to support a programme of at least 50 heart transplants, which would allow each surgeon to perform an average of 10 heart transplants a year. That size of programme would also maintain the skills of the whole multidisciplinary team and would ensure that properly resourced organ retrieval teams are available to retrieve and make use of all usable organs.

Those recommendations are fully supported by many organisations, including the Royal College of Surgeons and the cardiothoracic transplant advisory group of UK Transplant. Dr. Roger Boyle, director of coronary heart disease services, has been consulted and fully supports the proposals. The Government have agreed that the principles are right and that some reconfiguration of the service is necessary if we are to maintain the high quality of the best services.

I recognise what the hon. Gentleman said about the long-term relationship that patients build up with a particular team. They develop strong ties and loyalties and the prospect of any change is disturbing. The Government want to keep disruption of patients and transplant teams to a minimum. One way of achieving that is to maintain the larger programmes, as far as possible, but any changes to the service will affect some patients. I stress that if any reconfiguration of teams involves loss of cardiothoracic surgeons because we want to keep teams together, we would strive to replace them so that other cardiac surgery, particularly to fit in with the national service framework and expansion of services, also happens.

Most patients on the waiting list will be treated by the team that they know. However, in future, some new patients may have to travel further to a transplant unit. Many patients already travel long distances, as they would have to do for any highly specialised national service. In the case of most highly specialised services, there will always be tension between improving geographical access and maintaining clinical excellence.

The hon. Gentleman referred to patient involvement and the national service. The provision of the service has never been a question of money. The issue is not about making financial savings but about where the service should be provided to meet national demand.

On patient consultation, we hope that the conclusions of the current study will be available in the not-too-distant future so that people can comment on the discussion document. The important point is that we are totally committed to a first-class transplantation service in this country, and we shall continue to do our best, as part of our work on informed consent, to ensure that organ donors carry donor cards. No decision has been made on which hospital will be chosen, but it will be made in the best interests of ensuring that the facilities—

Mr. Eric Insley (Barnsley, Central)

When?

Ms Stuart

My hon. Friend is trying to tempt me. The discussion document will be issued soon and I cannot make an announcement today. However, I take on board what has been said about patient involvement. We all agree that we want a service that is in the best interests of patients. With a national service, patients may have to travel, but the reward is better care.

Question put and agreed to.

Adjourned accordingly at Two o'clock.