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24 Apr 2001 : Column 52WH

Queen Elizabeth Hospital, Birmingham

1 pm

Mr. Steve McCabe (Birmingham, Hall Green): I begin by acknowledging that there is a problem and a need to make a decision about the future of transplant facilities in this country. There has been a reduction in the number of transplants, largely because fewer organs are available as medical advances and road safety measures reduce the number of early deaths, something for which we should all be grateful. The Royal College of Surgeons was right to draw attention to the number of doctors who should be employed in transplant units, their work load, and the need to ensure that their skills are used on a regular basis.

The present size of units is based on historical accident, and to a large extent on the contract culture that was a dominant feature of the previous Government's approach to the NHS. In the early 1990s, the Department of Health recognised that there was a problem and envisaged evening out the size of units over time. Sadly, it never introduced mechanisms for achieving that, hence the situation in which we find ourselves today.

I regret to say that there is a strong feeling in Birmingham and the west midlands that the current National Specialist Commissioning Advisory Group's proposals, which pose such a threat to Birmingham, represent smash and grab opportunism by the established players in London and the south-east. As I have said, I recognise that the number of available organs is an issue. The Government recognise that even if their 10 per cent. target to increase donors is achieved, it will result in only about 30 additional transplants nationally per year.

There can be little argument that there is a need to examine where transplant resources are located and how they are used. We need to do everything in our power to increase the potential for organ donation and I welcome the Government's moves in that direction. We also need to ensure that any review treats different parts of the country equally, and takes account of issues such as geography, existing health factors per region and access to treatment. I do not accept that a fair review can simply focus on the traditional claims of established units in London and the south-east.

Birmingham has a strong demographic and institutional argument for retaining its transplant facilities. Our centre is sited in one of the largest conurbations in the United Kingdom. We already have an institution with excellent organ transplant infrastructure. The unit recently completed its 250th heart transplant and its 2,000th liver transplant. The unit has surgeons such as Robert Bonser, Tim Graham, Ian Wilson and Bruce Keogh, and cardiologists such as Sarah Thorne. We have first-rate people of whom we can be really proud. There is so much to be optimistic about in terms of the NHS in Birmingham.

Mr. Richard Burden (Birmingham, Northfield): Looking to the future for Birmingham, a new hospital has been announced, which will be a great addition. On a shorter time scale, there will be a new cardiac unit, which also promises to be a great addition to the Queen

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Elizabeth-Selly Oak complex. The opening of that unit is a further reason for keeping the transplant facilities in Birmingham.

Mr. McCabe : I entirely agree with my hon. Friend. We have an excellent new cancer unit and several leading cancer experts. As he says, a new, 33-bed cardiac surgery critical care unit will open, on schedule, in about eight weeks, which I understand will be the largest in Europe. The university hospital trust also received strong encouragement to establish what is only the second adult congenital heart disease programme in the country. Adult survivors of congenital heart disease are, as I am sure you are aware, Mr. Cummings, extremely likely to require transplants later in life, yet, astonishingly, after encouragement was given for the setting up of the programme, the NSCAG proposals would mean, if not the removal of the surgical arm, at least amputation of all but a stump. They would severely reduce a key area of potential treatment.

Birmingham, with all that it has to offer, is considered the right environment to host a centre for defence medicine for the men and women of our armed services. It may be the right place to treat them, but it will not be the place to go if one needs a heart or lung transplant.

Mr. Paul Keetch (Hereford): I congratulate the hon. Gentleman on obtaining the debate. He mentioned heart and lung transplants and he will know that the excellent centre in Birmingham covers not only the metropolitan west midlands but the rural parts of my constituency, and extends into Wales. It is a very large area. My constituent, Keri Davies, who is 47 years old, has been waiting three years for a heart and lung transplant. The additional stress of thinking that the unit might be closed has worsened his condition. Indeed, he was taken to hospital in Hereford last night. Does the hon. Gentleman agree that the Government must respond urgently and that as soon as possible they should decide to keep Birmingham going?

Mr. McCabe : I take note of the hon. Gentleman's comments and I see real urgency in the situation.

My right hon. Friend the Secretary of State recently gave the go-ahead for the building of Birmingham's first new hospital since 1938, for which we are all extremely grateful, but if NSCAG gets its way we shall be building a brand new hospital denuded of a key treatment facility. That will mean that patients from the midlands, Wales and the surrounding area, such as the constituent of the hon. Member for Hereford (Mr. Keetch) who require transplant surgery, will have to travel weekly to Harefield or Papworth, two of the least accessible hospitals in the country. In some cases, the travelling time will be so long that it will deny people the chance of a transplant even if a suitable organ becomes available.

One of the strangest things about the NSCAG proposals is that not only do considerations of geography, access and travel appear to have been ignored in their preparation, but most other aspects of transplant activity also seem to have been discounted. Those include assessment, donor retrieval and early and late follow-up activities. In fact, the proposals appear to show bias in favour of the status quo and they are heavily weighted in favour of stand-alone units rather than units that are part of a multidisciplinary service.

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That seems to be rather at odds with all recent advice, and contrary to the philosophy that we are encouraging elsewhere in the health service.

I do not know whether the Minister can help, but I find it difficult to explain to my constituents that the review has been fair and serious when those involved seem to have ignored any significant reappraisal of donor zones. If, for example, we were to increase Birmingham's area of activity to incorporate the east midlands, the Cardiff-Newport area of south Wales, Bristol and Oxford, we could change the donor catchment area and preserve the Birmingham unit. I am not trying to pit one unit against another. A proposal like this would result in a reduction in Papworth's influence in the east midlands, but that could easily be compensated for by a similar boundary review in the south.

As I said earlier, I agree that the Royal College of Surgeons was right to draw attention to the number of surgeons needed for each unit and the volume of work for each unit, but is it seriously being suggested that the only way to address such issues is to close down a highly successful solid organ transplant unit, which serves 6 million to 7 million people? Has no one ever heard of tele-medicine or video conferencing? Is it impossible for highly trained surgeons, whose skills we want to protect, develop and enhance, to travel occasionally to another hospital to perform or assist in a transplant operation? After all, the NSCAG proposals envisage sick people travelling hundreds of miles every week to obtain essential treatment. Would not such an approach be more in keeping with the spirit of partnership and co-operation--rather than competition--that we want to encourage in the health service?

Mrs. Caroline Spelman (Meriden): I congratulate the hon. Gentleman on securing a debate on this important issue. My point relates to his argument about organ donation zones. The reduction in the number of transplant centres, which would effectively do away with a transplant centre for a population of 6 million to 7 million, can be compared to leaving Denmark without a heart transplant centre. Is it not also inextricably linked with the number of intensive care beds, because keeping organs ready for transplant becomes much more complicated as the number of transplant centres is reduced? That is an important consideration.

Mr. McCabe : I emphasise the point that has been made about the catchment areas for donor harvesting, which was borne out by the report of the Royal College of Surgeons. It is also important to acknowledge that the work load of a cardiothoracic surgeon is only a fraction of his or her total operative commitment--they do plenty of other work. None the less, it is a key sub-specialty, and a decision to rob Birmingham of such facilities will mean that we will lose highly qualified staff and have trouble attracting others. It will also have an unwelcome impact on the successful collaboration between the hospital and the nearby medical school.

The directors of the transplant programmes at Birmingham, Manchester and Sheffield are all on public record as stating that, if given the go-ahead, the proposals will lead to deteriorating rather than improved patient access, particularly for the patients of the mid-north, midlands, south Wales and the south-west.

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There is a solution, which many more people than the 15 members of NSCAG are now proposing, and that is to agree to five units and adjust the catchment or harvest donor areas so that there is more equal distribution. That was originally envisaged as long ago as 1992, and it is perhaps regrettable that the then Government did not act when the problem was identified. That solution would also allow all the retained units to achieve the optimum annual number of transplants--about 50. It would also address problems relating to travelling, retain a wide spread of surgical skill across the country, and show those of us who do not live in London or the south-east that the people who manage and advise on the health service take our needs into account, as well as the views of the old-boy network, with its contempt for those of us who live north of Watford.

I am grateful to have had the opportunity to raise this matter on behalf of the people of Birmingham and my Birmingham and west midlands parliamentary colleagues. I ask the Minister to try to ensure that the full extent of the Birmingham situation is understood when the matter is finally decided on, and that the arguments in favour of five centres are seriously considered before a decision is taken. I also ask her to support the request made by Birmingham Members to meet with the Secretary of State so that we can put our case directly to him.

1.15 pm

The Parliamentary Under-Secretary of State for Health (Yvette Cooper) : I congratulate my hon. Friend the Member for Birmingham, Hall Green (Mr. McCabe) on securing the debate. As I am sure that he is aware, this is the third debate in this place on the future of the national cardiothoracic transplant service. We have already had debates on the centres in Sheffield and Manchester. My hon. Friend is right to point to the strengths of the case for his own area. We have had representations from Yorkshire and Manchester Members, in particular from those in whose constituencies the services are situated. We have also received extensive representations concerning the Birmingham centre from Birmingham Members, including those in the Chamber this afternoon--my hon. Friend the Under-Secretary of State for Health, the Member for Birmingham, Edgbaston (Ms Stuart), and my hon. Friends the Members for Birmingham, Selly Oak (Dr. Jones) and for Birmingham, Northfield (Mr. Burden).

The debate concerns the future of organ transplants at the Queen Elizabeth hospital, and it is worth reminding hon. Members that the hospital provides three important organ transplant services. My hon. Friend the Member for Hall Green was right to refer to the renowned liver transplant unit, which, on 7 July in Birmingham, will celebrate its 2,000th liver transplant. I should like to take this opportunity to congratulate Professor Paul McMaster and his team on an outstanding achievement that we all applaud. We all wish the liver transplant team well for what should be a wonderful day. The Queen Elizabeth hospital also has an important renal transplant unit, which we hope to see expanding as a result of the overall reorganisation of the organ transplant services.

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My hon. Friend made it clear that the debate is about the cardiothoracic transplant service. It is also worth making it clear that the debate concerns cardiothoracic transplants rather than the wider issues around cardiac care. The cardiac unit at the Queen Elizabeth hospital already has a distinguished record of research into heart failure and is recognised for its work in aortic aneurysm surgery. A new £13 million expansion of the cardiac unit at the hospital is due to open in a matter of weeks. That will enable the unit to perform an additional 450 cardiac operations, which will help it to meet the priority targets set out in the national service framework for coronary heart disease. The cardiac unit will build on its many strengths and continue to be at the forefront of developments in the treatment of cardiac disease. There will be further opportunities to develop and expand cardiac services when the recently announced £291 million replacement for the Queen Elizabeth hospital is built in a few years' time.

My hon. Friend concentrated on the issues relating to the future of cardiothoracic transplants. That is a very specific area about which there has been considerable debate and discussion, over a long period. That discussion stems from a problem with organ donation by younger people. As I have made clear in previous debates, the Government have restated their commitment to do everything possible to maximise organ and tissue donation and to maintain the very high standards of our organ transplant services. The Secretary of State spelt out that commitment at an organ and tissue donation summit on 27 February, at which he announced an NHS action plan intended to double the number of people on the organ donor register by no later than 2010, and to double the number of kidney transplants by 2005.

We must also recognise that there is a longer-term underlying problem of organ donation which we must address. Improvements in road safety and prevention of strokes in younger people are important health gains and are to be welcomed. For example, between 1990 and 1999, deaths from road accidents in people aged 16 to 59, which is the usual age for heart and lung donation, fell by almost 40 per cent. That is clearly good news, but it has an impact on organ donation. In the past five years, organ donors under 60 have fallen by 15 per cent. That fall could have been greater were it not for the dedication of staff in intensive care units and the efforts of intensive care specialists, transplant co-ordinators and transplant teams in identifying and using available donors.

Mr. Keetch : I appreciate that the Minister and the Under-Secretary of State for Health, the hon. Member for Birmingham, Edgbaston (Ms Stuart), cannot create organs for transplant out of nowhere, but are the Government giving any consideration to adopting the French system, whereby people must opt out of organ donation and there is a presumption of donation if one is tragically killed? Surely that would alleviate the problem overnight.

Yvette Cooper : The Government have considered a wide range of possibilities to increase organ donation, including at the recent summit to which I referred earlier. I am informed by my hon. Friend the Under-

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Secretary that there have been some problems with the French model. I am not aware of the details, but I shall write to the hon. Gentleman on that matter.

The fall in younger organ donors has meant a year-on-year reduction in the number of cardiothoracic transplants. Cardiothoracic transplantation has been designated as a national service since 1986. By 1991, there were seven adult centres in England, and the intention was to ensure that each centre performed at least 50 transplants a year. That followed a major expansion of the service in the late 1980s, which was built on the belief that the number of organs would continue to increase. Four new adult cardiothoracic transplant centres were designated at that time.

The Queen Elizabeth hospital in Birmingham is one of those centres. Last year, it performed 21 of the 290 heart, heart and lung and lung transplants performed in the seven English adult cardiothoracic transplant centres. One of the other new centres was St. George's hospital in London, which carried out 10 transplants before its programme was suspended following a run of poor results. The St. George's programme is the subject of an investigation by the Commission for Health Improvement. The other two new centres are the Wythenshawe hospital in Manchester and the Northern General hospital in Sheffield. The three original centres were Papworth hospital in Cambridge, the Freeman hospital in Newcastle and Harefield hospital in Middlesex. Those three hospitals already perform more than 50 transplants a year. The work to increase organ donation could lead to an additional 30 transplants a year, but even with that increase, there is little prospect that all seven adult centres could ever reach the original target of 50 transplants each a year.

When considering how to modernise transplant services, we accepted the recommendation of the Royal College of Surgeons on minimum staffing levels for transplant units. That is an extremely important factor. Because so much organ transplantation takes place at night or over the weekend, the Royal College of Surgeons recommended that surgeons should not be on call out of normal working hours more often than one day in four. That requires a minimum team of five surgeons. At the time of the report, only two of the seven centres had at least five transplant surgeons. If those surgeons are not able to perform enough transplants each year, it will be more difficult for them to maintain the necessary skills. If the current situation continues, there is a risk that members of transplant teams will begin to lose their skills and standards will fall. For the sake of current and future patients, we must ensure that each transplant team is well staffed, has access to all the support it needs and performs enough operations to maintain a high level of skill in all the members of the team. Patients who undergo such complex treatment as a heart transplant need to be reassured that their surgeons have the up-to-date skills and experience to treat them effectively. I should make it clear to the hon. Member for Meriden (Mrs. Spelman) that this is a debate about skills and staffing--that is why the reforms have been proposed--not a debate about intensive care.

Mrs. Spelman : However, the availability of intensive care beds is absolutely critical to any transplant

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programme. It is one of the major reasons why there is concern about ability to reach transplant targets, particularly in relation to renal transplant.

Yvette Cooper : The hon. Lady is right to say that intensive care provision is critical in order to maintain, if not increase, the numbers of donors. That is one of the reasons why we have increased the provision of intensive care. However, that does not affect decisions about the services, the appropriate configuration of services based on skills and staffing recommendations, and the need to maintain the appropriate level of skills among all those who are carrying out such complex operations.

The NSCAG is responsible for advising on which services should be provided nationally. The group has considered the impact of those factors and last year recommended that the national cardiothoracic transplant should be delivered in future from only four centres in England, which would allow each unit the optimum infrastructure to support a programme of about 50 heart transplants. Each surgeon would then be able to perform, on average, 10 heart transplants a year. That size of programme would maintain the skills of the whole multidisciplinary team and ensure that organ retrieval teams were available to retrieve and use all suitable organs. The NSCAG also recommended that, to minimise disruption to existing services, the two units that already have sufficient surgical staff--Papworth hospital in Cambridge and the Freeman hospital in Newcastle--should remain designated, that the transplant services based in London should be consolidated into a single centre and, finally, that a fourth national centre should be created by merging the three smaller transplant programmes provided by the Birmingham, Manchester and Sheffield centres. Those recommendations are fully supported by many organisations, including the Royal College of Surgeons, the cardiothoracic transplant advisory group of UK Transplant, and Dr Roger Boyle, the director for heart services.

On the basis of the evidence that we have been given, the Government have agreed that the principles are right and that this reconfiguration of the service is necessary if we are to maintain the high quality of one of the best cardiothoracic transplant services in the world.

The decision still has to be made about the site of the fourth national centre, and we recognise the need to make it as early as possible to remove uncertainty. However, it is also critical that we take the right decision, which means ensuring that it is made on the best available evidence. We have asked for a detailed study of the three sites to assess the impact of a large team on the capacity of centres, to look at the potential capacity, and to assess other factors, such as access to patients, which my hon. Friend the Member for Hall Green mentioned as being so important. We are waiting for the final assessment to be submitted and we shall issue a document setting out proposals to inform the public and to seek comments. I assure my hon. Friends and other hon. Members that there will be opportunities for them to make further, more detailed representations when those proposals are put forward. During that process, we shall aim to keep the disruption of patients and transplant teams to the minimum. Patients on the waiting list will, wherever possible, be treated by the

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team that they know. We shall support patients as much as possible through any transitions that need to take place.

It is a difficult decision. My hon. Friend asked if I would pass on requests for a meeting with the Secretary of State. I shall certainly do that and get back to him.

Dr. Lynne Jones (Birmingham, Selly Oak): Will my hon. Friend respond to the request of my hon. Friend the Member for Birmingham, Hall Green (Mr. McCabe) that the Government look at the possibility of retaining five centres, given the fact that the Government are intending or attempting to increase the numbers of heart transplants in the future?

Yvette Cooper : The assessment that has been made already has been done on the best available evidence. It has also taken account of the potential and our determination to expand the number of organ transplants. The recommendation was made to us, and we have accepted its principles. My hon. Friend and other Birmingham Members will have the opportunity to make further representations when the detailed proposals are drawn up, and I hope that, once the decisions are made and we are able to proceed, as much as possible will be done by all the trusts and centres involved to minimise any difficulties that may arise.

Mr. John Cummings (in the Chair) : Order. I regret that we must move on.

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