During training and the early years of my consultant career, cardiac surgery was a pioneering profession. We developed techniques and technology to improve safety and broaden the scope of what we could achieve. We sought to help younger, older and sicker patients. Premature babies, nonagenarians, those at death’s door. There was no such thing as a work-life balance. We were a proud, charismatic specialty, trusted and admired – but not any more.
After multiple hospital scandals NHS England decided to publish surgeons’ death rates, ostensibly to improve confidence in the profession. Logically, you might expect the best surgeons to have the highest death rates because they act as a magnet for the most complex and sickest cases. That’s what happened in the US, when a handful of states were forced into the process by a hostile press. The rest refused to follow.
But this was not an exercise in logic. It was a punitive act irrespective of the fact that most investigations attributed the misery to ‘general failings in the NHS’. Mortality rates were published hastily. Surgeons were ‘named and shamed’ — a phrase destined to become enshrined in NHS folklore. Very rapidly the emphasis shifted from patient care to self-preservation. So many people contribute to the recovery of a heart surgery patient that the simplest way to stay under the radar is to avoid the sickest patients. Low risk translates into low mortality.
We are in the consulting room with two fictitious patients. An 81-year-old man strides in. Thin and wiry. A golfer who has never smoked. He has a narrowed aortic valve and is short of breath by the ninth hole. Normal coronary arteries. Good lungs and kidneys. The surgeon registers low risk of death or stroke and the patient is accepted for valve replacement before his wife has even found a parking space. Any questions? No. The family didn’t arrive in time but he strides off happy. The NHS is wonderful!
The next man is waiting anxiously with his wife and daughter. A 62-year-old diabetic who has suffered two previous heart attacks, his tired heart is scarred and dilated. He can’t do very much. They have waited for months for a cardiology appointment, another three months for the coronary angiogram, then two months to see the surgeon. Walking in to the surgeon’s office from the waiting room makes him breathless. He is overweight with fingers strained by nicotine. What is the surgeon’s first impression?
He reads the cardiologist’s letter: severe three-vessel coronary artery disease with moderately impaired left ventricular function. Then peripheral arterial disease with a 90 per cent carotid artery stenosis – a narrowing of the artery to the brain which could cause stroke during an operation.
He looks up from the correspondence. The family wring their hands and fiddle with a long list of medication. First question: ‘Are you a smoker?’ Answer: ‘No.’ ‘When did you give up?’ ‘After the angiogram.’ The surgeon’s frontal cortex registers: smoker for 50 years, diabetic with bad lungs. Damaged heart and risk of stroke. If I operate on 100 patients like this, at least five will die.
From now on, the dialogue is slanted inexorably towards declining surgery. Avoiding another death is the surgeon’s priority. Risk aversion also saves the hospital money, as sicker patients stay longer in an expensive intensive care bed.
I find this bitterly disappointing from every aspect, yet this is the reality of defensive practice — the outcome when politics interferes with medicine. To attribute all post-operative deaths to the surgeon is equivalent to blaming a pilot for a bird strike to his aircraft engines.
Why do patients die after heart surgery? Very few of the cases can be attributed to surgical error. The predominant cause is ‘failure to rescue’ the patient from a common post-operative complication, an event which, better managed, could have saved the patient’s life.
Much of this can be related to inconsistent team work — the presence of locum doctors or agency nurses who are unfamiliar with management protocols. The problem is worst at night and weekends. Publication of surgeon-specific mortality data has not improved patient choice, waiting times, team consistency, staffing levels or life-saving equipment. Most cardiac centres in Britain are still not funded for rescue circulatory support devices which might save half of those who die from heart failure.
This has all had a miserable effect on my profession. Currently only 40 per cent of children’s heart surgeons had their medical training in the UK. From the General Medical Council specialist register, we know that 68 per cent of trainees entering cardiothoracic surgery in 2000 were UK graduates. In 2013, this figure was 14 per cent. Of those who completed their training in 2014, just a fifth were UK graduates.
Don’t misunderstand my point here. We are very pleased to have overseas surgeons in our cardiac units. Without them, there would be no service.
But we are witnessing the demise of a proud speciality for a point of political principle. Graduates in Britain now feel that cardiac surgery is just not worth the hassle. In the final analysis a profession that dwells upon death is unlikely to prosper, undertakers and the military apart. When a surgeon remains focused on helping as many people as his abilities allow, some will die. But we should no longer accept substandard facilities, inconsistent teams and a lack of life-saving equipment, otherwise patients die needlessly.
I have always loved the NHS. I was born within two weeks of its inception in 1948. It remains a treasured resource for the British people. But I have never seen the staff under such duress and in frank distress. Between them NHS England and the GMC have created a perfect storm.
The BMA does not exaggerate when it warns that fewer medical graduates go on to practise, that junior doctors prefer Australia and that seniors are retiring in droves. There is general mistrust of the propaganda from the Department of Health and their recruitment drives from abroad. Instead, let us treat our own graduates with respect and revert to a supportive environment. Restore confidence in our precious health service before it’s too late.
Britain still leads the way in stem cell research and in developing technology that saves lives – our ventricular assist device is a world beater. Last week came the grim suggestion that survival for heart failure in Britain had not improved in 15 years. We can improve it now if the NHS will fund these home-grown advances.
Fragile Lives by Professor Stephen Westaby is out now