Independent Review of Cardiac Surgery Service St Georges Hospital NHS Trust.

The current consultant cardiac surgical team membership is incompatible and requires restructuring with some urgency.

To facilitate the required changes in practice to sustain and develop the service an expansion to 8 full time surgeons is required. This would allow for a surgeon of the week, expansion of sub-specialisation roles and increased research and ambassadorial roles.

There is a need for an immediate appointment of 2 consultants which will be challenging in the current climate. One should be straightforward as there is a suitable post CCT surgeon working in the unit who could be interviewed for initially a long term locum role.

Seek out a proficient and credible cardiac surgeon to lead the unit. One of the issues that was raised by many of the interviewees was to widen the recruitment process to seek a competent experienced surgeon with an interest in mitral valve repair. The pursuance of such a person, who would ideally be placed to offer a leadership role, should not be limited to the UK

Pursue nationally and internationally, an experienced and innovative surgeon with potential leadership qualities to rebuild the unit appointed within an 18-month timescale with a gradual handover as the unit adapts to new ways of working and personnel.

Succession plan to be produced within 2 months. To plan for the probable retirement of at least one surgeon succession planning should commence now to seek a 3rd surgeon. Again, this could be from a sub-speciality offering more innovative surgical procedures such as robotics or less invasive surgery. International candidates could be approached

Develop a team approach led by the Clinical Director of a succession and sustainability plan

Skills development of junior surgeon(s). To assist the unit in further expansion of its services (either at SGH or as part of a wider South London network) one of the less experienced surgeons to be offered a sabbatical at a specialist unit where specific new skills can be developed.

Pathway leadership role. To complement the role of CGL which concentrates on the operational and governance issues of the unit a new role supporting development of a ‘total pathway of care’ model, encouraging multi-speciality team working across pre-, peri-and post-operative care. We see this as an essential step in promoting more critical analysis and safer care for all patients, but particularly those in a ‘high risk’ category. This role, while open to anyone, would be suitable for a relatively new consultant who wishes to develop new managerial as well as leadership skills

Develop the roles of junior members of the surgical team either internally as the pathway lead or externally to develop new skills useful to the unit.

Move to a single speciality surgical practice only. The unit should develop a policy of only employing single speciality surgeons. There is an increasing evidence base for splitting the role of cardiac and thoracic surgery and our recommendation is that this should be adopted by the Trust enhancing safe practice

Sustainability of the unit. Develop senior ambassadorial roles. The cardiac surgery service is under considerable scrutiny and suffering reputational harm. The most senior clinicians (and new leaders as they come on stream) need to take responsibility for rebuilding trust in the unit. This will involve significant work with colleagues in ‘feeder’ units, academic and service links with other cardiac surgery centres in S London. SGH has a significant experience in sub-speciality working, examples being HOCM, Aortic Arch disease, Marfans and complex mitral valve repair. Only by demonstrating a single vision for the service as a revitalised and innovative one, will organisations be convinced of SGH’s intent to build a better service. To achieve this senior surgeon’s may have to temporarily reduce clinical commitments.

Unit project manager, to support the expansion of consultant numbers and to develop a unit strategy the Trust should employ suitable project support.

Through the established Cardiac Task Group review all current practices across the surgical pathway and implement the changes highlighted in Appendix 5 to reduce variation in practice and reduce clinical risk.

Cardiac institute. There is already cooperation between cardiologists and vascular surgeons across South London. There has been some reluctance to include cardiac surgery into the process. This should be revisited and, supported by lead clinicians and an executive director sponsor, lines of communication opened up with GST to commence meaningful negotiations

Arrange with some pace 1:1 interviews with all consultant cardiac surgeons to explain the Boards intent on implementing the proposed changes and to review the role (or not) of the individual in such change.

Technical advice to improve patient safety. The following we hope are practical steps to assist surgical and associated specialities in improving clinical outcomes. These are summarised in Appendix 5.

Improved data entry Unsatisfactory at present.
a. There needs to be clinical sign-off of each case accompanied by data-validation/audit etc. This can be arranged internally – e.g. every month each surgeon checks at random the entries for one patient operated on by a colleague. If SGH do not play by the same rules as other units, they are doing themselves a disservice (in reality probably very minor effect on outcome data). We note the trust is moving to surgeons entering their own data via the dendrite system and a definite start date would be helpful.
b. The current data manager is the sole authority on data quality in the unit and responsible for data extraction, entry and coding. We believe this to be unsafe for the unit as there are no checks and balances, leaves the Trust vulnerable if he departs and is professionally isolating for him. Even with adoption of the Dendrite system this will not change and the Trust is advised to manage this situation so that further analytical support is available

Outcome monitoring.
a. We have found little evidence of ongoing outcome monitoring of VLAD plots, until a surgeon feels under threat, nor significant engagement by surgeons in morbidity review – e.g. unexpected long ITU stay, unexpected long cross clamp time. Needs to be standing agenda item at M&M.
b. We suggest that only the unit plot is shown to the meeting. CD or med director should review individual surgeons’ plots quarterly and take appropriate action as needed. This we believe would allow good professional discourse and interaction.

Pooling patients with decision on appropriate allocation at the MDT, led by ‘surgeon of the week’. This is dependent on recruitment but is a clear need in the next few months (3-6).