Taking patient services away from hospitals is never going to be an easy sell. So proposals to reduce the number of units that are allowed to perform children's heart surgery are likely to come in for vocal opposition from parent groups.
Later today, plans will be outlined to cut the number of centres in England from 11, down to six or seven. Among those at risk are the units at Glenfield Hospital in Leicester, Leeds General Infirmary and the Royal Brompton in London. The unit at the John Radcliffe Hospital in Oxford has already stopped operating after a run of deaths last year. The "Safe and Sustainable" review team has already made it clear that Oxford will not be allowed to perform children's heart surgery in future.
All the units under threat - including Oxford - are generally very popular among parents. When I went to the inquiry into the deaths at Oxford, several parents turned up to voice their support for the unit and its surgeons.
So expect headlines and very negative comments about what will be billed as closures and the axing of services.
It is worth looking at the background to all this in order to see why the changes are being proposed. The Bristol heart scandal highlighted appalling lapses in the care of children with congenital cardiac problems. In 2001, the Inquiry report led by Professor Ian Kennedy explained the need for children to have heart surgery in fewer specialist centres. The report concluded:
"...standards should stipulate the minimum number of procedures which must be performed in a hospital over a given period of time in order to have the best opportunity of achieving good outcomes for children. Paediatric cardiac surgery must not be undertaken in hospitals which do not meet the minimum number of procedures. Considerations of ease of access to a hospital should not be taken into account in determining whether PCS should be undertaken at that hospital."
Then in 2003 a review group led by Professor James Munro, President of the Society of Cardiothoracic Surgeons, recommended that surgical centres should do no fewer than 300 operations a year. That would have meant about half the centres closing. Action was not taken. In 2007 the Royal College of Surgeons called for fewer, larger surgical centres. A year later, Professor Sir Bruce Keogh, NHS medical director, instigated the current review. Last year the "Safe and Sustainable" steering group proposed new national standards (opens pdf) which would see a minimum of 4 surgeons working together. The review team will argue that units must carry out a minimum of 400 operations per year, with a recommendation that it should be at least 500. Only a couple of units currently meet those criteria. Now, finally we will have the detailed proposals setting out which units should lose their status are surgical centres.
In order to bolster the need for change, Professor Sir Ian Kennedy was asked to visit all 11 units and assess their standards. His report will also be published today.
The need for surgery to be concentrated in fewer, bigger centres is supported by a huge range of organisations, among them: the Society for Cardiothoracic Surgery in Great Britain and Ireland, the British Congenital Cardiac Association, The Royal College of Surgeons, the Royal College of Paediatrics and Child Health, the Paediatric Intensive Care Society and the Children's Heart Federation - an umbrella group of 20 charities which represent families.
Given that level of support, the real question is why it has taken this long to change things? Even today, the proposals are not final, but will be put out for consultation. Whilst there is broad support for change, individual hospitals have strong reasons for wanting to retain their surgical service. Take London as an example. There are three units which perform children's heart surgery: Great Ormond Street Hospital (GOSH), Evelina Children's Hospital, which is on the St Thomas' Hospital site overlooking the Houses of Parliament, and the Royal Brompton Hospital.
Under the current review it seems the Royal Brompton is the most vulnerable. GOSH does more paediatric cardiac surgery than any unit in England. Evelina is a purpose-built unit which opened in 2005. But the Royal Brompton and Harefield Trust is the largest specialist heart and lung centre in the UK and an acknowldged centre of excellence in Europe. It will argue that it defies logic for it to lose its role as a children's heart surgery unit. Furthermore, the Royal Brompton meets the standard of having four surgeons and does around 450 children's heart operations a year.
I understand that more than one option for the structure of services in London and elsewhere will be set out, so expect some vigorous negotiations in the coming months of the consultation period.
The review team will argue that change is essential. It will stress that no units are going to close and all will continue to offer diagnostic and outpatient services. But for hospitals with proud reputations and strong local support, the proposals will not be palatable.