Questions and Answers

“It is error only, and not truth, that shrinks from inquiry.” Thomas Paine (1737–1809), one of the intellectual founding fathers of the United States of America

There are cultures which seem to be very fond of and do consequently benefit from enquiries (or: inquiries, to do the mostly American spelling justice). The British one springs to the mind of the cardiac surgeon. Between 1998 and 2001 a thorough investigation of the circumstances under which children had died after cardiac surgery in the Bristol Royal Infirmary was undertaken. It became known as the Bristol Inquiry (surprisingly with an “I”) [1]. More than 900 000 pages of documents were analyzed, 577 witnesses called, and finally a huge and detailed report was published in 2001. In it one can find sentences like:

“It is an account of a time when there was no agreed means of assessing the quality of care. There were no standards for evaluating performance. There was confusion throughout the NHS as to who was responsible for monitoring the quality of care …” “It is an account of a hospital where there was a ‘club culture’; an imbalance of power, with too much control in the hands of a few individuals.“

This enquiry caused an enormous public awareness of the situation and was intended to have a regulatory effect. According to the constitution of the National Health Service (NHS), “(the patient has …) the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved organisation that meets required levels of safety and quality” [2]. Ten years later, however, the Oxford unit was closed almost overnight under circumstances similar to Bristol. At that time, another nationwide enquiry was already under way. This was published by the NHS in 2011 [3] under the title “Safe and Sustainable: Review of children's congenital cardiac services in England”. This enquiry presumed that there still was a continued need for change based on various assumptions such as

“Congenital heart services for children have developed on an ad hoc basis.” “Smaller centres are not sustainable.” “Smaller centres struggle to provide safe 24/7 cover.” “Smaller centres have problems with recruitment and retaining of surgeons and other key staff.”

Most of them were found to be valid. One of the principal investigators, Sir Ian Kennedy, said: “During the current assessment process … we found exemplary practice to be the exception rather than the rule. Mediocrity must not be our benchmark for the future” [3].

Based on the results of this latest enquiry, the steering group defined conditions which would allow a safe and sustainable quality of care. These include a minimum of 4 surgeons per team with a yearly case load of at least 100 to 125 each, thereby demanding that a unit should perform 400 to 500 procedures per year. The conclusions derived from this led to a proposal of 4 options for England and Wales, two naming 7 and two 6 institutions who should be allowed to surgically treat congenital heart disease by 2013. Four institutions feature in all options, five hospitals are currently under scrutiny for the remaining spaces. This regulation should allow for 3500 to 4000 operations per year, serving a population of about 55 million. For comparison: according to the annual report [4] in Germany (population 82 million), 4704 operations for congenital heart disease were performed in 2010 in patients under the age of 18 years. 1975 of these were done in children under the age of 1 year, spread over 26 (!) hospitals, with only 7 units doing more than 100 such procedures and just one providing exclusively paediatric service.

It is a valid fact across all borders that surgery for congenital heart disease is one of the most specialized and demanding fields of medicine into which few venture, in which less endure and even less find the surroundings essential for a flourishing unit. In this issue of The Thoracic and Cardiovascular Surgeon you will find a new study by the St. Augustin Group investigating expected versus observed surgical performance in a risk-stratified comparison, defining a “standardized ratio of surgical performance” [5]. We are proud and happy that the authors have chosen our journal to publish their results, again demonstrating their continued efforts to analyze and improve quality of care [6], [7]. Our board member Christian Schreiber has written an Invited Commentary, also emphasizing the definitive need for a rigorous and mandatory quality control in Germany. After years of tedious discussion this is now being established with the final and urgently needed political support of the “G‐BA” (Gemeinsamer Bundesausschuss, Federal Joint Committee) [8]. The outcome and its potential consequences will be interesting to see. Given that background I am particularly grateful to William Brawn of Birmingham Children's Hospital for providing us with an insider's report on the situation in England, supplementing important information for our readers [9].

In 1748 the Scottish philosopher David Hume, whose third centenary is commemorated this year, published his classic “An Enquiry concerning Human Understanding” which continues to influence philosophical thinking today, in particular epistemology. According to Hume, “observation of constant conjunction of certain impressions across many instances” will evoke a knowledge of “necessary connections” in the observer, thereby leading to better understanding. In his footnotes he suggests that: “to conform our language more to common use, we ought to divide arguments into demonstrations, proofs, and probabilities; by ‘proof’ meaning such arguments from experience as have no room for doubt or opposition” (my italics). This, very briefly, is what enquiries are all about.

The British democratic system has been the subject of much envy because it proved to be the most stable one to date worldwide. Heretics joke that this may be so because it is really part of a monarchy. Like with political stability, our neighbours across the Channel have taken the lead regarding the monitoring of quality of care for children with congenital heart disease and in drawing radical consequences. It is to be hoped that Germany is on its way to follow suit. It can certainly supply interesting and innovative tools [5], [6], [7].

References

• 1 The Bristol Royal Infirmary Inquiry .(July 2001). Online: http://www.bristol-inquiry.org.uk [accessed May 20, 2011]
• 2 The National Health Service .NHS constitution, section 2a (March 2010). Online: http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Documents/nhs-constitution-interactive-version-march-2010.pdf [accessed May 20, 2011]
• 3 The National Health Service .Specialised Services (January 2011). Online: http://www.specialisedservices.nhs.uk/safe_sustainable/childrens-congenital-cardiac-services [accessed May 20, 2011]
• 4 Gummert J F, Funkat A, Beckmann A et al. Cardiac surgery in Germany during 2010. A report on behalf of the German Society for Thoracic and Cardiovascular Surgery.  Thorac Cardiov Surg. 2011;  59 259-267
• 5 Photiadis J, Sinzobahamvya N, Arenz C et al. Congenital heart surgery: expected versus observed surgical performance according to the Aristotle complexity score.  Thorac Cardiov Surg. 2011;  59 268-273
• 6 Sinzobahamvya N, Kopp T, Photiaids J et al. Surgical management of congenital heart disease: correlation between hospital costs and the Aristotle complexity score.  Thorac Cardiov Surg. 2010;  58 322-327
• 7 Sinzobahamvya N, Photiadis J, Arenz C et al. Applicability of hospital reimbursement according to the German diagnosis-related groups system in conformity with the Aristotle complexity score.  Thorac Cardiov Surg. 2010;  58 328-332
• 8 Gemeinsamer Bundesausschuss .(October 11, 2010). Online: http://www.g-ba.de/downloads/62-492-472/RL_Kinderherzchirurgie_2010-11-11.pdf [accessed May 20, 2011]
• 9 Brawn W. Reorganisation of children's heart services in England. Plans for a safe and sustainable programme.  Thorac Cardiovasc Surg. 2011;  59 274-275