Exclusive: Fix ‘dark force’ surgical unit or lose it, leaked review tells trust

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Independent review leaked to HSJ finds “consultant cardiac surgical team membership is incompatible and requires restructuring with some urgency”
Dysfunctional heart surgery team contributing to worsening mortality rates
Reforms must come fast or St George’s could lose cardiac surgery unit altogether, investigation finds
Clear to reviewers that “internal governance of cardiac surgical outcomes has been inadequate during recent years”
Guy’s and St Thomas’ team brought in to provide “leadership support”

An independent review has challenged the leadership of a teaching hospital to make immediate changes to its cardiac surgical team or face losing the service altogether.

St George’s University Hospitals Foundation Trust, which is in financial and quality special measures, commissioned an external review of the unit in June because it has struggled to address high mortality rates and other problems.

The reviewers produced several recommendations, first among them that “the current consultant cardiac surgical team membership is incompatible and requires restructuring with some urgency”. It suggests the trust consider unspecified “radical solutions to breaking up the current surgical team”.

Poor working relationships between the cardiac surgical consultants has been a problem at St George’s for at least eight years with the surgeons “working in ‘camps’” and dysfunctional, the review reports. The issues appear to have first been brought to the attention of the trust’s board in 2010, in another private external review of surgical services.

Staff reported “a persistent toxic atmosphere and stated that there was a ‘dark force’ in the unit”, and the new review said: ”As the major players in this drama are still in post it is [as] unlikely now as in 2010 that the situation will improve.”

The review report is clear that the situation is urgent: “The trust can, in our view, no longer delay as to do so would risk external intervention either closing or restricting the scope of work at the unit in response to ongoing concerns over persistently high mortality.”

The final report was sent to the trust on July 10 and HSJ has obtained a copy.

The trust has already acted on some of the review’s recommendations, including agreeing that Guy’s and St Thomas’ Foundation Trust provide St George’s with “on the ground cardiac surgery leadership support”, a spokesman for St George’s told HSJ.

It is the second time in recent years that St George’s has had to call on its neighbour to the north for help. In September 2016 HSJ revealed the trust’s vascular surgery department was being “supported” by a team from Guy’s and St Thomas’, after a dispute with its interventional radiology department.

A St George’s spokesman also said it had made some changes to practice on the day it received the review report. This included splitting cardiac and thoracic surgery units to make two stand-alone teams of speciality surgeons, in line with a key recommendation from the independent review.

The trust has also set up “additional development opportunities for one of [its] cardiac surgeons”, as recommended by the review, and advertised for an additional consultant. This would take the roster to seven surgeons, one shy of the eight recommended by the independent reviewers.

How the trust manages data was criticised in the review’s final report. It called for it to improve data entry processes and ensure there is more analytical support for the data manager who has sole responsibility for data entry, extraction and coding. The hospital spokesman said the trust is addressing these issues and has already introduced a new management structure.

Death rates

The review was carried out by Mike Bewick, a former GP and former NHS England deputy medical director, with assistance from Simon Haynes, a consultant paediatric cardiac anaesthetist at Newcastle Hospitals Foundation Trust. They interviewed 39 members of administrative and medical staff.

Professor Bewick’s review and its recommendations come at a difficult time for the trust. It was downgraded from good to inadequate by the Care Quality Commission in 2016. As of June the trust had made “many areas made improvements” according to the CQC and was upgraded to requires improvement overall.

The reviewers said the trust’s cardiac surgical unit “is an iconic and cherished one serving a population at high risk” in south west London and beyond. It has enjoyed a strong reputation and is a tertiary referral unit. In 2018 it won a British Medical Journal award, Clinical Leadership Team of The Year, for work on the management of aortic aneurysm and aortic valve disease.

But it has also struggled for more than a year to deal with higher than expected death rates.

In June 2017 it conducted an internal review of the surgical team after it received an alert in April about high mortality rates from the National Institute for Cardiovascular Outcome Research (NICOR), a national service that reviews outcomes data. This came after data showing high rates of surgical site infections.

A multidisciplinary team “worked hard” to bring down infection rates from six per 100 to 2.4 per 100 but the mortality rate remains a problem.

The trust set up a cardiac task force to address mortality rates after the first NICOR alert. But the mortality rates increased from 3.2 per cent in data analysed from 2013 to 2016 again to 3.7 per cent in 2014-2017 data.

The report does show the trust’s mortality rate data has started to improve since the cardiac task force implemented its action plan in late 2017. The reviewers also reported “an increasingly rigorous approach since the second alert”.

However, “the NICOR alert is the ‘smoke’ of a supressed fire”, Professor Bewick’s report said. The task force had a wide brief and has made progress on several areas, including improving cardiac surgical data management and arranging meetings between the surgical team, the review says.

But “professional issues, based on poor personal relationship[s] between consultant surgeons, were seen as the major inhibitor of change” by the trust.

It therefore took what the reviewers saw as the “extraordinary step” of inviting external mediators to work with senior management, the surgeons, cardiologist and anaesthetists at a “2-day immersion event” in December 2017.

The mediation was successful over the short term however the reviewers were concerned that “this is only a veneer and that tribal behaviours persist”. They believe poor working relationships continue to pose an urgent problem.

Their recommendations “will all be unachievable if the continuing behaviours and poor relationships persist. As the major players in this drama are still in post it is [as] unlikely now as in 2010 that the situation will improve”.

A spokesman for the trust said: “We would like to stress that the cardiac surgery service we provide for patients is safe. However, it is very clear that major and urgent improvements are required, which we are already taking action to deliver.”

“Stifling”, shouting, bad-mouthing and a “dark force” – difficulties in the “training centre for Imperial”

The report sent to HSJ was unusual in the strength of language it used to describe behaviour in the unit. In interviews with 39 staff it mentioned a range of issues including:

“In our view the whole team shares responsibility for the failure to significantly improve professional relationships and to a degree surgical mortality.”
“There was a lack of cohesive leadership and this was stifling development and recruitment of new surgeons”
“Some felt there was a persistent toxic atmosphere and stated that there was a ‘dark force’ in the unit”
“Most staff, while shocked at the NICOR alerts believed poor performance was inevitable due the pervading atmosphere [sic]”
“It should not have been necessary to await an alert from NICOR before undertaking an internal review of governance procedures, identifying poor performance throughout the patient pathway (not necessarily just poor performance by the surgeons) and taking remedial action and subsequently monitoring the effects of the remedial actions.”
“Staffing levels on the ward had improved but theatre staff were often trained only to go elsewhere as conditions are deemed better. ‘We are a training centre for Imperial’ was one comment”.
“A minority of surgeons felt there was a partial approach from the governance team and one respondent was concerned of a vindictive attitude towards those that raised concerns over the service.”
“Most staff felt that the new CEO leadership and board were succeeding in ‘getting a grip’ but that the cardiac surgery performance and behavioural issues required a more forthright approach.”
“We were also aware that the trust and its workforce desire a solution to what appears to be an insolvable and indolent state within the cardiac service.”
“There is still a defensive approach to the NICOR report which is stalling a full and frank discussion about how the unit could be run more effectively to reduce harm.”
“We have found little evidence of ongoing outcome monitoring of VLAD [Variable Life Adjusted Display] plots, until a surgeon feels under threat, nor significant engagement by surgeons in morbidity review.”