Opinion: Why Greg Mulholland MP is wrong to criticise the NHS Medical Director

When I heard yesterday that the local MP had called for the NHS Medical Director to resign following his decision to suspend all paediatric heart surgery at Leeds General Infirmary I dismissed it as predictable populist rabble rousing in search of a good local headline. On realising it was our own Greg Mulholland I felt angry and ashamed. How could one of our MPs have got this so wrong? Or as Stephen Thornton, the Chief Executive of the Health Foundation put it last night, “How low will local MPs stoop? Why does ‘local’ always trump quality in their eyes”. Quite.

In reality Greg’s intervention is an all too frequent example of local health politics – and the desire of MPs to be seen to ‘defend’ local services against interference from ‘London based bureaucrats’ – clashing with rational, evidence based policy making and a drive to improve the quality of health outcomes. The case in Leeds brings into play the tragedy of the Bristol baby scandal of the early 1990s and the need to reconfigure health services to improve the quality of care for patients.

In the Bristol case many babies who underwent heart surgery died needlessly. The damning report that followed criticised secrecy about doctors’ performance and a lack of monitoring by management. This led to cardiac surgeons spearheading a campaign to publish more information about the performance of surgical heart units within NHS trusts. At the forefront of this drive for more openness was Professor Sir Bruce Keogh, an eminent cardio thoracic surgeon himself and now the aforementioned NHS Medical Director.

Greater transparency was badly needed in the NHS back then and remains as important as a quality driver today. As Lib Dems our implacable belief in the values of the NHS must never be allowed to mask the fact that there are significant variations in health outcomes between trusts that cannot be explained simply by the vagaries of case mix i.e. the age and relative health of patients. Or to put it bluntly some hospitals kill more patients than others.

In time a new measure known as the Hospital Standardised Mortality Ratio was developed to measure the relative performance of trusts across a number of surgical procedures. No one pretends HSMRs are perfect; but remember when they highlighted a problem at Mid Staffs in 2008-2010 the trust contested the data and refused to accept they had a problem.

So what was Bruce Keogh meant to do this week? Ignore the data he was presented with, just like those in charge of Mid Staffs? Hardly. In medicine, as most professions, there are conservatives who defend the status quo and resist reform, and innovators who are working to ensure greater openness and better outcomes for patients. Sir Bruce is firmly in the latter camp.

The wider issue here is the need to re-organise health services to support better quality. There is a growing consensus amongst clinicians and NHS managers that to deliver the best possible safety and quality for patients, complex medical procedures (e.g. child heart surgery) need to be carried out in specialist centres, rather than at every District General. Unfortunately, that will mean closing some units. Lib Dems trumpet the mantra ‘let doctors decide what’s best for their patients’. The test of this will be resisting the temptation to jump on local bandwagons in support of ‘local’ services.

Guy Lavis is former Head of Communications at NHS Choices (www.nhs.uk) which first published HSMRs in 2009. During that time he worked with Professor Sir Bruce Keogh. He is also a past Deputy Director of Communications at the Health Foundation.

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  • Morwen Millson 30th Mar '13 - 1:37pm

    I heard Sir Bruce Keogh yesterday and I thought he was brilliant. He had clearly agonised over his decision, but, rightly in my view, he had put the safety of patients ahead of the politics. He hasn’t closed the unit down, he has suspended operations until the facts around the unit’s performance can be clarified. Like the writer, I am concerned about MPs’ knee jerk reactions over health issues.

    Here in Horsham. we have a Tory MP who has got together with his colleague in neighbouring Crawley to campaign for a new hospital in Crawley, to save us all having to travel into Surrey for acute services. Interestingly, the campaign is invisible most of the time, but becomes much more prominent around election times. We’re just waiting for the latest installment in time for the county elections!

  • Has the data that led Sir Bruce to this decision been published? AIUI it hadn’t as of yesterday

  • Why won’t the NHS release the data then?

  • Tony Dawson 30th Mar '13 - 2:24pm

    “So what was Bruce Keogh meant to do this week? Ignore the data he was presented with, just like those in charge of Mid Staffs?”

    I thought that originally, then I heard the Director of NICE on TV this morning whose ‘handling’ of the ‘evidence’ which he passed on to Keogh seemed to leave a lot to be desired. He appeared to be mixing up all sorts of different criticism lines.

    What is absolutely urgent is to get that data out into the open where it can be subject to peer review and wider scrutiny as fast as possible.

    BTW. What was Sir Bruce Keogh doing while Labour was dismantling clinical accountability in the NHS in favour of tick-box culture?

  • Re. Hywel’s question regarding publication of the data: like you my impression was that it hadn’t as of yesterday. Clearly this needs to happen as soon as possible, for several reasons, but not least the need to assuage some of the conspiracy theorists around the timing of the decision to suspend operations at the Unit – coming only a day after the local NHS Trust’s High Court victory. However, it would be naive of me or anybody else to assume that this will placate those within the campaign to keep Leeds open or more generally to convince people of the need to move to fewer specialist regional centres of excellece. The history of the publication of mortality data within the NHS thus far has been characterised by NHS trusts challenging and disputing the figures rather than using them as they should – as a wake up call and a prompt to investigate to see whether precedures need to change.

  • This article is massively misleading. The article is suggesting that the data bruce keogh is basing this decision on is accurate. Dr Gibbs, who compiled the data has stated on record that the data is not in anyway ready for public consumption and should not have been used in this way. It has also been found, within 24 hours of its release, that the data was indeed misleading and inaccurate.

    Given that the data was misleading and that bruce keogh was apparently well aware that this could have been the case, he should never have made this decision. He should have listened to the data analysis expert and allowed the data to be properly assessed before taking such actions.

    These misguided actions have followed his embarrasing handling of the safe and sustainable review which was announced on wednesday to have been unlawful.

    Bruce keogh has made a raft of errors that have had a signifcant impact and should be held accountable for his serious mistakes and errors of judgement.

  • Richard Dean 30th Mar '13 - 4:23pm

    Is this a case of “damned if you do, damned if you don’t”?

    Presumably the Director was given figures which, though not fully checked, provided a prime facie case for action. If he had not taken action, but instead waited, would he have been criticised for endangering patients’ lives?

  • Looks like the figures may have been wrong: http://www.bbc.co.uk/news/health-21981778

    Maybe this is why the NHS won’t release them. Looks very dodgy when they won’t release figures and the closure comes 1 day after a high court victory against the NHS to keep it open.

  • What I find interesting is the public have yet to see any data from leeds, but there is a “any excuse, any way we will shut Leeds down” I am very doubtful of any data this government uses to blame the NHS of anything…

    If Stafford was so serious why are we not seeing prosecutions for the 1200 deaths, this alone suggests manipulation of data to suit the government and now we are seeing managed data interpretation at Leeds…

    The problem is when this government is gone we will see an enquiry into why data was so miss managed, to suit the NHS is bad, so we can privatise sections… this is the smell I am getting

  • James Baker 30th Mar '13 - 8:38pm

    Greg is representing the views of his constituents, more than 600,000 people have signed a petition asking for Children’s heart surgery to stay at Leeds. Guy you describe Sir Bruce Keogh as an innovator ” working to ensure greater openness”, yet the data he has made this decision on is not published or in the public domain. I would say that isn’t very open or transparent. The data needs to be published immediately so people can scrutinise the figures on which this decision has been made. I’m glad you agree it should be published, this is something Greg Mulholland MP has been calling for also, so in this regard at least you agree with him.

    I should like to make the point that data alone can’t make decisions, as Hume’s pointed out there is a significant difference between descriptive statements and normative or prescriptive statements. This is/ought gap reminds us that ultimately decisions of this nature have a moral and ethical element. It may or may not (the data isn’t public) be the case that the Leeds unit has a higher mortality rate, does it follow therefore that 600,000 people who want the unit open and in Leeds should therefore be ignored? That’s a complex moral question, and it can’t be reduced to an instrumental decision making based on data alone.

  • Richard Dean 30th Mar '13 - 8:58pm

    But the decision isn’t about closing the unit for good, is it? It’s about temporarily ceasing operations while a credible report of potential endangerment to patients’ lives is investigated.

    Are there any patient privacy issues involved in publishing this data? It’s also likely to be very distressing to people whose children have died there. Is it a really a good thing to make political games out of it?

  • Joseph Donnelly 30th Mar '13 - 10:34pm

    @James Baker

    That seems like a facetious use of the is/ought gap and I’m not sure it works here. But ignoring a esoteric philosophical debate around that, put simply, what on earth do those 600,000 people know about the safety of their heart unit and the problem is it isnt just local people who use this heart centre, its one of 10 in the UK, its effectively a national unit.

    I agree with Tony Dawson that ultimately the data needs to come out and proper review of it, clearly there have been issues in the communication of this closure.

    However, should what worries me about Greg Mulholland’s behaviour is that there is no way his ‘Bruce Keogh must resign, reopen the hospital’ line is coming from a well considered position of balancing the evidence against peoples wants and needs in the local area. The easiest response and the one that grabs the most votes just happens to be the one Mulholland is loudly calling for.

  • “Temporarily” stopping activities is a standard NHS technique for removing services where there is political sensitivity. Anyone who is gullible enough to mute criticism of this on the grounds that it has been declared to be temporary is really not the sharpest scalpel on the operating table. We all pay for the NHS so show us the supporting figures… If Leeds is so much worse than the others, why has this only just come out now?

  • Richard Dean 31st Mar '13 - 2:35am

    Honestly, Alistair, where do you get that illusion from?

  • Life experience Richard. A unit is closed “temporarily”. Staff about to transfer and take up posts there look elsewhere. Staff coming to the end of contracts look elsewhere. Before long reopening a unit becomes very difficult. The question is whether a lower standard of evidence is required if a manager claims a closure is merely temporary. I have an open mind about the optimal number of these units. If it is being claimed this is a data driven decision I simply cant see the issue with releasing the data. The data could be as simple as looking at the travel times to units around the corner country and closing the unit that would have the smallest negative impact on this. But once the decision becomes about medical performance, its has to be open to scrutiny.

  • James Baker 31st Mar '13 - 9:07am

    I don’t see how it is factitious to use the is/ought gap to explain the moral and ethical dimensions of the argument. If it IS the case that heart surgery at Leeds has a higher mortality rate OUGHT we close it?

    The is/ought gap goes to the heart of the matter (excuse the pun). It is also why I drew attention to the petition of 600,000 to demonstrate the public feeling. As democratic views should or could be another consideration of what ought to be done.

    If proponents of the closure say that democratic wishes of patients/residents are of irrelevance because they lack medical expertise, then that is a moral argument that needs some justification. If we accept the premise that democratic views should be ignored when an expert in a position of power thinks differently then that has all sorts of consequences for our democracy as a whole. Maybe in some situations it is justifiable for experts to make such a call, you wouldn’t want a dangerous building to stay open just because it was popular after all. All I am saying is that case needs to be made, are the dangers so significant that the unit should be closed? Personally I don’t know because the data isn’t available and hasn’t been published.

    Furthermore not only has the data on which this decision not been made public, the validity of the data is currently being questioned by senior doctors. It’s not just a communications disaster failing to be transparent on the data on which the decision was made, it makes expert and democratic scrutiny of the decision impossible. In that regard I would say it was negligent.

    You are correct Greg Mulholland is doing something that is popular and populist with the people he represents. He is an MP, that is kind of his job to represent people and be a local champion to their cause.

  • David Pollard 31st Mar '13 - 10:53am

    If the unit had been kept open, would you let your child be operated on there? I know I wouldn’t. I would go to Bradford or ANYWHERE else ’til the problem is properly sorted.

  • Peter Andrews 31st Mar '13 - 6:27pm

    When newspapers are carrying the following quotes from person responsible for the statistical analysis of mortality rates , then I am deeply suspicious of a decision to close the Leeds Children’s Heart even temporarily

    Dr John Gibbs, chairman of the steering committee for the Central Cardiology Audit Database (CCAD), which supplied the data, said the mortality figures were preliminary and had not undergone the ‘usual rigorous checking process’.
    ‘I’m absolutely furious,’ he said. ‘This data was not fit to looked at by anyone outside the committee.
    ‘It was at a very preliminary stage and we are at the start of a long process to make sure the data was right and the methodology was correct.
    ‘We would be irresponsible if we didn’t put in every effort to get the data right.’
    Dr Gibbs said the ‘ground-breaking’ study involved complex analysis which would require at least two months to validate.
    A problem had already been identified with the figures, he added, with some data being incorrectly discounted from results.

  • Yellow Bill 1st Apr '13 - 4:22am


    Unfortunately many of the parents who use Leeds are finding extreme financial hardship in travelling up to Newcastle. These are not commutable distances if you live in the wilds of Wesleydale and are on a low wage. So families find that the care of their child necessitates being apart for weeks at a time, with one parent having the expence of finding digs in Newcastle.

    As for travelling to Italy – untenable for too many up here

  • Nigel Quinton 1st Apr '13 - 2:47pm

    Why is closure of the unit apparently the only solution to poor outcomes? Surely the first response should be to identify the unit’s weakness and to improve it?

  • Nigel Quinton 1st Apr '13 - 2:48pm

    Always assuming the outcomes truly are ‘poor’ (I should have said)

  • Thanks to everybody for taking the time to respond to my article. I offer the following brief comments in reply:

    There has been much comment in the media about the data used to measure the performance of the Leeds Unit. However, it should be noted that the worrying data, complete or otherwise, was only one of the reasons given given by Bruce Keogh for the decision to temporarily suspend operations. Two ‘disturbing calls’ were made to the Medical Director by whistleblowers and he also received a call from what he described as an ‘agitated cardiologist’. The Children’s Heart Federation has raised concerns about the quality of care at Leeds too and there has been a suggestion that the Unit has not referred cases to other Units when the level of specialist care required was not available locally. I have also read that Leeds has suspended one cardiologist because of his/her mortality rates.

    Given these circumstances I maintain that a temporary suspension was the only option open to the NHS’s most senior clinician.

    @Tony Greaves refers to the ‘suspicious timing’ of the suspension. I am partial to the odd conspiracy myself and if I was a ‘campaigner’ in Leeds I would probably feel hard done by. Bruce Keogh himself recognised the timing would look poor. In my view the timing was almost so difficult as surely not to have been pre-meditated i.e. if there were those minded to undermine Leeds they would surely have waited so as not to look so obvious…

    @Albert “If Stafford was so serious…”. Sorry, but I can’t believe you wrote that. Are you really doubting the scale of this appalling tragedy?

    @James You describe Greg Mulholland’s role as ‘to represent people and be a local champion to their cause’. There’s no better way he can truly represent their needs than to campaign for high quality NHS care that is safe as it can be for young children and their parents.

    @Nigel You are absolutely correct that efforts ought to be made to made to improve Leeds’ performance based on data analysis. The difficulty here is that because of the life and death nature of the treatment some would argue that a temporary stop on all operations is the only way of guaranteeing patient safety.

  • David Allen 2nd Apr '13 - 9:48pm

    There is obviously skulduggery going on here. The only question is, by which side? or maybe both?

    “In my view the timing was almost so difficult as surely not to have been pre-meditated i.e. if there were those minded to undermine Leeds they would surely have waited so as not to look so obvious… ”

    That’s what defense counsel always says when the villain has done something which is of blithering stupidity!

  • Believe what you will, but many of sir Bruce’s comments were full of hyperbole and lacking in facts ( e.g. ‘Constellation of reasons’ why surgery should stop), meanwhile parents of sick children are left wondering if the surgeons and staff they have placed their trust in are competent. Bearing in mind that the previous day this was recognised as a regional centre of excellence, such a reputation should not be allowed to be destroyed in this way. After a series of lengthy meetings during which the NHS have been presented with all the information available, it now seems as though they have no way out, there is too much at stake to back down and admit they were wrong perhaps? For the sake of all the people in the region, patients, nurses and surgeons, we now need to know the truth about heart surgery at Leeds, no fudging, a clear cut transparent decision has to be made. If by by any chance something is found to be amiss, then it needs to be put right and the unit reopened, children’s heart surgery must remain in Yorkshire.

  • Mark Inskip 5th Apr '13 - 10:51am

    @Guy Lavis
    Last night a meeting of NHS England, Leeds Teaching Hospitals NHS Trust and the Care Quality Commission agreed to lift the suspension of heart surgery at Leeds. The announcement was accompanied by statements from the Leeds Teaching Hospitals NHS Trust Chief Executive and Bruce Keogh’s deputy. There has been not public statement from Bruce Keogh since his appearance last week on the Today programme.

    Given these developments do you think you attack on Greg Mulholland is still justified?

  • Mark Inskip 9th Apr '13 - 10:03pm

    @Guy Lavis
    It’s a pity you have chosen not to reply to my question as to whether you still think your attack on Greg Mulholland was still justified.

    Today we have learnt that death rates were within a normal range for the type of operations being carried out at Leeds, and that Sir Bruce had made his decision on inaccurate data. He blames the hospital for this despite the hospital, Dr Gibbs, who compiled the data, and Greg Mulholland stating on record at the time that the data was not accurate and should not have been used in this way.

    Could you perhaps comment on these developments?

  • What happened to Professional Standards? Is Bruce Keogh immune from the oversight of the GMC or are they just to be used for keeping uppity front line Drs in check whilst the generals get away scot free?

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