Performing child heart surgery

Professor Martin Elliott is co-Medical Director at Great Ormond Street Hospital, and a former paediatric surgeon. He discusses the challenges of balancing safety, economics and innovation in paediatric surgery. Watch the video, or read the Q&A, below

What does your role at Great Ormond Street involve?

My specific role is to be responsible for the quality and the safety of the work delivered at Great Ormond Street Hospital and to be involved in managing medical staff. I am also on the board of the hospital influencing what the board does, and decides, from the perspective of the patient and medical staff.

How safe is GOSH?

I am very pleased that we won the BMJ prize for safety last year and the HSJ prize as well. We are clearly doing something right, but I don’t think it will ever be good enough. I am very moved by the words of Steve Hanson who is the All Blacks coach; he said ‘don’t ask us how good we are, just be assured that we are going to be better next time’. We want to be the best in class. Every hospital should be striving to be the safest.

What are the biggest changes you’ve witnessed in your career?

I have lived through the arrival and growth of intensive care, and there has been a complete revolution in cardiac imaging

However, maybe the best thing is that people know more, and there is less of the ‘I’m a doctor’, and more of a partnership with your patients and their families. One of the hidden privileges of working with children and their parents is that they’re brutally honest.

You've spent most of your career as a paediatric cardiac surgeon. What are the challenges?

For me it’s been more of a privilege than a challenge. There were a large number of practical operations you needed to get your head around, and also you were predicting the outcome over a long period of time. You need to discover whether you have the right kind of hands to do that sort of work and people do, I think, separate into being more comfortable with the small, gentle tissues of a child than the bigger things of an adult. You find your niche and I was really lucky to find mine.

You find your niche and I was really lucky to find mine.

Martin Elliott
Great Ormond Street Hospital

What got you started in medicine?

When I was in school, I could only do French and biology, but I had a very charismatic biology teacher called Dave Holford. I went to medical school and I was seduced by a good fresher’s week-end in Newcastle. I loved the people I met and after that it was a love affair.

What have been your career highs?

A: Getting a job here, that was a big break. As the philosopher Stephen Toulmin said, you get where you are by hanging around smart people. Working at GOSH there is an endless stream of smart people around you who seem to know more than you do.

Have there been any low points during your career?

Martin Elliott Great Ormond Street HospitalThere’s one staggeringly, outstandingly difficult thing for me, in that I lost my son, Toby, five years ago suddenly and that was life-altering in every possible way you could imagine. 

I found it very difficult to do my day job after that not so much because of dealing with patients, surprisingly, but the sort of small, minor little arguments that you have with your immediate peers that don’t seem to matter anymore, and so I moved more into an administrative role as medical director following that where the arguments are bigger and I don’t know the people quite as intimately. 

The one thing you learn having lost a child is that it’s not just grief. You are actually a different person afterwards, a different family afterwards, different people afterwards.

You’ve just been appointed Gresham Professor of Physic, how did that come about?

I saw an advertisement in the paper and applied for it. It is for six public lectures per year for three years.

One of them raises the ethical question of ‘Could we do now, what we did then?’ Can you tell us more about that?

It’s a topic that eats away at me, partly because I have to make some of those decisions now in a more general sense for the hospital, but also because I was involved in some of the things that were new or pioneering. If you go back to why people went into cardiac surgery in those days it was because it was exciting and risky. You look back at the start of open heart surgery for example, using the heart-lung machine for the first time in humans, what must that have felt like?; to repair holes in the heart when you thought the mortality rate was going to be very high; the transplantation, the introduction of the arterial switch operation, which was associated with an enormous mortality rate in the early days.

Have we become more risk-averse?

We’re not just risk-averse from an immediate cultural perspective but also an entire structure of healthcare has become very, very risk-averse, and often for good reasons, but it does question how you make the next big leap.

Another of your lectures speaks of doing more for less. Is there a safety risk in doing this?

Doing more for less is becoming a moral responsibility. Healthcare has become increasingly expensive. We’re spending above 8 per cent of our GDP on healthcare. We have more staff, the work we do is more complex, the drugs get more expensive and the bits of kit we have to buy get more expensive. So there is this innate inflation in healthcare plus all the social care costs in the background. You just have to draw the graph to say ‘actually this isn’t going to work’.

So, can we cut costs safely?

There’s a cardiac surgeon called Devi Shetty who does cardiac surgery in Bangalore. He does 4,000 cases a year and he claims that he delivers paediatric surgical operations for $2-3,000. In the UK it would be around $50,000 and in the US probably around $100,000. We’re not going to fly all our patients out to India but what is it that he is doing to deliver those costs? Is he working his staff much harder, is he buying his kit for less, is he delivering the process of care more effectively, or is it because he is doing 4,000 cases in one building? Each of those things must be contributing to a reduction in cost.

We are going to be competing for a smaller amount of resource so we have to find better and cheaper ways of doing it. This could be anything from using technology, rationalising the number of centres, delivering care in a different way, for example not doing outpatients because you can follow-up with people on their iPad.

Where do you think the next big innovations will come from?

Technology is probably the biggest impact that I can foresee. We are on the brink of machine learning. We know more about people’s genome, we know more about the course of patients over their life, and we have imaging and functional data. Computers can better integrate this massive amount of data, and will help work out how best to treat people, challenging  conventional concepts of medical research, the decisions we make and how we make them. We will need whole new concepts of how we deliver information to families.

Other disruptive elements will come from the basic science that we are doing at the moment; stem cells, gene therapy, and understanding the cause and development of disease, personalised medicine, 3D printed valves and even whole organs, to modify the disease from your particular genetic abnormality. I can’t predict that but I’m living through it and some of it will work.

What has been your relationship with the BHF throughout your career?

The BHF got me started in research right at the beginning, because I applied for a grant and (happily) got it. But it’s not just me, everyone I have worked with at different times have continually had a research relationship with the British Heart Foundation. People have posts funded by the BHF and nurses have been funded by them to do things and so it has really been the supportive buttress for all of my clinical life and professional life even if my personal relationship with the BHF hasn’t been direct. 

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