A bitterly fought turf war over who should perform children's heart surgery in NSW has ended in stalemate, with administrators baulking at a politically unpalatable recommendation to shut the unit at the Sydney Children's Hospital Randwick, despite safety concerns.
Documents obtained under freedom of information laws show the Sydney Children's Hospital Network [SCHN] was advised in 2012 to move all paediatric cardiac surgery to Westmead, because offering the procedures at two sites was "neither safe in the long-term nor sustainable now".
But the network decided instead to merge the administration of the two units and bolster the number of surgeries performed at Randwick, with surgeons and cardiologists travelling from Westmead.
SCHN hoped this would neutralise an increasingly toxic competition between two of Australia's top children's hospitals, with the larger and better equipped Westmead cardiac unit gunning for the closure of the Randwick unit, which had a single surgeon and a diminishing patient load but duplicated many of the same resources.
The new model would also respond to safety and sustainability concerns about Randwick without closing the site.
SCHN cardiac services director Gary Sholler said that under the amalgamated model the more complicated surgery was sent to Westmead and cardiologists spent blocks of time at Randwick, while surgeons travelled between the sites.
"I think the model has been working fine," Associate Professor Sholler told Fairfax Media.
"We went through an interesting process, which was kind of exciting in a way, which had all the senior people coming together and working out how to make it work. These things don't happen overnight, but largely it's working fine."
Congenital heart disease is a problem with the structures of the heart that affects about 0.8 per cent of babies at birth, with symptoms ranging from zero to life threatening.
Last year doctors performed surgery on 747 babies in NSW, including 640 operations at Westmead and 107 at Randwick. Fourteen infants died within 30 days of the operation.
Countries around the world have examined the benefits of consolidating multiple small centres that perform children's heart surgery into a few large units, but the spiky politics of closing hospital services often prove to be insurmountable.
The United Kingdom has been trying to rationalise its paediatric cardiac surgery units since 2002 when an inquiry into a baby death scandal at one of the smaller units found the surgeons were inadequately skilled for the operation, but it has been blocked by public protests, hospital defiance and lawsuits.
International guidelines recommend that paediatric cardiac surgeons perform 100 to 125 operations each year to maintain their skills.
There is no suggestion that the organisation of services in NSW has resulted in any preventable deaths.
The 30-day mortality rate for heart surgery at Randwick was lower than Westmead in each of the last four years, though the most complicated surgeries were performed at Westmead.
But clinicians consulted in the review of cardiac services were concerned that the single surgeon operating at Randwick was performing fewer than 50 operations per year.
That surgeon is now performing about 36 paediatric surgeries per year, as well as adult surgery.
University of Sydney cardiology professor David Celermajer said there had been questions over whether NSW needed two units where paediatric heart surgery was performed or one, and there were obvious advantages to each approach.
"When three or four surgeons sharing the roster at one unit, according to international literature you might have better results," Professor Celermajer said.
"The cons are that kids in Randwick might have to travel to Parramatta if it was in Westmead, or kids living in Parramatta might have to travel to Randwick, so having two sites - in two electorates - might be easier if it could be safely and competently done."
A paediatric cardiologist who ordered unnecessary heart surgery on a three-day old baby at Randwick in 2012 told the health regulator last year he had made errors at a time that mutual distrust between the units had created an "extremely stressful" environment.
After electing not to follow the recommendation of the report, the SCHN closely guarded its contents and refused a request from Fairfax Media to access it under freedom of information laws for 12 months until shortly before the matter was due to be heard by the NSW Civil and Administrative Tribunal this month.
A version of the 28-page report released following advice the Information and Privacy Commissioner in September was almost entirely redacted, save for the introduction and a sentence that said there was no difference in mortality rates between the two units.
But after SCHN released the report, it said much of it was now outdated and the new administrative structure around cardiac surgery addressed the concerns raised.
"The Network Cardiac Service was built around a revised vision and aimed at retaining the best of the existing capabilities and building on them, whilst discarding less efficient or effective practices," SCHN said in a statement.
Associate Professor Scholler said the two-hospital model had been better positioned to respond to a recent and unexpected surge in demand than Westmead would have handled alone.
"The population has grown more quickly than anyone expected. In retrospect it's been a godsend having two sites."
But Australian Medical Association NSW president Brad Frankum said the management of children's heart surgery was symptomatic of a broader problem whereby there was no plan for paediatric services statewide.
Adult hospitals were funnelling even simple surgeries like the removal of an appendix to the children's hospitals, he said.
"It's appropriate for certain things to be concentrated on one site," Professor Frankum said.
"We know that for highly complex surgery, that fewer places doing it more frequently is safer than more places doing it infrequently, but when you have high volume services that aren't particularly risky or dangerous it makes no sense to overload the big hospitals with things that could be done in the peripheries.
"At the end of the day it's about the safety of patients. It's time for a fresh look at paediatric services and all these quality, safety, equity issues."
