Lifetime Achievement Awards
Professor Sir Bruce Keogh KBE FMedsci DSc FRCS FRCP
It is not surprising Sir Bruce was nominated by 100 judges as the most influential clinician between 2010 and 2015 by the Health Service Journal. His career now spans six decades and has had huge impact on national and international health care and as well as our own cardiothoracic specialty. A career that has focussed on improving socialised medicine in the broadest sense – to improve clinical outcomes, to improve safety of care and to improve patient experience. A career that has challenged clinicians to do better, to have the desire to do better and to place the patient at the centre of everything they do.
His major influence has been accomplished with several remarkable attributes, including unshakeable resolve, humility, humour, compassion, and warm-hearted affability.
Sir Bruce is currently chair of the Birmingham Women’s and Children’s Hospital, Foundation NHS Trust, since 2018. He was the first national Medical Director of NHS England from 2013 to 2018 and prior to that he was the first Medical Director for the NHS in the Department of Health, 2007 to 2013.
His clinical and academic appointments in cardiothoracic surgery spanned from 1991 to 2007. Firstly, he was British Heart Foundation Senior Lecturer and Consultant Cardiothoracic Surgeon at Royal Post Graduate Medical School, Hammersmith Hospital,1991 to 1995, and then Consultant Cardiac Surgeon at the Queen Elizabeth Hospital Birmingham for nine years until 2004. This article will try and convey how this period in Birmingham was so formative in propelling Bruce into the national and international spotlight. This was part of the reason that the substantive chair at University College London became a natural progression in 2004 in conjunction with being honorary consultant and Director of Surgery at the Heart Hospital. It is worth bearing in mind that changing consultant jobs in this era was most unusual and if they occurred were often associated with adverse events rather than career progression. Indeed, in all of Bruce’s life and career he has never allowed geography to be a barrier to fulfil his potential.
In SCTS Bruce was Honorary Secretary 1999-2004, President-Elect 2004-06, and President 2006-08.
In 1991 the majority of senior registrars taking up their consultant posts would have had most of their energies focussed on establishing their clinical reputation, which in turn was often intertwined with developing a private practice. Bruce was clearly in a completely different league as can be seen when, in his own words, he describes the ‘Golden Thread’ that became the four guiding principles of his career.
The ‘Golden Thread’ – in Bruce’s own words……
‘’This focus was not by accident. It was the consequence of several thoughts when I was first appointed a consultant cardiac surgeon in 1991:
Firstly, cardiac surgery was an expensive endeavour, and it seemed to me that understanding the value proposition for a tax funded system would become increasingly important.
Secondly, a personal set of values led me to the conclusion that if a surgeon or other interventionist were performing an invasive procedure on another person, they should be able to describe what they were doing and define how well they did it. To me that was, and is, the essence of professionalism.
Thirdly, as a new consultant I was keen to test the validity of research I was doing with scientists which called into question the perceived wisdom that coronary artery bypass surgery should be avoided in patients with heart failure. Our research had suggested that there was a significant subgroup of patients with heart failure who might benefit. As part of the study I, as a young consultant, was due to operate on these patients based on science, but against the teaching of the day. If things went wrong patients would die and I would also be in personal difficulty. So, I worked with colleagues, mainly in the US, to establish a risk adjusted outcomes measurement system as a protective measure for patients, the organisation and myself. In the end everyone survived and almost everyone improved, most improved substantially.
Fourthly, this interest in outcome measurement stimulated me to establish a national adult cardiac surgical database for outcome measurement and quality improvement in the UK. All patients in every unit are now included. This took about a decade from concept to completion.’’
Young Life.
Bruce was born in November 1954 in Salisbury, Rhodesia, now Harare, Zimbabwe. His parents were both leaders in their area of expertise – expertise that would become a major part of Bruce’s own life in that his father, Gerald, was a senior civil servant having been Chief Inspector of Public Services for the Federation of Rhodesia and Nyasaland, and his mother, Marjorie, a Hansard reporter in the parliament. The family conversations must have shaped Bruce’s understanding of public service, civil service, and government.
Bruce attended the private catholic boys school St George’s College in Harare. He was a lover of the outdoors but not a natural academic at this time. Indeed, he initially failed his A-levels and had to attend a ‘crammer’ to retake them.
Bruce was also growing up in a country going through major upheaval as the population was rising up for independence from its colonial past. A guerilla war was being waged since the 1960s by the Zimbabwe African National Liberation Army (ZANLA) and was intruding into many aspects of life. On the university campus a cache of mortars and hand grenades was discovered, and Bruce’s own cousin had been seriously injured in a land mine explosion. The situation was such that Bruce’s father recommended that his son should leave the country to study abroad.
Bruce had worked in a hospital as a porter to earn money, and in September 1973 he headed for England with a rucksack and £250. This was only his second journey out of Africa having been to England in 1970. This was a time when standard communication was the posted airmail letter and international phone calls had to be booked in advance, were very expensive and very poor quality.
The Struggle for a place at University and Medical School.
At the age of 11, already knowing he would like to be a doctor, he recalls sitting on the grass outside his house in Rhodesia listening to a transistor radio. The programme was about the National Health Service in Britain, and he was moved to go into the house and share with his mother that one day he would like to work in such a service.
With his passion for medicine he took particular notice, at the age of 13, of the high profile first ever heart transplant in neighbouring South Africa. He followed such advances in healthcare closely including the emergence of coronary bypass surgery as a treatment for coronary atherosclerotic disease, which were all covered in detail in the local newspapers. At about the same time Bruce recalls watching a black-and-white television program called "Your Life in Their Hands" which included separate episodes of heart surgery from both the Hammersmith and Heart Hospitals in London. As a young boy it all just looked fascinating - a paradox that he ultimately ended up working at both hospitals.
In the United Kingdom Bruce set about travelling and visiting various medical schools most of whom said don't bother to apply - some because of his less than perfect A-levels and some because of the perception that he was a privileged white boy from a country in conflict with Britain.
During his travels, a cousin introduced him to the admissions tutor for Nottingham University in a pub. He was clear that there were no places in medicine but that they had some empty slots to do a degree in chemistry and biochemistry.
So, Bruce went to Nottingham University in 1973 for a year during which time he focused on getting into medical school as his next move.
Towards the end of the academic year in Nottingham the British Government had frozen his bank account on account of his Rhodesian nationality. He was the only student to remain in Halls of Residence during holiday and was struggling to afford food. He sought a job at British Steel where the occupational health doctor told him he was too scrawny to endure the labour at the plant.... but for some reason went and made a phone call and returned to tell Bruce to go away and eat for a week to prepare himself for work …. and started paying him immediately to be able to afford food. Bruce has never forgotten this act of kindness.
Bruce was rejected by 19 medical schools including three in Africa.
He eventually managed to get into Charing Cross Hospital Medical School in 1974 via clearing. Even that was by chance… he had randomly written a letter to someone who was on the Council of the medical school explaining why they would benefit from his presence…….and it turned out, quite by chance, that that person was the Dean of the University of London responsible for overseas students and the quota hadn't been met that year. So, he attended an interview that was characterised by a particular question "what lessons can be learned from central and southern Africa that are applicable to the situation in South America at present.” Bruce describes that by the end of his waffly answer, ‘’They knew that I knew, that they knew, I didn't have a clue!’’
The Key Relationship
At a coffee break between lectures in those first days at Charing Cross, Bruce realised he was talking with the girl he would like to spend the rest of his life with.
For Ann it wasn’t such an epiphany…… she doesn’t recall Bruce making such an impact and when he did, she noted he was rather long haired and scruffy!
They became a couple that has already succeeded for 52 years.
When Ann qualified in 1979, they married – Bruce was now a year behind having done an intercalated BSc degree, in Physical Anthropology and Molecular Biology. Ann followed her career in paediatrics and took a career break of ten years to look after their four sons: Robert (1984), Chris (1985), William (1987), and Michael (1991). Those were different times with different expectations and priorities. For instance, for Chris’ birth Ann was alone in the delivery suite in Hammersmith hospital and felt fortunate that Bruce (as a cardiothoracic surgical registrar) was allowed down between cases to be with her at the birth – Bruce returned to theatre for the third case. And for William, Ann went into a full period of contractions but had to accompany Bruce to the laboratory while he completed his experiments and then on to the labour suite.
Surgical Training
Newly qualified and newly married, Bruce embarked on his surgical career. In 1981 his surgical house job was in Windsor. He then achieved the highly sought after and competitive role of anatomy demonstrator at Charing Cross for a year. Then for six months he was the senior house officer for Professor Blumgart at the Hammersmith in hepato-biliary surgery. This was followed with six months in Oxford as SHO in Accident and Emergency before joining the respected surgical rotation in the Northern General Hospital Sheffield in May 1984.
There is a remarkable anecdote from Bruce’s time at the Hammersmith with Professor Blumgart. With the benefit of hindsight, it shows Bruce’s strong sense of principle and the strength of his resolve. Considering all the challenges and hard work he had endured to train in medicine he was prepared to risk it all:
‘’There are some colourful stories from this time, but one relates to Professor Blumgart, who was head of surgery at the Hammersmith. He was an irascible, South African hepatobiliary surgeon who had previously been professor of surgery in Glasgow. One day I was due to admit a young woman, about 21 years old, who had cholangiocarcinoma. He took me aside and said that under no circumstances was I to tell her that she had cancer. I explained to him that I wouldn't offer the diagnosis, but if she asked, I would be honest. He told me that that if I told her, under any circumstances, I would be fired. Anyway, I clerked her in, and the first question she asked me was "do I have cancer,” to which my answer was "yes". He was true to his word and Blumgart went absolutely berserk. There then followed a six-week period of great difficulty (HR etc) when he was determined to have me fired from the organisation. Things got worse towards the end of this period when his son was admitted to hospital with appendicitis and I was told to book the operating theatres. I went to see his son and came to the conclusion that he had constipation not appendicitis. I tentatively rang the professor who asked me whether I'd booked theatres, to which I responded with my alternative diagnosis. Again, he went berserk and told me that both he and Chris Wood, a senior NHS surgeon, thought he had appendicitis. I stuck to my guns because I had nothing to lose. In the event he went and examined his own son, decided I was right and told his son to walk home, which was several miles away. After that, the desire to fire me seemed to abate and things went quiet.”
Cardiothoracic Surgical Training
Having passed his fellowship exam at the Royal College of Surgeons, Edinburgh in 1985, he returned to London to train in his favoured specialty, cardiothoracic surgery. He started as a registrar at the Hammersmith with the newly appointed *Professor Ken Taylor and the team. To facilitate conducting his research and achieving an M.D. (Doctor of Medicine) he also applied for, and was appointed, as a British Heart Foundation Junior Research Fellow. This academic work researching Coronary Laser Angioplasty was recognised with the award of his MD in 1989.
*Also, recipient of the SCTS Lifetime Achievement Award, 2018
Fellowship obtained and his research completed and written; Bruce had overcome the hurdles that allowed him to apply for the highly competitive position of senior registrar. He was successful to be appointed to the West London Rotation for cardiothoracic surgery. This included St George’s and Harefield. The former had a formidable and highly respected consultant team: John Parker, John Smith, John Pepper, and Tom Treasure. John Parker was not only a gifted surgeon but highly regarded in his ability as a cardiologist. The junior cardiologists and surgeons quickly learnt the three words to survive their tenure…….’’Yes Mr Parker’’! Although John Parker hailed from Zimbabwe, Bruce was still wary and in awe of the man. However, that changed significantly when it became apparent that the Parker family had lived only a mile away in Salisbury / Harare and their parents had been friends.
Whilst on the London rotation and at Harefield Bruce recognised the desirability of spending time with Sir Magdi Yacoub. As with many times of his career Bruce was not shy in asking for the opportunity nor was, he put off by the initial refusals. Magdi’s trainee places were all full, but in the end, he admitted there was an overseas senior registrar position available and being from Zimbabwe Bruce was eligible.
Sir Magdi had a reputation for not being in the hospital when the anaesthetic and surgery started, sometimes even further afield. Bruce deftly countered this by always putting the challenging cases first on the list…… so that whilst they were working together Sir Magdi was always punctual.
In 1991, Bruce’s first consultant role at the age of 36 was as the British Heart Foundation Senior Lecturer with Professor Ken Taylor at the Hammersmith Hospital. Four years later he moved to Birmingham as an NHS consultant where he stayed until 2004.
Data, Outcomes and Transparency
In the early 1990’s the satirical magazine ‘Private Eye’ was making repeated references to poor outcomes in paediatric cardiac surgery in Bristol – even referring to it as the ‘departure lounge’ or ‘killing fields’. There was a slow but creeping awareness that the public and media would not tolerate the medical profession having inside knowledge of poor performance and yet not preventing patients from being exposed to potential harm.
Cardiothoracic surgery in the United Kingdom and Ireland had a voluntary registry of all adult cardiac and thoracic surgery that had been started in 1978 by Sir Terence English, Papworth Hospital. This was an annual paper submission with data usually collected by the surgical registrar from the theatre books. At the Hammersmith, Bruce was working alongside Ken Taylor who, in 1986, had founded the UK Heart Valve Registry. Bruce took these concepts further and by 1994, while running the UK Cardiac Surgical Register, founded and co-ordinated the National Adult Cardiac Surgical Database. The dataset for each patient was standardised and allowed risk stratification using the EuroSCORE that had been developed by Sam Nashef. The quantity and quality of data submission from the cardiac surgical units was entirely voluntary and therefore was initially incomplete and variable in its accuracy.
In 1998 the whisperings in Private Eye changed to a clamour from the national press for an enquiry into Bristol paediatric cardiac surgery.
By becoming the Honorary Secretary of SCTS in 1999 Bruce positioned himself at the helm to lead our specialty. The mission was to have contemporaneous, complete and high-quality data from all the cardiac surgical units which would allow analysis of mortality and other outcomes, primarily as a quality improvement tool but also to reassure the public, politicians and the media that the specialty could be trusted. This data would be risk stratified so that mortality rates could aligned to the complexity of the surgery as well as the health status of the patient.
Bruce also had to manage the politicians and media who were adamant they wanted publication of surgical results at individual surgeon level. With the first SCTS Blue Book in 1999 outcomes were reported at a unit level but this was not satisfying their desire for transparency.
Sir Ian Kennedy’s independent review of children’s heart surgery between 1984 and 1995 was published in 2001 after three years of collecting and collating evidence. The findings applied to the wider NHS and not just to Bristol and its paediatric heart unit.
The Freedom of Information act had become law in 2005, and the Guardian newspaper used the act to request the adult cardiac surgical data which would allow them to create their own league tables of performance – something that SCTS desperately wanted to avoid. SCTS had to act and maintain professional control of the agenda.
Bruce went to the SCTS membership to ask for their support to publish surgeon specific outcomes.
It cannot be understated how controversial this agenda was for our specialty. Bruce was a relatively young consultant surgeon, and the established elders were most wary and reluctant of having their surgical outcomes analysed and shared. Private practice was still a major component in many surgeons’ priorities and could be adversely affected if their outcomes were shown to be worse than their colleagues.
There was significant reluctance, pointing out the data was incomplete and variable in its definitions and accuracy, but the vote went through. Bruce described this decision as ‘crossing the Rubicon.’
There were unintended consequences of publishing outcomes at consultant level. It became well known that many surgeons became risk averse to avoid increased mortality on their performance. Also, there was some very irresponsible national and local media coverage which was damaging as well as unfair to those individuals.
But overall, the impact of publication was very positive. Firstly, an independent study by the Nuffield Trust and Rand Corporation showed the completeness and quality of data had improved to near perfection – the surgeons and the units knew their data had to be good. Secondly the mortality after heart surgery progressively dropped over several years, despite the patients being older and sicker, to the point the UK could be proud of having the most consistent high survival rate after cardiac surgery. At first there were several units and individual surgeons who were three standard deviations away from the expected mortality, and over the years there are now only occasional units and individuals that are two standard deviations from the expected. This improvement exceeded other countries which had published unit level data, such as Sweden, which probably relates to an era when the consultant cardiac surgeon was autonomous in choosing which operation to do, how to do it, and directly responsible for post operative care on the ITU and ward.
Bruce had led the strongest willed and reluctant specialty through a transformation. His remarkable leadership was recognised by many, propelling his career into another stratosphere.
International Cardiothoracic Surgery
Soon after becoming the honorary secretary for SCTS, Bruce became chairman of the surgical database committee for the European Association of Cardiothoracic Surgery and in 2003 published the first European ‘Blue Book’ of cardiac surgical activity and outcomes from 10 countries. This was the first such international audit that had taken place and progressed to publication, an audit that eventually included 22 countries. This work was highly regarded, and he subsequently was appointed as Secretary General of EACTS, 2004 to 2008.
Bruce’s influence extended even further over the Atlantic to North America, with the Society of Thoracic Surgeons. He was a member of their Cardiac Surgery Database Committee from 1997 to 2003 followed by two terms on their Board of Directors (only the second non-American to do so).
Straddling the English Channel and the Atlantic Ocean gave the Bruce the perfect opportunity to align datasets of the two continents and this was achieved between 1991 and 2001 when he chaired the Joint EACTS / STS International Dataset sub-committee.
National Honour – Sir Bruce.
In 2003 Ann and Bruce returned from a welcome holiday in Mexico. It was difficult to open the front door due to the build-up of post and circulars, and they quickly set about filtering out the important letters from the unwanted……. Ann spotted a brown envelope on Bruce’s ‘discard’ pile and picked it out. Within was a very smart looking envelope from the Foreign and Commonwealth Office offering him, as a non-British citizen, an Honorary Knighthood which Bruce decided must be a joke. To find out the identity of the prankster he called the contact number only to find it was genuine. This was not an easy decision for him. Although flattered by the award he was acutely aware how such an honour might affect his standing and credibility with his surgical colleagues who he was leading at a critical stage to publishing their outcomes. He thought his endeavours would be perceived as merely a self-promotional journey. He sought counsel what he should do and was persuaded to accept, out of respect and politeness to all those who had proposed him. The honour inspired him to apply for British citizenship after which his knighthood became substantive. So, in 2004 he transformed from Mr Keogh to Sir Bruce Knight Commander of the British Empire KBE.
Academia
The University College London had been courting Bruce for some time to take up a chair. In 2004 all the necessary steps had been taken to offer the role. Bruce was not sure whether to take the job as Ann had already been a long-suffering surgeon’s wife for over twenty years and was well established in Birmingham. On asking for her opinion, she told him to take the job otherwise he would become bored! And so started thirteen years of getting the 06.00 Monday morning train and returning Friday evening. Professor Sir Bruce Keogh, The Heart Hospital, University of London.
Despite his huge focus on outcomes Bruce had a comprehensive academic background with over 100 peer reviewed publications and two textbooks. His other notable academic roles were:
BSc – 1977, Physical Anthropology and Cell Biology
MD – 1989, Laser Coronary Angioplasty
British Heart Foundation Senior Lecturer, Hammersmith 1991-95
British Heart Foundation Projects Grants Committee 1997 - 2003
Secretary Cardiac Surgical Research Club 1994-99
Editorial Board of Heart (formerly British Heart Journal) 2000-06
Editorial Board of Journal of the Royal Society of Medicine
At the Heart Hospital one of his new patients in clinic had looked him up – ‘’Are you any good?’’ he asked….’’You’re on so many committees can you remember how to operate?’’!
In 2006 Bruce established the National Institute for Cardiovascular Outcomes, NICOR, at the University of London. The aim was to bring together all cardiac audits including percutaneous intervention, electrophysiology, heart failure, and congenital cardiac surgery under one umbrella. This was a powerful resource that could not only measure the broad range of cardiac outcomes but also be a readily available resource to all the associated clinicians for research – a golden period for the audits.
National NHS Leadership
Bruce had, and still has, no political affiliation and his national appointments were achieved solely on professional standing, activity, and delivery.
Before his appointment as the first National Medical Director in 2007, Bruce was appointed to four roles in the Department of Health / NHS that spanned his time at Birmingham and the Heart Hospital. Not forgetting that at this time he was also President of SCTS, Secretary General of EACTS and significantly contributing to the American Society of Thoracic Surgeons. No Teams or Zoom options then, with all meetings being face to face and telephone conferences were in their infancy.
2002 -05 Member of the NHS Standing Medical Advisory Committee which advised the Secretary of State for Health on the provision of services: medical, nursing, midwifery, dental, pharmacy, and immunisations.
2002 – 04 Appointed to the Board of the Commission for Healthcare Improvement, the forerunner of the Health Care Commission and Care Quality Commission.
2004 – 07 Bruce was one of two medics on the 15-member board for the Commission of Healthcare Audit and Inspection which had the responsibility for regulating the totality of health care both in the NHS and the private sector. This was the predecessor of the Care Quality Commission (CQC)
In this role he chaired the commission’s Clinical Advisory Board and the National Service Framework Board which reported to Parliament on the progress of the National Service Frameworks, including that for Coronary Heart Disease.
He also sat on the Performance Assessment Committee charged with developing measures of hospital performance. This work must have been greatly helped by his experience of being Associate Medical Director for Clinical Governance in the Queen Elizabeth Hospital 1998 – 2004, at a time when such governance was a new concept.
In our current era with emphasis on consistent clinical pathways and outcomes it is worth remembering that in the 90s there was no such standardisation. All the work Bruce was involved in was trying to bring health care, hospitals, clinical teams, and individual consultants to a consistent good standard of clinical delivery of good outcomes and good patient experience. This work was all groundbreaking for the NHS.
For coronary artery disease alone, this work was transformational. In the 90s elective patients with angina had to wait months to see a cardiologist, months for an angiogram, months to see a surgeon and then months for an operation, often being postponed with next to no consideration of the impact. With an acute coronary syndrome patient’s access to care was incredibly variable and primary PCI was an unproven intervention only being taken on by young enthusiastic interventional cardiologists.
As part of the Modernising the NHS agenda in the early 2000s, the Department of Health established a Coronary Heart Disease National Taskforce 2000 – 06 of which Bruce was a member. This group identified the key objectives and oversaw implementation of the NSF. The work targeted prevention, primary care, expand revascularisation, better access to rapid access chest pain clinics, improve ambulance response times and improved information for patients. This work utterly changed the care of patients with coronary heart disease exemplified by the statistic that in 1999 there were around 40,000 CABG and PCI performed and by 2015 around there were 115,000 such procedures, with the increase all in PCI including Primary PCI.
Bruce had a further key role as Chair of the Department of Health Information Taskforce which recommended outcome measures. This led to him being asked by the Secretary of State to help set up and determine the content for the NHS Website (www.nhs.uk). He later went on chair the board.
2007 -2013 National Medical Director of the NHS
When putting all of this work in context it is not surprising Bruce was approached to apply for the role of National Medical Director. At the time though it was remarkable for our specialty to have a cardiac surgeon and current President of SCTS appointed to the top job.
This role had responsibility for oversight of the budgets and work programmes for the Healthcare Commission, National Patient Safety Agency and National Institute for Clinical Excellence as well as implementing the recommendations of the Darzi review to promote clinical leadership, patient empowerment, and participation.
As if this wasn’t hard enough there was then the financial crisis in 2008 and the age of austerity began with huge cutbacks in public and NHS budgets. The mammoth task was to make 20% efficiency savings to reinvest over five years.
Sticking to his ‘Golden Thread’ he developed a quality framework based on the three pillars of Safe Care, Effective Care, and a Good Experience for Patients. To this end he asked NICE to work with the Royal Medical Colleges to create an evidence base where high-quality care costs less.
He implemented the legal requirement that hospitals / health organisations should produce quality accounts that have the same standing as their financial accounts – this was far reaching including primary care and ambulance services.
This work also introduced the concept of Commissioning for Quality and Innovation (CQUIN) where there were financial incentives to deliver change and improve care. Here are two examples where CQUIN had major impact:
Only 25 to 40% of over 14 million patients per year were being assessed for VTE (venous thrombosis and embolism) prophylaxis despite WHO evidence. CQUIN managed to raise this to over 95% with a simultaneous reduction in VTE complications.
With fractured neck of femur CQUIN decreased mortality, decreased length of stay by 6 days, and enabled more patients to return to their own residence. This work alone saved 34,000 bed days.
As National Medical Director he was tasked with overseeing specific strategies for areas of care such as cardiac, stroke, diabetes, trauma, transplant etc. Two examples of the major impact of this work are:
The designation of 22 regional trauma centres resulting in a 50% increase in the odds ratio for survival in the highest risk trauma patients.
In London defining 8 hyperacute stroke units replacing 32 places delivering variable care – this resulted in less mortality, shorter length of stay and more patients returning to independent living.
In 2010 the government changed to a coalition and implemented a restructure of the NHS, known as the Lansley reforms. This involved 60% of the NHS budget being handed to Clinical Commissioning Groups (CCGs) and the formation of a new NHS Commissioning Board, known as NHS England, which achieved legal status on April 1st, 2013. Bruce was the second appointment to the organisation after the chief executive, David Nicholson. Bruce was one of 8 executive directors serving 53 million people with a budget of £97 billion. The Secretary of State tasked him to make clinical outcomes the currency of business, and it was made clear he had to deliver on all the set priorities and would be judged on the sole metric of delivery.
2013 – 2018 National Medical Director NHS England
As the first National Medical Director of NHS England, Bruce set to work orchestrating implementation of clinical leadership as it had never been done before and as envisioned by the Darzi review. Only a Chief medical officer remained in the Department of Health with the transfer of chief Scientific Officer, Chief Pharmaceutical Officer, Chief Dental Officer, Chief Allied Health Professional and all the National Medical Directors into the new NHS England.
A further 25 national Clinical Directors were appointed, an assembly of clinical leaders from the 211 CCGs created along with and the formation of 12 regional clinical senates.
To encourage and implement innovation he established 15 Academic Science Networks as well as Strategic Clinical Networks to share and implement evidence-based pathways.
Bruce delivered on time the implementation of the new Medical Revalidation and became the Responsible Officer for all doctors.
His team developed the National Outcomes Framework conceived of five domains:
Reduce Premature Mortality.
Improve Experience of Patients with Long Term Conditions.
Improve Acute Care.
Improve Patient Experience and
Improve Clinical Safety.
Each one had a director responsible for embedding their domain into the payment for performance provider contracts.
If David Nicholson and the Department of Health needed evidence of Bruce’s delivery, then they were rewarded with four Keogh reports in 2013 alone:
Review of the Regulation of Cosmetic Interventions.24th April 2013. Independent Report. Bruce led this review to address the widespread unregulated nature of these interventions.
The review was prompted by the PIP breast implant scandal, which showed lapses in product quality, aftercare, and record-keeping, as well as misleading advertising and unsafe practices across the sector. Non-surgical interventions made up 75% of the activity and were almost entirely unregulated, with no more controls than a bottle of floor cleaner. The work focussed on three key areas: high-quality care with safe products; skilled practitioners and responsible providers; an informed public, and accessible service if things go wrong.
The Keogh Review – Review into the quality of care and treatment provided by 14 hospital trusts in England. The key themes included:
Limited understanding of patient engagement: There was a lack of awareness on how important it is to genuinely listen to patients and staff to improve services.
Data utilization for quality improvement: The capability of hospital boards to use data effectively to drive quality improvement is often hindered by fragmented data access.
Geographical and professional isolation: Some trusts operate in isolation, which can lead to difficulties in recruitment and reliance on temporary staff.
Lack of transparency for accountability: There is an imbalance between transparency for accountability and support for improvement, suggesting a need for a change in mindset.
Need for leadership and governance improvement: There are patterns of ineffectual governance and assurance processes, with trust boards often unaware of problems.
The 14 trusts included in the review are listed below and we can reflect these themes are sadly still applicable to some of these trusts as well as several others that have been investigated over the intervening years.
Urgent Seven Day Services – 15th December 2013. New clinical standards backed by rewards and sanctions. ‘’NHS England’s National Medical Director Sir Bruce Keogh sets out a plan to drive seven day services across the NHS over the next three years, starting with urgent services and supporting diagnostics’’.
This report was in response to higher mortality rates, poor patient experience, increased length of hospital stays and readmission rates. i.e. the increased risk of mortality at the weekend could be raised as much as 11 per cent on a Saturday and 16 per cent on a Sunday, according to an analysis of over 14 million hospital admissions in 2009/10. Causes included: variable staffing levels in hospitals at the weekend; fewer decisions makers of consultant level and experience; a lack of consistent support services such as diagnostics and a lack of community and primary care services that could prevent some unnecessary admissions and support timely discharge.
Urgent and Emergency Care – 13th November 2013 ‘’ Sir Bruce Keogh proposes new blueprint for urgent and emergency care across England.
‘’The National Medical Director of NHS England today proposes a fundamental shift in provision of urgent care, with more extensive services outside hospital and patients with more serious or life-threatening conditions receiving treatment in centres with the best clinical teams, expertise, and equipment’’. ‘’Highlighting opportunities to shift care closer to home, he says 40 per cent of A&E patients are discharged requiring no treatment; up to one million emergency admissions were avoidable last year; and up to 50 per cent of 999 calls could be managed at the scene.’’ ‘’And citing modern treatment of the nation’s two biggest killers – heart attacks and strokes – he points out that survival rates have improved significantly by taking patients to specialist centres that provide the best available hospital treatment.’’
Sometimes a Rocky Road
Bruce’s evidence based and structured approach to 7-day services, initially focussing on urgent and emergency care was seriously undermined by political opportunism. Firstly, it was announced at the Conservative party conference that the NHS was to become a seven-day service for all services including elective delivery. And secondly the health secretary decided in 2016 to impose a new contract on junior doctors so that working Saturday and Sundays would be regarded as normal time. There was a major backlash from the medical profession, much of it directed in Bruce’s direction which he took very personally.
The role also involved regular attendance at the Houses of Parliament for Health Select Committees and the Public Accounts Committees. Despite being a seasoned debater and used to tough challenge he found the latter to be exceptionally brutal, which he often attended with just the chief executive.
Investing in the Next Generation of Doctors and Medical Leaders
In 2011 Bruce established the National Medical Directors’ Clinical Fellowship Programme for junior doctors. This gave aspiring medical leaders one year in a national healthcare department such as the Department of Health, NHS England, NICE, MHRA etc. The scheme now has several hundred graduates.
In 2012 Bruce made it compulsory for final medical year students to spend four days shadowing the FY1 where they were about to work – and so came the end of being thrown on to the wards on August 1st straight from final exams into the challenge of clinical work.
And in 2013 he ensured Junior Doctors were involved in CQC inspections as pivotal barometers of quality, safety and culture in clinical teams and their institutions.
Further Positive Impact
Before the end of his tenure Bruce oversaw two further high impact reports. In 2014 Ian Barnes published the Pathology Quality Assurance review, with the key themes being the need for transparency; the presence of unacceptable variation; the need to improve testing and the need to improve patient experience.
And in 2017 the Ambulance Response Programme – this is an excerpt of Bruce’s letter to the Secretary of State for Health:
‘’ Over 18 months the Ambulance Response Programme covered over 14 million calls, testing a new operating model – allowing call handlers 3 minutes to gather more information to allocate to 4 Categories of Urgency,
The trial has demonstrated that, should these changes be adopted nationally:
Early recognition of life-threatening conditions, particularly cardiac arrest, will increase. Based on figures from the London Ambulance Service, it is estimated that up to 250 additional lives could be saved in England every year.
Up to 750,000 patients every year would receive an immediate ambulance response, rather than joining a queue.
The differences in response time between patients living in rural areas and those in cities would be significantly reduced.
All achieved with no patient safety or adverse incidents attributed to the ARP in those 14 million calls.’’
These recommendations are still used by all the NHS Ambulance Services.
By the end of 2017, and a whole decade of being the NHS’ National Medical Director, Bruce had inspired and led a seismic change in the delivery of healthcare. In that time there had been a reduction of blood borne MRSA infections by 90%. There was greater clinical leadership. There had been an increase in the diagnosis rate of dementia from 40% to 70%. There were 11 specialties sharing outcomes on NHS choices at consultant level and improved services at weekends, most notably in trauma, angioplasty, stroke, vascular and paediatric intensive care. And on that theme, one final statistic…….
99% of eligible patients were receiving primary angioplasty for their heart attacks of which 90% had their arteries opened within 90 minutes.
A further example of the seemingly impossible becoming expected practice.
At Christmas 2016 Bruce was relaxing at home in Birmingham and realised he’s spent seven consecutive nights at home with Ann. He wondered when he had last spent so much time at home………
Ann knew the answer – it was July 2004.
And this was the realisation it was time to change. NHS England kept him dangling for a whole year longer before he could take up the position of Chair of the newly paired hospitals Birmingham Women’s and Children’s Hospital where he has been since 2018.
Not that this has been an easy role either. The Women’s hospital is one of two dedicated Women’s hospitals in the UK which brings its own opportunities and challenges. And the Children’s hospital is the busiest in the country with the widest range of specialties. It is unique in maintaining continuity of mental health care for young people through to 25 years old.
Bruce’s mantra has not changed as chair – for a hospital to do well he asks:
Look after the staff and train them well.
They measure and know their outcomes.
They conduct research and
They promote innovation.
Thank you.
Bruce has had a stellar career through extremely hard work and dedication that has transformed so many aspects of health care.
He has put patient care (safety, quality, and experience) at the very heart of everything he has done, and it is very hard to remember what healthcare looked like before his leadership.
Thanks to Bruce our own specialty has gained enduring respect for our quality assurance and improvement.
It is remarkable to have witnessed, and still see, his consistent–
Clarity of Vision
Clarity of Purpose
Apparent tirelessness
And the ability to show such steely resolve whilst being so very affable:
Professor Sir Bruce Keogh KBE
Professor John Pepper
John Pepper Lifetime Achievement
John Pepper was born into a naval family in the city of Plymouth. In what might well have augured a lifetime of significant contribution to the management of cardiothoracic disease, his father developed tuberculosis shortly before John was born. In those days, of course, tuberculosis was managed in one of the sanatoria that have become the cardiothoracic units in which many of us now work. When a mere toddler, his mother moved the family to Surrey and John would often be left with his maternal grandfather, a general practitioner of Swiss-German extraction, while his mother travelled to Aberdeen to spend a week with her husband confined, as he was, to the Toma Dee sanatorium.
School in Surrey led to what John, with characteristic modesty, claims to have been a ‘lucky admission’ to Clare College, Cambridge in 1965. Cambridge was followed by a scholarship to embark upon clinical training at Guy’s Hospital Medical School and graduation as a doctor in 1971. John completed the bulk of his general surgical training in Leeds, the epicentre of GI surgery in the UK at the time. He was admitted to the Fellowship of the Royal College of Surgeons in 1975 and embarked on specialist training in cardiothoracic surgery. He was variously SHO to Donald Ross at Guy’s Hospital, registrar at the National Heart and London Chest Hospitals, before being appointed to the Guy’s, St Thomas’s, Brook senior registrar rotation.
At an improbably young age, John was appointed consultant at the London Chest Hospital; his workload encompassed adult cardiac surgery but also an extensive thoracic practice including oesophageal as well as pulmonary surgery and a weekly endoscopy list at Southend General Hospital. John’s lifetime commitment to research and training became evident at this early stage in his career: he completed a research project on myocardial protection using this stuff called cardioplegia, a novelty at the time; developed an animal model of lung transplantation, organised symposia for the annual Cardiac Surgery Course at the Cardiothoracic Institute and gave lectures to local general practitioners.
In 1982, John Parker was looking for a colleague with whom to expand the cardiothoracic surgery programme at St George’s Hospital, which had just decamped from Hyde Park Corner to its current home in Tooting. Those who knew Parker know that he had a shrewd eye for identifying talent and could be very persuasive and so John duly moved to Tooting. Over a period of ten years, the unit expanded prodigiously, the research output, with cardiological luminaries such as Michael Davies and John Camm and David Ward was stellar and, for a decade or so, cardiac surgery at St George’s was ‘Parker and Pepper’.
John was intimately involved in every aspect of the department, but his energy, passion for innovation and technical skill were perhaps best exemplified by the establishment of a cardiothoracic transplantation programme, something that he accomplished entirely single-handedly without central funding.
As a young registrar, I well recall meeting John at the somewhat surreal party that is multi-organ retrieval. In those days, John would drive to the donor hospital in his white VW Golf GTi, retrieve the heart-lung bloc, divide the bloc and distribute the organs accordingly, before racing back to St George’s to implant the heart and spend most of the next several weeks managing every detail of the patient’s subsequent recovery.
In 1991, when Magdi Yacoub was appointed to the Chair in Cardiac Surgery at the National Heart and Lung Institute, John was persuaded to join him as Senior Lecturer. There were some who wondered why an established consultant, already a senior figure in our specialty, would want to take what, in those days, was seen by some as a step sideways, but they don’t know John.
Ego wouldn’t have featured in that calculation; John would have seen only the opportunities to learn more about our specialty, to contribute to the training of future generations and participate in something exciting. At the Brompton, John had an exceptionally busy practice, always putting patients front and centre, training the young, conducting and supervising research, developing new surgical procedures, and raising more than £8m in grants. He became a Reader in 1995 and a full Professor at Imperial College in 1999.
The procedure most recently associated with John’s name is the PEARS (Personalised External Aortic Root Support), inspired by and developed in conjunction with a patient on whom John had operated. The enthusiasm with which John has travelled the world proctoring others in the use of device is matched only by the modesty and self-effacement that he exhibits when responding to others laying claim to have been responsible for accomplishments that were in reality his.
He was awarded the Tudor Edwards medal by this society in 2015 and, in the same year, was made an Officer of the Order of the British Empire. John has held countless executive positions in learned societies, been a member of the editorial boards of most of the high-impact journals in our specialty and held honorary positions in hospitals and medical schools around the world. He is one of the most cited authors in the field of aortic surgery.
John is a man of irrepressible good humour and enthusiasm, and I have never seen either desert him. He is a man of exceptional modesty and self-effacement who understood, more than anyone I have met, the need to lead by example; as his registrar, I well remember him taking up a mop to clean theatres in between cases when the rest of us could think only of sloping off for lunch. Confronted by such an example of leadership, even I had to give serious consideration to skipping lunch.
Of the many qualities that John possesses, if I were pressed to single out one, it would be his innate and unshakeable sense of fairness exemplified both by his willingness to go out on a limb to help those whom he thinks have been wronged by the system and the fact that, of his many, many achievements in medicine none has come about from trampling on others, a rare thing even in the supposedly genteel world of academic medicine.
On the contrary, his achievements have come about through his inexhaustible energy, his genial manner which belies a searing intellect and his inability to say ‘no’ when someone asks for his help. Since he finally retired last year, I have lost count of the number of people who have said to me, “…of course, John Pepper used to do it but since he retired…”
Lest you think that all of the above left John with no time for anything else, you would be wrong: in 1973 he married Hilary, a lawyer turned magistrate; Hilary and John have therefore just celebrated fifty years of marriage. Two sons, Thomas Robert and Ross Henry, followed in 1977 and 1983 respectively. John is a polymath: his richly deserved and, it is to be hoped, long and healthy retirement is filled with learning to speak Russian, sailing his boat in Norfolk, time with his young grandchildren and wider family, as well as taking his much-loved Labrador for his weekly hydrotherapy sessions.
I have had the great good fortune to have been his registrar, his senior registrar, his consultant colleague, and am proud to call him a friend. When John sent me an SMS at some improbably early hour (even in retirement, he is up and about at four in the morning), asking if I would “say a few words” at this event, I could not have been more touched. Joining, as he does, previous winners including Magdi Yacoub, Terence English, Donald Ross, Peter Goldstraw, Bill Brawn, Marian Ionescu, I cannot think of anyone more deserving of such an award. I would ask therefore that you stand, and bring the roof down in acknowledgement of John Pepper, recipient of the Society of Cardiothoracic Surgeons Lifetime Achievement award.
