It is an insight into the character of a man who, when asked to reflect on a defining moment in an illustrious career, pays tribute to the patient whose life he saved rather than bask in his own extraordinary achievements. And if this feature were no longer than the first paragraph, it would be enough to convey the nature of Sir Terence English.
I have more than a passing interest in his distinguished career. My own father suffered from heart disease in his forties and had a life chequered with cardiac surgery. Kicking off with coronary artery bypass surgery in 1981, he wore his chest scar with pride. His ‘zipper’ was, he believed, testimony to ‘that wonderful British institution that is the National Health Service’. So, with this in mind, I take great pleasure in speaking with Sir Terence at his home one warm September morning.
Sir Terence English is a retired cardiac surgeon who now lives in Oxfordshire but spent his professional life in Cambridge, where he was a Consultant Cardiothoracic surgeon at Papworth and Addenbrooke’s Hospitals from 1972 to 1995. For many, his name is synonymous with an era of ground-breaking heart surgery. However, his entry into the field of Medicine was far from inevitable. In fact, Sir Terence’s background is as eclectic as his family descent – a mixture of Scottish, Irish and Afrikaans – all mixed with an essential Yorkshire goodness. Born in South Africa in 1932, he was schooled in Natal before a career in Mining Engineering in Johannesburg beckoned. After leaving school he spent a year as a diamond driller in Rhodesia (now Zimbabwe), something which ultimately provided timely opportunities for summer jobs whilst completing his degree at Witwatersrand University.
‘I had an extraordinary time as a diamond driller in Rhodesia as it was then. It was a small team and very tough. I learned quite a lot about life and teamwork and working under pressure. This inevitably has an impact on your outlook, too, particularly with regards to people and how they help you.’ It is a theme that Sir Terence will return to time and time again in his surgical career – namely, the importance of ‘teams’ in the delivery of care.
Following the unexpected inheritance of a small bequest from a family trust, Sir Terence decided to use this as an opportunity to refocus his efforts on a career in Medicine – in part inspired by a maternal uncle and surgeon. He used the money to travel to England where he studied Medicine at Guy’s Medical School. Whatever academic success Sir Terence had there was inevitably (and to this day) overshadowed by his captaincy of the Guy’s Hospital First XV Rugby Team in 1961, when he led the team that won the Rugby Inter-Hospital Cup. His establishment as a living legend (at Guy’s Hospital, at least) seems to have been assured from that moment on.
He qualified from London University in 1962 and began training – at first in general surgery and subsequently in cardiothoracic surgery. Surgical rotations brought him into contact with notable luminaries of the era, which included Donald Ross and Sir Russell Brock. After Fellowship exams, he completed cardiothoracic training at the Royal Brompton but took the opportunity to visit Christiaan Barnard in South Africa and spend a year with John Kirklin in Alabama. After he was ultimately appointed to Papworth and Addenbrooke’s hospitals, his main surgical interest became heart transplantation.
As a heart transplant pioneer, he overcame many challenges – public funding, public and professional fear and an ensuing press frenzy among them – to become the much-celebrated and renowned cardiac surgeon who, in 1979, performed the UK’s first transplant with long-term success.
But, instead of seizing the opportunity to fanfare his part in this incredible milestone, he warmly reflects on former patients, dedicated teams, his mother, four children and the invaluable support he received from all quarters to put others at the forefront of our conversation.
In the pantheon of medical pioneers, he is an unassuming interviewee. According to Sir Terence, the charismatic 52-year-old London builder Keith Castle, who enjoyed five-plus more years of life thanks to his life-saving transplant, was the PR powerhouse who piqued the public consciousness during the epoch of early human-to-human heart transplant surgery.
Sir Terence turns 91 this month (October 2023). Although sometimes hazy on specific dates (and rightly so, there have been so many of relevance), he is as passionate about heart transplantation as ever and cheerfully admits that as an early adopter and pioneer, the rules were there to be broken. With a moratorium imposed on the procedure in the UK at the time, Sir Terence ignored this national ban to perform his world-leading heart transplant operation on Castle at his base in Papworth Hospital. So inspired was he by the heart transplant programme at Stanford University in California, where excellent results were being achieved, he felt there was a great need to match it in the UK.
Back then, the procedure seemed unsavoury for many – some medical colleagues included – and it is a wonder that heart transplants developed as they did. A Wellcome witness seminar that reflected on early transplant surgery in the UK and took place at Queen Mary University of London in 1997, almost 20 years later, summed up the mood perfectly: ‘The first human heart transplant challenged human concepts of individuality and the place of mankind in the same way as did the first pictures of Earth as seen from outer space – powerful, laudable, technical achievements that strangely disturbed, distorted and disrupted the sense of self.’
But bringing this vision to fruition was never a ‘one-man band’. Sir Terence is keen to name those who went before him, including Christiaan Barnard, a fellow South African who performed the world’s first human-to-human heart transplant operation, and Donald Ross, another South African-born British thoracic surgeon who led the team that carried out the first heart transplantation in the UK in 1968.
Ultimately, the ‘team’ has always been the heartbeat of excellent clinical practice – something learned and remembered from diamond drilling on the African continent and beyond. Even the press officer at the time of Castle’s operation was instructed to talk about the ‘Papworth team’ rather than reference the surgeon himself – the legacy listed among his proudest achievements.
‘I realised very early on that this was not a one-man band as it had been with Chris Barnard in Cape Town and that I had to get people who were all involved and committed. I managed to build up a team at Papworth over about 18 months. They were top trainees who had seen what was happening and wanted to participate, so I could be very selective. I’d say: “Unless you are prepared to work as a team and not as an individual without reference to your immediate colleagues, we don’t want you.” This was a powerful message that resonated, and we became known as the Papworth team.’
Amid a scenario where there were few successful cases globally, and ethical concerns were rife within and outside the field, Sir Terence knew the consequences of not getting it right.
‘The chief medical officer put together the advisory panel, and they interviewed me to decide whether it was worth pursuing. I prepared very rigorously and was very surprised that things went so well. I left feeling that we’d taken a big leap forward. But then I got a letter from the chief medical officer saying, “Well done, English, you’ve done some good work but there is no money for a programme, and we don’t want to see any one-off transplants.” And that was that.’
Undaunted, Sir Terence decided to proceed with heart transplantation, beginning a challenging yet transformative period in his life.
‘People were very much against heart transplantation at the time, largely because Donald Ross, who I greatly admired, had done a transplant in London, which hadn't worked. And that was soon after Barnard’s first procedure. I only got on the scene five years later because it took me time to build up a proper team, which was vital. You've got to fill all the notches – great anaesthetists, immunology, histology and so on, and you have to project it to become acceptable.’
His first transplant operation, however, was a heart-wrenching setback, as the patient’s condition took a critical turn, while Sir Terence was removing the donor heart at a different hospital, forcing him to make a fateful decision. He proceeded with the transplant, but tragically, the recipient had suffered brain damage and never recovered consciousness.
‘The first one was a bloody disaster; it was so sad. My senior registrar, who was very good and had worked with me a lot, was with the patient at Papworth, and I was taking the heart out from the patient not very far away in East Anglia, and we communicated and so on. And then I got a phone call just as I took out the donor heart to say that our patient, Charles McHugh, arrested before they could even start anaesthetising him. They resuscitated him, but couldn’t determine whether he’d suffered brain damage. It was a tough decision but I knew this was his only chance. It was a difficult operation because he had high pulmonary vascular resistance, but it worked. The problem was he never woke up properly afterwards and we had to keep him on and off the ventilator. Inevitably, he got a lung infection and died after 12 days. And then the roof fell in.’
The demise of McHugh created a bit of a press circus, with criticism from all angles, including a particularly virulent column written by journalist Bernard Levin. Undeterred, Sir Terence carried on.
‘I went to see this wonderful woman in charge of medicine in the region around Addenbrooke’s, and I told her: “Listen, I want you to know. I will do two more transplants using my facilities at Papworth. If I can get funding after that, I will go on. If I can't get funding, I will stop”. And bless her, she supported us, thank goodness.’
But for Sir Terence, the second recipient was Keith Castle, who had a pivotal role in winning over sceptics. His resilience and personable character helped renew confidence in heart transplantation, while honed surgical skills did the rest. Castle became somewhat of a celebrity in the UK, and his willingness to raise the organ donation profile quickly captured the public imagination. All of which was hugely helpful to Sir Terence’s desire to push forward.
This propensity to champion others is a theme throughout our conversation and a laudable character trait. Paying tribute to those around him matters greatly, and one wonders if his early mining engineering experience shaped this attitude toward the ‘team’ concept.
That initial successful operation allowed him to grow Papworth into one of Europe’s leading heart and lung transplant programmes. It also paved the way for many subsequent accomplishments, including the first heart-lung-liver transplantation in the world in conjunction with Professor Roy Calne.
The path to establishing a successful heart transplantation programme could have been smoother. Sir Terence encountered resistance and competition. Nonetheless, he pushed forward with unrelenting determination, securing funding and support.
His autobiography, Follow Your Star: From Mining To Heart Transplants - A Surgeon’s Story, catalogues his unique career path and his recollections are littered with anecdotes about fellow surgeons, family life and his mother, whose influence was central to his developing a career in medicine.
A ‘remarkable woman’, he fondly recalls, she faced the challenge of raising two children under the age of four alone after her husband’s untimely death. Her unwavering support and belief in her son's pursuit of medicine left an indelible mark. Indeed, his mother seemingly predicted his path with extraordinary prescience shortly before his second MB exams in 1958 and just before she was killed in a car accident in South Africa.
In a letter published in his book, she writes: ‘But I – and everyone who loves you… will hold strongly to the conviction that you will not know failure, and that your lucky star will be shining strong and serene – even if it’s behind the fog and clouds of a London sky. Keep a clear head and a stout heart, and you will not fail.’
If he was to find a crumb of comfort in this tragedy, she did at least know that he was finally on his way to becoming a doctor.
Even now, Sir Terence is moved by the memory of her.
‘I'm so sad. She was young when she died. She never saw anything I achieved, but she knew I had gone back to study medicine and knew I would stick with it.’
A stand-out aspect of Sir Terence’s career is his commitment to educating and mentoring the next generation of surgeons. He takes great pride in the success of his trainees, who have all made significant contributions to the field of transplantation. For him, it is a source of immense satisfaction and fulfilment.
In his memoirs, he writes: ‘Certainly, I found the relationship between trainer and trainee to be one of the most rewarding aspects of my professional career, and it has been a great pleasure in retirement to see how many of our Papworth trainees subsequently achieve leadership positions within the speciality of cardiac surgery.’
Aware of the difficulties that many surgical trainees faced because of rapidly shortening surgical training programmes, Sir Terence intervened in the implementation of the 1991 New Deal for Junior Doctors in the UK to allow surgical trainees to work beyond the 72-hour limit (without compulsion or pay) to achieve the requisite surgical competencies. The exemption for surgical trainees from restricted training hours became widely known as the ‘English’ clause. Less than six years later (and despite widespread concerns within the profession), it was abolished by the Department of Health.
Sir Terence’s achievements extend beyond his surgical prowess. He has advocated for informed patient consent, ensuring that patients fully understand the complexities of heart transplantation before proceeding. He also highlights the critical role played by anaesthetists and the need to collaborate closely with them.
Sir Terence has held numerous roles throughout his career. These include Membership of the General Medical Council (1983-1989), President of the International Society for Heart Transplantation (1984-5) and President of the Royal College of Surgeons (1989-1992), President of the British Medical Association (1995-6) and latterly Master of St. Catherine’s College in Cambridge (1993-2000).
Despite these unrivalled personal awards and successes, he hopes his legacy will be that he has ‘projected the value and strength of teamwork as opposed to individual surgeons’.
And what of his professional heroes? There is no hesitation in his answer. ‘Dr John W Kirklin, one of my generation’s most influential cardiac surgeons, Sir Russell, later Lord Brock, who was a leading British chest and heart surgeon and one of the pioneers of modern open-heart surgery, and of course Donald Ross, who was a great guy,’ he adds.
As our conversation delves into the future of transplantation, Sir Terence acknowledges the ongoing research in xenotransplants and artificial hearts. He concedes that researchers worldwide are inching closer to solutions, although the artificial heart ‘remains a distant and difficult goal’.
Sadly, Sir Terence suffers from faltering eyesight due to age-related macular degeneration, which is a constant source of frustration for him and dramatically impacts two of his favourite passions – driving and reading. With his vision impaired, he can no longer get behind the wheel, but his love for cars is well-documented in his book. ‘If my vision were still okay, I’d still be driving. What would I have? I’d have a nice old Land Cruiser, and then I’d have something a little modern, something smarter.’
Regarding his other much-loved hobby, he relies on Lady (Judith) English to read to him. Luckily, they agree on most genres, but should one lose interest in a chosen book, they will happily abandon it to start a new one.
Lady English is the former Principal of St Hilda’s College, Oxford and has also enjoyed an impressive career. Interestingly, she drew much press attention when, under her leadership the Governing Body of Oxford’s last remaining women-only college voted to admit men. Together, the couple seem a spirited and indomitable force.
As I leave their home in the pretty Oxfordshire village of Iffley, Lady English welcomes a gift of Sir Terence’s ‘favourite bread’ from their next-door neighbour, the American folk singer-songwriter Peggy Seeger. It is an apt and quintessentially English scene.
A BBC Radio 4 programme plays on my journey home, and there is a discussion on transhumanism, the yearning for immortality and how merging humans with artificial intelligence is pretty close. ‘Post-human’ apparently is on the horizon for us all. It seems a fitting footnote to the day, and one wonders what Sir Terence would have to say about this so-called next evolutionary step. One suspects there would most definitely be mention of the power of pioneering collaboration and teamwork.
Julie Bissett
