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Daily transcripts
Hearing summary
25th May 1999
Today the Inquiry continued to hear evidence from Mr Graham Nix, current Deputy Chief
Executive and Director of Finance at the United Bristol Healthcare NHS Trust (UBHT) and an
executive director during the span of the Inquiry’s terms of reference. Today he
described the directorate structure at UBHT and commented on the lines of management
accountability. Mr Nix went on to discuss the role of clinical directorates and executive
directors in negotiating and writing contracts with purchasers of healthcare –
principally Avon Health Authority. He also described the arrangements with the
Supra-Regional Services Advisory Group in terms of funding for services and application
for funds for capital developments. Mr Nix then commented on the Bristol hospital’s
aim to increase cardiac surgical services, suggesting that paediatric cases were less cost
effective than adult cases because of length of time spent by the patient in the Intensive
Care Unit. In connection with this, he commented on the proposals to transfer all
paediatric cardiac surgery to the Bristol Children’s Hospital, thereby releasing the
BRI intensive care unit for emergency adult cases. He answered questions about the
de-designation of infant and neonatal cardiac surgery as a supra-regional service and said
that the implications in terms of future funding for the service were a matter of concern.
He concluded by discussing quality monitoring and clinical audit arrangements in terms of
their inclusion in contracts of service with purchasers of healthcare.
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FULL TRANSCRIPT
1 Day 23, 25th May 1999
2 (9.30 am).
3 THE CHAIRMAN: Mr Maclean, good morning. Perhaps I should
4 first deal with the application which was made last
5 evening, and then call on you, if I may.
6 MR MACLEAN: Yes.
7 CHAIRMAN'S STATEMENT
8 THE CHAIRMAN: I will just read out what we have agreed.
9 Let me repeat what was said yesterday morning,
10 that the Inquiry is only beginning its task of receiving
11 and hearing evidence on the subject of the local scene
12 here in Bristol, and specifically, upon the management
13 of paediatric cardiac surgical services.
14 We anticipate hearing evidence from a number of
15 perspectives or points of view, not least that of
16 Dr Roylance himself.
17 At this very preliminary stage we have all heard
18 Mr Langstaff say that nothing in the questioning of
19 a particular witness should have been thought to suggest
20 any predetermined view on the part of Inquiry counsel,
21 still less on the part of the Panel, and I emphasise
22 that once more.
23 It follows from this that in the course of this
24 Inquiry there will be ample opportunities to ensure that
25 any person is able to answer criticisms made of him or
0001
1 her.
2 It does not need to be done instantly. In the
3 case of Dr Roylance, he may submit comments or rebuttal
4 at any time, and he himself will, of course, be giving
5 evidence shortly.
6 Miss Powell's application was specifically for an
7 amendment to be made to our procedure whereby advance
8 notice of any criticisms of another person that may be
9 put to a witness should be given to the person who may
10 fall to be criticised, or his or her legal
11 representatives.
12 The Panel is not minded to grant that
13 application. It seems to us to be an excessively
14 elaborate way of doing what Inquiry counsel have already
15 sought to do in the spirit of co-operation.
16 Further, it seems to us that it is important that
17 the Inquiry should be able to explore potential avenues
18 of criticism with a witnesses, even in circumstances
19 when notice has not been given. It might not be
20 practicable to do so, perhaps because they arise out of
21 the comments of the witness when giving evidence, or
22 because questions arise out of the contribution of
23 another representative at the Inquiry, which may reach
24 Inquiry counsel at a very late stage.
25 The answer to any potential problem caused by
0002
1 that, as we have already indicated, lies in the fact
2 that we will be here for a considerable length of time,
3 sufficient to hear any comments or evidence in rebuttal.
4 Finally, it is open to every representative within
5 the parameters of the procedure that we have already
6 announced to ask himself whether any witness called or
7 from whom a statement has been received may have
8 evidence that would support the perspectives or view of
9 his clients, and if so, to ask Inquiry counsel to
10 explore that possibility.
11 It seems to us that use of that entitlement,
12 coupled with what counsel to the Inquiry have already
13 said about both their practice and their intentions,
14 should avoid this situation from arising again.
15 We hope, therefore, that this is satisfactory to
16 all concerned.
17 Mr Nix, you will forgive me for having dwelt on
18 that: it was important and I was grateful to Miss Powell
19 for raising it.
20 Mr Maclean?
21 MR GRAHAM NIX (recalled):
22 EXAMINED BY MR MACLEAN (continued):
23 MR MACLEAN: Mr Nix, you affirmed yesterday and we need not
24 go through that process again, but you are obviously
25 giving your evidence today on the same basis as you were
0003
1 yesterday. You understand that?
2 A. Yes, I do.
3 Q. Can I turn to the question of the directorates? This
4 was a key concept of the management structure of the
5 UBHT, was it not?
6 A. Yes.
7 Q. If we look in your witness statement at WIT 106/21, at
8 the foot of paragraph 43 you say:
9 "Management responsibility was devolved to the
10 directorates with the Clinical Director working like
11 a Chairman ... and the General Manager working as the
12 Chief Executive for the Directorate?
13 A. Yes.
14 Q. Then over the page you set out the various
15 directorates. Can you just explain which directorates
16 would be involved in the delivery of paediatric cardiac
17 surgery as at April 1991?
18 A. Surgery, because cardiac surgery was part of the
19 surgical directorate at that time, and children's
20 services, because at that time we would have had closed
21 heart surgery at the Children's Hospital and cardiology
22 at the Children's Hospital.
23 Q. So children's services would embrace paediatric
24 cardiology at the Children's Hospital?
25 A. Yes.
0004
1 Q. And closed heart operations at the Children's Hospital?
2 A. Yes.
3 Q. But open heart operations, adult and paediatric, would
4 fall within the Directorate of surgery?
5 A. Yes.
6 Q. And that had, as an associate directorate, cardiac
7 surgery?
8 A. Yes.
9 Q. But other directorates would be involved as well as, for
10 example, anaesthesia?
11 A. Yes, and radiology.
12 Q. This pattern, I think, has been described as being on
13 the John Hopkins medical school structure of management
14 as a directorate system. Were there any other
15 structures of management that were considered for
16 potentially being applied to the Trust?
17 A. Not that I am aware of, no.
18 Q. Where did the genesis of this particular structure come
19 from? Whose idea was it to apply it to the Trust?
20 A. It would have come from John Roylance as the Chief
21 Executive.
22 Q. Did you have any discussions with Dr Roylance about the
23 appropriate management structure which was to be in
24 force after April 1991?
25 A. We must have had some discussions. I do not recall
0005
1 any. I am sure it was not about whether or not we had
2 directorates or not; it was more probably about how many
3 directorates we had and what services and how they might
4 be structured. We must have had those discussions, but
5 I do not recall them now.
6 Q. You do not recall the content of them?
7 A. No.
8 Q. So would it be fair to say that from a very early stage
9 it had been decided by Dr Roylance, and I think it is
10 your evidence, that the management structure would be
11 based on these directorates, and that that was
12 thereafter taken essentially as a 'given'?
13 A. Yes. I think there were two areas of discussion I do
14 recall. One was about community as a directorate, and
15 the other was how many directorates would be within the
16 field of mental health, psychiatry as it is listed here,
17 because I recall there was some issue over whether we
18 would have a directorate for the elderly acute or not.
19 Q. This general pattern of devolving power to directorates
20 as it were chaired by a Clinical Director and with the
21 Chief Executive, as it were, of the directorate being
22 the General Manager, was that a structure that was
23 replicated in other Trusts in the area, acute Trusts?
24 A. Within acute Trusts, clinical directorates was
25 a structure that was being created. I think people had
0006
1 different arrangements with regard to the status of the
2 Clinical Director in it, in that within UBHT the General
3 Manager was accountable to the Clinical Director and the
4 Clinical Director accountable to the Chief Executive,
5 and some of the Trusts at that time, the General
6 Managers would be accountable to Chief Executives.
7 Q. So to the extent that the reporting line for the General
8 Manager of the Directorate was to the Clinical Director,
9 and from Clinical Director to Chief Executive, that
10 suggested that this structure was an attempt to devolve
11 more power to the Clinical Director than some other
12 examples of the same basic structure?
13 A. Yes. You have to recognise that UBHT was, I think, the
14 seventh largest Trust in the country at that time and
15 has been for a number of years. It is only recently
16 where there have been mergers that there are now
17 a considerable number of larger Trusts and some of these
18 directorates were as large as some Trusts, so it was
19 only right that they should have a significant amount of
20 delegation and as you can see, the range of services
21 provided are quite different.
22 Q. And the Clinical Directors, who I think you told us
23 yesterday were appointed by Dr Roylance --
24 A. Yes.
25 Q. -- they were all at the time of their appointments in
0007
1 post as clinicians at whatever hospital was appropriate?
2 A. Yes.
3 Q. They were not brought in from elsewhere?
4 A. No.
5 Q. Was there any discussion as to whether or not people
6 might be brought in from elsewhere to bring a different
7 perspective?
8 A. Not that I can recall, no. It was about having
9 a clinician who understood the service that was being
10 provided, and how it was provided.
11 Q. You have told us about the reporting line from the
12 General Manager of the Directorate to the Clinical
13 Director. Take something like cardiac surgery which
14 involves a team approach. You have already explained
15 the different directorates that would be involved in
16 actually carrying out an open heart operation,
17 particularly on a child who may have come from the
18 Children's Hospital originally and perhaps goes back to
19 the Children's Hospital subsequently.
20 A. Yes.
21 Q. If something goes wrong, if there is some systemic
22 failure, let us assume, in the delivery of cardiac
23 services or some other type of surgery, how would the
24 different directorates be able to collectively
25 investigate and put matters right?
0008
1 A. The staff within each of the directorates are working
2 together all of the time, so certainly I would expect
3 them to work together to resolve any issues that are
4 occurring, and if necessary, for the Clinical Directors
5 to meet to review the issues and to find the way
6 forward. Clearly, if that did not work, then I would
7 expect that to come up to the Chief Executive.
8 Q. Let us take a purely hypothetical example --
9 I emphasise, purely hypothetical -- of a junior surgeon,
10 a trainee surgeon, who thinks that there is something
11 wrong with the practice of anaesthesia in the theatre.
12 Would that junior surgeon look to the General Manager of
13 Surgery or the Clinical Director of Surgery, or would he
14 or she be in a position to go to the Clinical Director
15 of Anaesthesia, the General Manager of Anaesthesia? How
16 would they go about bringing their concerns to the
17 attention of more senior people?
18 A. I do not know, is the truth of it. But I know what
19 I would have expected to have happened, which is for
20 them to have had a discussion at the level of the team
21 providing the care, and then, as I have said, to raise
22 it within, if it is a junior surgeon, I would expect
23 that person to raise it with their consultant.
24 Q. The consultant surgeon?
25 A. Yes.
0009
1 Q. And the consultant surgeon would take it to the Clinical
2 Director of Surgery?
3 A. Or to have a discussion with the anaesthetist. I think
4 that you have to recognise that clinical directorates
5 were about managing the organisation, but that flowing
6 sort of horizontally across this was a lot of contact
7 between all of these groups, and I would have expected
8 a conversation to have gone on at that level.
9 Q. These directorates had their own finance input and their
10 own personnel input?
11 A. Yes. They shared finance. There are three senior
12 finance people supporting all of these directorates so
13 they have a number of them each.
14 Q. Personnel would embrace ...
15 A. For some of the personnel, some of these directorates,
16 they would have their own personnel support, and for
17 others, they would have a personnel officer supporting
18 a number of directorates. There was not enough to give
19 one each to each one.
20 Q. Let us change my hypothetical example and assume there
21 is a problem which is purely confined within
22 a particular directorate, it is not a question of
23 a junior surgeon spotting something wrong with
24 anaesthesia, but a junior surgeon spotting something
25 wrong with surgery, to change the example. Might there
0010
1 not be a danger with having separate directorates that
2 problems would be too easily confined within their own
3 box rather than brought to general attention?
4 A. There could be that situation, but the aim was that
5 people would talk together. All health care is a team
6 delivered and we certainly would not have wished the
7 directorates to get involved or to become chimneys of
8 their own. If there were difficulties, then I would
9 have expected that to be raised at the monthly meetings
10 of Clinical Directors with the Chief Executive, or the
11 Senior Managers meeting.
12 Q. So if there is a problem in, to use your word, one
13 "chimney", the way in which that becomes more widely
14 known across the Trust depends on the relevant Clinical
15 Director bringing the matter to the attention of the
16 Chief Executive?
17 A. Or raising it with the other Clinical Director, yes.
18 Q. But it would be a rare problem, would it not, which the
19 Clinical Director would want to share to another
20 directorate without bringing to the attention of the
21 Chief Executive?
22 A. No, I do not think that is the case. I think that they
23 will make comments, and comments have been made
24 previously between directorates. I think that some
25 people might have classed it as the last stage, to have
0011
1 taken it to the Chief Executive, because they have not
2 been able to resolve it locally.
3 Q. Now --
4 A. By the way, whatever was on my screen has now
5 disappeared.
6 Q. Let us have another screen.
7 THE CHAIRMAN: I will bring it back, I apologise. I took it
8 off so we could just concentrate on the question.
9 MR MACLEAN: The system now is that there is a Director of
10 Cardiac Services?
11 A. Yes.
12 Q. So this structure at the page we were looking at has now
13 been altered?
14 A. Yes.
15 Q. How does paediatric cardiac surgery now fit into the
16 directorate structure?
17 A. Now, at this date, today?
18 Q. Yes.
19 A. Then all open and closed cardiac surgery and paediatric
20 cardiology is provided through the children's services.
21 Anaesthesia is still provided from the Directorate of
22 Anaesthesia and radiology through radiology, and
23 currently obviously we have a Cardiac Services
24 Directorate in the Royal Infirmary which includes
25 cardiology and adult cardiac surgery.
0012
1 Q. Just looking at your witness statement at paragraph 46,
2 page 23, in the last sentence there cardiology had
3 previously been included in the Directorate of
4 Medicine. Should that be adult cardiology?
5 A. Yes, it should be.
6 Q. The original plan was that these directorates would be
7 given their own budgets and would negotiate their own
8 contracts with purchasers?
9 A. They would have their own budgets and they would be
10 involved in the discussions with purchasers. They would
11 be involved in the negotiation, but clearly, as a Trust,
12 I would personally be involved in many of these
13 discussions to make sure that we balanced financially,
14 so they could not go off and do their own thing
15 completely.
16 Q. If we look at paragraph 48, just turning down, you say
17 that individual directorates were generally involved
18 with either attending meetings with purchasers or
19 responding to requests. Directorates, clinicians and
20 managers, the General Manager and the Clinical Director,
21 were involved directly in discussions with Avon Health
22 Authority, but for the non-Avon purchasers, the only
23 directorates represented on a regular basis were cardiac
24 and children's.
25 Then there is a qualification about the Oncology
0013
1 Director in Somerset?
2 A. Yes.
3 Q. Forget for a moment about cardiac and children. Why was
4 it that the clinicians and managers would be involved in
5 discussions with Avon Health but not with other
6 purchasers?
7 A. The majority of services provided by UBHT were for the
8 local population and the purchaser for that was clearly
9 Avon Health. The only people who would know in detail
10 how we provided services and our capacity to provide
11 services were the clinicians and the managers involved
12 in those relevant areas. So we always had meetings
13 special for each directorate with Avon Health to discuss
14 the problems, capacity and ideas from the directorates
15 to develop their services.
16 So they had to be involved there.
17 With the non-Avon purchasers, we could not -- we
18 would have taken our clinicians and managers away from
19 doing their job of providing services if we had included
20 them in all of the discussions with purchasers, because
21 there were too many. For the majority of them, they
22 were not major suppliers of services to non-Avon
23 purchasers, apart from cardiac and children's.
24 Q. What was special about cardiac and children's services?
25 A. Children's services provided services really to every
0014
1 Health Authority in the South West region and beyond, so
2 it went into as it is now the South Western region, so
3 it provides services in Dorset, Wiltshire and over into
4 Wales, and cardiac in a similar way but it did not have
5 quite the same range as we saw yesterday. Very few
6 patients came from Cornwall and Plymouth to Bristol, so
7 cardiac would not have been involved in those
8 discussions.
9 Q. So would it follow that the General Managers of cardiac
10 and children's services and the Clinical Director of
11 cardiac and children's services were significantly more
12 heavily involved in discussions with other purchasers,
13 other than Avon, than were other General Managers or
14 Clinical Directors?
15 A. Yes.
16 Q. So there would be a greater demand on their time in
17 travelling around the region, talking to purchasers,
18 than would be the case with others?
19 A. Yes. You are talking about possibly 4 to 8 other
20 meetings a year.
21 Q. If we go over the page to page 24, paragraph 49, you
22 say:
23 "In the main contracts were agreed by individual
24 directorates before they were signed by the Chief
25 Executive."
0015
1 Are we to draw a distinction between the phrase
2 "agreed by" and "negotiated by"? Is what you are
3 getting at here that the contracts for most directorates
4 would be drawn up and would then be approved by the
5 individual directorates before formally being signed by
6 the Chief Executive?
7 A. Yes. The reason for the use of the words was that, yes,
8 they would be involved in the discussions with the
9 purchasers, and in some context you could call that
10 negotiating, where they would give a bit of additional
11 volume in exchange for additional cash. But at the end
12 of the day, with Avon in particular, you would have to
13 broker a deal, taking into account the volumes that had
14 been agreed for the individual directorates, but we
15 needed to make sure we were picking up such issues as
16 inflation, funding, changes in National Insurance and
17 other things, that we needed to bottom out for the whole
18 of the Trust.
19 So at the end of the day, we would have had
20 a high-level discussion between the Chief Executive, the
21 Finance Director of UBHT, the Director of Operations and
22 Avon Health's Chief Executive, Financial Director.
23 Q. So that would be from the Trust point of view yourself
24 and Mrs Maisey?
25 A. Yes. We took a lead in the early 1990s on the
0016
1 contracting.
2 Q. And on the Health Authority side, it was then the
3 Bristol and District Health Authority?
4 A. Yes. It would have been Deborah Evans, Pam Charlwood,
5 I cannot remember the name of the Chief Executive
6 preceding Pamela Charlwood, and Bill Healing.
7 Q. And Deborah Evans I think had the title of Contracts
8 Monitoring Officer?
9 A. Director of Contracting.
10 Q. Mr Ross in his evidence last week described the
11 directorates as being "semi-detached". He accepted,
12 I think, that that was a fair expression -- page 21 of
13 his evidence. Would you agree with that
14 characterisation of the directorates?
15 A. It was described sometimes that UBHT was like
16 a "holding company" with individual directorates
17 operating as elements beneath that holding company.
18 Q. Is that another way of saying "semi-detached"?
19 A. Yes.
20 Q. Are those directorates more or less semi-detached now
21 than they were in 1991?
22 A. They are less semi-detached now. They still have
23 responsibility for delivering their contracts and their
24 financial targets, but the requirements on the NHS have
25 changed over time and there is a lot more central
0017
1 control.
2 Q. Central control coming down from the top of the Trust
3 management structure?
4 A. Yes.
5 Q. Is that a change, in your opinion, for the better or for
6 the worse?
7 A. I think that we needed to change the way that we managed
8 the Trusts so that we were able to meet the changing
9 demands of the NHS. The requirements on us to report
10 nationally had changed quite significantly. There are
11 very specific targets placed on the Trust now in terms
12 such as waiting times and we needed to make sure that
13 was managed properly.
14 Q. What type of change, what kind of difference in approach
15 was it that was coming through the National Health
16 Service that necessitated these changes?
17 A. If you look back at 1991/92, there were no rules set up,
18 really, nationally. We had guidance about the National
19 Health Service and what we were trying to achieve, but
20 how we achieved it was very much left to individual
21 Trusts. As we have moved on through the 1990s, the
22 prescription from the centre in the issuing of executive
23 letters, giving us direction on issues, has increased:
24 we are getting more and more letters of direction.
25 Q. Is that a pattern that was apparent before the change of
0018
1 government?
2 A. Yes.
3 Q. What, if anything, has been the change since the change
4 of government?
5 A. Since the change of government obviously we have a new
6 system, not quite the same as in 1991, but still quite
7 radical in its effect. So we are getting more and more
8 executive letters now than I can ever remember, and
9 a lot more targeted investment that we have to respond
10 to.
11 Q. Is one of the effects of those changes that acute Trusts
12 across the country now have more similar structures than
13 they did back in 1991?
14 A. I am sure there are a lot of similarities between the
15 structures. I think some of it depends on how your
16 facilities are structured as well, but, yes, there is
17 a lot of similarity now. I am not quite sure how much
18 that has changed now from the early 1990s, because
19 I believe then that most people had gone down the
20 clinical directorate route.
21 Q. Is it still the case that the General Manager of the
22 Directorate is accountable first and foremost to the
23 Clinical Director or is there now a more direct line
24 between General Manager of the Directorate and Chief
25 Executive of the Trust?
0019
1 A. General Managers are still accountable to the Clinical
2 Directors. I think there is a stronger link between the
3 Chief Executive and the Clinical Directors, as we have
4 had to, and there is a strong link with General
5 Managers. There has to be a strong link.
6 Q. Let us look, then, back at who was who in the UBHT at
7 the start of Trusts. If we go, please, to UBHT 23/671,
8 this is the note of a meeting, as opposed I think to
9 minutes of a meeting, of the prospective members and
10 officers of the United Bristol Healthcare Trust held on
11 7th December 1990. We see your name there.
12 If we go to 672, if we just scan down:
13 "Mr Graham Nix, the Financial Manager, commented
14 that the United Bristol Healthcare Trust was one of 14
15 out of 56 awarded Trust status earlier this week."
16 So Trust status had just been confirmed and it was
17 going to go live from April 1991?
18 A. Yes.
19 Q. At the foot of the page:
20 "Mr Christopher Dean Hart, Chairman of the
21 Hospital Medical Committee, commented that what Mr Nix
22 had said made it easier for him to commend Trust status
23 to his colleagues. They were at the forefront with the
24 public and were the most expensive employees ...(673) Their
25 first consideration was for the quality of care they
0020
1 gave and secondly for costs. The medical staff are
2 considerably influenced by the advice they receive from
3 the learned Royal Colleges and their Trade Union, the
4 BMA."
5 So the Trust having been confirmed, the inaugural
6 board meeting, I think, took place on 2nd January 1991.
7 That is UBHT 23/603. We see the non-executive directors
8 are named on the left-hand side and then the executive
9 directors of the Trust are the first five names on the
10 right-hand side, going down to Mr Stone.
11 A. The Executive Directors with voting rights are the first
12 five.
13 Q. Yes, I think there had been a debate as to whether the
14 final voting member should be Mr Stone as Personnel, or
15 Mr Boardman as Development. In the end, they both went
16 to Mr Stone?
17 A. Yes.
18 Q. This really reflects paragraphs 34 to 38 of your
19 statement. We need not, I think, go into it in any
20 greater detail. If we look at UBHT 296/009, sorry to
21 inject a little law into proceedings, that is the
22 statutory instrument, that is the Establishment Order
23 for the UBHT, and we see that it was made on
24 4th December 1990. It came into force on
25 21st December. If we scan down, 2:
0021
1 "There is hereby established an NHS Trust which
2 shall be called the United Bristol Healthcare National
3 Health Service Trust."
4 A. Yes.
5 Q. If we look over the page (10), the functions at the top of
6 the page:
7 "To own and manage hospital accommodation ...
8 at the Bristol Royal Infirmary" and associated
9 hospitals. There was to be a Chairman, paragraph 4(1),
10 5 non-executive directors and 5 executive directors?
11 A. Yes.
12 Q. The operational date was to be 1st April 1991,
13 paragraph 5(1).
14 That was the legal green light for the Trust. You
15 were at this time the acting Treasurer of the Health
16 Authority following the departure of Mr Parr?
17 A. Yes.
18 Q. If we go in your witness statement -- we do not need to
19 go to it. Your witness statement explains that the main
20 players in the Trust were the Chief Executive, John
21 Roylance, the Personnel Director, Ian Stone, you were
22 the Director of Finance, Mr Wisheart was the Medical
23 Director replacing Mr Dean Hart who was initially
24 Medical Director?
25 A. That was after the first 12 months of Trust status.
0022
1 Q. Yes. Mrs Maisey was Director of Operations, and
2 Mr Boardman we have seen was in charge of Development?
3 A. Yes.
4 Q. The Health Authority at the same time had obviously
5 changed its structure in response to the
6 purchaser/provider split. If we go to WIT 38/79, and
7 turn it round, that is the structure, is it not? That
8 is what I think you had in mind a moment or two ago. We
9 see it is dated on the left-hand side 10.4.91.
10 A. Yes.
11 Q. So this would be the structure of the Health Authority
12 at the inception of the Trust, and the part of this
13 which is relevant for our purposes, we have the District
14 General Manager acting, because Dr Roylance has gone off
15 to be Chief Executive of the Trust?
16 A. Yes.
17 Q. The Treasurer was Mr Healing, so he would be your, as it
18 were, opposite number?
19 A. Yes. He was the Finance Director of Frenchay and he was
20 appointed I think in March 1991.
21 Q. And the other people relevant for our purposes is
22 probably Miss Evans?
23 A. Yes.
24 Q. Whose title was Director of Contracting?
25 A. Yes.
0023
1 Q. Can I go back in time a little, UBHT 249/1, this is
2 a meeting of the Health Authority on 25th February
3 1991. We see that you attended this because you were
4 a member of the Health Authority?
5 A. Yes.
6 Q. And various other familiar names either as observers or
7 attenders. If we scan down a little under "Chairman's
8 remarks", Mr Bill Healing had been appointed to the post
9 of Director of Finance?
10 A. So it is February not March, as I said just now.
11 Q. If we go, please, to page 3, I think the bottom of the
12 page:
13 "The Chairman reported that Professor Stirrat..."
14 Who was he, or is he?
15 A. The Professor of Obstetrics and Gynaecology at
16 St Michael's Hospital, a University employee.
17 Q. "... had written to say that he had been completely
18 reassured that the quality of the surgery involved in
19 the waiting list initiative was satisfactory following
20 his comments in the last meeting. Mr Wisheart reported
21 that a thorough (4) investigation had taken place and not
22 a shred of evidence had supported Professor Stirrat's
23 informant."
24 Do you remember the context of that discussion?
25 A. No. Is it possible to go back to the previous minutes?
0024
1 Q. Not at the moment, I am afraid. You do not recall the
2 context of that discussion?
3 A. I am sorry, no.
4 Q. But it would seem at all events as though Professor
5 Stirrat had put something in writing and Mr Healing had
6 responded?
7 A. It seems it was raised at the previous meeting.
8 Q. The Trust obviously has standing orders and standing
9 financial instructions as well?
10 A. Yes.
11 Q. I do not want to dwell on those too much, but can I just
12 go briefly to UBHT 8/730?
13 These are the standing financial instructions and
14 if we look at the bottom of the page, this version
15 actually is the revision from 1994. Perhaps you can
16 help me as we go along as to the extent to which there
17 is any material change since 1991?
18 A. The standing financial instructions, very little. We
19 used the Health Authority financial instructions for the
20 first three months, and then I revised them and they
21 basically stayed as written until 1994. Then they have
22 been amended each year since, just marginally.
23 Q. That is very helpful. Can we go to 732, paragraph 1.5?
24 Paragraphs 1.5 to 1.9 explain your role, do they
25 not? Perhaps you would just have a look through them.
0025
1 A. Yes. I do not know them off by heart, but yes.
2 Q. Can we go to 734? 3.3 to 3.5:
3 "Service budgets are to be compiled by managers
4 within guidelines and policies set by the Board." It is
5 your job to co-ordinate the preparation of the overall
6 budget within the total income received by the Trust?
7 A. Yes.
8 Q. And you are the person who requires officers to provide
9 the statistic and other information for comparing
10 budgets and forecasts?
11 A. Yes.
12 Q. "The Chief Executive can delegate the management of
13 budgets for defined services to the officers responsible
14 for the performance of those services", so that would be
15 the Clinical Director?
16 A. Yes.
17 Q. And obviously they are to exercise control of their
18 budgets in accordance with the rules.
19 If we go to 736, 4.2 to 4.4, your job is to
20 prepare, certify and submit the annual accounts which
21 statute imposes an obligation on the Trust to send to
22 the Ministry?
23 A. Yes.
24 Q. You submit returns as the Secretary of State demands?
25 A. Yes.
0026
1 Q. Then section 21 of these financial instructions deals
2 with standards of business conduct.
3 Can we go to 745 and can we go on a bit to 765?
4 Keep going, please.
5 Page 8/772, "Standards of Business Conduct". If
6 we scan down that page and go over a couple of pages,
7 please, to 774, the foot of the page, and again over the
8 page (775), please, 21.17 and 21.18, "Commercial
9 in-confidence":
10 "Staff should be particularly careful of using or
11 making public internal information of a commercial
12 in-confidence nature particularly if its disclosure
13 would prejudice the principle of a purchasing system
14 based on fair competition."
15 Then 21.18, perhaps you would read that to
16 yourself.
17 Are those the rules that have applied to
18 commercial in-confidence matters for employees of the
19 Trust since April 1991?
20 A. Yes.
21 Q. And those are to be read, are they not, alongside the
22 guidance given by central government about the so-called
23 "whistle-blowers' charter"?
24 A. Yes.
25 Q. Can I turn, then, to supra-regional services, and I hope
0027
1 fairly briefly. You deal with that in your witness
2 statement at 106/5. We need not go to that. Can we go
3 to UBHT 278/579? This is data which I think you
4 compiled as long ago as 1984, I think it is. If we
5 could just see the whole page, please, we see the
6 handwriting at the bottom of the page. Is that yours?
7 A. Yes.
8 Q. If we just highlight that, the third asterisk:
9 "Information supplied by Mr Wisheart's secretary,
10 21.5.84."
11 If we scan up the page again, we will see where
12 that comes from.
13 A. Yes.
14 Q. It comes from the figure 3, does it not: number of
15 operations performed, open heart, actual, 1983 to 1984
16 was 3?
17 A. Yes.
18 Q. That is on open heart surgery, on under 1 year old
19 children?
20 A. Yes, at the BRI.
21 Q. And the estimate for 1984 to 1985, 12 to 20, where would
22 that come from?
23 A. Mr Wisheart.
24 Q. From the same source as footnote 3?
25 A. Yes. It may well have included the discussion with Hyam
0028
1 Joffe.
2 Q. The cardiologist?
3 A. Yes.
4 Q. Can you help us with the handwriting, "7 days, LOS"?
5 A. Length of stay, then to BCH, so I must have asked how
6 long would these children remain in hospital because
7 I would have had to have created costs, and that was the
8 data I was given.
9 Q. We will see that in just a moment. In your statement
10 you refer to the first document you had on file as being
11 one of 17th April 1984 which refers to Bristol having
12 already been designated a supra-regional centre.
13 Can you for your part shed any light on why
14 Bristol was originally designated?
15 A. I am sorry, no.
16 Q. You were not involved in that?
17 A. No. I had a copy of the letter from the Regional Health
18 Authority asking for information.
19 Q. Were you aware of any application having been made to
20 the Department of Health for supra-regional status to be
21 granted to Bristol?
22 A. Not for neonatal and infant cardiac surgery. I can
23 recall working with a number of other groups to make
24 applications in future years, but not for this one.
25 Q. When such applications were made, were they the sort of
0029
1 applications that you had an input into?
2 A. Yes.
3 Q. So if there had been an application in about 1983 for
4 supra-regional status, what type of financial input
5 would there have been and from whom?
6 A. Well, I joined Bristol & Weston Health Authority in June
7 1983. The person I took over from for the expansion of
8 cardiac surgery for the first 100 cases from 275 to 375
9 was a gentleman called Mr John Light, so whether he had
10 an involvement in it, I do not know, but I do not
11 certainly recall personally being involved.
12 Q. I know, Mr Nix, that you have kept copious files, for
13 which we are most grateful, but so far as you are aware,
14 there is nothing on file relating to an application for
15 designation as a supra-regional centre?
16 A. No. There is one file with all the supra-regional
17 documents in for the Finance Department and there is
18 nothing prior to that letter, I mentioned in my
19 statement.
20 Q. That letter I think is 17th April 1984. Its reference
21 is UBHT 278/577. Do you suspect or know that there was
22 an application, a formal application, made to the
23 Department of Health?
24 A. I do not know. I think that supra-regional services,
25 these were probably the first ones that were designated,
0030
1 I assume, and therefore whether or not people were asked
2 for an application or not, I am not clear. After that,
3 there was a proper application system and we would have
4 had a Working Group working on it.
5 Q. Certainly those who would be involved in an application
6 for designation as a supra-regional centre for neonatal
7 and infant surgery would include at the very least
8 paediatric cardiologists and the paediatric cardiac
9 surgeons?
10 A. Yes.
11 Q. So perhaps we might more usefully ask them?
12 A. Yes.
13 Q. Can I go to UBHT 62/49?
14 This is your estimate of neonatal and infant
15 cardiac surgery expenditure for 1983/84. That is your
16 writing again, is it not?
17 A. Yes.
18 Q. If we look down the page, please, to the Bristol Royal
19 Infirmary, three patients during 1983, length of stay
20 varied from 3 to 9 days?
21 A. Yes.
22 Q. And the operating times were all between three and
23 four hours?
24 A. Yes.
25 Q. So the prices that you calculated would be based upon an
0031
1 average taken from those three cases and the operating
2 times from the previous year; that is all you had to
3 work on?
4 A. That is all I had, yes. Can I say that the figure in
5 the bottom right-hand corner of œ705,000 was
6 over-estimated and it was recalculated on subsequent
7 pages within the document, because the length of stay
8 was over-estimated. That is not that length of stay,
9 which is clearly actual, but some of the others.
10 Q. I think this estimate was based on 3 and a half hours
11 operating time?
12 A. Yes.
13 Q. So that type of information would have come from the
14 surgeon's log or from the surgeons themselves, as to
15 operating time?
16 A. Yes, or from the theatre register. I cannot remember
17 which.
18 Q. The Regional Health Authority every year would send
19 forms to you to be filled in for onward submission to
20 the Supra Regional Services Advisory Group?
21 A. Yes.
22 Q. And I think we mentioned Mr Joomun yesterday?
23 A. Yes.
24 Q. He was the District Statistical Officer and for example
25 in 1985, you passed the form on to him and asked him to
0032
1 pull together the data?
2 A. Yes. Well, various. I would always want the forms to
3 come back to me so as I could check from year to year
4 and have a discussion with Mr Wisheart and Dr Joffe
5 about their estimates for -- the form required actual
6 for the previous year, estimate for the year you were in
7 and a forecast for the future year, which clearly
8 Mr Joomun could not do.
9 Q. Was there any difficulty in obtaining the necessary
10 information?
11 A. Yes.
12 Q. Why?
13 A. We had to get people to concentrate on it.
14 Q. Which people?
15 A. Both to get the information out from Mr Joomun and to
16 create time to see Mr Wisheart and Dr Joffe.
17 Q. Can we can to UBHT 278/473.
18 This is a memo from Dr Baker, who was the District
19 Medical Officer, I think, to you?
20 A. Yes.
21 Q. If we just scan down and pick it up in the paragraph now
22 at the top of the page:
23 "There is an additional central pre-emption of
24 œ15,000 ... the letter contains advice with regard to
25 the capital implications of supra-regional services and
0033
1 allows for applications to be made for such capital
2 allocations for the financial year 1987/88."
3 Just pausing there, as you understand it, the
4 position was that in the early days of supra-regional
5 services, only revenue funding not capital funding was
6 available; is that right?
7 A. No. I cannot recall whether there was capital in the
8 early days. All of my submissions were related to
9 revenue. Whether there was any capital, I cannot recall
10 that, but clearly it has come into play here.
11 Q. It is certainly available from 1987/88?
12 A. Yes.
13 Q. "Dr Baker said it may be we have missed the boat having
14 committed capital at the Children's Hospital for the
15 cardiological aspects of neonatal and infant cardiac
16 surgery."
17 That is a reference to the cath' lab?
18 A. Yes.
19 Q. "But arguably some part of the capital requirement for
20 the cardiac surgery developments in the BRI could be
21 made in respect of the neonatal and infant workloads."
22 He suggests there might be liaison with the
23 regional treasurers and planners.
24 Do you remember if that was followed up?
25 A. I would imagine it would be, but from Bristol & Weston
0034
1 Health Authority's point of view, the Regional Health
2 Authority had provided the capital and revenue to us to
3 allow this development to proceed, so the key here,
4 really, is can the region get any of its money back that
5 it has invested from the region's allocation from the
6 supra-regional system? I am sure we must have had
7 a discussion about that once the issue had been raised.
8 Q. Do you remember if any application for capital funding
9 was ever made by Bristol to the Supra Regional Services
10 Advisory Group?
11 A. I did not think we had ever made a submission, but
12 I have subsequently found out that a discussion and an
13 outline submission was made in June 1992.
14 Q. What was the outcome of that?
15 A. We did not get any capital, so I assume that it was
16 rejected in some way.
17 Q. It was rejected, I think, because the bid was
18 incomplete?
19 A. Well, up until Friday evening of last week, I was not
20 aware that we had made a submission. There were no
21 papers in any of my files related to this yet you had
22 mentioned something to me and I spoke to Kate Orchard,
23 the Manager of Cardiac, and she said she was asked about
24 it at the GMC, and on Friday I spoke to Mr Wisheart and
25 asked did he know anything about it, and on Friday
0035
1 evening I saw a copy of a paper that had been submitted
2 in 1992 -- in fact I saw two papers. The first was one
3 that I had written which was what work would need to be
4 undertaken to make a submission, and that was dated
5 9th June, and then, about a fortnight later, the very
6 short paper had been submitted. It was sent down under
7 a compliments slip from Dr Joffe and on that compliments
8 slip it indicated that Mr Owen had suggested that an
9 application should be made and that the application that
10 had been sent in was an interim statement. I do not
11 recall being involved. I cannot remember anything about
12 it, and there is nothing on the files, but clearly, the
13 document is not extensive in its content.
14 Q. Just unpicking some of that, would it surprise you that
15 a bid for capital funding had been made to the Supra
16 Regional Services Advisory Group in 1992 when you were
17 Finance Director of the Trust without you knowing
18 anything about it?
19 A. Yes. Or for me to not recall doing it, or have anything
20 on file, I find surprising.
21 Q. Having now learned a little more about the situation,
22 are you satisfied that you did not in fact have anything
23 to do with the application that was made?
24 A. I know that I wrote the paper, because my name is on the
25 bottom. This is the paper which said what we would need
0036
1 to do to make a proper application. But I do not recall
2 anything to do with the submission that was actually
3 made. It was in effect committing the Trust to putting
4 capital into a scheme. I would certainly have recorded
5 it if the Trust Board had agreed to commit capital to
6 this scheme, and it certainly did not.
7 Q. You have seen the paper submitted by Dr Joffe and I have
8 not, and I do not think the Inquiry has.
9 A. Well, I had not until Friday evening, and at that time
10 I had not gone through the files of the papers that had
11 been suggested you might be referring to today, so I was
12 not sure anything was in there or not, so I did not ask
13 for a copy.
14 Q. You were shown the paper by Mr Wisheart last week?
15 A. Yes, I went to his home on Friday evening.
16 Q. Was the document handwritten by Dr Joffe, or typed and
17 signed by Dr Joffe?
18 A. No, it was a typed document. It was a handwritten
19 compliments slip.
20 THE CHAIRMAN: May I interrupt just for a second? You said
21 the Inquiry has seen it or has not seen it?
22 MR MACLEAN: I have not myself seen it. We are checking
23 whether the Inquiry has it on the database.
24 A. I am sorry, Chairman, it was because I was... This was
25 raised with me and I could not recall it as to why
0037
1 I actually went investigating to see whether I could be
2 helpful today.
3 MR MACLEAN: I myself was first aware of this document
4 yesterday morning when Mr Nix mentioned it. We have not
5 yet uncovered whether we have, but we do not obviously
6 have it.
7 THE CHAIRMAN: Thank you. Forgive me for interrupting.
8 MR MACLEAN: Was there any other application for capital
9 funding made before 1992?
10 A. Not that I am aware of, that I can recall.
11 Q. You suggested in your answer earlier that Mr Owen had
12 apparently, so you understand, suggested that the
13 application might be made?
14 A. Yes, I believe that was actually written on
15 a compliments slip from Dr Joffe.
16 Q. So it would appear, would it, that Mr Owen had suggested
17 that to Dr Joffe, and perhaps to Mr Wisheart?
18 A. Certainly to Dr Joffe.
19 Q. Do you know when that was suggested by Mr Owen?
20 A. I am sorry, no.
21 Q. But Dr Joffe's --
22 A. The inference would be in 1992.
23 Q. Do you know when in 1992?
24 A. No. I know that I clearly had done some work on writing
25 this paper, which is a list of issues to be considered
0038
1 in June of 1992.
2 Q. So that was June 1992?
3 A. Yes.
4 Q. And the application was made after that?
5 A. Yes; a couple of weeks. The document itself is dated.
6 Q. Did you ever meet Mr Owen at any stage?
7 A. I cannot remember meeting Mr Owen. I can remember
8 meeting Mr Angilley.
9 Q. And Mr Angilley was the Administrative Secretary of the
10 Supra Regional Services Advisory Group?
11 A. Yes, for a number of years.
12 Q. And he was subsequently replaced by Mr Owen?
13 A. Yes.
14 Q. Do you think that, looking back on it, opportunities
15 were available for applications to be made for capital
16 funding to the Supra Regional Services Advisory Group in
17 the late 1980s?
18 A. Clearly there were, because of the paper from Dr Baker,
19 yes.
20 Q. Can you shed any light on why an application was not
21 made until the last year in which -- or to take effect
22 in the last year in which neonatal and infant cardiac
23 surgery was designated?
24 A. I can offer some explanations, but I cannot do more than
25 that, which would be to say that clearly the
0039
1 organisation was receiving capital from the Regional
2 Health Authority and was on a development programme that
3 had been agreed which was quite substantial.
4 That development has been completed and there was
5 clearly a time for an element of consolidation, which
6 occurred, but I cannot recall any discussions about
7 should we or should we not make applications.
8 Q. Can you think of any reason why an application should
9 not have been made? Apart from the cost of filling in
10 the form and the postage stamp, there was no cost to the
11 Health Authority, or related to the Trust?
12 A. The cost would have been in assessing whether or not it
13 was feasible to achieve something, calling the Working
14 Party together, working on that application as well as,
15 as you say, the sheet of paper and the postage stamp.
16 Q. But there were working parties working anyway on the
17 development of cardiac services in Bristol and it was
18 hoped money was going to come from the Regional Health
19 Authority to fund that?
20 A. Yes.
21 Q. So the marginal cost of also asking the Supra Regional
22 Services Advisory Group for some money would have been
23 minimal, would it not?
24 A. Yes.
25 Q. Let us just go back to Dr Baker's letter, which I think
0040
1 we still have on the screen. He says the letter, that
2 is the letter he has had about the supra-regional
3 funding, makes request for financial and workload data
4 from the service to be returned by June 1986.
5 Until that time, that task had fallen to you and
6 Mr Joomun?
7 A. Yes.
8 Q. He says "It may be appropriate for the matter now to be
9 in the hands of the General Manager for the Central
10 Unit", that was Mr Watson at the time?
11 A. Yes.
12 Q. And the General Manager for the children's surgery?
13 A. Yes.
14 Q. "Perhaps you would let me have your comment on these
15 matters. I think it is important that we get the right
16 managers to accept the right responsibilities in the
17 future! However we must protect our own anxieties that
18 the appropriate financial and workload data may not be
19 forthcoming."
20 What were those anxieties that you shared with
21 Dr Baker?
22 A. I would want to make sure that the data was consistent
23 from year to year, and clearly, I would have wanted to
24 have had a strong handle on any financial submissions
25 that were made.
0041
1 Q. Was the suggestion by Dr Baker that it might be
2 appropriate to put the matter in the hands of the Unit
3 General Manager and the children's sub-unit General
4 Manager in fact taken up?
5 A. I would agree that the Central Unit General Manager and
6 the General Manager for the Children's Unit needed to
7 own what was being submitted. That did not necessarily
8 mean that they had to do the work to create that data.
9 I expect they were involved after this letter, but ...
10 Q. Can we see UBHT 278/390? This is a typical example, is
11 it not, of the expenditure and workload information
12 return to the Supra Regional Services Advisory Group
13 which was done annually?
14 A. Yes.
15 Q. And the information and workload and expenditure was
16 used as a basis for the revenue allocation the following
17 year?
18 A. Yes.
19 Q. You say in your statement at WIT 106/6 that Bristol was
20 visited by the Department of Health and later by the
21 National Health Service Management Executive on a number
22 of occasions?
23 A. Yes.
24 Q. I think it is their paragraph 10. You mentioned that
25 you met Mr Angilley. Do you recall who else from the
0042
1 Department of the Executive was involved in those
2 visits?
3 A. No, not by name, because any dealings I had were with
4 Mr Angilley. My memory for names is not wonderful.
5 Q. We have seen then that the amount of money you got from
6 the Supra Regional Services Advisory Group was
7 a straightforward multiplication of the cost by the
8 number of the operations done?
9 A. Yes -- not just operations: echocardiograms, cardiac
10 cath's, outpatient attendances.
11 Q. Procedures?
12 A. Procedures, yes.
13 Q. So the more procedures one did, the more money would be
14 received in the following year, broadly?
15 A. It was not the number that you did in the current year;
16 it was about what your estimates were for the growth in
17 the following year. You could not do the work until you
18 actually had the money, so it was about what your
19 estimates were.
20 Q. If one's numbers were over a period of time to go up,
21 then the amount of money would go up accordingly?
22 A. Yes.
23 Q. And so as the Treasurer or Assistant Treasurer at the
24 time, you would have known that were the numbers to go
25 up the income for the Health Authority would also go up?
0043
1 A. Yes.
2 Q. Were you ever aware -- I think we touched on this
3 yesterday -- of these visits leading to any express
4 encouragement to perform more neonatal and infant
5 cardiac procedures, particular operations, at Bristol?
6 A. No.
7 Q. If there had been any encouragement in any of these
8 visits and somebody from the Department of Health had
9 said "I am encouraging you, Bristol, to do more
10 operations", how would that encouragement have been
11 followed through?
12 A. Certainly we would have had a discussion about how we
13 might achieve higher numbers.
14 Q. How might you have done?
15 A. As Financial Director, you are always looking for
16 mechanisms to bring more cash into your organisation to
17 allow the clinicians to do what they wished to do.
18 Q. Of course.
19 A. The system we were operating was very much reflecting
20 what was happening within the organisation rather than
21 from my point of view of doing anything proactive about
22 it.
23 Q. Were you ever aware that those outside of Bristol, in
24 the Supra Regional Services Advisory Group, or those
25 advising the Advisory Group, thought that the numbers of
0044
1 neonatal and infant operations at the BRI was too low?
2 A. No, I do not believe so. In some of these areas it is
3 getting difficult to recall what I knew then and what
4 I know now, because since 1995 I have been -- there are
5 not many days that go by without me having something to
6 deal with to do with cardiac surgery, paediatric cardiac
7 surgery, but I cannot recall anything at that time
8 related to that sort of drive.
9 Q. The revenue and workload information we have just looked
10 at was just that: it was concerned with numbers and
11 money?
12 A. Yes.
13 Q. At the General Medical Council on Day 58 -- I think the
14 reference is page 54 -- you were asked about the
15 information gathering process for supra-regional
16 services. I do not think we have this scanned in, but
17 can I just remind you of the question?
18 You were asked:
19 "So you would be obtaining information from the
20 clinicians for an application for supra-regional
21 status?"
22 You said:
23 "Yes: every year we had to make a return of what
24 we had spent, how many cases we had done both for
25 inpatients and outpatients, and with the help of
0045
1 Dr Joffe, Mr Wisheart and others we had to give
2 a forecast for the following year."
3 A. Yes.
4 Q. You were asked:
5 "It was largely quantitative rather than
6 qualitative?"
7 You replied:
8 "My side of that, yes."
9 A. Yes.
10 Q. But in fact there was no other side which was
11 qualitative, was there?
12 A. I do not believe that any returns were sent to the
13 supra-regional services that I am aware of, no.
14 Q. There were no qualitative returns sent to the Supra
15 Regional Services Advisory Group?
16 A. Not that I was involved with.
17 Q. Certainly not by you?
18 A. No.
19 Q. And so far as you are aware, not by anybody else,
20 either?
21 A. No.
22 Q. In due course there were contracts drawn up between each
23 supra-regional centre in the NHS Management Executive
24 for supra-regional services?
25 A. Yes.
0046
1 Q. And in late 1990, I think as you say at page 7 of your
2 witness statement, you were involved in discussions
3 about the contract.
4 If we go, please, to UBHT 64/73, this is called
5 draft 2 of the contract?
6 A. Yes.
7 Q. I am not sure that we have draft 1. Whose writing is
8 that in the annotations there, do you know?
9 A. Ian Cameron's, who works for me within the Trust.
10 Q. So the annotation on the left-hand side says "discussed
11 13th December 1990". That is Mr Cameron, first of all?
12 A. Yes.
13 Q. Then you?
14 A. Yes.
15 Q. Mr Wisheart?
16 A. Yes.
17 Q. Dr Joffe?
18 A. Yes.
19 Q. And Dr Baird?
20 A. No, I would imagine that is Ian Barrington, General
21 Manager of Children's Services, I would think.
22 Q. And three people, unidentified, from the Department of
23 Health?
24 A. Yes.
25 Q. Do you remember who they were? Might they have included
0047
1 Mr Angilley and Dr Halliday?
2 A. Yes.
3 Q. Do you remember who the third person was?
4 A. No.
5 Q. If we go, please, to page 76, clause 11:
6 "Quality: the unit will ensure that the quality of
7 the service is clinically and socially satisfactory,
8 cost-effective and will seek constantly to improve it.
9 It will regularly monitor all relevant aspects of the
10 service and make the results available to the
11 purchaser. The variables to be monitored, the methods
12 to be employed and the results will be the subject of
13 regular discussion with the purchaser. Examples of
14 improvements which have contributed to better patient
15 care should be included in the annual report."
16 Apart from the workload and costs type of return
17 we have looked at an example of, were you involved in
18 making any other results available to the Supra Regional
19 Services Advisory Group?
20 A. No.
21 Q. Or the National Health Service Management Executive?
22 A. No.
23 Q. Were you a party to any of the promised regular
24 discussions with the purchasers?
25 A. From what I recall, they came once a year, but from
0048
1 1991/92 onwards other people were involved rather than
2 myself.
3 Q. Which people would be involved in those discussions?
4 A. I might have a finance person there -- another finance
5 person rather than me doing it personally.
6 Q. But that was the regular annual visit that had always
7 taken place?
8 A. Yes. I did not think there was any -- I know there was
9 no change from our point of view.
10 Q. Can we go back to page 74? We see the whole page, first
11 of all. If we go to the middle of the page, there is
12 a clause there:
13 "Reduced activity ..."
14 This is about what is going to happen under the
15 contract if fewer operations are done than anticipated,
16 right?
17 A. Yes.
18 Q. The second paragraph of 9.3.2:
19 "If the unit wishes to reduce the indicative
20 volumes for any reason, prior agreement of the purchaser
21 must be obtained and any change in the funded value of
22 the agreement negotiated by the parties to the
23 agreement."
24 A. Yes.
25 Q. Somebody, Mr Cameron, perhaps, has put a line through
0049
1 that?
2 A. As being unacceptable to us.
3 Q. The writing on the left-hand side, is that Mr Cameron's
4 as well?
5 A. Yes.
6 Q. That says:
7 "Occupied bed days, significantly more than other
8 centres."
9 A. Yes.
10 Q. So that means that the under ones at Bristol were in
11 hospital for longer than the under ones in other
12 centres?
13 A. Yes.
14 Q. Do you remember any discussion of that fact?
15 A. No.
16 Q. Why should a line have been put through that part of the
17 clause as being unacceptable to Bristol?
18 A. Because, I mean, for us we would want to keep some
19 stability in the funding coming into the Trust.
20 Q. If we go back to 76, please, to clause 11, just looking
21 at the last couple of sentences, variables are to be
22 monitored; the results will be the subject of regular
23 discussion with the purchasers; examples of
24 improvements should be included.
25 Can we split the screen and as well as that page
0050
1 have DOH 4/4?
2 This is, I hope, the final version of this
3 contract. We will not go back to the beginning of it,
4 if you do not mind.
5 Can you just highlight paragraph 11?
6 What is missing, I think, are the last two
7 sentences from the right-hand side:
8 "Examples of improvements which have contributed
9 to better patient care should be included in the annual
10 report."
11 That does not appear in the final version of the
12 contract?
13 A. No.
14 Q. And the last sentence, "A check-list of quality
15 measures, some of which may be applicable to the service
16 being attached at Appendix B", does not apply either?
17 A. No.
18 Q. What we do have is that the purchaser, the Department of
19 Health in this context, accepts the quality standards
20 agreed with the unit's major participants, the Bristol
21 & Weston Health Authority?
22 A. Yes.
23 Q. So the Department of Health is saying, in effect,
24 "Whatever deal you have done with your major purchaser
25 will be the standard to apply for this service as well"?
0051
1 A. That is the arrangement that we pushed through with all
2 purchasers, because it would not have been manageable to
3 have quality standards agreed with every purchaser that
4 we had. So the drive was to make sure that the service
5 specification and standards were adopted by all
6 purchasers, i.e. the Avon Health Bristol and districts
7 were adopted by all purchasers.
8 Q. Do you remember any significant debate on that from the
9 Department of Health, or were they content to go along
10 with it?
11 A. No, that was a line that we held with all purchasers,
12 bearing in mind that at some stage we actually reached
13 nearly 600 purchasers.
14 Q. Let us go back to the document on the right-hand side,
15 please. We can take away the other one. Clause
16 12: "Information". Are those annotations all the same
17 writing?
18 A. Yes.
19 Q. Still Mr Cameron?
20 A. Yes.
21 Q. "Quarterly review statements to be submitted to the NHS
22 Management Executive --
23 A. We did not submit quarterly statements to the NHS
24 Management Executive, as far as I am aware.
25 Q. No. This is a draft, of course?
0052
1 A. Right.
2 Q. "Region of residence and source of referral of all
3 patients", Mr Cameron has written "probably be deleted.
4 They get info through other channels"?
5 A. Yes.
6 Q. The overall comment, perhaps, of the annotator,
7 "Summary...", I cannot read the next word, "not too
8 much detail required"?
9 A. Yes.
10 Q. Was that your impression as well, that the contracts
11 with the Supra Regional Services Advisory Group were not
12 requiring too much detail from the provider unit?
13 A. Yes. Some contracts would have wanted a patient data
14 set for every individual patient.
15 Q. If we go to page 78, please, this is Appendix B to the
16 draft contract. The first sentence:
17 "The NHS Management Executive recognise that as
18 the unit currently provides quality care."
19 What was that recognition based on, so far as you
20 are aware?
21 A. I do not know.
22 Q. Did a similar sentence appear in all of the providers'--
23 if I can use that word, we are just a little bit before
24 Trusts -- contracts? Did you always get purchasers to
25 sign up to a recognition that you were currently
0053
1 providing quality care?
2 A. I would not have expected a statement like that to have
3 appeared, no, but I would have expected them to --
4 I would have thought that we did provide quality care,
5 yes, but I would not have expected it to be stated in
6 a contract. This is a Department of Health contract,
7 not ours.
8 Q. Yes. Are you aware of the contents of the Department of
9 Health contract with other centres?
10 A. No.
11 Q. So you cannot comment on whether that sentence would
12 appear, as it were, in a standard form?
13 A. No.
14 Q. Perhaps we should just scan down the quality check-list
15 while we are here?
16 A. Presumably the Department of Health had files with their
17 papers in it.
18 Q. We have asked the Department of Health for the relevant
19 files. We are not expecting to find those. Can we just
20 have a look at the full page, please?
21 We see that the quality check-lists -- it is a bit
22 small now, but it includes, for example, if we look
23 towards the bottom of the page:
24 "9. Providing appropriate information and advice
25 to patients and families ...
0054
1 12. Clinical audit from outcome morbidity and
2 mortality from other appropriate variables ..."
3 If we go finally under this section to DOH 4/1,
4 this is the first page of the final version of the
5 contract. We looked at clause 11 a moment ago. If we
6 go to page 9, we will see that it is signed by
7 Dr Roylance as Chief Executive of the Trust?
8 A. Yes.
9 Q. The Trust was able to enter into these contracts shortly
10 before the inauguration date of 1st April 1991?
11 A. Yes. We were required to sign all of our contracts
12 before the end of March.
13 Q. And if we scan down a little, we will see a signature
14 from the Management Executive.
15 If we go back to page 5, paragraph 4:
16 "A copy of the return made by the unit to the UK
17 cardiac surgical register ... was to accompany the
18 annual report."
19 That was the first time that that had been done?
20 A. Yes.
21 Q. Did you have any role in the sending of that register
22 with the annual report?
23 A. No, the only thing we did was submitted the financial
24 information. We were not involved in submitting any
25 annual report.
0055
1 Q. The contract for the following year, 1992/93, made
2 provision for something called a "mid-year review". The
3 reference for that -- we do not need to go to it, it is
4 UBHT 64/265, and the mid-year review was said to depend
5 on local circumstances.
6 Are you able to help us with the nature of any
7 mid-year review of supra-regional services that was
8 carried out at Bristol?
9 A. I do not think any mid-year reviews were undertaken.
10 The only thing that I recall being undertaken was
11 a management consultancy firm looking at our approach to
12 costing which was BDO Consulting.
13 Q. You learned in due course that neonatal and infant
14 cardiac surgery was to be de-designated?
15 A. Yes.
16 Q. With effect from, as it turned out, 1994?
17 A. Yes.
18 Q. What did you understand the reason for that
19 de-designation to be?
20 A. I do not think I necessarily had one. The reason it was
21 designated was to restrict the number of centres in the
22 country undertaking neonatal and infant cardiac
23 surgery. That was the aim of supra-regional. Why it
24 was de-designated, I cannot now recall why. We were
25 just told that that was what was happening and we had to
0056
1 make preparations for transfer of that funding back to
2 the health authorities.
3 Q. That caused some difficulty, did it not, because there
4 was a concern, certainly on your part, that some of the
5 money that went to the health authorities might not find
6 its way back to the Trust?
7 A. Yes. Financial Directors do not like change like that.
8 Q. So did you enquire from any source as to why this change
9 had come about?
10 A. No. It was more about what will be the plan to transfer
11 the funding and will we be in a position to achieve full
12 funding in the following year. That would have been my
13 main concern.
14 Q. Did you know whether the de-designation had anything to
15 do with Bristol's performance?
16 A. Not at the time, although I have read documents
17 subsequently that identified concerns about Bristol and
18 one other centre, I think.
19 Q. But at the time, you did not know whether it did or did
20 not have anything to do with Bristol's performance?
21 A. No.
22 Q. The Supra Regional Services Advisory Group, or, perhaps
23 more accurately, the Department of Health, planned to
24 split up the money which had previously been spent on
25 the supra-regional service on an occupied bed days by
0057
1 region or district of residence basis?
2 A. Yes.
3 Q. Rather than a finished consultant episode basis?
4 A. Yes.
5 Q. And Bristol was not happy about that?
6 A. No.
7 Q. Why not?
8 A. Because it put all of the numbers of -- no matter what
9 procedures were undertaken it was all being converted
10 into an occupied bed day basis, yet there were
11 significant differences in the unit costs of
12 a catheterisation or a non-surgical admission and an
13 open heart cardiac case and a closed heart cardiac
14 case.
15 I believed that each of the centres could possibly
16 have differing ratios. What we did is a bench top check
17 of the fact that health authorities, we would contract
18 with health authorities in the New Year on the basis of
19 finished consultant episodes and procedures, yet they
20 would have been given the money on the basis of bed
21 days. That gave us problems in that the amount of money
22 going to each Health Authority did not match the bills
23 that we would be sending them. That would lead to
24 difficult contract discussions.
25 Q. There was some correspondence about that, but in the end
0058
1 the Department of Health stuck to its guns?
2 A. Yes, I lost.
3 Q. And Bristol essentially lost that battle?
4 A. I did not manage to change the Department of Health, but
5 we always have to try these things, and then I had
6 discussions with the Regional Health Authority on the
7 basis that the money would have gone to the Regional
8 Health Authority and it was up to them how they
9 distributed it.
10 MR MACLEAN: I think we will come to that in a moment.
11 I wonder, sir, if this is a convenient moment for
12 a short break?
13 THE CHAIRMAN: Yes. Shall we say 15 minutes, and therefore
14 until just after 11.15?
15 (11.00 am)
16 (A short break)
17 (11.15 am)
18 MR MACLEAN: Mr Nix, can I just deal with one matter? Do
19 you remember the reference to Professor Stirrat and
20 Mr Wisheart and so on about the waiting list initiative
21 and the quality of surgery?
22 A. Yes.
23 Q. You asked me for the previous minute.
24 A. I thought that might be helpful, because it did refer to
25 the previous meeting.
0059
1 Q. It threw me only temporarily, I hope. Over the break we
2 have gone through the database. Can I just say that the
3 previous meeting of the Bristol & Weston Health
4 Authority was on 21st January 1991. The minutes of that
5 meeting we have. The reference is UBHT 249/0012. It is
6 not yet published on any of the core CDs, but it will be
7 published on the next one.
8 If these minutes help, and they may not in fact,
9 we will send them to you, Mr Nix, and if you care to
10 have a look at them if they jog your memory in any way,
11 perhaps you could put down in writing what your
12 recollections are?
13 A. Certainly.
14 Q. I do not think I need to take up any more time at this
15 stage over that.
16 We were dealing with de-designation and your
17 mention just before the break of the letters that passed
18 between and you the Regional Health Authority Director
19 of Finance.
20 Can you go to UBHT 64/316? Just at the very top
21 of the page, please, this is your reference GRM, this is
22 your letter, your initials?
23 A. Yes.
24 Q. To Miss McDonald, Director of Finance?
25 A. Yes.
0060
1 Q. You say in the middle of that first paragraph, you have
2 discussed the paper with the relevant clinicians and
3 managers, and considered the position both from the
4 South West purchasers' and the UBHT's viewpoint and the
5 implications for contracting for 1994/95?
6 A. Yes.
7 Q. You set out the two concerns, the first being the method
8 of distribution. That is what I asked you about just
9 before the break.
10 A. Yes.
11 Q. If we go over the page (317), the second concern is under the
12 heading "Distribution between regions":
13 "Whichever method of funding distribution is used,
14 it is clear that the bulk of funding will be allocated
15 to the South Western Regional Health Authority."
16 That is because the bulk of the neonatal and
17 infant cardiac surgery patients in the last year of
18 supra-regional services had come from that region?
19 A. Yes.
20 Q. 25 per cent or thereabouts to Wales and about 5 per cent
21 to Wessex.
22 Your concern is really highlighted in the next
23 paragraph:
24 "The Trust was extremely concerned with the impact
25 of the distribution of funds to the Welsh health
0061
1 authorities and the Welsh Office."
2 A. Yes.
3 Q. That was because, put shortly, the Trust was concerned
4 that that money would not find its way back to the
5 Trust?
6 A. Yes.
7 Q. The reason for that you speculate on in the next
8 paragraph:
9 "It was undoubtedly due in the main to the
10 expansion of the well-funded unit at Cardiff". In other
11 words, Welsh children were being sent to Cardiff rather
12 than to Bristol?
13 A. Yes, and there is statistical backup for that.
14 Q. Yes, I think the Inquiry has seen that.
15 A. I mean attached to this letter.
16 Q. You sent a copy of your letter, I think, to the NHS
17 Executive for the South and West, if we look at
18 UBHT 295/651: the reference there is to the letter you
19 prepared for the Regional Health Authority on behalf of
20 the Trust. That is a copy there, you are enclosing
21 a copy of the same letter?
22 A. Yes. Bear in mind that there were two routes up to the
23 centre: Regional Health Authority was dealing with the
24 purchasing angle and there was a regional outpost of the
25 NHS Management Executive, which was the provider side.
0062
1 Q. So the reason for copying the letter to the Health
2 Service Executive was because of the first concern, the
3 bed days versus finish consultant episode concern,
4 rather than the 25 per cent of the money to Wales
5 concern?
6 A. Both, really. I wanted them to take that up centrally
7 for me, concerns about funding going to Wales.
8 Q. What did you hope or expect them to do?
9 A. The hope was that they would follow what I had asked
10 them to do, which was not to allocate that volume of
11 money to Wales and to change the method of distribution.
12 Q. Did they?
13 A. No. That does not mean you should not try.
14 Q. If we go to UBHT 64/297, that is a worked example.
15 I think this is the Department's worked example, is it
16 not, of how the money would be divided up?
17 A. Yes. This was in their consultation -- I think it was
18 a consultation document, or it may well have been just
19 a document saying "This is how we are going to do it".
20 Q. So that explains -- we need not go through the algebra
21 of it; I think it is clear enough how the division was
22 done.
23 A. Yes.
24 Q. That is how in fact it was done on that model?
25 A. Yes.
0063
1 Q. After de-designation, Avon residents were treated as
2 part of the block contract which the Bristol and
3 District Health Authority had with the UBHT?
4 A. Yes.
5 Q. And within that contract, it is right, is it not, that
6 no distinction was drawn between a paediatric open heart
7 operation and an adult one?
8 A. That is correct.
9 Q. If we go to UBHT 295/618, this is a document, it has
10 some handwritten annotations on the right-hand side. Do
11 they matter?
12 A. No.
13 Q. We see below the heading "Inpatients", a third of the
14 way down, if we highlight that block, the top line
15 there:
16 "Cardiac surgery, neonatal and infant cardiac
17 services, and the National Health Service Management
18 Executive was a block contract."
19 Can we see at the top the columns, please? The
20 total contract volume was 60 for 1994/95, and the total
21 contract value was 322,000?
22 A. Yes, for inpatients only.
23 Q. In fact, the previous year, if we go to the right-hand
24 column, 52 cases had been undertaken rather than the 60?
25 A. Yes.
0064
1 Q. So that gives us the total number of cases done for that
2 year -- and I think that year was 1993/94; is that
3 right?
4 A. The current year would be -- yes, 1993/94.
5 Q. That is the last year in which supra-regional neonatal
6 and infant services were designated as a supra-regional
7 service?
8 A. Yes.
9 Q. The plan for the current year, the new year -- you see
10 those columns in the middle of the table --
11 A. Yes.
12 Q. There is a zero besides NHS/NE, that is because
13 de-designation had occurred and they were no longer
14 going to be the purchasers?
15 A. Yes.
16 Q. What we then have to do, in order to find out what the
17 contracted activity was for under 1s, is to add up the
18 numbers in the rows which deal with under 1s. So, for
19 example, open heart under 1, Bristol and District Health
20 Authority, is the second row?
21 A. Yes, 16.
22 Q. If we look down, Cornwall and the Scilly Isles add 2,
23 under 1s?
24 A. Yes.
25 Q. 16 ECR contract estimates, and so on?
0065
1 A. Yes.
2 Q. I think the table goes over the page but I think there
3 is a total of 56 cases contracted for that year,
4 including the estimated ECR contracts.
5 So the numbers were more or less expected to be
6 static in the following year?
7 A. Yes.
8 Q. I think it is right to say that there were no contracted
9 activity for under 1s from Wales. If we go to page 619
10 we see the top of the page: Wales, Gwent; Wales,
11 Mid-Glamorgan, but there is no under 1s shown as being
12 sent from Wales?
13 A. I think you will find that there were subsequent
14 discussions to this for cardiac cases coming to Bristol.
15 Q. Let us look at one of the relevant letters, then. Let
16 us look at 295/14: this may be what you are getting at.
17 It is your reference "GRN" at the top.
18 A. Yes.
19 Q. This is to the Clwyd Health Authority, March 1995, so
20 now nearly a year after de-designation had taken place,
21 and you refer in this letter to a general shift in
22 workload away from Bristol, primarily to Cardiff, in
23 respect of open heart surgery?
24 A. Yes.
25 Q. That is the first bullet point, do you see that?
0066
1 A. Yes.
2 Q. You also refer, in the next bullet point, to the fact
3 that the 1994/95 workload had become very low due to
4 capacity problems at the BRI, in particular the blocking
5 of ITU beds by paediatric and neonatal patients which
6 was restricting the capacity in the emergency adult
7 block.
8 So this was the problem which was addressed at
9 about this time by the plan to move all paediatric open
10 heart cardiac surgery to the Bristol Children's
11 Hospital, thereby freeing up some space in the BRI to
12 expand the adult workload yet further; is that right?
13 A. Yes.
14 Q. We will come to see in a moment how the split site was
15 dealt with.
16 If we go to page 15, and just scan down a little
17 bit. The proposal for 1995/96 -- this is dealing with
18 the Clwyd contract, is it not?
19 A. Yes.
20 Q. Sets the contract at a lower level than 442,000 for
21 1994/95, but at a higher level than the value of
22 1994/95's workload. So the proposed contract was for
23 œ258,000, including 1995/96 inflation at 3 per cent?
24 A. Yes.
25 Q. So what that tells us is that the contract for 1995/96
0067
1 had a value of 442,000, but in fact the value of the
2 work done in that year for Clwyd was less even than
3 œ258,000?
4 A. Yes.
5 Q. So there was a very significant failure to, as it were,
6 hit that target in 1994/95?
7 A. Yes.
8 Q. And that was because, was it, in the main, adults who
9 would otherwise have been referred to the BRI for
10 surgery could not get in because of the capacity
11 problem?
12 A. Yes.
13 Q. So at this stage we see that the blockage in the system,
14 as it were, the lack of capacity at the BRI, is
15 beginning to cost the Trust significant sums of money?
16 A. The Trust would be getting its finances from other
17 places, other than some of these more distant
18 purchasers. We were still doing the volume of work, it
19 was just coming closer to home rather than from
20 a distance such as this, so it would have been impacting
21 on Avon.
22 Q. It was clear from this type of data that there was
23 a potential to make significantly more money if the
24 blockage in the system could be removed?
25 A. Yes. There was potential to increase the incomes and
0068
1 therefore expand the service.
2 Q. So were the service to be expanded, were more capacity
3 to be found, this type of information would make the
4 Trust confident that the increased capacity would be
5 taken up?
6 A. Yes.
7 Q. So this type of position in terms of the under-hitting
8 of the target was presumably not exclusive to Clwyd?
9 A. No, it was across a number of areas and we also had
10 purchasers who wished to expand their volume of care
11 provided to this particular specialty.
12 Q. So at that stage there is a clear economic incentive for
13 the capacity of the Bristol Royal Infirmary to do open
14 adult cardiac surgery to be expanded yet further?
15 A. Yes.
16 Q. If we just deal with the question of the split site --
17 A. I think you will find that there is a similar situation
18 in the year before, as well.
19 Q. Can we just deal then, I hope fairly briefly, with the
20 question of the split site. Obviously funding choices
21 had to be made by the Health Authority before Trusts
22 were on the scene?
23 A. Yes.
24 Q. As between the expansion of the service in area A
25 compared to area B?
0069
1 A. Yes.
2 Q. We have seen that in 1987 the cath' lab improvements and
3 developments took effect. There was a catheterisation
4 room at the BCH for the first time and the two existing
5 cath' labs at the BRI had been updated?
6 A. Yes.
7 Q. We saw yesterday, and I do not want to go into it again,
8 the expansions that had taken place in the number of
9 open heart operations in the Bristol Royal Infirmary
10 from 275 when you came on the scene, when the Inquiry's
11 period began, more or less, up to 600 and beyond by the
12 end of the 1980s?
13 A. Yes.
14 Q. We have, at HA(A) 6/19, if you blow up the top of that,
15 a draft of the South Western Regional Health Authority
16 Hospital Medical Advisory Committee, the Regional
17 Hospital Medical Advisory Committee, strategic statement
18 number 2.
19 I am not sure when this document was produced, but
20 if we look at page 22, paragraph 20, it is clear from
21 that paragraph that it must be a document produced
22 before 1991?
23 A. Yes.
24 Q. Because of the future tense, "will be reviewed"?
25 A. Yes.
0070
1 Q. This report, if we go back to page 19, worked on the
2 basis, if we just scan down to paragraph 3, that the
3 rate of congenital heart disease was 8 per 1,000 live
4 births?
5 A. Yes.
6 Q. Are you familiar with that type of estimate for --
7 A. Not that specific one, but numbers like that I have seen
8 before, yes.
9 Q. The recommendation from the region in this report was
10 that Bristol should be used by all the districts in the
11 region and that Bristol only should be used to take up
12 any excess of cardiac work in relation to adults.
13 I perhaps do not need to comment on that
14 specifically.
15 As to children, which is what I am interested in
16 at the moment, page 22, if we can just scan down there,
17 please, "Services for children", it explains what the
18 position was in paragraph 23. Paragraph 24 deals with
19 the supra-regional status. Then paragraph 25:
20 "The current split of cardiac surgery services for
21 children onto two sites is unsatisfactory, particularly
22 as the children in the Royal Infirmary are admitted to
23 an adult ward. It is recommended [underlined] that all
24 cardiac services for children should be provided from
25 a comprehensive children's department or hospital."
0071
1 In fact, in 1989 -- we are not sure when this
2 document was produced and I daresay we can find out, but
3 it was before 1991?
4 A. Yes.
5 Q. I suspect it was before 1990. In 1989, a Working Party
6 looked at the question of moving open heart paediatric
7 surgery to the BCH.
8 Do you recall that?
9 A. I recall I think in my statement saying that work did go
10 on, but I was not clear about when that was.
11 Q. If we go to UBHT 159/26, this is a Working Party. If we
12 go to paragraph 2.3, that is what it was to do?
13 A. Yes.
14 Q. You were a member of this Working Party, if you go to
15 page 27?
16 A. Yes.
17 Q. You were on it; Mr Barrington, the Children's Hospital,
18 was on it; Mr Hutter who was a surgeon, I think?
19 A. Yes.
20 Q. Dr Jordan, the cardiologist, and Mr Wisheart, and
21 others?
22 A. Yes.
23 Q. In 1989, the cost of moving paediatric cardiac surgery
24 to the BCH was thought to be prohibitive?
25 A. Yes.
0072
1 Q. Was that the reason that the split site remained after
2 1989?
3 A. Yes.
4 Q. Why was it prohibitive?
5 A. I assume that the Regional Health Authority at that time
6 said that the cash that was required to deliver that
7 expansion, seeing as we had already expanded currently,
8 was not affordable.
9 Q. Was there any other source of funding that could have
10 been tapped in order to do something about the split
11 site?
12 A. The only one we have talked about which presumably would
13 have been the possibility, would have been
14 supra-regional, part of, not all of.
15 Q. But we know that no application was made to them until
16 Dr Joffe's application in June, or subsequently in 1992?
17 A. Yes.
18 Q. Can we go to document JDW 1/241? This is I think at
19 least a part of the Working Party report. If we go to
20 244, it is dated at the bottom of the page 1st November
21 1990.
22 Those initials are whose?
23 A. Janet Gerrish.
24 Q. She was the Manager of the BRI?
25 A. Yes.
0073
1 Q. The sub-unit at that time?
2 A. Yes.
3 Q. If we go to 241 and scan down to paragraph 2, the
4 actual workload in 1989/90 for open heart operations for
5 all children was 150.
6 A. Yes.
7 Q. If we go to 242, there were at this time four paediatric
8 intensive care unit beds. That was the figure that was
9 reached following the expansion that took place that we
10 discussed yesterday. Do you remember, we were looking
11 at the figures?
12 A. Yes.
13 Q. 4, 8, 8 and 4?
14 A. Yes.
15 Q. At the bottom of that page, it said that there was
16 considerable pressure on beds in the Bristol Royal
17 Infirmary especially in the ITU because of long
18 occupancy periods by children?
19 A. Yes.
20 Q. If we go in the same file, 341, to 342, there is
21 a reference here, is there not, at 4.2.2, to the South
22 Western Regional Hospital Medical Advisory Committee
23 statement of November 1989, so it may be that that is
24 the same document we were looking at earlier,
25 recommending that all cardiac services for children be
0074
1 carried out from a department or hospital with access to
2 a full range of children's services?
3 A. Yes.
4 Q. I suspect that is a document we were looking at
5 earlier.
6 A. I would agree with that.
7 Q. So from at least November 1989 that recommendation was
8 in place?
9 A. Yes.
10 Q. At paragraph 4.3, "Operational constraints, the effect
11 of the planned development of paediatric cardiac surgery
12 in Cardiff is unclear. Approximately 40 per cent of
13 present BCH workload is from Wales."
14 In fact, by the time de-designation took place,
15 that had come down to about 25 per cent. We have just
16 seen that in the letter to the Regional Health
17 Authority; is that right?
18 A. Yes. That related, of course, to supra-regional rather
19 than all children, which this presumably relates to.
20 Q. Yes, you are quite right. What were seen as being the
21 "disbenefits", if that is the right word, of moving all
22 paediatric open heart surgery to the Bristol Children's
23 Hospital at 1989/90?
24 A. The only thing I can think of is the cost of actually
25 achieving that move, because you will see above it says
0075
1 "theatre, no beds available", or theatre sessions, so
2 it did require the provision of additional theatre
3 intensive care and bed capacity at the Children's
4 Hospital.
5 Q. Any other reason, other than cost?
6 A. I think there was certainly -- I recall, but whether it
7 is correct or not -- there was an issue about staffing,
8 availability of staff to manage two separate units
9 through availability of perfusionists and medical
10 staffing.
11 Q. If we go to 343, and scan down, please, benefits of
12 moving paediatric open heart surgery would be that the
13 total paediatric cardiac service was on one site and the
14 care of children would be in a dedicated children's
15 environment. The disbenefits: major capital expenditure
16 is required at Children's Hospital ... 2. Highly
17 specialised service divided between two sites?
18 A. Yes.
19 Q. That "highly specialised service" is presumably cardiac
20 surgery, is it?
21 A. Yes.
22 Q. So that would be lumping cardiac surgery and adults
23 together with cardiac surgery in children as being one
24 specialised service?
25 A. Yes. I think that is referring to the technical backup
0076
1 to two sites rather than one, like with perfusionists.
2 Q. If we go to UBHT 159/44, this is a paper stamped
3 7th September 1990. If we go to page 47 --
4 A. Can I ask what annex that document was to?
5 Q. Yes. Can we go to the foot of the page, first? "SCJ"
6 is Steve Jordan, is it not?
7 A. Yes.
8 Q. He is a cardiologist?
9 A. Yes. He is an adult cardiologist who did a lot of
10 paediatrics and then just did paediatrics.
11 Q. Can we go to page 45? At the top of the page, Dr Jordan
12 says:
13 "Currently closed heart operations are carried out
14 at the Children's Hospital, but for open heart
15 operations, all children have to be admitted to the
16 Royal Infirmary where they are cared for in
17 a non-paediatric environment. This is against all
18 current thinking on the management of children in
19 hospital. The fragmentation of the service makes for
20 considerable difficulties with staff of all types. No
21 other centre in the UK has open and closed surgery split
22 between two sites in this way."
23 Then it goes on to make a point about
24 transplantation, and then says:
25 "An additional factor is that an amalgamation of
0077
1 all the children's heart services on the Children's
2 Hospital site would allow a much-needed increase in
3 adult cardiac surgery at the BRI."
4 A. Yes.
5 Q. So is it fair to say that the cardiologists, adult and
6 paediatric alike, had been pushing for paediatric open
7 heart surgery to be moved to the BCH for some time by
8 the time of the decade 1990?
9 A. From all the evidence you have given, yes, that is the
10 case. There were also paediatricians pushing for other
11 specialties to be centred on the Children's Hospital as
12 well.
13 Q. If we move on to 1993, can we go to JDW 3/303? This is
14 a paper following a recent meeting of the cardiac
15 surgery planning group, and it says, in the first
16 paragraph, that "The possibility of transferring the
17 paediatric workload currently being undertaken at the
18 BRI to the Children's Hospital was a means of increasing
19 throughput in adult surgery", so that was the motivation
20 at this stage for looking at it again?
21 A. Yes.
22 Q. If we go to the end of the second paragraph, can I ask
23 you to read that second paragraph, and then to explain
24 the reference in the last sentence, if you can?
25 A. That is saying basically that if this is to be
0078
1 successful, we have to make sure that it is fully costed
2 properly, and that we have taken into account the
3 revenue cost of investing capital, because that is
4 something that came on to the scene with capital charges
5 and in ongoing revenue. The reference to it -- another
6 compromised arrangement -- may well refer back to the
7 discussions we had with the Regional Health Authority
8 back in the late 1980s where there was some concern
9 about the level of investment to the service.
10 Q. What was compromised, and by whom?
11 A. It would have been compromised by the Health Authority
12 in accepting, or allowing, I suppose, an expansion of
13 the service beyond what was agreed as the limit, because
14 you will recall that the unit was set up to do 600 cases
15 but did reach 720, so whether there was -- there was,
16 I think, from papers we saw previously, some discussions
17 about the level of nurse staffing related to that volume
18 of throughput.
19 Q. So that discussion in the late 1980s was about the
20 expansion to 750. You will remember we looked at
21 documents yesterday about the Regional Health Authority
22 agreeing to go along with the expansion that is planned
23 in the late 1980s, as long as the cost did not exceed
24 that which they had been told about?
25 A. Yes.
0079
1 Q. So it is your recollection that the compromise that is
2 referred to was the compromise with the Regional Health
3 Authority about funding the expansion of the service?
4 A. I would perceive that that is what that relates to, yes.
5 Q. And the focus of that expansion, as we discussed
6 yesterday, was adult cardiac surgery?
7 A. It did not define "adult"; it talked about "total number
8 of cases".
9 Q. What is happening by this stage is that again, as there
10 has been throughout this whole period, there is
11 a pent-up demand for adult open heart surgery in the
12 BRI?
13 A. Yes, there is.
14 Q. And the feeling of frustration that one might get from
15 reading this memo is that steps that have been taken in
16 order to deal with that pent-up demand continue to prove
17 to be inadequate. Is that fair?
18 A. Yes, and I think it would be fair to say that we still,
19 even today, have pressures on open heart cardiac surgery
20 in that the demand is exceeding our capacity to deliver
21 at present, and we have expanded and expanded over the
22 years.
23 Q. But children's services in children's cardiac surgery
24 had never been a commander of the same big numbers as
25 adult cardiac surgery?
0080
1 A. No. As I have said, people did not actually pick it out
2 separately. They did not pick it out separately, and
3 therefore we tended to talk about all open heart cases
4 rather than separating out children and adults.
5 Q. In the end, what led to paediatric cardiac surgery being
6 moved to the Children's Hospital was the necessity to
7 free up further capacity in the BRI to take the extra
8 demand for open adult cardiac surgery?
9 A. Yes, and it brought with it, because of the demands from
10 purchasers and the need that was shown in our waiting
11 lists and the numbers of emergencies, that finance was
12 available to cope with both the cost of the capital
13 investment and the ongoing revenue cost of running the
14 service at the Children's and at the Royal Infirmary.
15 Q. Is it fair to say that Dr Jordan's concerns, starkly put
16 in the paper stamped 7th December 1990, were heeded in
17 the mid-1990s because they were allied to the pressing
18 need to increase capacity for adult surgery at the BRI?
19 A. Yes. You will find that in one of the business plans
20 for the Associate Directorate of Cardiac Surgery it was
21 raising the issue as well, that we needed to find some
22 way of achieving this.
23 Q. Can we go to UBHT 275/130, please?
24 This is a memo dated 12th May 1994 to the Cardiac
25 Expansion Working Party. Can we just move the cursor
0081
1 from the bottom of the screen? If we just scan down,
2 alas we cannot see who is under the black mark.
3 A. It is not me.
4 Q. It is not, I think, you. Can we go over the page to
5 131? This sets out the history. If we go to the third
6 paragraph, please:
7 "The feasibility of making the transfer has been
8 investigated in the past, the most recent report dated
9 October 1990."
10 We have looked at documents from that date.
11 A. Yes.
12 Q. That of course postdated Dr Jordan's memo stamped
13 17th September 1990, in answer to your question about
14 the appendix, I think, but I do not know for certain
15 that was appended to the report when the report was
16 considered, because it was, as it were, putting
17 a contrary view.
18 A. Right.
19 Q. I am not 100 per cent sure of that.
20 "To date it has been concluded that the cost of
21 such relocation involving the construction of a new
22 cardiac theatre, additional ITU beds and additional
23 staffing has been prohibitive."
24 But now other matters had come on to the horizon.
25 If we go over the page to 132, in the middle of
0082
1 the page, we see that the cardiac unit in the BRI was at
2 capacity because it is treating 850 adults in 1993/94
3 and it is anticipated that will go up to 950 in 1994/95?
4 A. Yes.
5 Q. But without any increase in the number of children?
6 A. Yes.
7 Q. So it says those facilities are at capacity.
8 If we go to 134, under the heading "Qualitative
9 Appraisal", option A was the option to continue to
10 provide services at the current level?
11 A. Yes.
12 Q. National and local demand, and so on; the Health of the
13 Nation; reduction in deaths from coronary heart
14 disease. That of course is to be distinguished from
15 congenital heart defects that people might be born with?
16 A. Yes.
17 Q. It was the former and not the latter that was the focus
18 of the Health of the Nation, or one of the focuses of
19 the Health of the Nation?
20 A. Yes.
21 Q. "UBHT is a centre of excellence, and is currently one of
22 only two sites offering cardiac surgery in the South and
23 West region (the other being Southampton)."
24 So nothing had come of the Plymouth suggestion
25 since the 1980s?
0083
1 A. Southampton was only included because there was a change
2 in the regional office's boundary to join what was South
3 West and Wessex. You have a much wider regional
4 coverage.
5 Q. "If capacity is not expanded to meet increased demand,
6 purchasers will place increasing numbers of contracts
7 with Southampton or other out-of-region providers,
8 e.g. Oxford, Cardiff, London and Birmingham."
9 Then there is a reference to Plymouth being at the
10 planning stage and the presence of a further threat.
11 "In addition to loss of new work, UBHT may lose
12 current business as its unit costs will not be
13 competitive. It will lose expertise due to lack of
14 experience in volume of operations performed,
15 particularly in paediatric procedures. Quality and
16 outcomes which are directly related to numbers will
17 fall, all of which could potentially lead to further
18 loss of contracts and opportunities for cardiac surgery.
19 "This situation is counter to UBHT's philosophy as
20 a centre of excellence and a major Teaching Trust at the
21 leading edge of health care."
22 This is I think a document produced by that
23 Working Party with a list of people?
24 A. Yes, with the aim of getting the Trust to agree an
25 investment in cardiac surgery.
0084
1 Q. If we go to page 135, paragraph 2, that sets out the
2 position. That is essentially the explanation of the
3 split site in the first sentence?
4 A. Yes.
5 Q. "Contrary to best practice and to current guidance in
6 the management of children in hospital". There is
7 mention made that Edinburgh had some other arrangement
8 which it was, as it were, "fixing"?
9 A. Yes.
10 Q. If we go down the page, please, to letter B, "Skills
11 differences":
12 "Care of children in hospital demands
13 appropriately trained staff. Paediatrically trained,
14 experienced, competent medical staff in all specialties
15 are constantly available in the BRCH but not,
16 implicitly, in the BRI." Is that fair comment?
17 A. You would have medical staff with experience of
18 children, but not paediatricians.
19 Q. Then there is reference made to the nursing staff:
20 "70 per cent of Children's Hospital nursing staff
21 are registered sick children's nurses, compared with
22 only 2 full-time equivalents in the BRI cardiac unit."
23 In the BRI cardiac intensive care unit at this
24 time, there were the same number of adult beds as there
25 were children's beds, 4 each?
0085
1 A. Yes, in that document we saw. Whether that had changed
2 or not, I would not be able to tell you.
3 Q. Then, if we go over the page, 136, paragraph (b)4:
4 "The expansion of the ITU beds at the BRCH require
5 support. Open cardiac surgery will facilitate improved
6 training for staff of all disciplines". Yet more reason
7 for moving open heart surgery for children to the
8 Children's Hospital?
9 A. Yes.
10 Q. Then scanning down to (d)1, waiting time for priority
11 paediatric cases was 4 to 5 months, the optimum period
12 in terms of outcome would be 4 to 6 weeks and those
13 waiting times for paediatric operations were longer than
14 the major competitors.
15 Obviously there is a worry that waiting lists,
16 being a high profile visible indicator of something at
17 least in the Health Service that the public are aware
18 of, a centre with a longer waiting list might be less
19 attractive to purchasers than a centre with a shorter
20 waiting list, obviously?
21 A. Yes, until you have cleared your waiting list.
22 Q. Then (2), "The pressure to increase adult cardiac
23 surgery combined with less complex care management and
24 shorter lengths of stay tends to militate against
25 selection of paediatric cases for admission in the BRI,
0086
1 resulting in unacceptably long waiting lists."
2 Are you able to help us with how long that
3 tendency had been evident?
4 A. No. Clearly that is a clinical issue. I can understand
5 what the sentence was saying, but not how that was shown
6 in any practical way in the Royal Infirmary.
7 Q. That would be the sort of thing Mr Wisheart could deal
8 with?
9 A. Absolutely. Someone within the Directorate would have
10 written that, obviously.
11 Q. If we turn to 137, Disadvantages: "There are no
12 disadvantages in quality applicable to this option."
13 Do you remember that second disadvantage we saw in
14 paragraph 7.2.2 of the 1990 document, JDW 1/343?
15 A. Yes the staffing and the --
16 Q. Can we just look at that again, JDW 1/343.
17 A. It was the cost of the split site.
18 Q. At the bottom of the page, 7.2.2 has disappeared by
19 May 1994?
20 A. Yes.
21 Q. But if the point at 7.2.2 was a good one in 1990, it
22 would still have been a good one in 1994?
23 A. Theoretically, yes.
24 Q. Well, actually, yes?
25 A. Okay.
0087
1 Q. So can we take it that in fact the real reason, the real
2 disbenefit, for 1989 was 7.2.1?
3 A. Clearly, at that time somebody must have believed that
4 7.2.2 was an issue and that is why it was put down
5 there. I mean, clearly the capital investment and the
6 revenue, which is not listed there, interestingly, would
7 have been a major hurdle to overcome.
8 Q. If we go back to the 1984 memo, UBHT 275/138 -- that
9 blanking out, I should say, has not been done as far as
10 I know by the Inquiry. I think that is the same
11 heavy-handed highlighter pen we saw at the beginning of
12 the document, so I have no idea what is under that.
13 What I want is the passage, "Opportunities and
14 Threats".
15 A. There is a handwritten sheet which shows the financial
16 appraisal. I did personally check out the finances and
17 identify the risks of this move.
18 Q. Can I, before we go any further with this, just ask you
19 when you were first aware of a perception that the
20 quality of paediatric cardiac services of Trusts might
21 fall below that elsewhere?
22 In your view, was there such a perception?
23 A. No, not that I was aware of. I think, obviously,
24 I learned a lot from 1995 onwards, which was one that
25 de Leval Hunter produced.
0088
1 Q. We promised each other yesterday we would not get into
2 that at this stage. Can we just go back to page 130,
3 please? Just the bottom half of the page. Professor
4 Angelini is a Professor of Adult Cardiac Surgery.
5 Is there anyone there who worked for you on the finance
6 side of the Trust?
7 A. Yes, Colin Hawkins.
8 Q. Anyone else?
9 A. No.
10 Q. What was Colin Hawkins' role?
11 A. He was the Financial Manager for the BRI or medicine,
12 surgery, directorates and my deputy.
13 Q. Your deputy?
14 A. Yes.
15 Q. If we go back, then, to 138, "Opportunities and Threats"
16 if we scan down, if we can go over the page to 139:
17 "(b) Threats: following the removal of
18 supra-regional designation for under 1s from April 1994,
19 the workload which has hitherto been protected is now
20 open to competition from other providers. There is
21 a perception that the quality of paediatric cardiac
22 services in UBHT does not match the standards of the
23 Trust's major competitors and it is imperative that the
24 Trust demonstrates continued commitment to improved
25 quality in waiting times and outcomes which will have an
0089
1 impact on mortality and morbidity in specialist areas."
2 Do you remember ever having heard about that
3 perception?
4 A. I must have read it at the time, yes, but it is not
5 something that registered with me like that. The big
6 thing for me in this whole exercise that was going on
7 was, could we financially deliver what people actually
8 wanted to do, and at this stage, yes, we found
9 a mechanism to do that by using the funding and the
10 expansion of adults to allow that to happen.
11 Q. You would have seen this document?
12 A. Yes, I must have seen it because I certainly did the
13 work with putting together a handwritten schedule of
14 what I thought the risks were and the range of risks
15 financially.
16 Q. When you read it, it did not strike you as being news or
17 particularly striking that there was that perception
18 that quality in paediatric cardiac services did not
19 match that of elsewhere?
20 A. It is interesting. When you are a Finance Director, you
21 do not actually read, I am sorry to say, every piece of
22 paper that comes across your desk; you tend to home in
23 on what are the key issues for you, which is, will this
24 plan stack up? What are the capital costs, what are the
25 revenue costs and have we got purchaser support for
0090
1 this?
2 Q. But forgetting about the document for a moment --
3 I appreciate you are a busy man, lots of things to
4 read. Forgetting about the document for a moment, the
5 fact that there was, in 1994, such a perception in the
6 Trust's own documents would have been news to you?
7 A. Yes. It was not discussed by the Board or by Executive
8 Directors.
9 Q. And then it is clear, is it not, as a matter of English,
10 that there was to be improved quality both in waiting
11 times and in outcomes, so the quality there was not
12 simply being measured in terms of long waiting times?
13 A. No.
14 Q. If we go on the same page to paragraph 2 --
15 A. It is interesting that there is no actual statistical
16 backup for the statement either, in the document.
17 Q. No. We see what is said at paragraphs 2, 3 and 4.
18 Can we just deal with paragraph 3:
19 "Concern is felt that with the acknowledged
20 increase in the volume of adult cardiac surgery, the
21 needs of children may take a lower priority. In
22 addition, as the number of adults cases increases, the
23 ratio of children to adult operations will reduce,
24 resulting in dilution of experience and skills in an
25 increasingly specialist area of work which may put
0091
1 patients at added risk."
2 That dilution was ongoing at this stage. You
3 remember the document we looked at a moment ago which
4 showed the increase in adult surgery from 850 to 950
5 without paediatric operations having gone up at all?
6 A. Yes. And I recall the document we looked at yesterday
7 which said that the children requiring open heart
8 surgery were in the main elective admissions, whereas,
9 obviously, adults, a number of them are emergency
10 admissions.
11 Q. When I suggested to you a moment ago that as a matter of
12 English, paragraph 1, the concern was not simply put in
13 terms of waiting times but was also concern of outcomes;
14 you noted a comment that there were no statistics to
15 back up that statement in the document?
16 A. Yes.
17 Q. What type of statistics would you expect to back up such
18 a perception, if that perception was in fact there?
19 A. If I was making my case, then I would have listed the
20 unit's actual performance against national standards.
21 That is what I would have expected to have occurred and
22 that is what I would have expected to see now.
23 Q. Do you remember any discussion of the relative
24 performance of Bristol compared to other cardiac units
25 backed up with such information or statistics?
0092
1 A. No. The only time that I said that I can recall
2 something was a presentation done by Mr Wisheart and
3 Dr Joffe to visitors, the supra-regional people to
4 Bristol, where they looked at the workload and compared
5 that with national standards. They subdivided it down
6 into individual types of procedures.
7 Q. But in terms of quality of the outcome, as opposed to
8 the number of operations that was being carried out, you
9 do not remember any discussion comparing Bristol with
10 elsewhere?
11 A. No.
12 Q. What would the appropriate forum in the Trust have been
13 for such a discussion? Which committee, for example?
14 A. Well, I would have expected it to have been undertaken
15 between those that were involved in providing the
16 service; as the first step. I mean, you could say that
17 it was an audit issue, a clinical audit issue, or
18 a medical audit issue, but there was no other forum,
19 apart from the Medical Committee, but I am sure they
20 would not have discussed it there.
21 Q. You were the Deputy Chief Executive and you would be as
22 familiar with the appropriate management structures of
23 the Trust as Dr Roylance was, so if anything happened to
24 Dr Roylance, if he was called away, for example, or on
25 holiday, you would be able to hold the fort until he
0093
1 returned. That is what being a deputy is all about?
2 A. Yes, but I have indicated that I have a responsibility
3 for part of the Trust, not for clinical issues.
4 Q. But to the extent that there was a perception of
5 relative failure compared to other centres, both in
6 terms of outcomes and waiting times, at least the second
7 of those would be something that the finance end of the
8 Trust would be interested in, because, as we have
9 already seen, long waiting times can lead people to take
10 their business elsewhere?
11 A. Yes. We knew the issue to do with waiting times, but
12 that did not mean the organisation would not deliver the
13 volume of work in a particular year. If people were not
14 referring to a hospital, then what would happen is, your
15 waiting lists would come down.
16 Q. How did the senior management of the Trust keep abreast
17 of the relative performance, both in waiting times and
18 outcomes, of its services compared to competitors?
19 A. There was no information on outcomes. There was
20 information provided to general practices about waiting
21 times for outpatient attendances; there was information
22 within the Trust to do with waiting times for inpatients
23 and day cases.
24 Q. You suggested that it might have been a question for the
25 clinicians involved in a particular area, first of all,
0094
1 to keep abreast of their relative performance?
2 A. Yes.
3 Q. And suggested that it might be a clinical or medical
4 audit issue?
5 A. Yes.
6 Q. But audit topics, were, I think, selected each year,
7 particular topics would be audited; is that right?
8 A. They were selected, as I understand, although I was not
9 involved, within the Directorate. I can only recall one
10 time where there was a discussion with the purchaser
11 regarding looking at some audit type issues, and they
12 were arranged when Mr Wisheart and Dr Baker and
13 Dr Roylance identified a number of issues to look at.
14 Q. There was no other, as it were, top management mechanism
15 of keeping an eye on relative performance of any
16 particular specialty in the Trust?
17 A. Not that I am aware of, no.
18 Q. Do you think there could have been?
19 A. I think that there is a lot of development work in that
20 area now and people are struggling with it. The
21 clinical governance and all the changes that have come
22 about because of that are making NHS organisations to
23 look at it in a completely different way and a new way,
24 developing on from what was medical audit to clinical
25 audit and now clinical governance. They are all part of
0095
1 that same journey.
2 Q. So there could have been, but it was not the done thing?
3 A. I would not have said it was developed that far, but
4 bearing in mind -- I am sorry to reiterate it -- that
5 that is not really my field of expertise.
6 Q. Save that you were the Deputy Chief Executive of the
7 Trust?
8 A. For financial and administrative matters and Mr Wisheart
9 was designated by the Trust Board in 1983 as the Deputy
10 Chief Executive for clinical issues.
11 Q. Can I move on to something else?
12 The initial contracting experience of the Trust,
13 when it was contracting with its major purchaser from,
14 in its area, the Bristol and District Health Authority
15 as it became, I think you say in your statement that
16 Mr Boardman and Mrs Maisey and yourself did a lot of the
17 initial work on contracting for the non-Avon
18 purchasers. Perhaps there was more involvement from the
19 Trust directorates at local levels. I think we
20 discussed that this morning.
21 A. Yes. I think in the very early days, Mrs Maisey and
22 Steve Boardman and myself actually had a major role in
23 the Avon work, and the Bristol and District work as
24 well, because it was all new and we had to keep very
25 tight control on volumes of money.
0096
1 Q. In the annual contract that was agreed, leaving aside
2 neonatal and infant cardiac surgery for the moment,
3 which was initially still designated --
4 A. Yes.
5 Q. -- but for children of more than one year, there would
6 be no distinction drawn between surgery on them and
7 surgery on adults for the purpose of the contract?
8 A. For open heart surgery, no. The closed heart would have
9 been identified because they were at the Children's
10 Hospital rather than the Royal Infirmary and the
11 contract showed which hospital they were. We did our
12 contracts by individual hospital as well as by
13 specialty.
14 Q. Yes, but the contract would show in it that there was
15 a contract for X open heart operations at the BRI at
16 Y pounds each?
17 A. Yes.
18 Q. And X would include adults and children?
19 A. Yes.
20 Q. In fact, is there a difference in cost between the
21 paediatric open heart operation and an adult open heart
22 operation?
23 A. Yes.
24 Q. What is the difference?
25 A. The major determinant of cost is length of stay and time
0097
1 in theatre, either; if you can find information on those
2 two factors, then you can identify the bulk of the
3 difference in cost. And we knew that children stayed
4 longer.
5 Q. So paediatric open heart operations are more expensive
6 than adult ones?
7 A. Yes. At the beginning of contracting, of course, we
8 might have had the knowledge but we did not actually
9 have the time to increase the sophistication of the
10 costing. But as you go into the follow years from
11 1991/92 onwards, then we did identify not only for
12 cardiac but for other services particularly high cost,
13 low volume specialties and their prices.
14 Q. If we go to HA(A) 10/90, this is that part of the, as it
15 were, global contract between the Health Authority and
16 the Trust dealing with cardiac surgical services,
17 is that right, in the first year of the Trust? You see
18 it in paragraph 1.1?
19 A. Yes.
20 Q. So this is the first contract that the Trust entered
21 into for cardiac surgery services, to your knowledge,
22 other than the supra-regional ones?
23 A. Yes.
24 Q. You would have been involved as the Financial Director,
25 you would have had an input into this contract?
0098
1 A. Almost certainly I would have passed comment on it, yes.
2 Q. That contract has to be read alongside the general
3 service agreement which governed all these individual
4 service agreements?
5 A. Yes.
6 Q. They were, as it were, general terms which applied?
7 A. Yes, there were general terms about payment, inflation,
8 arbitration, best endeavours, and then there were whole
9 lever-arch files full after a period of time -- I am not
10 sure they existed on Day 1 -- about service
11 specifications.
12 Q. If we go to UBHT 23/437, these are the service agreement
13 key objectives?
14 A. Yes.
15 Q. If we go to 439, in 1991/92, the first year of the
16 Trust, service agreements have been made with
17 15 separate purchaser health authorities which covered
18 almost all of the Trust's projected operating costs.
19 So the other one per cent may have been the odd GP
20 fund-holder, or something like that, would it?
21 A. Yes. This is not as such a service agreement, this
22 looks like a report on actually where we were with
23 service agreements rather than the content of service
24 agreements themselves.
25 Q. And 3.2 shows that the three major purchasers accounted
0099
1 for 85 per cent of the current operating costs?
2 A. Yes. That would be Southmead, Frenchay and Bristol
3 district, I assume.
4 Q. And those were block agreements?
5 A. Yes.
6 Q. We went into that yesterday, we explored what that
7 meant.
8 A. Yes.
9 Q. Can we go back to the service and specification for
10 cardiac services at HA(A) 10/90, paragraph 3.3.1:
11 "The service will be consumer orientated and will
12 seek to maximise consumer choice within available
13 resources."
14 Who is the consumer? Is that the patient or the
15 Health Authority?
16 A. I would assume that is the patient.
17 Q. What kind of choice did they have?
18 A. I do not know.
19 Q. Not much, for cardiac and surgical services?
20 A. I would not have thought so, no.
21 Q. Because they were only available on one site?
22 A. Yes.
23 Q. We see, if we scan down that page, children, there is
24 a percentage target for infant operations. There is
25 a range which has not been filled in, that would be
0100
1 between X and Y open operations and between X and Y
2 closed operations?
3 A. Yes.
4 Q. The target for infancy, under 1 year old, was 35 per
5 cent of those corrections being undertaken in that age
6 group.
7 That would be important because the purchaser
8 would want to know how many of the children's congenital
9 heart disease would be operated on before their first
10 birthday, thereby falling within the supra-regional
11 services agreement; is that right? That would be the
12 importance of that?
13 A. Yes.
14 Q. Were there any sanctions for not meeting the target of
15 that sort?
16 A. No.
17 Q. The Health Authority, the purchaser, from its point of
18 view, would be content, would it not, for that target to
19 be at the upper end of the range, or even higher,
20 because the more people who are in the target of 4.3,
21 the more money will be forthcoming from the Supra
22 Regional Services Advisory Group and the less from the
23 purchaser?
24 A. Yes.
25 Q. And it does not matter to the Trust who is paying for
0101
1 the operation, so long as someone is?
2 A. It does matter to the Trust, because if we can get
3 another organisation to pay for it and not the Health
4 Authority, that meant that more money was available in
5 Avon for the care of residents of Avon.
6 Q. Was there any difference in the price paid for the
7 operation, if it came from the Department of Health, as
8 opposed to if it came from the Health Authority?
9 A. I am sure there must have been a difference in price.
10 I cannot imagine they were the same. If you go on to
11 when we had the de-designation, then we did have
12 difficulty assimilating the funding coming from the
13 supra-regional into the over 1s. We had to change the
14 prices and there is a whole series of letters which went
15 out to purchasers explaining why that happened and what
16 we had to do about it.
17 Q. Was the change in price that the price for the over 1
18 operations went up after de-designation?
19 A. Yes, it did.
20 Q. Was that because the price that was now going to be
21 obtained from under 1s, from the Health Authority, was
22 lower than the price that had hitherto been obtained
23 from the Department of Health?
24 A. Yes. We did a remix of the costs across the headings.
25 One of the things about the system was that if you
0102
1 had made a decision or did a calculation at a particular
2 point in time that got set in stone with this system,
3 and it was very difficult to actually alter something at
4 a later date if you found you had made a mistake earlier
5 on.
6 We had examples, and it ranged from physiotherapy
7 where, right at the beginning, we just costed
8 physiotherapy as a cost per attendance and then found we
9 had been stuck into that channel right up to today.
10 Because physiotherapy is just a simple thing, there are
11 straightforward physiotherapy referrals within the
12 district, but then there are referrals from
13 physiotherapy into the specialist unit within the Royal
14 Infirmary and the cost difference is quite substantial.
15 Q. So the Health Authority has an incentive to have the
16 target at 4.3 as high as possible?
17 A. Yes.
18 Q. Every operation paid for by the Department of Health is
19 more lucrative than the same operation carried out on
20 the Health Authority's money, and the greater number of
21 operations carried out on under 1s frees up more
22 resources from the Health Authority to be spent in other
23 areas, so both the Trust and the Health Authority have
24 a mutual incentive, in purely financial terms, to carry
25 out as many operations in infancy as possible?
0103
1 A. Yes. The way you are putting it is right. I do not
2 think we actually ever thought of it like that at that
3 time.
4 MR MACLEAN: Sir, is that a convenient moment for a further
5 break? Can I indicate that, with a little bit of
6 chopping, we are making quite good progress and I would
7 hope that we would finish Mr Nix's evidence by about
8 two o'clock?
9 THE CHAIRMAN: Yes. We will break for half an hour, until
10 1 o'clock. As regards the evidence, you will take
11 whatever time you need, in consultation with others who
12 may have things that they wish to have raised.
13 MR MACLEAN: Yes.
14 THE CHAIRMAN: But thank you for giving us that general
15 guidance.
16 (12.32 pm)
17 (Adjourned until 1.00 pm)
18 (1.00 pm)
19 MR MACLEAN: Mr Nix, before lunch I dealt with the memo in
20 1994. Do you remember the context of the discussion
21 about the split site? There is one aspect of that which
22 I perhaps should have dealt with then and did not. Can
23 we go back to UBHT 275/139, paragraphs 3 and 4?
24 Paragraph 4, in particular:
25 "If the Children's Hospital is to retain and build
0104
1 upon its reputation, the appointment of a consultant
2 paediatric cardiac surgeon was required to undertake and
3 oversee this service."
4 Pausing there, we know that Mr Pawade took up the
5 post in May 1995?
6 A. Yes, he was appointed in an interview, I think, in
7 September 1994.
8 Q. And he continues to operate as a paediatric cardiac
9 surgeon?
10 A. Yes.
11 Q. The next sentence says:
12 "It has proved impossible to attract a suitable
13 candidate under the current split site arrangements."
14 By the time that Mr Pawade was appointed, it is
15 right, is it not, that moves were afoot to bring an end
16 to the split site arrangement?
17 A. Yes. Agreements had already been made much earlier that
18 year. In fact, I thought it was in late 1983/early
19 1984, as part of the capital programme to build a new
20 theatre and to expand the intensive care unit -- the
21 paediatric intensive care unit.
22 Q. I am told within the text of what you have just said,
23 Mr Nix, you say you thought it was in late 1993 or early
24 1994; is that right?
25 A. Yes, that the decision was made to invest in that.
0105
1 Q. It is implicit in paragraph 4 that there had been
2 earlier attempts to attract a paediatric cardiac surgeon
3 to the Children's Hospital, or to the BRI.
4 A. I know now that an approach was made to appoint
5 a Professor in paediatric cardiac surgery.
6 Q. What about attempts to attract a non-academic post?
7 A. I do not know anything about that.
8 Q. Did you have any role in the attempts before the date of
9 this memo, which had proved unsuccessful to appoint the
10 paediatric cardiac surgeon?
11 A. No, I did have not any involvement in that area of the
12 work, but I was involved and I did sit on the interview
13 panel for Mr Pawade.
14 Q. Who would have been involved in those earlier attempts
15 to attract the paediatric cardiac surgeon?
16 A. I understand now that James Wisheart was involved, but
17 I do not know if anyone else was involved in that.
18 Q. Would Dr Roylance have been involved?
19 A. I would have expected so, but I do not know that.
20 I know that Mr Wisheart definitely was.
21 Q. Would Mr Stone have been involved as Director of
22 Personnel, or would he not have been involved if
23 Mr Wisheart was?
24 A. No, Mr Stone would not have been involved the same way
25 as I was not involved.
0106
1 Q. You mentioned an academic appointment. We know that the
2 Professor of Cardiac Surgery, who was appointed a few
3 years ago now, was Professor Jani Angelini?
4 A. Yes.
5 Q. It is right he did not undertake any substantial
6 paediatric cardiac operations?
7 A. Actually, I was not aware he did any paediatric work.
8 If he did, then I am not aware of that.
9 Q. So the reference in the last sentence about finding it
10 difficult or impossible to attract a suitable candidate,
11 cannot be a reference to a difficulty in filling a place
12 which ultimately went to Professor Angelini, but is
13 rather a reference to filling the place which eventually
14 went to Mr Pawade? It is a complicated question.
15 A. Yes. My understanding was that the wish was to have
16 a Professor in Paediatric Cardiac Surgery, which they
17 could not attract. This is my understanding of it now.
18 They could not attract because of the split site
19 arrangements and they went out to advert and appointed
20 a Professor of Adult Cardiac Surgery instead, to give
21 academic leadership to cardiac surgery, and a further
22 advert went out funded from the development for
23 a paediatric cardiac surgeon.
24 Q. Do you know now the identity of any people who refused
25 to undertake the appointment because of the split site
0107
1 arrangement?
2 A. I know the name but I cannot recall it. It was
3 a paediatric cardiac surgeon from London.
4 Q. Was it Martin Elliott?
5 A. Yes.
6 Q. Was he, to be clear, in the running for the appointment
7 as a paediatric cardiac surgeon or for the academic
8 post? Which?
9 A. I understand it was for Professor of Paediatric Cardiac
10 Surgery, but that is really a question for Mr Wisheart
11 or Dr Roylance.
12 Q. As to the extent there are matters of interest in
13 paragraph 4, those are most appropriately put to
14 Mr Wisheart and Dr Roylance?
15 A. Yes.
16 Q. Can I go back to HA(A) 10/90, the contract for the first
17 year of the Trust, and go to paragraph 3.4?
18 "In drawing up the services, emphasis will at all
19 times be placed on the quality of care provided for the
20 patient."
21 Can we go then to HA(A) 10/93? These clauses,
22 although they are in the service agreement for cardiac
23 surgery, the type of clause we see at 14 would be pretty
24 typical, would it, for other specialties as well?
25 A. I cannot recall all of them, but I am sure there were
0108
1 general statements like that in an overarching
2 document. It would surprise me if there was one
3 specific for cardiac as this one is, because my
4 understanding of the system that was set up was that
5 there was an overarching agreement which talked about
6 these sorts of generalist type issues, and then there
7 was a sheet of paper within what you class as service
8 specifications, actually trying to identify exactly what
9 the service was.
10 So this document, when I saw it, it actually
11 surprised me that one like this existed.
12 Q. Can you help us with what mechanisms are referred to
13 in 14.1?
14 A. I am not quite sure what the author of that really
15 meant, but, I mean, you could make a long list. Given
16 what I understand now, I would be interested in health
17 and safety, infection control, a whole range of things
18 to do with quality from that point of view and it could
19 go on, then, into the sorts of things you have on the
20 previous list, what information we provide to patients,
21 the waiting times.
22 Q. The type of information we saw in Appendix B to draft 2
23 of the supra-regional contract?
24 A. Yes. There are about 14 or 15 of them listed.
25 Q. You say that is, from what you understand now, what you
0109
1 might expect. Is that what you would have expected in
2 1991?
3 A. No, I do not think so. That is more like a motherhood
4 sort of statement saying "We have to have something
5 about quality so we will write that in there", but I do
6 not think it was ever defined.
7 Q. You say "mother"; "motherhood" in "apple pie"
8 statements?
9 A. Yes. Clearly, people recognised that a statement on
10 quality had to be included but it was not defined in any
11 detail. This was the start of a process. You have to
12 bear in mind that in 1991 an awful lot of work was being
13 done on both sides to get the system up and running.
14 Q. You remember the discussion we had this morning about
15 whether matters might be appropriate for audit for the
16 clinical and medical audit, and I was asking you whether
17 or not there were any other structures at a higher
18 management level.
19 A. Yes.
20 Q. Can we go over the page to 94 to clause 15?
21 "The audit will include audit of outcomes, the
22 medical process the management process."
23 A. Could you just identify where that is?
24 Q. I am sorry, 15.1.
25 "The audit of outcomes will include measures of
0110
1 30 day mortality, one year mortality and one year
2 symptomatic state."
3 That is follow-up.
4 "Symptom relief assessments to be agreed with the
5 referring cardiologists".
6 15.4: "Audit information will be made available to
7 the Director of Public Health Medicine as the
8 purchaser's representative. This will be subject to the
9 agreement on confidentiality ... regarding individual
10 patients and also concerning the release or publication
11 of audit information."
12 The Director of Public Health Medicine was
13 Dr Baker, was it?
14 A. Yes.
15 Q. He had previously been a colleague of yours in the
16 Health Authority?
17 A. Yes.
18 Q. He was the District Medical Officer?
19 A. Yes.
20 Q. And he had been one of your, as it were, collaborators
21 in the past in making pitches to the Regional Health
22 Authority for the development of cardiac services?
23 A. Yes.
24 Q. So would it be fair to say that he was familiar with the
25 cardiac surgery setup in 1991?
0111
1 A. Yes, and he has a particular interest in that area, not
2 in pulmonary but in cardiac and cardiology.
3 Q. Are you able to help us with the type of information
4 that was supplied to Dr Baker pursuant to that clause?
5 A. I am not aware of any information being provided, but
6 that would have come from the cardiac surgeons, the
7 cardiologists, if it came from anybody.
8 Q. So to the extent that anything passed to Dr Baker
9 pursuant to this clause, you would have expected it to
10 have been passed by Dr Joffe or Jordan, for example, or
11 Mr Wisheart or Mr Dhasmana?
12 A. Yes. Nobody else would have access to that sort of
13 information.
14 Q. What about the General Manager of Cardiac Services, as
15 it became, or the Director of Surgery as it was at this
16 time?
17 A. They might have had access to it, but I would not have
18 thought so. I would not have imagined the Manager would
19 have attended their medical or clinical audit meetings,
20 but --
21 Q. If we go to page 96, clause 23.1 -- it must be over the
22 page.
23 THE CHAIRMAN: You may mean 21.3.
24 MR MACLEAN: My note says 23.1. I am most grateful to the
25 Chairman who is characteristically ahead of me.
0112
1 21.3: "Monitoring of quality standards laid out in
2 the service agreement and reported to purchasers in
3 regular reports. The sample sizes and methodology for
4 data collection to be agreed with purchasers in
5 advance. Purchasers reserve the right to request
6 follow-up of monitoring reports, including verification
7 of data. Any such requests to be handled by the
8 authorised officers for the service agreement."
9 What light can be shed on the follow-up by
10 purchasers of monitoring reports sent to them?
11 A. The only monitoring reports that I know that were
12 submitted were handled by Mrs Maisey, which were related
13 to patient waiting times, times waiting in A & E
14 departments to see a doctor or a nurse and a whole range
15 of that sort of data, and including information about
16 the community and times that district nurses and health
17 visitors got to their appointments, and I know that
18 there were follow-up questions from the Health Authority
19 about performance in those areas, but I am not aware of
20 any other follow-ups or of any report presented to the
21 Health Authority on the sorts of issues we were
22 discussing a few moments ago.
23 Q. So if we go to your witness statement, at WIT 106/24,
24 paragraph 50, in the last sentence -- perhaps you could
25 read that paragraph to give it some context. It is the
0113
1 last sentence:
2 "Performance against these specifications was not
3 discussed at contract meetings with purchasers, other
4 than waiting times."
5 That is essentially what you have just told me in
6 the previous answer?
7 A. Yes.
8 Q. Mr Nix, I am helpfully assisted by Mr Langstaff and
9 through him by Miss Powell. Dealing with the question
10 of the point, the impossibility of finding a cardiac
11 surgeon, you remember we looked at that document
12 a moment ago, I think what I have been asked to clarify,
13 and I am happy to do so, is that Mr Elliott was
14 a candidate for the academic post which was finally
15 filled by Professor Angelini?
16 A. That was my understanding, yes, but as I said, I think
17 that is a question really to be raised to Mr Wisheart or
18 Dr Roylance and not to me.
19 Q. So I think I may have said at one stage to you --
20 according to the transcript I did say that the reference
21 in the last sentence about finding it difficult or
22 impossible to attract a suitable candidate could not be
23 a reference to the position of surgeon filled by
24 Professor Angelini, but in fact in so far as the
25 sentence is a reference to Mr Elliott, that would be
0114
1 concerned with the filling of the academic post.
2 Maybe you cannot comment?
3 A. I think I actually corrected you when you said that.
4 Q. I think we are all agreed that Mr Elliott was in for the
5 academic post?
6 A. Yes.
7 Q. He did not take it?
8 A. No.
9 Q. Professor Angelini did?
10 A. Yes.
11 Q. To the extent that the last sentence in that passage we
12 looked at is a reference to Mr Elliott, then it is
13 a reference to the academic post?
14 A. Yes.
15 Q. I hope that clarifies things to the satisfaction of
16 those who are behind me, to whom I am grateful.
17 Now can we go, please, to August 1991, and to
18 HA(A) 16/2?
19 This is produced by three health authorities, one
20 of them Bristol & Weston, specifications for health care
21 in Bristol and District, 1992 to 1993 and it is called
22 the "Statement of intent and guidelines".
23 These three health authorities were shortly to
24 become the Bristol and District Health Authorities?
25 A. Yes.
0115
1 Q. And there was to be a single budget for the purchase of
2 Bristol and District health care. We see that from
3 page 4?
4 A. Yes.
5 Q. I think we may have looked at this document yesterday:
6 if we go, please, to UBHT 38/430, this is 20th November
7 1991, so this is about 6 months into Trust status. This
8 is a letter to Dr Roylance from Catharine Hawkins. You
9 see that she says:
10 "I have just finished reading the interim reviews
11 of the DHAs and family health service authorities
12 region-wide, and at all but one review we heard how
13 poorly Bristol Trust is now performing on cardiac
14 surgery contracting, and as a consequence some are
15 shifting their contracts this coming year and others
16 plan to shift them in 1993."
17 Is that a concern about the standard of the job
18 that was being done, or is that a reflection of what we
19 saw earlier, that there was a blockage in the system and
20 not enough cases were being done?
21 A. I think it is related to the waiting lists for surgery
22 at Bristol and the fact that patients were in some cases
23 sat in local hospitals waiting to be transferred to
24 Bristol for operations.
25 Q. The next sentence, is that a reference in part to you
0116
1 or, if not, to whom?
2 A. It says "business managers", so that could not possibly
3 be me. I think that is because health authorities did
4 not like us saying "There are more cases needed to be
5 done, and this is our estimate and this is the
6 investment you will need to make". I know that some
7 health authorities, over the years, and that year is
8 just one example of it where we were saying, "Sorry,
9 there is not a lot we can do unless... You have to
10 invest more". So I would imagine it is about that.
11 Q. Did you discuss the contents of Catharine Hawkins'
12 letter with Dr Roylance?
13 A. No, never saw it.
14 Q. We see in the last sentence we have on the page:
15 "I am sure Mr Wisheart would like to be made aware
16 of the gross dissatisfaction region-wide."
17 You would have expected, therefore, that
18 Dr Roylance would have brought this to Mr Wisheart's
19 attention?
20 A. Yes.
21 Q. But you do not remember him bringing it to your
22 attention as the other Deputy Chief Executive?
23 A. This was November 1991, and I was not a Deputy Chief
24 Executive at that stage, and neither was Mr Wisheart.
25 In fact, he was an Associate Clinical Director in 1991.
0117
1 Q. Mr Dean Hart was the Medical Director?
2 A. He was the Medical Director.
3 Q. We have Dr Roylance's reply, which is January 1992,
4 UBHT 38/426.
5 A. Can we have a look at the top of the page. The reply
6 was written by Mr Wisheart.
7 Q. So "JR" is John Roylance?
8 A. Yes.
9 Q. "JDW" is Mr Wisheart?
10 A. Yes.
11 Q. And "AM"?
12 A. Is the Secretary.
13 Q. So Dr Roylance had indeed brought the contents of
14 Catharine Hawkins' letter to Mr Wisheart's attention, so
15 this letter, which would go out under Dr Roylance's
16 name, you are able to tell us is in fact from
17 Mr Wisheart?
18 A. It would have been drafted by Mr Wisheart.
19 Q. Can we have a look at what is said?
20 " ... very grateful ... for conveying their
21 opinions. Only Exeter had mentioned it direct." And
22 then there is a recitation as Dr Roylance has it in the
23 letter of what Mr Wisheart told him. It deals with
24 volume and with cost.
25 If we go over the page (427), "Quality:
0118
1 "The outcome of our work is at a quality level
2 similar to that expected nation-wide as documented in
3 the UK cardiac surgical register."
4 It goes on to deal with waiting times.
5 So is this little exchange of correspondence at
6 this time something that again we have to take up with
7 Dr Roylance and Mr Wisheart?
8 A. Yes, absolutely.
9 Q. Can we go to UBHT 295/697? This is a contract or
10 a computer printout of the cost and volume of the
11 contract for the provision of health services for
12 1993/94, so we are now in the third year of Trust
13 status.
14 We see the neonatal and infant cardiac surgery
15 part of the contract at page 698.
16 Is this right: that we get neonatal and infant
17 cardiac surgery at the top of the page -- this is the
18 last year of supra-regional services?
19 A. Yes.
20 Q. And it is that same number: 60 contracted for, that we
21 saw earlier. In fact it turned out that the number was
22 52?
23 A. Yes.
24 Q. So the next entry, "cardiac surgery", is treating adults
25 and children alike?
0119
1 A. Yes.
2 Q. And so there are 7 different sources of referral for the
3 general run cardiac surgery?
4 A. Yes.
5 Q. And then bypass and valve operations are separated out
6 at the foot of the page, I assume because those were the
7 "big ticket" items; those were the ones where the big
8 numbers were?
9 A. No, it is because we had started to subdivide out some
10 of them. So for some of the areas, like Cornwall and
11 North Devon, that is a combined figure under the heading
12 "Cardiac Surgery", but for Somerset, who were a major
13 referral to Bristol, they clearly wanted us to start
14 separating out coronary artery bypass grafting and heart
15 valve operations.
16 So if you look at a most up to date one then you
17 will see that heart valves and coronary artery bypass
18 grafts and children are basically the groupings that are
19 now used. So this is a transition, really, from 1991
20 through to what we are doing now, as things change with
21 different purchasers.
22 Q. This table gives us an idea of price, does it not?
23 A. Yes.
24 Q. It looks as if, does it not, the Trust is receiving
25 œ5,373.68 for each neonatal and infant operation?
0120
1 A. Yes.
2 Q. Which is actually less than the sum it was receiving for
3 any of the other paediatric or adult cardiac surgery
4 operations?
5 A. Yes.
6 Q. And yet when we look at the entries under cardiac
7 surgery, whilst most of the entries are the same price,
8 at œ6,907.25 it looks as if Wessex and Somerset in
9 particular are getting a somewhat rawer deal?
10 A. Yes, they are paying slightly different prices --
11 significantly different prices.
12 Q. If one is Somerset, one is paying rather a lot more?
13 A. I hope they are not looking at the transcript.
14 Q. Why would that be? Is that just a reflection of
15 commercial reality, that you have been able to do
16 a better deal than Somerset?
17 A. I think that is unfair, asking me that question. We are
18 supposed to have the same price for every purchaser. We
19 are not allowed to build in surpluses. There were sets
20 of rules. I cannot actually explain why the prices
21 there are different and why Somerset are paying more, to
22 be honest. I would not have expected them to pay
23 different prices. The fact we have split out heart
24 valves, I would have expected there to be a lower price
25 under cardiac surgery for the rest of the Somerset work,
0121
1 but that is not reflected.
2 Q. Indeed, because the price of the valves themselves was
3 significant?
4 A. That is why the heart valve operation I would expect to
5 be higher, I think anyway, because of the cost of the
6 valves.
7 Q. It may be that that is a document that might benefit
8 from some further study, perhaps, and if it does, by all
9 means let us know. But the fact that the price for
10 neonatal and infant work is lower than the general run
11 of work is also rather contrary to the discussion we had
12 before the last break about the relative sums achievable
13 from the Department of Health on the one hand and the
14 Region on the other?
15 A. Yes, or the Health Authority on the other. I think you
16 have to recognise that you are picking one document out
17 of a whole series, and it is actually pretty difficult
18 to go back and understand some of the figure work that
19 was created at that time. It is a long time ago to
20 remember exactly all the finite detail as to why some of
21 these prices were different.
22 Q. Can I go to the contract negotiation? For that same
23 year, 1993/94, HA(A) 3/21, this is a note, not a formal
24 minute, of the meeting that took place with the main
25 purchaser, the Bristol and District Health Authority?
0122
1 A. Yes. This is the sort of top level discussion, if you
2 like, that I mentioned before, that you would have
3 discussions going on between directorates but you would
4 get the Chief Executives of the two organisations to
5 meet, and you had Dr Gerald Johnson as the Chief
6 Executive for Bristol and District.
7 Q. You by this time are the Deputy Chief Executive and
8 Finance Director, as you always were, and Mrs Maisey is
9 the Director of Operations, I think, at this stage.
10 Mr Wisheart was Medical Director and I think by this
11 time may have been Deputy Chief Executive?
12 A. I think you will find that the Board minute designating
13 as such was March, but I think I was operating as such,
14 probably.
15 Q. 6, Sarah Broadbridge, what was her responsibility?
16 A. She worked for me in the contracting area, so she helped
17 to keep all the detailed information together.
18 Q. The fact that your name comes first there, in that list
19 of UBHT personnel, does that indicate that whilst
20 Dr Johnson headed up the authority team, you were
21 essentially in charge, in the absence of Dr Roylance,
22 leading the Trust team?
23 A. Yes.
24 Q. How many of this type of meeting would there be in the
25 course of a year leading to the conclusion of
0123
1 a particular yearly contract?
2 A. One or two, not many, and it would be -- it may well be
3 before Christmas and then one or two, usually the crunch
4 ones, in about March. When we have the pressure of
5 having to sign the contracts before the end of the year,
6 we are clearer about the financial implications of the
7 review body awards for doctors and nurses.
8 Q. Can we go to 23? And 6(c). This is a note of the
9 meeting, so since the meeting it has been established
10 that supra-regional funding will not change for 1993 and
11 1994 and the Panel already knows that there was
12 initially a suggestion that de-designation should take
13 place from 1993, but in the end, a further year was
14 given to designation?
15 A. Yes.
16 Q. If we scan down the page, and I think over the page (24),
17 A, Outcomes:
18 "James Wisheart tabled a paper outlining UBHT's
19 suggestions for clinical audit... these to be considered
20 by public health..." -- that is Dr Baker's department?
21 A. Yes.
22 Q. "In the light of suggestions from other Trusts. James
23 Wisheart to provide an explanatory paragraph for each
24 audit. Debbie Evans..." She was a health authority
25 employee --
0124
1 A. Director of Contracting.
2 Q. "She raised MI and thrombolitic therapy which might be
3 discussed with UBHT subsequently."
4 So is it right that clinical audit would take
5 place annually and would look each year at different
6 selected periods?
7 A. First off, can I just say I think you might find
8 Dr Keiran Morgan was the Director of Public Health at
9 this stage, but this needs to be checked with the Health
10 Authority and not Dr Baker. This, I think, refers to
11 the situation where I had mentioned that at some stage
12 there were some discussions about specific topics for
13 clinical audit and this is, I believe, the list that
14 Mr Wisheart was producing to discuss with Avon, or
15 Bristol and District.
16 Q. So Mr Wisheart's list, presumably the final decision as
17 to which topics were to be audited lay with the
18 purchaser?
19 A. I think in the main, the clinical audit was, as
20 I understand it, actually organised within the Trust
21 through the directorates, but there was a specific
22 initiative that had been discussed with Avon on trying
23 to find some areas of agreement that clinical audit in
24 those areas could be pursued.
25 Q. So the areas to be clinically audited were in essence
0125
1 self-selected by the Trust?
2 A. As I understand it, within the directorates, and this
3 was something special that they were trying to develop.
4 Q. And in particular, the suggestions, at least in this
5 year for clinical audit at the UBHT, were set out in
6 a paper tabled by Mr Wisheart?
7 A. Yes.
8 Q. Can I go now to UBHT?
9 A. I do not believe I can recall that actually happening
10 before, or after that year either.
11 Q. What happening?
12 A. Agreeing a list of special clinical audit topics.
13 Q. 295/26, service specifications 1994/1995, "GRN" at the
14 top of the page. That is you, obviously?
15 A. Yes.
16 Q. "This specification states the requirements of the
17 Bristol and District Health Authority in respect of
18 cardiac services for children to be purchased for
19 residents of Bristol and district."
20 If we go to the bottom of the page, cardiac
21 surgery for children aged under 1 year will be part of
22 the block contract for 1994/95, so de-designation having
23 taken place, they are subsumed into the general block?
24 A. Yes, and subsequent to that, we removed the distinction
25 of under 1s to over 1, and then developed with
0126
1 "children" as a heading rather than maintaining the
2 differentiation, because it always seems strange to me
3 that a child who was 365 days old fitted into one
4 category while one that was a day older did not.
5 Q. Yes. That was a historical throwback to the division
6 that the Department of Health had chosen to make when
7 designating only for under 1s?
8 A. Yes.
9 Q. You discussed with me earlier, you remember when we were
10 looking at the quality provisions in the supra-regional
11 contract, and the passages that Mr Cameron had put
12 a line through?
13 A. Yes.
14 Q. Then we saw the final version of the contract which
15 referred back to the, as it were, standard contract that
16 the Trust had with its main purchaser?
17 A. Yes.
18 Q. You explained that the Trust was not in the business of
19 having any more than one standard, and so set that
20 standard by reference to its main purchaser?
21 A. Yes, because you could not expect clinicians to have to
22 keep referring to a whole range of different
23 specifications.
24 Q. I think we can see an example of that at UBHT 100/38
25 (sic). That does not look right. Never mind.
0127
1 The Trust Management Board on 5th April 1993 had
2 a meeting, a meeting which actually you sent your
3 apologies to, and there was a discussion there of GP
4 fund-holders and they were looking for their own bespoke
5 quality service.
6 I think the Trust decided, did it not, that under
7 no circumstances would it sign contracts which involved
8 a financial penalty for non-compliance with quality
9 standards and insisted on the maintenance of the
10 standard set out in the contract of Bristol and
11 District?
12 A. Yes. I cannot remember the discussion, but we would
13 have kept a line on that, yes.
14 Q. I am sorry, I lost that reference. I must have pressed
15 the wrong button, but we will never find it at the
16 moment. I can, if necessary, refer you to that later.
17 At your witness statement, WIT 106/24, you refer
18 to the service specification for cardiac surgery for
19 children for 1994/95. We just looked at that. Do you
20 remember, we saw the reference at the bottom of the
21 page to under 1s being part of the block contract?
22 A. Yes.
23 Q. You quote from the service specification:
24 "Bristol and District Health Authority expects
25 a provider to comply with the general quality standards
0128
1 which are common to all services, see Schedule 3(a) on
2 general quality standards and monitoring, 1993/94.
3 "The quality of investigation and intervention
4 will keep fatality and morbidity to minimum levels
5 according to national standards, taking account of case
6 mix and will be the subject of monitoring and clinical
7 audit."
8 We will look at Schedule 3 in a minute, but just
9 looking at paragraph 2, how were national standards to
10 be taken account of, bearing in mind the discussion we
11 had before the last break about the mechanisms or lack
12 of mechanisms for national comparisons?
13 A. I do not know. I was here trying to extract the bits
14 that I thought were relevant to put before the Inquiry,
15 given that you had asked me specific questions. So
16 I researched this and listed it. I am not aware of how
17 we were doing that within the Trust.
18 Q. It is plainly relevant for the Inquiry to have this and
19 we are grateful for it. The service specification for
20 cardiac surgery would have been drawn up by whom, in
21 1994/95?
22 A. Probably the basis of it would have been done by the
23 Health Authority, and then the whole issue of the
24 specifications were handled by Mrs Maisey, who got them
25 from Avon Health and distributed them throughout the
0129
1 Trust to the clinical directorates for them to make
2 comment on, collected that back in and passed it back to
3 Avon for amendment and if necessary, individual
4 directorates would have had telephone conversations and
5 correspondence with Deborah Evans at Avon Health. That
6 is how they were created.
7 Q. The reference to taking account of case mix, as to how
8 that should have been taken account of, that would be
9 a matter which would be best known to the cardiac
10 surgery directorate, would it?
11 A. Yes. The only thing, I mean, clearly as we have already
12 said, from a client's point of view, I was interested
13 whether they were coronary artery bypass grafts or valve
14 replacements and I was interested in whether or not they
15 were children or adults. That was all we really needed
16 to know.
17 Q. Was it your understanding that the Trust was warranting
18 that national standards would be met in terms of
19 fatality and morbidity?
20 A. Personally, I would have expected it to have been
21 achieved. But I do not think the Trust actually did
22 anything proactively -- I know they did not do anything
23 proactively to monitor this.
24 Q. I just want to deal with one more contract, I think, and
25 then one more area, and then there may be some sweep-up
0130
1 questions, but we are coming towards the end.
2 Can I take you to the service specification for
3 1995/96 at UBHT 295/28.
4 This is one year on from the one we have just
5 looked at.
6 A. Yes.
7 Q. We can see from page 29 that, in the course of this
8 year, if we scan down, you see under the heading
9 "In-patients", the move was to take place during
10 1995/96?
11 A. Yes.
12 Q. It in fact took place towards the end of 1995?
13 A. Yes.
14 Q. After Mr Pawade had started work?
15 A. In May 1995.
16 Q. This is the quality aspect, your witness statement at
17 page 24 dealt with the contract for 1994/95, 1995/96 and
18 it is essentially, in fact exactly, the same?
19 A. It did not change every year. There were elements added
20 but it was not a complete rewrite in any way.
21 Q. We have dealt with paragraph 2. We need to go to
22 Schedule 3(a) to see what is said there, at 295/30.
23 These are the standards which apply to all
24 services purchased by Bristol and District from the
25 Trust for that year?
0131
1 A. Yes.
2 Q. If we scan down, we see that reference is made to:
3 "Looking at outcomes crudely, for example, "Did
4 the health of patients improve as a result of their
5 stay ... Avon Health also recognised that some measures
6 which on the surface relate to process rather than
7 outcome, can themselves influence outcomes?"
8 A. You missed out reading "the NHS is very far from
9 developing good outcome measures, especially linked to
10 costs."
11 Q. Yes. If we go to 31, please, at the top:
12 "Avon Health will focus in 1995/96 on quality
13 standards ..."
14 Then there are some key objectives.
15 If we go to 33, there is reference to the
16 Patients' Charter and to the Health of the Nation, and
17 5, to specialty-specific requirements which are included
18 in the individual service specifications.
19 That is the paragraph 2 referred to at page 24 of
20 your statement.
21 A. Yes.
22 Q. So that is the bit that is bolted onto these general
23 quality conditions in the case of cardiac surgery?
24 A. Yes.
25 Q. Then we see what is said about content and format of
0132
1 monitoring.
2 At 36 it deals with information that is to be
3 provided:
4 "Clear explanations will be given on any treatment
5 proposed, including any risks and alternatives, before
6 patients decide whether they agree to treatment."
7 How would these general terms have been drawn up?
8 Obviously I understand that the paragraph 2 business is
9 directorate-specific, but how did these standard terms
10 applicable to all the service come about?
11 A. I would imagine they were initially drafted by Avon
12 Health, and then shared with the Trust. They would have
13 developed over a number of years. But how within UBHT
14 we would have handled this, to be honest, I could not
15 recall.
16 Q. Would this be Mrs Maisey's department in drawing up the
17 standard terms?
18 A. I would have expected this to be part of the overall
19 one, or the individual ones; it may well have been sent
20 out to each of the directorates, but that may be
21 a question for her.
22 Q. Can I deal with one or two other matters in conclusion?
23 I think we touched earlier on the fact that there were
24 some visits by Department of Health personnel and in
25 your statement at paragraph 10 on page 6 -- WIT 24/6 --
0133
1 you remember we looked at this very briefly earlier?
2 A. Yes.
3 Q. Were you aware of those visits ever producing criticism
4 from the Department of Health about the neonatal and
5 infant cardiac service at Bristol?
6 A. No.
7 Q. Can we go to page 24 in your statement, again, just to
8 the paragraph that we have been at? I think focusing at
9 the bottom of the page on paragraph 2, I have asked you
10 about the taking account of national standards and
11 taking account of case mix. It is the reference to the
12 subject of monitoring and clinical audit.
13 Was the reference there to clinical audit the same
14 type of topic by topic clinical audit that Mr Wisheart
15 was proposing in the document we looked at a few minutes
16 ago? Is that right?
17 A. No, I think -- take Mr Wisheart's list, I think, and put
18 that just to the side for a moment, because I would see
19 this as saying that they expected the Trust to have
20 clinical audit being undertaken in all the specialties
21 within the Trust and within cardiac in particular. The
22 work that we were discussing with Mr Wisheart's list was
23 more general across the Trust in other specialties, not
24 just cardiac.
25 Q. Are you aware of any of the monitoring of clinical audit
0134
1 processes ever having thrown up concerns about
2 paediatric cardiac surgery in particular, or cardiac
3 surgery in general?
4 A. No.
5 Q. Can we go then to WIT 106/29? Paragraph 61, turning now
6 to Dr Roylance.
7 You use the words there that Dr Roylance's wish
8 was that the Executive and the Board was a supporting
9 one to the clinical directorates, and I think you
10 earlier used the analogy of a holding company?
11 A. Yes.
12 Q. And a sheltering one to the directorates from the NHS
13 Executive and outside impositions, and that the
14 Executive Directors of the Trust, of which you were one,
15 were to act like a protective filter answering questions
16 from the centre without always imposing on the
17 directorates?
18 A. Yes.
19 Q. Would it be fair to characterise Dr Roylance's view of
20 his role vis-a-vis the directorates to be to shelter
21 them from unnecessary scrutiny from outside. Is that
22 what you mean by "shelter"?
23 A. No, it was more to make sure that they had the time to
24 concentrate on delivering the patient care that they
25 were good at doing, and for us to answer requests for
0135
1 information from the NHS Executive and elsewhere if we
2 were able to do that, rather than every time a question
3 came down, we were to actually ask the clinical
4 directorates.
5 Q. What type of outside impositions do you have in mind?
6 A. Requests from District Audit, for example, to do major
7 pieces of work that might not actually have any benefit
8 or perceived benefit for the Trust. We worked very
9 closely with District Audit, but we could say "No" to
10 them and say no, we did not think that was appropriate
11 at this time; requests for information from the centre,
12 bearing in mind in 1991, in effect, Trusts had very
13 little imposition from outside, but as the years went
14 by, then more requests for information came to the
15 Trust, so it was trying to allow the directorates to
16 actually get on with what they were there to do.
17 Q. The reference to "protective filter": a filter is
18 something that allows only certain matter through,
19 stopping other matter from passing through, like
20 a sieve?
21 A. Yes, that is in effect what I have been talking about:
22 another explanation of us trying to actually answer the
23 questions, and to handle the NHS Executive's regional
24 outpost rather than always involving the directorates in
25 those discussions, if we were able to.
0136
1 Q. So there was a buffer between the clinical directorates
2 which were semi-detached one from another, and were the
3 little pockets which were collectively made up of Trusts
4 and the outside world of the NHS --
5 A. Yes, if you go back in time, the Regional Health
6 Authority that used to exist did actually act as
7 a buffer between health authorities and the Department
8 of Health.
9 Q. And in what way was this buffer thought to be helpful or
10 desirable?
11 A. We thought it was helpful because it was a matter of
12 trying to, as I said, allow the directorates to get on
13 and do the job that they were there to do, and apply
14 their skills to that area, rather than always to
15 answering questions from the NHS Executive, or even
16 sometimes purchasers.
17 Q. We mentioned the General Medical Council briefly,
18 I think once or twice. You were asked I think questions
19 in I think last April. Can I briefly cover some of that
20 ground again? You first came across Dr Roylance when?
21 A. When I joined the [Health Authority] in July 1983, I did
22 some work with a colleague, a finance person, a chap
23 called Terry Cozens, and John Roylance about the
24 distribution of medical equipment budgets, I think out
25 into what were then sub-units.
0137
1 Q. You worked closely with Dr Roylance once he became
2 District General Manager and through to Trust status?
3 A. Yes. I mean, the relationship developed at completely
4 different levels within the organisation. I joined as
5 planning accountant which would be, to give you some
6 idea, about fourth in line probably, and then had
7 promotion. I did not expect to stay at Bristol & Weston
8 that long. Before that I had moved every two to three
9 years, but I gained promotion within the Finance
10 Department at Bristol & Weston and I enjoyed the work.
11 Obviously as I did different jobs and got a bit more
12 senior, I had more contact with Dr Roylance and
13 Mrs Maisey and John Watson and other people.
14 Q. When Dr Roylance became District General Manager and
15 later when he was Chief Executive of the Trust, he was
16 in both positions effectively the boss?
17 A. Yes.
18 Q. What was his attitude to his immediate colleagues, for
19 example, the Executive Directors of the Trust? How did
20 he treat them and react to them?
21 A. John was always, to me, very supportive, and I think to
22 everybody else.
23 Q. How would you characterise his relationship with you?
24 A. Very supportive.
25 Q. Was he somebody who consciously and continually kept
0138
1 a close check on how you did your job, or was he more
2 hands-off?
3 A. No, he was more hands-off. He trusted people to -- he
4 appointed people to jobs and he expected them to do it.
5 He would be supportive of them in doing it. When you
6 got things wrong as well as when you got things right.
7 Q. He was medically qualified himself, as you acknowledge?
8 A. As a radiologist, yes.
9 Q. Was there any difference in his attitude towards
10 clinical colleagues compared to non-medically qualified
11 colleagues such as yourself?
12 A. I did not actually personally feel there was any
13 difference between the way he treated me personally and
14 the way he treated other people. He did think that to
15 work in the Health Service you needed to understand the
16 service very fully and that people with a clinical
17 background knew how the system worked.
18 Q. You say that you did not feel there was any difference
19 between the way he treated non-medical qualified people
20 and others, and do you think there was a perception
21 among other people that there was a difference?
22 A. I think in some areas, yes, there were some people who
23 would think that they were treated differently if they
24 did not come from a clinical background. I am not sure
25 in reality that was true.
0139
1 Q. They would be treated more or less favourably if they
2 had a non-clinical background?
3 A. Dr Roylance thought that people with a clinical
4 background had additional skills to run the service.
5 Q. So the having of clinical skills would bring with it the
6 managerial skills required to run the directorates?
7 A. No, it added another string to their bow; you had to be
8 a good manager, but if you had that clinical element as
9 well and that background, then that gave you an added
10 advantage.
11 Q. I think we have discussed this once or twice; the
12 clinical directors of the Trust were selected by the
13 Chief Executive?
14 A. Yes.
15 Q. So the analogy might be between the Chief Executive and
16 the Prime Minister selecting his Cabinet. Is that
17 a fair analogy?
18 A. Yes.
19 Q. And the Clinical Directors would remain Clinical
20 Directors so long as they retained the confidence of the
21 "Prime Minister" figure of the Chief Executive?
22 A. There were different arrangements in different areas
23 within the Trust. Some Clinical Directors were
24 appointed with -- well, all of them were appointed with
25 the support of their colleagues and some of them had
0140
1 a very clear remit that they were doing the job for two
2 years, and that somebody else within their directorate
3 would take that job on after that. An example of that
4 is Anaesthesia, which regularly has changed Clinical
5 Director every two years. Then there are other areas
6 where, in all the period we are looking at from 1991,
7 there have only been two Clinical Directors, such as
8 Children's Services.
9 So it varied from place to place.
10 Q. We have touched on this earlier: at the General Medical
11 Committee in the context of the discussion over the
12 directorates system, you were asked what would
13 Dr Roylance's guidance to you be if the professional
14 group of a directorate proved unable to correct
15 something that had gone wrong?
16 We understand that the idea is that the
17 Directorate will run matters concerning that Directorate
18 and will fix any minor problems that might emerge, but
19 I think you were asked about Dr Roylance's attitude when
20 a problem had gone beyond the confines of the
21 Directorate. What was your impression of that?
22 A. I cannot recall the answer I gave then.
23 Q. What is your recollection now?
24 A. John's view was certainly that doctors and clinicians
25 were professionals and therefore they would analyse
0141
1 their problems and would be self-correcting, and there
2 was always the comment that you should never get between
3 the clinician and the patient because that is an area in
4 which management cannot survive because of the strong
5 bond between the individual patient and the clinician
6 caring for them.
7 Whether that is what I said then or whether that
8 answers the question, I am not sure.
9 Q. But if there was corrective action to be taken within
10 a directorate, to what extent did you understand the
11 philosophy of the Trust to be that assistance should be
12 given to the directorate from the Executive of the
13 Trust?
14 A. I mean the Executive were supportive of the directorates
15 to improve and correct and move on, and we should learn
16 from the mistakes.
17 Q. To what extent did the Executive Directors of the Trust
18 and the Chief Executive intervene in clinical matters?
19 A. We did not -- well, certainly, I did not. We would not
20 be expected to.
21 Q. Would anyone else among the Executive Directors be
22 expected to, other than the Medical Directors?
23 A. I was going to say, other than John Roylance and the
24 Medical Director, no, not really. Clearly, if there was
25 a nursing issue, then Mrs Maisey would be involved.
0142
1 That might have extended to the professions allied to
2 medicine, but I am not sure.
3 Q. But Dr Roylance as a Chief Executive and a medically
4 qualified person and the Medical Director would be the
5 Executive Directors who might on occasion intervene in
6 clinical matters?
7 A. That is what I would have expected to happen, yes.
8 Q. How would you characterise Dr Roylance's approach to
9 members of staff, at whatever level, who might want to
10 raise matters with them?
11 A. John was always open. People had to go and see him
12 a lot of the time. He went out into the hospital and
13 did visits in the hospitals, and did visits, but not too
14 many. He used to go regularly to the Hospital Medical
15 Committee, a monthly meeting of consultants. There was
16 a Clinical Director's meeting and the Senior Managers'
17 meeting, and a whole range of other events that John
18 would go to, and you could speak to him.
19 Q. Can I just repeat that we have not gone into the Hunter
20 de Leval report, and we have not gone into particular
21 expressions of concern which emerged certainly by early
22 1995 about Bristol.
23 A. Yes.
24 Q. And, I repeat, and we discussed yesterday, there will be
25 a further statement I think, from you dealing with that.
0143
1 I just want, I hope, finally to deal with the
2 question of the Deputy Chief Executive role. As
3 I understand it, you are now the single deputy to
4 Mr Ross?
5 A. Yes.
6 Q. And Mr Ross, as he explained in his evidence last week,
7 is concerned that you, as his deputy, should be able,
8 ready and willing, to step into whichever part of his
9 role is necessary if he were to be called away or
10 whatever.
11 A. Yes.
12 Q. In the position when Mr Wisheart was Deputy Chief
13 Executive, it was different, was it not?
14 A. Yes.
15 Q. And when Dr Roylance was away, can you just explain how
16 the respective deputies, yourself and Mr Wisheart, would
17 divide up Dr Roylance's work?
18 A. I do not think we looked at it like that, but I would
19 actually go through all of the post into the
20 organisation and deal with it. I would chair the
21 meetings that were necessary to be chaired when he was
22 away, and if there were clinical issues, then we would
23 have had a discussion and I would have passed it on to
24 whoever the relevant person would have been.
25 Q. So if it were decided that the matter was a clinical
0144
1 matter, then you would pass it on to Mr Wisheart?
2 A. I would have taken advice as to who was the best person
3 to deal with that, and pass it on. I cannot actually
4 recall many clinical issues ever occurring, apart from
5 the one in 1995.
6 Q. Mr Wisheart was the Deputy Chief Executive and so were
7 you. Mrs Maisey was not?
8 A. Yes.
9 Q. Did you assume any heightened significance when
10 Dr Roylance was away?
11 A. Yes. I mean, we all did. We had to work as a team. So
12 if there were issues that were coming in, then I would
13 discuss them with the other Executive Directors, if
14 I felt that that was necessary.
15 Q. At the GMC you described Dr Roylance as somebody who saw
16 part of his own role to be "visionary"?
17 A. Yes.
18 Q. What did you mean by that?
19 A. John talked very much about the day-to-day operational
20 arrangements being the responsibility of a number of the
21 other Executive Directors, and he, as Chief Executive,
22 needed to think about the strategic direction of the
23 organisation, the vision for the future, the direction
24 of travel; and therefore spent less of his time on
25 operational issues.
0145
1 Q. So tell me if this is an unfair characterisation in any
2 way: to what extent would it be accurate to describe
3 Dr Roylance as looking at the "big picture"?
4 A. Yes, that is what I would expect: an element of the job
5 of all Chief Executives is to think of the overall
6 direction of the organisation, the "big picture" as you
7 put it, and to guide the organisation as its Chief
8 Executive.
9 Q. And is that a characterisation that would apply with
10 equal force now to Mr Ross?
11 A. Mr Ross does give leadership and strategic direction to
12 the organisation but does spend a higher proportion of
13 his time on operational matters.
14 Q. So to what extent would you say that there was
15 a difference in the amount of hands-on management of
16 day-to-day issues now as compared to the early days of
17 the Trust?
18 A. Well, the trouble is that it is very difficult to
19 compare now and the early days of the Trust because the
20 demands that are placed on us are completely different,
21 and I would suggest even heavier than they were in
22 1991. The targets set for the Trust do need very strong
23 management now, such as the major emphasis by the
24 current government on numbers of patients waiting on the
25 inpatients and day case waiting lists and new
0146
1 requirements on the number of patients waiting for
2 outpatient attendances. I think that is a significant
3 issue that needs all of the Executive Directors' input
4 to try and achieve with the directorates.
5 Q. I think at the GMC you were asked what percentage of
6 Dr Roylance's time was spent on, I think, what
7 President Bush once famously described as the "vision
8 thing" and what part of his time he spent on operational
9 matters.
10 You said:
11 "In the early days, John drew diagrams about this,
12 and it was something like 10 per cent was actually
13 operational and 90 per cent was about the future, that
14 sort of order."
15 A. Yes.
16 Q. Then you were asked about your and Mrs Maisey's division
17 of operation and vision, but what I want to ask you
18 about is whether, in his four years or so as Chief
19 Executive of the Trust, that 10 to 90 proportion for
20 Dr Roylance altered in any way?
21 A. No, I do not believe it did. I think 10 to 90 is pretty
22 stark. It might be 20/80. But it is of that sort of
23 order.
24 MR MACLEAN: Sir, would you give me one moment so I can
25 check behind to see if there are any other matters?
0147
1 Happily, there is a deafening silence.
2 Mr Nix, I do not want to ask you any more
3 questions at this stage. Can I thank you very much for
4 your attention over the last day and a half? It may be
5 that there are some questions from the Panel; it may be
6 that there is some re-examination.
7 Could I just say that there are one or two matters
8 that have cropped up in our discussions which may need
9 some further thought, by you and by others. If there is
10 anything else that you wish to say to the Inquiry, any
11 more documents that you wish to submit along with the
12 helpful and voluminous documents you have already
13 personally submitted, I know, then we would be most
14 grateful to have those. We can have those at any time,
15 and we will of course be contacting you to deal with the
16 matters of concern in the Block 6 issues in due course.
17 It may be that we will see you again, giving oral
18 evidence dealing with that.
19 Are there any questions from the Panel?
20 THE CHAIRMAN: There are some.
21 Examined by THE PANEL:
22 MRS MACLEAN: Mrs Nix, you have talked to us today about the
23 question of excess demand for cardiac surgery as
24 evidenced by the waiting lists.
25 A. Yes.
0148
1 Q. And about your position as holding the reign between the
2 demand for resources and the finding of them.
3 In view of that, I would like to draw to your
4 attention something which Sir Terence English said to us
5 some days earlier in our proceedings.
6 When talking about the wishes of clinicians to
7 develop their work and faced with a shortage of
8 resources, not an unusual position in any hospital
9 Trust, he described one approach of clinicians as being
10 to push forward, to make a maximum use of facilities to
11 really almost drive through this shortage of resources,
12 and that that was one way forward in finding the key to
13 opening further resources.
14 I wondered whether you had a view on whether you
15 had observed that kind of strategy in operation in
16 Bristol?
17 A. That sort of phenomena is something that a Financial
18 Director faces on a regular basis, running an
19 organisation the size of the UBHT with a teaching
20 hospital and academics, and it is the same, I believe,
21 in most hospitals, that clinicians of all types want to
22 do the best they can, and with the numbers of people on
23 the waiting list, they will strive and strive to deliver
24 more and more care, by looking at innovative ways of
25 doing that.
0149
1 I think that within cardiac surgery in Bristol,
2 you could say that they had done an element of that:
3 they had a unit that they had carefully designed to
4 undertake 600 cases a year, and you can see the sort of
5 volumes of patients that are currently being cared for
6 through that unit now. I know there have been
7 subsequent minor changes, but not significant.
8 So that is there, and it is -- I mean, I know it
9 is a tactic by some, but I do not see that it was played
10 out in a forceful way, but it was them trying to meet
11 the demands of their waiting lists.
12 MRS MACLEAN: Thank you.
13 THE CHAIRMAN: Mrs Howard?
14 MRS HOWARD: Mr Nix, two questions: you have mentioned on
15 a number of occasions now your very clear view of the
16 split role as Director of Finance and a bifurcated role
17 as Deputy Chief Executive.
18 I wonder if you could give me some clarity as to
19 the strategies you employed to assure yourself that you
20 understand the pressures and aspirations within the
21 Clinical Directors in terms of delivery of the service
22 in order that you could fulfil your financial duties in
23 terms of probity to the Board and financial management
24 across the management Trust as a corporate entity?
25 A. My style is to be very open, and I know all the Clinical
0150
1 Directors personally. I am out and about in the
2 organisation. A lot of the General Managers would come
3 to me. My office is in a situation which is very
4 convenient and it is between the carpark and the
5 hospital and the people come in and out. I have created
6 a style, I believe, where everybody knows if they ring
7 me I will always get back to them and that if I support
8 what they are saying, then I will pick it up and run
9 with it and help them to deliver it.
10 So my approach has always been to understand the
11 service, and through that, I think, I have been able to
12 work with Clinical Directors and make sure that
13 I understand what the issues are out in the directorates
14 so that I can fulfil my role to the Board.
15 The other side of it is that I still maintain,
16 which is different to many Trusts, a central finance
17 function, so the financial managers who support the
18 directorates are actually part of finance, and my rule
19 to them is that I class them as being successful if when
20 the Directorate draws their structure they draw them in,
21 so in other words they are seen to be very much part of
22 the Directorate and owned by the Directorate, but
23 clearly by doing that, they understand what is going on
24 and they keep me abreast of what is happening within the
25 organisation. So it is a whole range of approaches.
0151
1 But most important to me is that I actually understand
2 the service, and that came from my initial training back
3 in 1974, when I actually worked on the wards and in
4 theatre, and I spent 12 months doing that, going to
5 physio, occupational therapy, pathology, spending
6 numbers of weeks, so I actually do understand, strangely
7 for an accountant, exactly what does go on in the
8 service.
9 I am also married to a nurse.
10 Q. That probably helps!
11 A. It certainly does.
12 Q. My second question is to ask for a personal comment on
13 the way in which your role has changed and become a much
14 wider role and how that is viewed, you believe, within
15 the Trust, in terms of effective delivery of service.
16 A. When Hugh Ross came to the Trust, I did say to him that
17 if he wanted a straight Financial Director, then he did
18 not actually have one in me; I have an interest in the
19 service. I am very much task-orientated; I want the
20 service to do well and there are patients at the end of
21 it, and I think that because of the way I have responded
22 to and worked with the directorates, then I have a lot
23 of support from them. That has enabled me to fulfil
24 both of the jobs and within my own department, clearly,
25 having set it up in 1991, and in fact taken a number of
0152
1 what I believe to be the best finance staff into the
2 Trust, they have individually developed and they are
3 able to fulfil the finance function, even if I am not
4 there. So by me doing other roles, it has allowed them
5 to have more headway into doing the things they want to
6 do. I think I have a lot of support within the Trust.
7 MRS HOWARD: Thank you.
8 THE CHAIRMAN: Professor Jarman?
9 PROFESSOR JARMAN: To take up the point you have just
10 mentioned about the patients being at the end of it,
11 yesterday the 1983 Griffiths Report was mentioned.
12 A. Yes.
13 Q. Do you have any views about the importance of that with
14 regard to management over the period of time that we are
15 concerned with?
16 A. I believe that people should be accountable for what
17 they are actually doing and Griffiths really brought in
18 general management, that although you quite rightly,
19 I believe, still have the debates, at the end of the day
20 there is one person who, having heard those debates,
21 hopefully will have consensus of view, but if there is
22 not, that person can actually make the decision.
23 I think that leads to better management of an
24 organisation. I think that has been demonstrated in the
25 NHS and elsewhere, that actually having one person
0153
1 responsible for what is going on is quite key.
2 Q. So Griffiths recommends, and I am quoting here:
3 "Real output measurement against clearly stated
4 management objectives and budgets should become a major
5 concern of management at all levels."
6 Do you have any comment on that?
7 A. No, I support that. I think that we should be clear
8 about what we are doing, what we are trying to achieve,
9 measuring against that. Clearly, in my own field,
10 I believe I have strong financial management and we have
11 delivered our financial targets year on year -- it
12 slightly wavers every now and again, like most people.
13 But this teaching hospital, teaching Trust, is not in
14 the financial difficulties that some around the country
15 are -- although, to be honest, we are struggling this
16 year -- and the change in the National Health Service in
17 1991 actually helped us towards that, which was rather
18 than money coming out to the Health Authority with no
19 information on what you were supposed to deliver, it
20 clearly changed in 1991, because one of the major
21 changes then was an identification of targets for
22 workload.
23 Q. I am asking the question in relation to your comment
24 about patients: does your reply mean that you interpret
25 real output measurement as being financial results, or
0154
1 which also include real output measures with regard to
2 things like patient mortality, or not?
3 A. I am sorry. I think that what I was referring to really
4 was that I thought we had moved on with regard to the
5 volume of patients and information about how many
6 patients we were caring for and how the efficiency of
7 the service has developed tremendously in that area.
8 I do not believe the service has got very far in
9 monitoring outcomes.
10 Q. So you believe that at the time period we are
11 considering, that measurement of outcomes was an
12 important factor concerning yourself?
13 A. I do not think it was. Certainly, outcome as to patient
14 care, to be honest, I never questioned. I think that
15 prior to 1991 the outcome that I always thought about
16 was not about the quality of care that we were giving
17 individuals technically, or the doctors and nurses were
18 giving technically. I thought that we were not very
19 good at treating patients as people. I think that is
20 one outcome that we have achieved in the last eight
21 years, to get much better at treating patients as
22 people, i.e. making sure that they have good information
23 about what is going to happen to them, receiving them
24 well, asking them whether they actually enjoyed the
25 experience through patient surveys and things like
0155
1 that. I think that is certainly where I believe we have
2 improved in the last 8 to 9 years, as well as the links
3 to GPs, of course.
4 Q. So if there was an annual report from the paediatric
5 cardiology and cardiac surgery from the BRI indicating
6 significantly higher mortality rates at the BRI, that
7 would not be part of your concern?
8 A. Well, it would be a concern of mine, if I actually knew
9 the content of the report.
10 Q. It has come to the Inquiry earlier that it showed
11 mortality rates significantly higher.
12 A. Yes. I mean, clearly I am aware of that now, in fact
13 I have been aware of that since 1995, but not prior to
14 that.
15 Q. I see. But had you been aware, it would have been part
16 of your concern?
17 A. Yes, absolutely. I think as an Executive Director you
18 have an interest beyond your own professional area.
19 Q. So I am interpreting that it just did not come to your
20 notice?
21 A. No.
22 Q. Would you have any view as to why it did not, or might
23 not have?
24 A. Those sorts of issues, we did not really get into
25 discussing those sorts of issues; it was never brought
0156
1 to an Executive Director's group, or to the Trust Board.
2 PROFESSOR JARMAN: Thank you very much.
3 THE CHAIRMAN: Mrs Howard has another question.
4 MRS HOWARD: I am sorry, Mr Nix, it has really come out from
5 that previous exchange. Do you have a general comment
6 you would like to make to the Inquiry about the role of
7 non-executive directors in respect of some of the issues
8 that we have touched upon today and maybe more
9 specifically, in some of the issues you have just
10 touched on with Professor Jarman?
11 A. Certainly my involvement with non-executive directors
12 has been helpful. We have used their skills. They
13 themselves have been around the buildings and visited
14 different services, but they have not been used in the
15 way that they are now in providing a lay input into
16 discussions about clinical governance and those sorts of
17 areas. But they were not at that time.
18 Q. Do you have a comment about why they were not at that
19 time?
20 A. I do not think anybody was, either executives, certainly
21 from my own point of view and if I was not aware of it,
22 then the non-executives would not have been either, I do
23 not believe.
24 MRS HOWARD: Thank you.
25 THE CHAIRMAN: I have no questions. Mr Miller?
0157
1 RE-EXAMINED BY MR MILLER:
2 MR MILLER: Your time at Bristol, if we include the Bristol
3 & Weston part first followed by the Trust, it is almost
4 exactly equal in each institution, so you were almost as
5 long at Bristol & Weston Health Authority as you have
6 been in the Trust?
7 A. Yes.
8 Q. So you saw the pre-directorate structure in operation,
9 and the post-directorate structure after the setting up
10 of the Trust?
11 A. Yes.
12 Q. From the non-clinical point of view, in your eyes did
13 the setting up of the directorate system create
14 watertight compartments within the hospital, the BRI
15 particularly, with no horizontal contact between
16 different groups, different medical groups?
17 A. No. You could not run the service by making them
18 watertight groupings, as you have said. It was
19 a management setup to run the organisation, but clearly,
20 you had to have very good horizontal contact because
21 people providing the care were part of the teams. We
22 talked yesterday about having anaesthetists and surgeons
23 and the theatre staff needing to work right across, if
24 you like, the artificial management structure that had
25 been put in place.
0158
1 Q. So it is a management structure as opposed to cutting
2 off links between different medical specialties?
3 A. Yes.
4 Q. Because taking cardiac surgery as an example, there
5 would have been a need to use radiological resources,
6 anaesthetic, pathological?
7 A. Yes, pathology, the lot, yes, and there would have to be
8 good liaison between all of them.
9 Q. But if a particular problem was seen within
10 a directorate, I think you said yesterday that you would
11 expect a doctor with a concern to take it up with his
12 Clinical Director, or alternatively with the Clinical
13 Director in the other directorate?
14 A. Yes, or with his senior colleague in that area, if you
15 were a junior doctor, as was used yesterday.
16 Q. I wonder if we could have up UBHT 64/73: it is the draft
17 contract for the supra-regional services made with the
18 NHS Executive.
19 A. Yes.
20 Q. It starts with that. We looked at it yesterday.
21 A. Yes.
22 Q. I wonder if we could have page 78, which you were asked
23 to look at this morning.
24 A. Yes, the quality check-list.
25 Q. That is the check-list. It appears to start on the
0159
1 premise that it is already recognised that the unit
2 currently provides good care?
3 A. Yes.
4 Q. So there is an acknowledgment of that at the outset?
5 A. Yes.
6 Q. Would you have understood that the Department of Health
7 had satisfied itself at that stage that the unit did
8 provide good care?
9 A. As I have just said to some of the panel members,
10 I assume that the quality of care, technical care, was
11 always good anyway in the Health Service. I have never
12 thought of it being anything else, and a comment like
13 that would reinforce it, but I would not necessarily
14 have read it like that at the time.
15 Q. But this is not a new arrangement at that stage. It is
16 new because of the Trust, but in fact the supra-regional
17 contract had been in place for some time?
18 A. Yes.
19 Q. And there had been periodic visits over the years from
20 Department of Health officials?
21 A. Yes.
22 Q. And the Royal Colleges?
23 A. Yes.
24 Q. Were you ever concerned with the clinical side of those
25 visits, when doctors came to look at the unit to see how
0160
1 it was performing?
2 A. I have never been involved in any of the Royal College
3 visits; I do get information now, but I would not at
4 that stage.
5 Q. You were only asked to look at, I think, two of those,
6 but there is a whole series on the check-list as to what
7 the Department of Health says would constitute a good
8 quality of care, is there not?
9 A. Yes.
10 Q. We highlighted this morning two of them, but in fact
11 they range over a much wider area?
12 A. Yes, and the majority of them, the ones I have read, are
13 sensible.
14 Q. When it came to de-designation, you were asked this
15 morning about your views, what you thought about the
16 designation and what you thought you had done wrong,
17 effectively, in Bristol, but did you understand at the
18 time it was de-designation across the board, or it just
19 applied to Bristol?
20 A. No, I knew it was de-designation across the board,
21 because the information supplied from the centre was how
22 it was going to be de-designated and how they were going
23 to handle the disposition of the funds back to the
24 health authorities, so we are very clear that it was
25 everybody.
0161
1 Q. So -- again I think you were asked this morning -- did
2 it cross your mind it was because you were not providing
3 the service that the whole service was being
4 de-designated?
5 A. I would be concerned if it was only us, yes.
6 Q. Just two other things I would like to ask you about.
7 There has been a focus for obvious reasons on the fact
8 that this Inquiry is primarily concerned with paediatric
9 cardiac surgery and therefore, we look at all the
10 documentation that relates to that.
11 The implication this morning was that you had
12 "missed a trick" with the Supra Regional Services
13 Advisory Group by failing to get money which must have
14 been available to you by which a split site could have
15 been avoided.
16 A. Yes.
17 Q. That is as I understood the questioning this morning,
18 and that somehow, despite having fairly hefty finger on
19 most of the pulses, you had missed it?
20 A. Yes.
21 Q. What do you say about that, that you had failed to get
22 cash that was available?
23 A. I am always disappointed if I fail to get cash which is
24 available. My antennae is pretty good for cash!
25 Financial Directors smell it. One comment would be that
0162
1 one is, I think, always certainly looking at the
2 Regional Health Authority because they were the ones who
3 were the main links into that; and the other is clearly
4 that an organisation which has œ200 million turnover
5 means that there are an awful lot of services and an
6 awful lot of routes, and unfortunately it is possible to
7 miss possible funding -- but not often.
8 Q. From the documentation which none of us had but which
9 you had seen, I think last Friday, it looks as though an
10 incomplete application was put forward, or an informal
11 application was put forward, which was not proceeded
12 with?
13 A. Yes. As I saw it, it was a holding submission which
14 seemed to infer that we would follow it up with a much
15 more detailed submission. I would not have wished to
16 have signed off personally the document that actually
17 went.
18 Q. Can you help us, because we do not have it, as to what
19 the funding that was being sought was to be applied to?
20 A. It was for the split site and I believe from
21 recollection we were talking about œ800,000 in capital,
22 which was split œ300,000 and œ500,000. I cannot recall
23 exactly whether it was the Trust that was finding
24 œ300,000 or œ500,000 out of the œ800,000.
25 Q. Obviously the document will be available in due course,
0163
1 but it was relating to the split site so historically
2 there was the Working Party that looked at it in 1989?
3 A. Yes.
4 Q. The outcome was that it was cost prohibitive. This
5 would have been in 1992?
6 A. Yes.
7 Q. And then in 1993/1994, again the matter is raised?
8 A. Yes.
9 Q. Unsuccessfully at that stage?
10 A. Yes.
11 Q. As far as the 1989 one was concerned, that is an
12 application to the region for capital?
13 A. Yes. That would have been the only route to get
14 capital. In fact, I think it was led by the region.
15 Q. But that is a free-standing application which has, as
16 its aim, the relocation of surgery in the Children's
17 Hospital?
18 A. Yes.
19 Q. And the region turned it down?
20 A. It is difficult to know who turned it down. It is
21 difficult to perceive. The Regional Health Authority,
22 who held the purse strings, clearly must have said no at
23 some stage.
24 Q. Although you are the Financial Director, are you the man
25 who says, "Here is the cash in my hand", in order to be
0164
1 able to pay for it? If you have been turned down by the
2 region for capital, is it in your hands to say you will
3 find the capital somewhere else?
4 A. No, that would have gone to the Health Authority or to
5 the Trust. In fact, in Health Authority times, you
6 would still have had to have Regional Health Authority
7 approval for that level of spending.
8 Clearly, the other part is the revenue. It is
9 pointless building something if you cannot actually run
10 it.
11 Q. So renewed efforts were made initially in 1992 by --
12 Dr Joffe, I think you said, signed the draft that was
13 there?
14 A. Yes.
15 Q. With you saying what was needed to make a proper bid?
16 A. Yes.
17 Q. Then 1993/94.
18 Parallel to that, we saw the documentation
19 yesterday taken through by Mr Maclean, the various
20 working parties in the earlier period, where you were
21 dealing with the expansion of the adult cardiac surgery?
22 A. Yes.
23 Q. You were asked, "Why were you on those?"
24 Could those working parties have proceeded without
25 you being there?
0165
1 A. No, you would have had to have had a finance input to
2 those working parties, because clearly the clinicians
3 and managers would have worked out what they thought or
4 what the implications in staffing terms were. But all
5 of that had to be transferred into financial
6 arrangements.
7 Q. By the time in 1993/94 it was successful, where was the
8 impetus coming from? Was it coming from a clamour to
9 get the children transferred up to the Children's
10 Hospital, or was it getting the increase that was
11 necessary in adult cardiac surgery accommodated in the
12 BRI? Where was the pressure?
13 A. The main pressure point was being able to cope with the
14 volume of referrals for adult cardiac surgery and the
15 children's was an outlet that allowed the two things to
16 be achieved. One was to transfer children up to the
17 Children's Hospital and all of the benefits that came
18 from that, and the second allowed the expansion of
19 adults to cope, or better cope, with the demands.
20 Q. So that is the trade-off, as it were, for getting the
21 increase. The adult surgical capacity in the BRI allows
22 you to say you will move the children and that will give
23 you the capacity?
24 A. Yes.
25 Q. But that had not been a feature in the earlier bids?
0166
1 A. No.
2 Q. Can I ask you then to look at one final document, which
3 is UBHT 295/139?
4 This document, again, I think it is a Working
5 Party?
6 A. Yes.
7 Q. We saw that you were not involved in that Working Party,
8 and it was primarily being made up of the cardiac
9 surgeons and cardiologists, I think?
10 A. The schedule I have on the screen is a list of -- it
11 looks like the second page of the revenue costing of the
12 expansion to 600 cases, yes.
13 Q. This is a substantially medical Working Party, is it
14 not?
15 A. The Working Party that would have created the data to
16 allow me to create this.
17 Q. Even 'flying blind', then, I have the wrong document.
18 A. All of the working parties that I have sat with have --
19 the main Advisory Group into working parties is the
20 medical staffing and nurse staffing. Clearly at
21 different stages in a working party you will have
22 architects, engineers, quantity surveyors, involved, but
23 most of it would be --
24 Q. I am sorry, this was the Working Party which included
25 I think the cardiologists and cardiac surgeons. This is
0167
1 the perceived failure in the system in terms of outcome,
2 if you remember, that Bristol was not keeping up with
3 its competitors -- 275/139, I could not read my own
4 writing, I am sorry.
5 This is the "Threats", which was one of the things
6 that was set out. It was the first paragraph about the
7 improved quality in waiting times and outcomes which
8 will have an impact on mortality and morbidity in
9 specialist areas.
10 You were asked why you did not react to that when
11 it came across your desk, but this is, as I understand
12 it, essentially a paper produced by the Cardiac Services
13 Department directorate?
14 A. Yes. These sections would have been written by the
15 clinicians involved in the service, and to some extent,
16 you do see some of these sorts of comments, that if you
17 are trying to make a case to achieve substantial
18 financial investment, then you will have words like some
19 of the ones that are used in these paragraphs.
20 This reflects back to something that was said
21 earlier on by the Panel in their question, of -- some
22 people would call it "shroud waving"; that is a general
23 term sometimes used. But clearly, there is reality in
24 a lot of what is said, but you can put twists on it to
25 make your point.
0168
1 Q. Is this something that you might have seen emanating
2 from other departments, or is it only from cardiac
3 surgery that we have these problems?
4 A. No, that is not unusual, and I have to say that we use
5 it within our discussions with purchasers as well.
6 Q. But phrased in that somewhat elliptical form, is it
7 something you look at now and think, "Gosh, I wish I had
8 recognised what was there as a problem and reacted to
9 it"?
10 A. Yes, clearly I do now, yes.
11 Q. Do you see any reason why you did not at the time?
12 A. I think I said, when I was asked about it, that I am not
13 always sure with all these documents I read every word.
14 I am an accountant. I go to the table with some figures
15 on it, and --
16 Q. We know that also answerable to the Board and the Chief
17 Executive was the Medical Director, who would have an
18 input into clinical matters?
19 A. Yes.
20 Q. Without wishing to pass the buck or get you to pass the
21 buck, did you have the capacity to monitor the outcomes
22 of all the specialties concerned in the BRI, by going
23 through documents like this and picking up straws in the
24 wind?
25 A. No, you could not possibly do that, with everything that
0169
1 was going on within the Trust. To some extent, I would
2 not necessarily have seen that as my job either, but ...
3 MR MILLER: Thank you, Mr Mix.
4 MR LANGSTAFF: Mr Nix, you have now been asked questions by
5 six people, and I cannot let you go without throwing my
6 own oar in and asking you the seventh, which is the one
7 we ask of all witnesses: is there anything further you
8 would wish to say at this stage, so that we have clearly
9 in mind what you would like to tell the Inquiry, to help
10 this Inquiry?
11 A. No, I do not think -- I have put a lot of thought and
12 effort into my original statement and the creation of
13 the finding of the documents that I submitted. I do not
14 believe I have anything else to add to that at this
15 time.
16 THE CHAIRMAN: Mr Langstaff, I fear I am interrupting you,
17 but let me first of all thank Mr Miller for his helpful
18 contribution. I thought the last question, as it were,
19 had a shade of "feeding" in it, but there it is.
20 I understood the motive behind it and those sort of
21 things do help to clarify for us.
22 May I also thank you, Mr Nix. You have given us
23 two days of your time. We are very grateful. We have
24 heard what you have said and we have seen what you have
25 written, and also the documents that you have put in.
0170
1 As Mr Maclean has made it abundantly clear, we
2 need to come back to you in one form or another on other
3 matters. We will put that marker down there, and
4 I repeat it, just so that any impression otherwise is
5 not gained elsewhere from those who follow the
6 proceedings on the Internet, or wherever else.
7 So we have been talking about Block 3 evidence and
8 we are grateful to you for what you have been able to
9 tell us.
10 At this point, you may, if you wish, please stand
11 down while Mr Langstaff reminds us of what we are going
12 to do in the forthcoming weeks.
13 (The witness withdrew)
14 MR LANGSTAFF: Sir, as those who have looked at the
15 timetable will know, there is no further witness this
16 week, nor will there be any witness next week. The
17 reason is not, I hasten to add, that the staff of the
18 Inquiry or the Inquiry are taking an over-generous Bank
19 Holiday weekend, because the work they are doing is
20 continuing and I am pleased to report that statements
21 are continuing to come in, more, really, in a flood than
22 a trickle.
23 Amongst them has been the statement of
24 Dr Roylance, whose evidence we shall hear on Monday 7th
25 June at 10.30. It is anticipated that his evidence will
0171
1 take probably the best part of two days. It will be
2 followed on the Wednesday of that week by Mrs Maisey.
3 The evidence that both can give has perhaps been
4 foreshadowed by the evidence we have had from recent
5 witnesses dealing with the narrowing down of our
6 concerns from the national to the local context.
7 That is what the immediate future has in store for
8 us.
9 THE CHAIRMAN: Thank you for helping us with that,
10 Mr Langstaff. So now we adjourn. Before we do, again,
11 I would like to pay tribute to and thank on behalf of
12 the Panel the helpful submissions made by those behind
13 you into the questioning; it has been extremely useful.
14 I hope it continues in the way that it is now happening.
15 We adjourn now and we reconvene, therefore, on
16 Monday, 7th June at 10.30. Thank you.
17 (2.50 pm)
18 (Adjourned until 10.30 on 7th June 1999)
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7 Examined by MR MACLEAN (continued):........ 3
8 Examined by THE PANEL ..................... 148
9 Re-examined by MR MILLER................... 158
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Published by the Bristol Royal Infirmary Inquiry, July 2001
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