Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts Hearing summary   7 July 1999   Inquiry hearings resumed today with evidence from Dr Marie Thorne, Head of the School of Organisational Behaviour, Bristol Business School, University of the West of England. She described her research role at United Bristol Healthcare NHS Trust (formerly Bristol and Weston HA) which began in 1989 when she observed the process of the establishment of the Trust. She explained that she was able to sit in on meetings, visit wards and departments and talk to hospital staff. She went on to make observations about the roles of the Trust Board, its Chairman, Chief Executive and about the appointments, credibility, responsibilities and pressures of Clinical Directors. She commented on the management style of the Chief Executive, Dr John Roylance, and his accessibility to staff, particularly Clinical Directors. She concluded by discussing the culture of UBHT.

FULL TRANSCRIPT

   1                       Day 35, 7th July 1999
   2   (10.30 am)
   3   THE CHAIRMAN: Good morning everyone. Good morning,
   4     Mr Langstaff.
   5   MR LANGSTAFF: Good morning, sir. Sir, before Mr Maclean
   6     asks Dr Marie Thorne to give her evidence, I would just
   7     like to say that it was announced last week that the
   8     hearing which was due for Monday and Tuesday of this
   9     week would have to be postponed because a member of the
  10     Panel had suffered a bereavement.
  11        We know that the Panel member was in fact you,
  12     sir, that it was your brother who died. Your brother
  13     himself, as it happens a surgeon, underwent a liver
  14     transplant operation which unfortunately was
  15     unsuccessful, as is sadly sometimes the way with such an
  16     operation, and he died in intensive care last week.
  17        On behalf of Counsel to the Inquiry, the legal
  18     team, those behind me and I suspect everyone here today,
  19     I should like to express publicly our condolences and
  20     our sympathy to you and his family.
  21   MRS HOWARD: Mr Langstaff, the Panel chose to announce the
  22     postponement of the hearings in the way we did to
  23     safeguard the privacy of the immediate family and the
  24     Chairman. We join in expressing our condolences and
  25     hope that that privacy will continue to be respected.

   1   MR MACLEAN: Sir, this morning's witness is
   2     Dr Marie Thorne. Perhaps she could come to the witness
   3     chair, please.
   4        Dr Thorne, could I ask you to stand up again to
   5     take the oath?
   6            DR MARIE THORNE (SWORN):
   7            Examined by MR MACLEAN:
   8   Q. Could you first of all give us your full name, please?
   9   A. Marie Louise Thorne.
  10   Q. And you are the head of the School of Organisational
  11     Behaviour at the Bristol Business School based at the
  12     University of the West of England?
  13   A. That is correct.
  14   Q. If you look at the screen to your right, could we have
  15     document WIT 171/1, please? Is that the first page of
  16     a statement that you have made to the Inquiry?
  17   A. Yes, it is. Could you enlarge it, please?
  18   Q. Could we enlarge the bottom half of the page, please.
  19     I think you have a particular problem with one of your
  20     eyes?
  21   A. I have a particular problem with one of my eyes. I did
  22     explain this morning and I apologise to you.
  23   Q. If we go to page 17, please, the bottom half of the
  24     page, that is your signature?
  25   A. Correct.

   1   Q. And that is the last page of the statement you have made
   2     to the Inquiry?
   3   A. Correct.
   4   Q. Have you had a chance to read that statement through
   5     recently?
   6   A. Yes, thank you.
   7   Q. Is there anything in it you want to change?
   8   A. No, I do not think so.
   9   Q. As I think has been explained to you, we do not intend
  10     to go through the statement line by line, or even
  11     paragraph by paragraph. The Panel have your statement
  12     and have read that, and we take it as having been read.
  13        You have also submitted some other documents to
  14     us, have you not? If you go to page 18, this is
  15     a document prepared by you following a management
  16     development session on 17th March 1992, which you refer
  17     to in the body of the statement.
  18   A. Yes.
  19   Q. Then at page 22 you prepared some comment on
  20     a particular paper which we will come back to, which was
  21     presented as evidence to the Inquiry by Mr Ross, the
  22     present Chief Executive?
  23   A. Yes.
  24   Q. I think you have also submitted to us, if we go to
  25     page 25, a published paper concerned with the role of

   1     Clinical Directors?
   2   A. Yes.
   3   Q. And I think it is right to say that that is based in
   4     large part, is it not, on a project that you undertook
   5     at the UBHT?
   6   A. Yes.
   7   Q. I think there is a second paper at page 36, again based
   8     in large part on the research that you carried out at
   9     the UBHT?
  10   A. Yes, but this paper was also based on my experience of
  11     being involved with the fast-track clinical development
  12     programme for senior consultants at Oxford Regional
  13     Health Authority, and also developing and running
  14     a medic programme for senior consultants for the South
  15     West Regional Health Authority. So that is the fora in
  16     which the models were actually developed in terms of
  17     working directly with Clinical Directors. I think that
  18     needs a little amplification.
  19   Q. The first paper we looked at was published in the Health
  20     Services Management Research Journal, volume 10, 1997?
  21   A. Yes.
  22   Q. This one was published I think also in 1997, was it not?
  23   A. Yes.
  24   Q. There are two other documents. If we go to 49, this is
  25     the first page, is it not, of a long document that you

   1     submitted to the UBHT following a lengthy period of
   2     research and discussion and interviews with the Clinical
   3     Directors at the Trust?
   4   A. Yes.
   5   Q. And if we scan down to the bottom of the page, it is
   6     January 1995?
   7   A. Yes.
   8   Q. We will come back to that document. Finally, page 109,
   9     and again, we will come back to this one later, this is
  10     a letter, as we see from the top of the page, which you
  11     wrote in June of last year to Hempsons, who were then
  12     and are now the solicitors to Dr Roylance?
  13   A. Yes.
  14   Q. And as we see from the first paragraph, which I hope you
  15     can just about read, you submitted the letter as
  16     a testimonial to the Professional Conduct Committee of
  17     the GMC on behalf of Dr John Roylance?
  18   A. Yes.
  19   Q. We will come back to some of those documents a little
  20     later.
  21        Could you just explain to me, please, how it was
  22     that you came to be engaged first of all at the UBHT --
  23     actually it was still then the Bristol & Weston Health
  24     Authority, in the latter part of 1989?
  25   A. Yes. It is rather a strange story, I think. I was

   1     course director of the UWE MBA programme at that time
   2     and one of the people that had been invited to come and
   3     talk to the MBA group was -- I think he was Director of
   4     Human Resources at that stage for the district, Ian
   5     Stone, and he came and talked about the possibility of
   6     creating a new-style NHS Trust and all the changes that
   7     were happening in the Health Service. After that
   8     I chatted to him. One of my academic and practical
   9     interests is actually managing change. We had
  10     a conversation and he said, "You might find it very
  11     interesting to come and see what we are doing". So it
  12     started as simply as that.
  13        I then went and had a conversation with
  14     Dr Roylance. I arranged an appointment to see him and
  15     said to him, would he be interested, would he allow me
  16     to come and look at the organisation.
  17        I think one of the things for the organisation at
  18     that time, one of the documents that had been produced
  19     by the NHS was that anyone who was applying for a Trust
  20     would need to create a business plan. That was the
  21     language that was used. As we will see later, that was
  22     quite an erroneous description of what was really
  23     required for an application for Trust status, and I do
  24     not know whether they considered I may have some
  25     expertise in that area because of my background, but

   1     I was really there as a "fly on the wall". That was
   2     the expression.
   3   Q. Before this conference that you have mentioned, had you
   4     met Mr Stone, Dr Roylance or any of the other people who
   5     became big players subsequently in the Trust?
   6   A. No.
   7   Q. You had never worked with them before?
   8   A. No.
   9   Q. At that stage you were an academic, you were in charge
  10     of the MBA programme at the University?
  11   A. Yes.
  12   Q. What was it in your background that fitted you for the
  13     role that developed into part researcher, part
  14     consultant, part "fly on the wall" at the Trust? What
  15     had you done previously?
  16   A. I think it depends which aspect of that you are asking
  17     me about, because I am fairly multifaceted, so I have
  18     extensive experience of working with senior managers;
  19     I have extensive experience of working as a facilitator
  20     on strategic planning exercises with organisations, in
  21     developing senior managers and senior staff, in looking
  22     at issues with groups on managing change and coping with
  23     that. I have been an internal consultant and I have
  24     also been a management consultant.
  25        I have a fairly mixed background, so it is rather

   1     difficult to say as an academic, because as an academic
   2     I also continue to practice, because we believe that
   3     theory and practice are inexorably linked.
   4   Q. So to what extent had your work embraced the Health
   5     Service before 1989?
   6   A. The work I had done in the Health Service -- I have
   7     never worked in it, I have only worked for it; there is
   8     a very unsubtle difference, I believe -- had been
   9     particularly in long-stay mental health working with an
  10     organisation that was, in the language of the NHS,
  11     "decanting" and putting people out into the community,
  12     so I have experience of the NHS in that context and with
  13     that organisation, there is also quite a lot of
  14     complexity in terms of the nature of the patients, the
  15     clients that they had, so they had everything from
  16     forensic patients to people with multiple disability,
  17     and also a forensic unit.
  18   Q. In 1989, to the extent that you were, as you put it, the
  19     "fly on the wall" in the lead-up to the implementation
  20     of Trust status in April 1991, were you performing at
  21     that time a similar role in any other prospective Trust
  22     or was --
  23   A. No.
  24   Q. This was the only one?
  25   A. Yes.

   1   Q. Since then, to what extent have you worked in other
   2     hospitals or other Trusts elsewhere in the country?
   3   A. As I say, I was heavily involved with one of the Oxford
   4     Regional Health Authority programmes, which was,
   5     I think, one of the very earliest in the country, and
   6     a battery of people from Milton Keynes, Radcliffe
   7     a whole range of places, and part of my role there was
   8     not only designing and delivering part of the programme,
   9     but it was also supervising the projects that the
  10     consultants did, so I would visit them regularly.
  11        I have also worked for a considerable number of
  12     Trusts in the South and West region doing a whole range
  13     of very different activities from working with
  14     consultant groups, working with an awful lot of
  15     psychiatrists, oddly enough -- I am very good at working
  16     with psychiatrists, for some reason -- and working with
  17     management groups, General Managers, trying to help them
  18     with -- and also with Trust boards. I am working with
  19     non-executives because sometimes it is a very difficult
  20     circularisation process to get boards together because
  21     they come with very different agendas.
  22   Q. In 1989, that was a few years, not a great number of
  23     years, but a few years after the implementation of the
  24     Griffiths report and general management into the Health
  25     Service?

   1   A. Yes.
   2   Q. How would you characterise the NHS as you found it in
   3     1989, four or five years after the implementation of the
   4     Griffiths report?
   5   A. To me, I can very well remember my first visit to what
   6     was the district open public meeting, the Bristol and
   7     District Health Authority meeting. I found the whole
   8     thing to be quite fascinating because I had not been
   9     involved in that kind of arena before and the separation
  10     of the offices from the general committee, the setting
  11     and layout of the room, I found it very, very
  12     interesting because of course part of my interest in
  13     developing people on the MBA programme is developing
  14     them precisely for general management.
  15   Q. What about the interaction between the General Manager
  16     and the doctors?
  17   A. Can you clarify that, in what sense? You mean when
  18     I first went to Bristol and District?
  19   Q. Yes. Did general management seem to be working or not
  20     working?
  21   A. I had very limited experience of it, because at the time
  22     when I arrived, I think it was the time when Mrs Maisey
  23     was just being switched from what was I think called the
  24     South unit to the Central unit, so I arrived and I met
  25     John Watson, who then went off I think into the

   1     purchasers or something, so I hardly met him. Those
   2     were the two key General Managers to my way of thinking
   3     of the large areas. So that was really my first
   4     experience of meeting large-scale General Managers in
   5     the Bristol context.
   6   Q. So you did not come with any view as to whether general
   7     management across the NHS or general management in
   8     Bristol was being successfully or unsuccessfully
   9     implemented?
  10   A. I never enter any situation with any prejudice. It is
  11     singularly unhelpful.
  12   Q. Your role in 1989, you have expressed it as being
  13     a "fly on the wall". Can you be any more specific as
  14     to what the role was? Who, for example, was paying for
  15     it?
  16   A. Initially, the University.
  17   Q. Your own employer?
  18   A. Yes; so it was a joint thing because it was a potential
  19     opportunity for research and it was subsidised by the
  20     University and I think also jointly by UBHT, because it
  21     was deemed to be a potential benefit for them, because
  22     they did not know what the outcomes would be or the
  23     involvement would be. A lot of the work I do with
  24     people, it sounds very odd, but actually, that is the
  25     kind of research I do, because if you do cultural

   1     research, you cannot predict outcomes, by definition.
   2     Often they may not be terribly comfortable, because you
   3     may have to present people findings which they do not
   4     particularly like.
   5   Q. You said that initially you were funded in part by the
   6     University. That implies that there might be a period
   7     later when that ceased to be the case?
   8   A. Yes, it was, and I mean, this was an engagement where my
   9     time, effort and energies were much more front-end
  10     loaded, if I can put it like that, because my workload
  11     and patterns of work and involvement in the University
  12     changed over time, as did the needs and interests of the
  13     UBHT. That is absolutely right, otherwise you inculcate
  14     a dependency which is counter-productive.
  15   Q. You are still employed by the University?
  16   A. Yes.
  17   Q. You have always been employed by the University?
  18   A. Yes.
  19   Q. What percentage of your working life were you spending
  20     at the Trust, or would-be Trust, paid for by the Trust,
  21     as opposed to at the University or on projects paid for
  22     by the University?
  23   A. I would say it was kind of notionally a minimum of a day
  24     a week, so it was probably a whole day, but it might be
  25     spread over a couple of mornings or a couple of

   1     afternoons, but I might actually take some weeks say
   2     perhaps as much as two days in some weeks, depending on
   3     what I was doing or where I was. It was very flexible.
   4     Remember, I also would do things in what was my own
   5     time, so in terms of vacation time and so on and so
   6     forth.
   7   Q. You have explained that you met Mr Stone at the
   8     conference --
   9   A. No, at the University. He came to speak to my students
  10     at the University. Somebody had suggested he would be
  11     a good speaker.
  12   Q. You met Mr Stone and got chatting and you suggested you
  13     might be interested in knowing more and you went to see
  14     Dr Roylance?
  15   A. I think I wrote to him first.
  16   Q. Was there an interview or something of that sort for the
  17     position you eventually obtained?
  18   A. Yes, but I do not think I would call it a position as
  19     such, because I think if you allow people in to do
  20     research, I do not think if anyone would say they were
  21     allowed to do research on the premises they had
  22     a "position", because I was not performing to all
  23     intents and purposes a function. But yes, I had
  24     a lengthy conversation with him which I think one would
  25     describe as a kind of mutual interview.

   1   Q. That was the first time you had met Dr Roylance?
   2   A. Yes, absolutely. I did not know him from Adam.
   3   Q. What did he say? How did he present the goal or the
   4     idea that he had at that stage?
   5   A. I do not think he did. I think he was interested. He
   6     was very interested in knowing what I was interested in,
   7     and what I would want to pursue, and at that time,
   8     I said to him, "I am really quite interested in finding
   9     out about the culture here, and therefore, how the
  10     culture may need to change".
  11        So we had quite a long discussion about my kind of
  12     academic views of culture, what this might involve, the
  13     sorts of things I might want to do, because if you are
  14     a researcher, gaining access is an incredibly difficult
  15     thing, so I was trying to give him an indication of
  16     where I might want to go and what I might want to do,
  17     and see if that was legitimate, because if it was not,
  18     it obviously was not going to work out. So it was
  19     a kind of mutual thing, really.
  20   Q. What I am trying to find out is what Dr Roylance
  21     presented to you, if anything, in the mutual process in
  22     the interview. What did he say he was doing? Why
  23     should he take the trouble to see you at that time?
  24   A. I think it may be difficult for people to understand,
  25     but this in part exemplifies some of the things that

   1     I said about him and that is that he does have an
   2     open-door type of policy, he does see people, but also
   3     he has an immense interest in knowledge and development,
   4     and because I think he came from a teaching background,
   5     he was very interested because he felt he would always
   6     describe himself as not a management person, and I think
   7     he was very keen to learn and to find out some of the
   8     things that were kind of common and current in
   9     management, and I think he felt there was a kind of
  10     mutual dialogue that we could have, whereby he could
  11     describe what he was trying to do, and I could reframe
  12     that into what was managerial language, if you like.
  13        So that was a --
  14   Q. Can I just stop you there?
  15   A. You may need to, because I am not sure I am answering
  16     what you are asking me, but I am finding it difficult.
  17   Q. First of all, I think we both suffer a little bit from
  18     this: we are speaking very quickly. Everything that we
  19     say is taken down, albeit not "used in evidence against
  20     us", we hope. Can I ask you to speak just a little more
  21     slowly, for the stenographer's benefit?
  22   A. Thank you, I will.
  23   Q. You said Dr Roylance explained what he was trying to do
  24     and you helped him to put that into a context of
  25     managerial language. Is that an accurate way of putting

   1     it?
   2   A. Yes. I think that was where we started from. Neither
   3     of us knew what was going to happen or whether this
   4     would work out. I think that was the basis on which we
   5     entered.
   6   Q. What was Dr Roylance trying to do, as you understood it?
   7   A. Are you asking me about 1989 now?
   8   Q. Yes.
   9   A. In 1989, when I first met him, for him the most
  10     important thing, the thing that came across most
  11     forcibly, and I think this was very interesting, was
  12     actually in his view, the government had decided there
  13     were going to be Trusts: he saw his role as the Chief
  14     Executive, his primary role was to implement government
  15     policy and he was very vociferous about that. So he
  16     said "If there is going to be Trusts, if we are going to
  17     be a first-wave Trust, then I will implement government
  18     policy to the best of my ability" and that meant trying
  19     to sort out what a Trust was, because no-one knew. That
  20     was really what was the most interesting thing for
  21     someone like me, because no-one knew what this was going
  22     to be.
  23   Q. To the extent that Dr Roylance was District General
  24     Manager and going to be Chief Executive of the Trust and
  25     to the extent that it was not known what Trusts would

   1     actually look like, what did you think you could bring
   2     to this process to assist those who were planning the
   3     Trust?
   4   A. Initially I do not think I had a clear view of that.
   5     I think one of the skills that I have is that I have
   6     very good process skills, so, for example, when the
   7     project team were sitting in a room and they were
   8     discussing a variety of things, it would be very easy
   9     for me to listen to their arguments very much as
  10     barristers do, to listen to their arguments and identify
  11     where people were speaking across each other or were not
  12     clear, so I would say "Can I just interject at this
  13     point and suggest you are actually discussing two quite
  14     different things". So you would be able to pick up
  15     monologues in space or you would be able to pick up when
  16     people were using exactly the same term differently. So
  17     that is a process, and I know I have those skills and
  18     I think those skills in working with the project team
  19     were very useful.
  20   Q. Was the idea you would observe this and then write
  21     a paper on it as a research tool, a research project?
  22   A. Yes.
  23   Q. Or was the role that you were going to actually give
  24     some advice to the people who were planning the Trusts,
  25     or both?

   1   A. I think it kind of unfolded. I think it was very much
   2     the former, because I went to quite a lot of meetings
   3     and sat relatively quietly until asked to speak. But
   4     I was always asked to speak, which was always quite
   5     interesting. So I can be inordinately quiet, even
   6     though I speak very quickly. Listening is a very
   7     important skill for a researcher.
   8   Q. What were the rules of engagement? What was your brief
   9     in terms of access to people?
  10   A. John Roylance was very clear. He said to me, "You have
  11     access to everything. I have nothing to hide. If
  12     anybody anyone says you cannot go anywhere you want to
  13     go, come and tell me". It was as basic as that. And
  14     I said to him "Gosh!"
  15   Q. So where did you go?
  16   A. I went to project meetings which were held both at
  17     Bristol and also at Weston, because Weston was also
  18     forming. I went to District Health Authority meetings;
  19     and then as time moved on I went to management Board
  20     meetings, I went to the clinical policy Board meetings,
  21     I went around all the wards. I had tours of anywhere
  22     I wanted to go. I have seen the very basement of the
  23     BRI. I have seen and chatted to people in hospital;
  24     I have been almost everywhere. I have been very, very
  25     privileged.

   1   Q. Did you work on your own or with other people?
   2   A. I could do either, and people would be immensely helpful
   3     and clinicians were particularly helpful, because
   4     remember, I had a very limited knowledge and so
   5     clinicians were very helpful. If you are genuinely
   6     interested in people, it is amazing, even the most busy
   7     person will give you an inordinate amount of time,
   8     because you are trying to learn things about their
   9     culture.
  10   Q. When you say "limited knowledge", limited knowledge of
  11     the Health Service at that time?
  12   A. Yes, and limited knowledge also of medical practice.
  13     That was also quite important, because I would chat to
  14     doctors informally.
  15   Q. Did you have any knowledge of medical practice at that
  16     stage?
  17   A. Mostly psychiatry.
  18   Q. And you had not, as you said, worked for or been
  19     actually engaged by the Health Service as part of your
  20     work previously?
  21   A. No.
  22   Q. Would it be right to say that the key body for the Trust
  23     was going to be its Board in terms of providing
  24     direction?
  25   A. I think that is its kind of statutory obligation, yes,

   1     as I understand it.
   2   Q. But where else would the key power lie?
   3   A. I think that one of the issues is about the
   4     understanding of the term "strategy", for example,
   5     because strategy to someone like me may have a very
   6     different meaning to other people, and therefore, for
   7     me, there is a difference between corporate strategy
   8     which is the provenance of the Board, in other words,
   9     the vision, the mission, the direction, and the very
  10     nature of the organisation. In other words, the Board's
  11     role is to define, if I may use management jargon for
  12     a moment, "what business we are in", whereas, if you
  13     look at something like clinical directorates, who
  14     I would also see as primary centres of emerging
  15     strategy, then if we take that into a business context,
  16     they would be the area at which strategy would be
  17     designed for competition.
  18   Q. But the first question is to decide which business you
  19     are in?
  20   A. Absolutely.
  21   Q. So that was a job for the Trust Board?
  22   A. Yes.
  23   Q. As you understood it, what was the role of the Trust
  24     Board?
  25   A. I think the role of the Trust Board was to help in

   1     identifying what this vision would be, to help clarify
   2     the nature of the organisation, and to actually set the
   3     tone of the organisation itself. So they were very
   4     interested in "What kind of Trust do we want to be?" so
   5     "We will be a Trust, but what kind of Trust do we want
   6     to be and therefore what are the implications of that?"
   7     as long as all the kind of fiduciary duties and all the
   8     other things which are absolutely and terrifically
   9     important.
  10   Q. So there was a choice to be made as to what kind of
  11     Trust to be within the statutory framework?
  12   A. Yes.
  13   Q. What were the options?
  14   A. I think the options, I think one of the clearest options
  15     was whether they were going to be kind of fiercely
  16     competitive, for example, or not. I think one of the
  17     interesting things for someone like me, who is an
  18     outsider, there was a lot of discussions about Trusts
  19     becoming competitive. Nobody quite knew what that meant
  20     at the time, and of course retrospectively, a lot of the
  21     literature suggests that was not quite as clear-cut as
  22     it might be. I also think there were a lot of things
  23     about freedoms which also did not come into being.
  24        So, for me, I think the first and most important
  25     thing was the position that the Trust was going to take

   1     vis-a-vis its main external environment, which was
   2     obviously the government, which was obviously other
   3     Trusts and particularly its purchasers, because they
   4     were now entirely dependent, theoretically, on their
   5     purchasers for funding.
   6   Q. That would apply to all Trusts?
   7   A. Yes.
   8   Q. What was the role of the Chairman of the Trust as you
   9     understood it?
  10   A. I think the role of the Chairman was to take a strategic
  11     overview and to manage the work of the Board
  12     effectively. I think that means actually managing the
  13     cohesion of the Board and actually looking at the
  14     competencies of the constitution of the Board, because
  15     that is inordinately important, having the right balance
  16     of people. I think that is a very important role for
  17     a Chairman to play, and I think it is also about
  18     actually being in some senses a figurehead whom people
  19     recognise as a symbol of a kind of strategic level, but
  20     are almost dissociated from the executive role because
  21     I also think that is important. So they have to ensure
  22     the non-executives do not try to become operational,
  23     because that is the road to disaster.
  24   Q. How did you understand the non-executive directors were
  25     going to be appointed?

   1   A. At the time I thought they were straightforward kind of
   2     political appointments, so I thought --
   3   Q. Political with a big P or with a small p?
   4   A. I think with a big P. My understanding was that most of
   5     these appointments are political appointments, through
   6     the Secretary of State ultimately, so far as
   7     I understood.
   8   Q. So they would be, as you understood it, members of the
   9     Conservative Party, or sympathetic to the Conservative
  10     Party, or what?
  11   A. I doubt very much if people wanted people on Trust
  12     boards who were absolutely anti-Trusts, for example,
  13     because remember at this stage in the game a lot of
  14     people were very anti-Trusts and I also think they were
  15     looking for, as far as I understand, people who had
  16     either community experience or extensive business
  17     experience, so there was a particular type of person who
  18     was going to make the health service more businesslike.
  19   Q. As far as you were aware, who selected the non-executive
  20     directors for this Trust -- obviously appointed by the
  21     Secretary of State, but how were the ...
  22   A. To be perfectly honest, I am not clear. It is a bit
  23     like the Pope. I felt it was like smoke and people
  24     appeared. I am not being facetious. There seemed to be
  25     an awful lot of rumblings and names would be muttered,

   1     but one never knew whether they were going to be
   2     appointed.
   3   Q. What about the role of the Chief Executive? What did
   4     you understand Dr Roylance to see as his role as Chief
   5     Executive?
   6   A. Well, as I said earlier, I think the most forceful thing
   7     that came across to me was that it did not matter what
   8     his views about almost anything were, he was a servant
   9     and he was there to actually implement government
  10     policy. He was not there to argue with it, which some
  11     people found quite irritating.
  12   Q. A servant of whom?
  13   A. Of the government. He was there to implement government
  14     policies as effectively and efficiently as possible.
  15     I think he was fiercely defensive of the reputation of
  16     the UBHT as it became. I think he wanted it to maintain
  17     its academic ethos, he wanted it to be innovative and he
  18     certainly wanted it to be the best Trust which gave the
  19     best possible patient care. I think those were the key
  20     things. From that, everything else followed, in my
  21     experience.
  22   Q. To what extent was it important, as you saw it, that
  23     Dr Roylance was himself a clinician?
  24   A. I do not know what you mean by "important". Could you
  25     clarify that for me? Important in what sense?

   1   Q. Would it have made any difference to his being Chief
   2     Executive if he had not been a clinician?
   3   A. I think if it had been anyone else it would have made
   4     a difference.
   5   Q. That is a different point, obviously.
   6   A. I think being a clinician must have made a difference,
   7     if you want me to answer as clearly as I can.
   8   Q. What kind of difference?
   9   A. I think he had more respect from the medical staff.
  10   Q. Than a non-clinician would have had?
  11   A. Yes, because I think they felt he understood them
  12     better, because he had been obviously from the
  13     professional culture and he had access to that.
  14   Q. So he was seen as being "one of us" by the clinicians?
  15   A. Only partly, because he had crossed, in a sense, the
  16     divide, because he had become, almost apart from one
  17     session, a full-time manager when he became -- I think
  18     it was when he became General Manager of the district.
  19     At that time, I think, there was an enormous push to try
  20     and get doctors to take these roles on, but I think an
  21     awful lot of them fell by the wayside, just as a lot of
  22     the air commodores and all these other people they tried
  23     to bring in did.
  24   Q. We will come to the appointment of Clinical Directors
  25     and so on in a minute. So is it fair to say that to the

   1     extent that Dr Roylance was a clinician, as he was, that
   2     was an advantage in his relationships with the medical
   3     staff?
   4   A. I think it could be an advantage. I think it would also
   5     be a disadvantage.
   6   Q. Was it a disadvantage in terms of his relationship with
   7     the professional managers? Was that the other side of
   8     the coin?
   9   A. No. I think it could be an advantage and disadvantage
  10     with the clinicians before we even get on to the
  11     managers, but I think -- I am not sure about the
  12     managers, because most of the managers I spoke to had
  13     worked for him for quite a while. So I cannot really
  14     comment, I am afraid.
  15   Q. If we go to your statement, please, at page 4,
  16     paragraph 2.4, you say :
  17        "The Chief Executive derived power from his
  18     professional expertise and credibility as a doctor,
  19     along with his ability to 'envisage the future' and to
  20     interpret and translate that vision for the other key
  21     staff in the Trust."
  22        What was the vision of the future that Dr Roylance
  23     had that you are referring to here?
  24   A. I think his "vision of the future" was that the
  25     organisation had to -- this may sound rather odd, but

   1     had to recognise the reality of the NHS was that funding
   2     was limited, that there were difficult decisions that
   3     had to be made and that health care could not carry on
   4     in the way that it had in the past because it was
   5     unrealistic. I think his vision for the future was very
   6     much that there would probably be quite a "small", in
   7     inverted commas, acute provision, that the creation of
   8     constant innovation was going to create enormous
   9     problems because a lot of these things could not be
  10     funded. So people would be creating new drugs, people
  11     would be creating new techniques. In fact that was
  12     incredibly important: how do you actually manage and
  13     keep pace with this immense innovation which gives so
  14     many people prospects and hope but may not be
  15     deliverable within a resource envelope?
  16        So he had very strong and profound views about
  17     health care which translated into UBHT in terms of
  18     trying to say "How do we bridge this gap between, you
  19     know, the University, how do we work with our purchasers
  20     to ensure that they get the best possible value for
  21     money in terms of patient care, and how are we going to
  22     enable this to happen, because we are going to need
  23     people who were going to be terribly fleet-footed, who
  24     are going to have to be flexible, who are going to have
  25     to be innovative, and it is not going to be terribly

   1     comfortable for people".
   2   Q. Those people are going to be in large part the Clinical
   3     Directors who are going to be responsible for leading
   4     each of the directorates of the Trust?
   5   A. Yes, but I think in terms of his vision, it went --
   6     well, you know, you always use an inverted pyramid so it
   7     went from the top, the people at the very front line of
   8     services. They were the people who invariably are often
   9     the most affected by change. People talk strategically,
  10     but operationally it is often when people find their
  11     beds have gone or they are suddenly using day case
  12     surgery or people are not even having surgery for
  13     something, the whole service may just disappear.
  14   Q. Let us look at the last sentence that paragraph. How
  15     did Dr Roylance influence others and get them to see
  16     things from his perspective?
  17   A. By his capacity to argue: he was immensely
  18     argumentative.
  19   Q. So by face-to-face contact and oral discussion?
  20   A. Yes.
  21   Q. If we look to the next paragraph:
  22        "The Chief Executive saw it as his role to frame
  23     the future vision, values and culture of the Trust in
  24     consultation with the key staff in the Trust."
  25        Who were the key staff?

   1   A. I think the key staff were people like the Trust Board,
   2     who had ultimate responsibility, so you could not have
   3     a Chief Executive who had a vision which was not
   4     commonly accepted and shared. That would be totally
   5     inappropriate. I also think it was Clinical Directors,
   6     I think it was key managers. I think this extended
   7     quite a long way, because it was a very, very large
   8     organisation.
   9   Q. There is an element of chicken-and-egg, the Clinical
  10     Directors: are they appointed after the vision, values
  11     and culture have been agreed upon, or before?
  12   A. I think what you have to say is that the vision is
  13     evolving, and I think in one of the papers I produced it
  14     started off by saying "cloudy vision", and I think it
  15     can be overly simplistic to say, "here is the vision".
  16     Obviously, as things emerged in different directorates
  17     about new techniques and so on and so forth, then
  18     obviously these things had to be taken account of.
  19     Therefore, I think the important thing is to have
  20     a central vision of the type of organisation. That is
  21     role of the centre, to have a view of the type of
  22     organisation to identify what is important, what should
  23     be valued, and then for people to be able, through
  24     discussion, to map their view of their service onto that
  25     so it is not something which is separate.

   1   Q. If we go over the page, please, you say:
   2        "Many of the ideas that informed his vision were
   3     based upon his [Dr Roylance's] own concept of being
   4     a medical professional, or his "model of medical
   5     management" as it was informally called.
   6        Then this is the point you have just been making:
   7        "His vision was not to impose a new set of values
   8     onto the Trust. Instead, he tried to identify the
   9     existing values that were central to the role and
  10     identity of the medical profession and reinforce them."
  11   A. Yes.
  12   Q. If we go down a few lines, do you see the sentence
  13     beginning:
  14        "The values to which he subscribed were directly
  15     related to those endemic in the medical profession,
  16     putting the patient first, expecting people to be
  17     self-correcting, providing support to those who required
  18     it to help them succeed and trusting people to deliver
  19     the work that needed to be done through these. However,
  20     these values were carefully supported through tightly
  21     controlled financial structures and processes for
  22     support and development ..."
  23        You go on to refer to being "inside the box" and
  24     so on.
  25        If people are to be trusted to deliver the work

   1     that needed to be done and were expected to be
   2     self-correcting, would it be particularly important to
   3     make sure that the people selected for important roles
   4     were suited to those roles?
   5   A. Yes, I would think so.
   6   Q. You say in your statement that the philosophy was to
   7     have the Trust Board at one level, then the clinical
   8     directorates, and then the wards?
   9   A. Yes.
  10   Q. And as little bureaucracy between those levels as
  11     possible?
  12   A. Yes.
  13   Q. So it would follow, would it not, that the selection of
  14     Clinical Directors would be very important?
  15   A. Yes, I think it was.
  16   Q. How important was it that the Clinical Director was
  17     temperamentally, emotionally suited to the role of
  18     Clinical Director?
  19   A. I do not think I am equipped to answer that, because
  20     I think you would need to have a kind of assessment
  21     centre to do that kind of thing. I think that the most
  22     important thing was -- well, what my research revealed
  23     was that the Clinical Director was acceptable to the
  24     group because you cannot lead people unless they are
  25     prepared to follow you. I think that is a very

   1     important thing. My findings are replicated all over
   2     the country. This is actually very, very important,
   3     because it is a co-dependent role, and I think, as
   4     I demonstrated in some of the things that I wrote, that
   5     Clinical Directors discovered that they cannot go in and
   6     try to use authority structures; they have to use
   7     leadership structures.
   8   Q. Who in fact appointed the Clinical Directors to the
   9     UBHT?
  10   A. The Chief Executive.
  11   Q. Dr Roylance?
  12   A. Yes.
  13   Q. With anyone else?
  14   A. I am not sure. As far as I know, I think the final
  15     appointment was in his hands, but people were being put
  16     forward so they had to be credible to the group, but
  17     also acceptable to the management structure, so they had
  18     to be able to bridge those two things.
  19   Q. What was the selection process?
  20   A. I think it was a form of interview.
  21   Q. Do you know what form the interview took?
  22   A. I think people described it as having had -- their names
  23     came forward by a variety of different devices.
  24   Q. Once the names had come forward, what form did the
  25     interview take?

   1   A. I think it was an interview in his office, from what
   2     I can recall.
   3   Q. Did you ever attend any of those?
   4   A. No.
   5   Q. If we go to page 54, this is part of your feedback.
   6     Remember, we looked at the front page, the primary date
   7     feedback, "becoming a Clinical Director"?
   8   A. Yes.
   9   Q. You see in the first paragraph:
  10        "At UBHT the structure is not seen as critical as
  11     the appointment of Clinical Director is not a prescribed
  12     formula. Once the Clinical Director is in place, then
  13     the rest is up to him or her to sort it out. As the
  14     selection of the person to take on this role is so
  15     crucial to the perceived effectiveness of the
  16     directorate, this is where the feedback will start."
  17   A. Yes.
  18   Q. So was it a good thing or a bad thing that the
  19     appointment of the Clinical Director was not done to
  20     a prescribed formula?
  21   A. You mean the appointment or the selection?
  22   Q. The selection.
  23   A. I think it is a very, very good thing, because I think
  24     you have to understand, one of the terms I use is it is
  25     "metalogic" to understand the complexity of the

   1     organisation. One of the dangers is that you try and
   2     standardise something, so people are fooled into
   3     thinking that if you standardise something, it is
   4     actually equitable. Where you have very different types
   5     of organisation, in these sub-units, if you look at
   6     psychiatry and surgery, they are so totally different
   7     and the cultures in those are so totally different.
   8     Trying to say they will all be the same is actually
   9     quite unhelpful. Therefore, the artistry is to manage
  10     and recognise difference, and therefore, I do not
  11     believe that the difference is in any way detrimental in
  12     this sense; in fact, I think it is positive.
  13   Q. Let us look at the next paragraph, 2.2:
  14        "There is very little that can be identified as
  15     common to the selection and appointment of Clinical
  16     Directors. It is often a highly political process that
  17     may result in the appointment of the most experienced,
  18     the most senior, the youngest, the most reluctant or the
  19     most keen consultant into that role."
  20        Why should the most reluctant consultant end up as
  21     Clinical Director?
  22   A. Because often they are the most talented. One of the
  23     problems in the NHS is to have the credibility of one's
  24     colleagues. The kinds of people that I met, not only at
  25     UBHT but also at somewhere like the John Radcliffe, were

   1     they very people that other people wanted to lead them,
   2     the people who were the researchers, the excellent
   3     clinicians, the people who were incredibly talented and
   4     invariably inordinately busy. They probably had
   5     something with the Royal Colleges and everything else.
   6     Therefore, whilst they felt a duty, they were
   7     inordinately reluctant to take on anything else, and
   8     also to recognise that perhaps over a period of three
   9     years, this could potentially decimate their research
  10     potential, for example.
  11   Q. When you say they were most talented, they were often
  12     the most talented clinicians?
  13   A. Absolutely.
  14   Q. To what extent is there a correlation between a talent
  15     as a clinician and a talent as a Clinical Director?
  16   A. I think sometimes it can be very close, because I am not
  17     sure whether it is terribly well understood, but one of
  18     the things I have learned is that actually most
  19     consultants have been managing for quite a long time, so
  20     there are lots of things they are very good at and very
  21     able at and a lot of the things they need to do as
  22     leaders, as the Clinical Director, are part already of
  23     their role but is not recognised as such. In a lot of
  24     my work, in working with consultants, it has been to try
  25     and get them to recognise that a lot of things they

   1     already do are managing even though they do not
   2     recognise them and articulate them in that way.
   3   Q. You say sometimes there is a very close correlation.
   4     Are there other times when there was not so close
   5     a correlation?
   6   A. I think that is inevitable because there are lots of
   7     people with different personalities, so one may be
   8     inordinately talented but prima donna.
   9   Q. Is it possible to generalise about whether a particular
  10     talented clinician will or will not be talented as
  11     a Clinical Director?
  12   A. I think it depends.
  13   Q. Does that mean it is not possible?
  14   A. I think it will depend on the individual. If you
  15     presented one, you would probably be able to get
  16     a relatively good idea.
  17   Q. So it would depend on the particular individual?
  18   A. Yes, I think so.
  19   Q. So it is not possible to make a generalisation?
  20   A. No, I do not think so.
  21   Q. You refer here to the appointment process. If we go to
  22     page 25, please, this is one of your published papers.
  23     That is the front page of it, just so you know what
  24     document we are referring to. If you go to page 27, on
  25     the left-hand side, it is the same point as we have just

   1     seen in the other document, "Becoming a Clinical
   2     Director". Are you able to read that paragraph?
   3   A. Yes, thank you.
   4   Q. Four lines down:
   5        "In contrast, in this case" and there you are
   6     referring to the UBHT?
   7   A. Yes.
   8   Q. "... in this case, no job descriptions existed as
   9     a deliberate strategy. A lack of prescription reflected
  10     the professional culture. Selecting the right person
  11     was crucial. Having done that, it was essential to
  12     provide the minimum of constraints to accommodate the
  13     diverse individuals and specialties."
  14        What I am trying to get at is, what was the
  15     mechanism which enabled those making the appointments to
  16     be confident that they had got this crucial appointment
  17     correct?
  18   A. I think you will have to ask that of the people who were
  19     appointing. I do not feel I could answer that for you.
  20   Q. If we look to the last paragraph on that left-hand
  21     column:
  22        " ... all Clinical Directors had two common
  23     attributes, professional credibility" and you mean with
  24     other clinicians?
  25   A. Yes, with the clinicians they would be leading.

   1   Q. And "organisational acceptability"?
   2   A. Yes.
   3   Q. In other words, the troops were prepared to be led by
   4     that particular general?
   5   A. No. "Organisational credibility" relates to the
   6     professional culture. "Organisational acceptability" is
   7     that they are appointable in terms of the Chief
   8     Executive, so there will probably be a number of people
   9     who may be put forward but not everyone would
  10     necessarily succeed.
  11   Q. So that means capable of being appointed by a group that
  12     does the appointing?
  13   A. Yes.
  14   Q. "Professional credibility stemmed from professional
  15     competence ... High levels of professional competence
  16     are not necessarily indicators of capability in a new
  17     and very different role. Credible clinicians are more
  18     likely to be competitive with a high personal
  19     achievement need, and their desire for success in a new
  20     and different role placed them under extra pressure and
  21     stress."
  22        To become a Clinical Director involved a big
  23     change, did it not, for medical consultants who had no
  24     experience or understanding of working in that kind of
  25     hierarchical structure?

   1   A. I think what I have tried to explain, and probably done
   2     it extremely poorly, is that one of the things which
   3     I think is quite important is recognising that many
   4     consultants have been managing for a considerable number
   5     of years. They have to manage their patients. Some
   6     people were already in particular specialties that have
   7     heads of services and heads of departments, so they
   8     have, to my way of thinking, considerable managerial
   9     experience.
  10        When I tried to explain this, they had not always
  11     mentally thought of it in that way because it is not
  12     natural for them to do so.
  13        So, for example, if I draw on my experience of
  14     developing Clinical Directors, I have never gone in
  15     there and said, "Here are business school models and
  16     ways of working. You must do this ... Here are the ten
  17     principles", or something. The artistry is to talk to
  18     people about what they do and to work emergently from
  19     their own professional experience, to say to them, "Look
  20     at all these things you have been doing quite naturally
  21     that other people are labelling as managing", for
  22     instance.
  23   Q. How easy do the Clinical Directors, to the extent it
  24     is possible to generalise, find being a Clinical
  25     Director?

   1   A. I do not think many of them found it easy at all. I do
   2     not think "easy" is a word anyone would use. I think
   3     stressful, I think arduous, I think exciting,
   4     challenging, frustrating, a whole range of adjectives,
   5     but I do not think I ever heard "easy".
   6   Q. So would "difficult" be a better word?
   7   A. I think "challenging", because doctors thrive on
   8     difficulty.
   9   Q. If we look at your witness statement page 11,
  10     paragraph 2.15, if we just have a look at that
  11     paragraph, the Clinical Directors often had to rely upon
  12     the General Managers heavily for running the
  13     directorates?
  14   A. Yes.
  15   Q. If we go over to page 8, you refer there, in
  16     paragraph 2.11 -- this is the reference I was after.
  17     The idea was that traditional professional boundaries
  18     might become weaker as directorates reflected
  19     disease-based areas of patient needs. You refer to the
  20     Director of Cardiac Services as being one example?
  21   A. Yes.
  22   Q. To what extent were you aware of the process by which
  23     General Managers, to go with the Clinical Directors,
  24     were appointed?
  25   A. Not aware at all, to be honest.

   1   Q. To what extent were the Clinical Directors given
   2     guidance or assistance in recognising the fact that they
   3     had been, as you put it, managing already in the past?
   4   A. I think I can recall there were a number of things that
   5     were done. From the very start, there was a very early
   6     meeting held at -- I think it was Leigh Court, where
   7     there was a presentation by the executive team. That is
   8     where the phrase "the box" came from, where Clinical
   9     Director's responsibilities were clearly outlined to
  10     them. It was drawn as a box and it contained finance,
  11     moral ethics, legal and something else and the idea was
  12     to try and explain to them that what the Trust wanted
  13     was them to take ownership and to be accountable for
  14     their decisions, because if you remember, one of the big
  15     problems -- I mean, you have to think why all of this
  16     was introduced in the first place. It was because --
  17     I am drawing very heavily on the literature here, for
  18     which I make no apology; I think it might help. General
  19     management had been introduced in a sense almost to
  20     control doctors and to reduce spending and actually had
  21     failed to deliver that.
  22   Q. That is what I was asking you earlier on.
  23   A. I am drawing on the literature. I cannot draw on my
  24     experience from UBHT, because as I arrived, there was
  25     a kind of dismantling of that, in effect, but that had

   1     failed, so I think if you look at the White Paper, the
   2     idea is that doctors were going to be engaged at every
   3     level in management and I think in part, this is what it
   4     is trying to address.
   5   Q. Can we look at page 55? This is back to your primary
   6     data feedback document. The second new paragraph on
   7     that page, the second line "Most Clinical Directors
   8     found the appointment failed to clarify the role or what
   9     they had let themselves in for, as there was no job
  10     description or contract to identify what they were
  11     supposed to do or for how long they would do it."
  12   A. Yes.
  13   Q. "Informality and ambiguity are deliberate and critical
  14     elements of the execution of the process and the
  15     definition of the role at UBHT."
  16        Just help me with that sentence. Ambiguity being
  17     a deliberate element of the definition of the role, is
  18     a slightly difficult concept for me to grasp. Ambiguity
  19     in what way?
  20   A. Well, in the sense that I think part of the
  21     understanding in the Trust was a clear recognition that
  22     change was not going to start and then going to stop,
  23     and therefore it was a fluid situation and there were
  24     constant directives, constant changes in policy
  25     nationally, and as these rolled out there were new

   1     things, along came the Patient's Charter and all these
   2     other things, therefore I think part of the issue was
   3     that ambiguity was something that people had to
   4     tolerate.
   5        Therefore, it sounds paradoxical, but actually
   6     being clear that things are ambiguous. So the clarity
   7     that things are ambiguous was actually quite important.
   8     That is to give people a sense of understanding and to
   9     accept this rather than to keep saying, you know, "What
  10     exactly is my role?" If you and I are Clinical Director
  11     and General Manager -- I will let you be Clinical
  12     Director, so if you are Clinical Director and I am
  13     General Manager and we are in a particular directorate,
  14     you may be inordinately interested in finance for some
  15     reason. You may have been head of service or something
  16     in your former life so you may want a grip on finance.
  17     I may be terribly good at strategy and in inverted
  18     commas "marketing", and we may find that is the way our
  19     two roles shape down and it works awfully well for us.
  20     Alternatively, it may be that you -- and if you have
  21     read the document I wrote which was the feedback thing,
  22     some Clinical Directors felt strategy was their
  23     provenance and they were very keen on doing that and
  24     leaving a lot of the detailed finance to the General
  25     Manager. That is what I mean by "it was too

   1     ambiguous". It was to allow people to play to their
   2     strengths.
   3   Q. Is it right, do we get from this page the idea that most
   4     Clinical Directors would have welcomed more guidance as
   5     to what it was they were supposed to be doing as
   6     Clinical Director?
   7   A. I think some of them would.
   8   Q. This is your document.
   9   A. Yes.
  10   Q. The second new paragraph:
  11        "Most Clinical Directors found the appointment
  12     failed to clarify the role of what they had let
  13     themselves in for".
  14        Did most of those Clinical Directors think there
  15     ought to have been greater clarification, or were they
  16     content with the fact they did not know what they had
  17     let themselves in for?
  18   A. I think there are two things. What they had let
  19     themselves in for, I think, is an indication of a lot of
  20     the difficult issues that they had to deal with, that
  21     I am not sure they were expecting to have to deal with.
  22     I also think in terms of clarifying the role, you could
  23     have given them a job description but it would not
  24     necessarily have been a job description that they would
  25     then have wanted to implement.

   1   Q. But it may or may not have helped them, but that is what
   2     they wanted; that is what they felt they wanted. That
   3     is what your research found; is that right?
   4   A. I think in part it was.
   5   Q. If we go to page 61, this is still the same document,
   6     your document, at the foot of the page, under the
   7     heading "Support to Reduce Stress" in the first
   8     page there:
   9        "A General Manager is provided to undertake the
  10     operational running of the directorate and specialist
  11     finance and personnel staff are allocated to each
  12     directorate. Although Clinical Directors found this
  13     essential, many would still have liked some formal
  14     development, particularly at the outset and during the
  15     early stages in the role."
  16        Then this:
  17        "A paradox of support emerged. The organisation
  18     would not impose development on Clinical Directors or
  19     create a formalised system of succession management and
  20     preparation."
  21        I will come back to that phrase in a minute.
  22        "However, many who might have been interested in
  23     such activities were also reluctant to ask, maybe
  24     believing that articulating this could be seen as
  25     a potential sign of weakness."

   1        So there are lots of people who would like to have
   2     some help but are frightened to ask?
   3   A. I think what you have to look at is the issue relating
   4     to stress in terms of the findings here, because I think
   5     one of the things --
   6   Q. I will come to that in a minute --
   7   A. One of the things about this is that one of the most
   8     important things for doctors is about "face" and "losing
   9     face" and therefore they were very concerned because,
  10     remember, they thought, to their way of thinking, a lot
  11     of the consultants I met thought management was
  12     a "doddle" compared to medicine: they were all these
  13     terribly high intellectual achievers and therefore
  14     management should come terribly easily to them.
  15   Q. Is that a correct view or an erroneous view, in your
  16     opinion?
  17   A. What that management is terribly easy?
  18   Q. That if you are a clever clinician, if you are terribly
  19     good at orthopaedic surgery because you are a clever
  20     person, does it follow that such a person would find
  21     management easy?
  22   A. I think they would find some parts of management easy,
  23     yes, but not necessarily others.
  24   Q. By whom would articulating the desire for more
  25     assistance have been seen as a sign of weakness?

   1   A. By whom? I am sorry, I am not understanding.
   2   Q. I am looking at your penultimate paragraph:
   3        "Many who might have been interested in such
   4     activities were reluctant to ask, maybe believing that
   5     articulating risk could be seen as a potential sign of
   6     weakness."
   7        By whom?
   8   A. I think amongst their peers. It was interesting because
   9     a number of Clinical Directors did go on Clinical
  10     Directors' development programmes. At this stage,
  11     I think two had been on the Bath programme; one had
  12     certainly been on the Bristol programme that I had run.
  13   Q. If we go to page 57, again still the same document,
  14     under the heading "Stress": is stress for a Clinical
  15     Director always a good thing or always a bad thing?
  16   A. I think it depends very much how people cope with it,
  17     whether it is a good thing or a bad thing. I think some
  18     stress can be quite positive for people, but I think
  19     continuous stress may or may not be -- I would have
  20     thought the potential could not be a good thing.
  21   Q. How do you define stress?
  22   A. I think it is experiencing a lack of control, which is
  23     a kind of clinical definition of it. We experience
  24     stress when we feel we cannot control things.
  25   Q. Not being able to cope?

   1   A. We cannot control. I am not a clinical expert in this.
   2   Q. You talk here about the part-time temporary nature of
   3     the clinical directorate role, and we know that all the
   4     Clinical Directors were still clinicians?
   5   A. Yes, absolutely.
   6   Q. And it comes through from this paper it was important to
   7     their own self-esteem that they were clinicians and
   8     necessary in order to have the respect of the other
   9     clinicians?
  10   A. Absolutely.
  11   Q. The next paragraph, the one beginning "Clinical
  12     Directors experience ...":
  13        "There is little discussion between the Clinical
  14     Directors about their workload or how they manage their
  15     role. Consequently, individuals have little idea of how
  16     their role compared to others and their sense of
  17     isolation or distance from other Clinical Directors and
  18     colleagues can add to the stress."
  19        Again, if we go to the bottom of the page,
  20     under "Overload":
  21        "Work overload is often expressed through a sense
  22     of disappointment and feelings of personal failure. The
  23     limited amount of formal time allocated is seen as
  24     insufficient and most Clinical Directors spent
  25     considerably more, particularly at the start when the

   1     learning curve was recognised as very steep. However,
   2     few Clinical Directors see this as a reflection of the
   3     demands of the job, describing it instead as a symptom
   4     of their own failings and inefficiency."
   5        Do you take it from this paragraph that what you
   6     are saying is that there are many Clinical Directors who
   7     found themselves overloaded with work, and tended to
   8     internalise or personalise the reasons for that by
   9     feeling that they were inadequate?
  10   A. Yes.
  11   Q. And imagining, quite wrongly, that all the other
  12     Clinical Directors were better than them and much more
  13     able to cope?
  14   A. Yes. I think so. You see, in a sense, we are in
  15     a perennial paradox, and that is that the very people
  16     who have the highest achievement, the ones who wanted to
  17     try and do the job best, were often the most busy, and
  18     they were therefore the ones most concerned with doing
  19     best, so they would punish themselves the most. It was
  20     very much a kind of almost a vicious circle, because if
  21     you cared and you were talented and interested and all
  22     the rest of it, you could never devote enough time to
  23     it.
  24   Q. Did you find from your research by talking to these
  25     Clinical Directors -- I think you spoke to all of them,

   1     did you not?
   2   A. Yes.
   3   Q. Did you find that all of them were spending longer on
   4     their role as Clinical Director than the number of
   5     sessions formally allowed for that?
   6   A. Yes. What you see here in this document -- I have not
   7     had an opportunity to describe how this document fits
   8     with anything, but it is actually thematic, so these are
   9     themes which were endemic across Clinical Directors in
  10     terms of my interviews with them.
  11   Q. By what proportion, if you are able to generalise, did
  12     Clinical Directors exceed the number of sessions
  13     formally allocated?
  14   A. I could not say as a proportion, I am sorry.
  15   MR MACLEAN: I think before I move to the next topic, sir,
  16     is that a convenient moment for a short break?
  17   THE CHAIRMAN: Yes. Shall we take a break, Dr Thorne, from
  18     11.45 until noon, and reconvene then?
  19   (11.46 am)
  20               (A short break)
  21   (12.05 pm)
  22   MR MACLEAN: Dr Thorne, can we go back to page 55, please?
  23     It is still that same document we have looked at
  24     before. I want to look at the last paragraph beginning
  25     "Informality and ambiguity". In the second line, you

   1     say:
   2        "The formal view of the Chief Executive is to
   3     regard the lack of prescription as evidence of allowing
   4     the Clinical Director to interpret the role in
   5     a 'professional' way."
   6        Why do you say "The formal view of the Chief
   7     Executive ..."?
   8   A. Because I think that is what he stated and therefore
   9     I think I tried to put that in to reflect what I think
  10     was his kind of official pronouncement on it.
  11   Q. There was not an informal view that was any different,
  12     was there?
  13   A. No, but I think it is trying to make the point.
  14   Q. If we go to page 57, this is where we were a moment
  15     ago. We have looked at this paragraph on stress. From
  16     the second paragraph under that heading, the one we
  17     looked at a little earlier, about there being little
  18     discussion between the Clinical Directors about their
  19     workload and how they managed their role, so they did
  20     not know much about how their role compared to others,
  21     was that something that surprised you, or did not
  22     surprise you, when you conducted your research?
  23   A. I think it was, if I can be kind of half-and-half,
  24     I think I was partially surprised because I knew that
  25     CDs met regularly and I knew that a number of them would

   1     phone each other up and would indeed talk to each other
   2     about particular problems. I think it is, if you took
   3     the whole lot right away across the board, so I do not
   4     think there had been a kind of fora, a round-Robin
   5     discussion about this. There were obviously subgroups
   6     and people who would support each other and phone each
   7     other up, so I think there was a kind of informal
   8     network. Therefore I was partially surprised, if that
   9     makes any sense?
  10   Q. If we go to page 59, still on the same point,
  11     paragraph 4, you say at the end of that first paragraph:
  12        "The underlying surgeons were encapsulated by one
  13     Clinical Director who said, 'the very best people seem
  14     to be able to cope with everything'. At UBHT, every
  15     Clinical Director believes himself to be this type of
  16     person. Hence expressions of vulnerability are rarely
  17     made or commonly shared within the organisation."
  18        Then you quote one particular Clinical Director
  19     who was under particular stress at a particular time.
  20        Was it that there was a fear of appearing weak, of
  21     appearing not to be able to cope among Clinical
  22     Directors, part of some macho culture?
  23   A. I think it is part loss of face on the part of the
  24     medical culture, very much, so I do not think doctors
  25     are terribly good at saying "I am not coping terribly

   1     well", or did not appear to be here.
   2   Q. Do you consider that to be an unhealthy state of
   3     affairs?
   4   A. I am not sure. I think it is very common. I am not
   5     sure that it is necessarily a good thing. I am not sure
   6     everyone is clear about what this document is, because
   7     you have not really introduced it. Part of what I would
   8     like to say is that this document was produced as part
   9     of my research to give everyone who had taken part
  10     feedback on the information that I had gathered, so part
  11     of the kind of cultural research that I do is to
  12     actually engage with the participants; I do not go away
  13     and do research on people, I actually work with them, so
  14     I am giving them feedback. We had a half-day session
  15     when these issues were raised, so it enables these
  16     things to come out.
  17   Q. Thank you, I understand that.
  18   A. Thank you. I am not sure everyone else did.
  19   Q. What I am just examining at the moment is the extent --
  20     your research found that commonly Clinical Directors did
  21     not feel able to ask for help when they were under
  22     stress or overloaded because they feared losing face?
  23   A. I do not think they were afraid to necessarily ask for
  24     help. They were constantly asking for help from people,
  25     but I think there is a difference between asking for

   1     help and feeling confident that you can fulfil all of
   2     the obligations which are placed upon you. They are
   3     very different things, in my experience. They would ask
   4     their General Managers for help. They were constantly
   5     on the phone to people like the Director of Finance, the
   6     Director of Operations or even the Personnel Director.
   7     So they would be constantly going to people.
   8        There is a difference between actually doing that
   9     and feeling, even with that level of support, quite
  10     vulnerable, because you have an inordinate amount of
  11     work all of which needs to be done, and often it needs
  12     to be done now. So you feel as if you are failing.
  13     Part of my work with them is to try and say to them,
  14     "You are not failing. Nobody is doing any better. You
  15     are highly competent with a degree of credibility to
  16     juggle all these difference things". In the past
  17     doctors had always juggled professionally well like
  18     Chairman of a division and so on and so forth, but this
  19     was the very first time in the history of the NHS that
  20     he had actually crossed this divide into this kind of
  21     management domain, if you like. It was a different
  22     world for them. That added to the stress.
  23   Q. I asked you a minute or two ago about the extent that
  24     Clinical Directors felt unable to articulate problems
  25     that they had, I asked you whether or not that was an

   1     unhealthy state of affairs as far as you were
   2     concerned. I think you said that it was not necessarily
   3     healthy?
   4   A. Yes.
   5   Q. Could such a state of affairs ever be healthy for an
   6     organisation like this?
   7   A. It depends what you mean by "healthy". I do not think
   8     it is necessarily healthy for the individuals.
   9   Q. Could it ever be healthy for the individual?
  10   A. Some people spend their entire lives with a mask on,
  11     masquerading as being perfect in a whole range of ways
  12     and they find that inordinately productive because they
  13     put on a mask at work which is a role and they play out
  14     that role and a lot of their inner feelings are never
  15     revealed. It is only very recently in management that
  16     even the term "emotions" has become prevalent in the
  17     literature, yet we all carry these things with us. This
  18     has only been prevalent in the literature for the past
  19     eight or nine years. It tells you an enormous amount of
  20     research has gone on there; the feelings of the human
  21     beings have been ignored. This is precisely what we are
  22     dealing with here. It would be quite wrong for me to
  23     make a judgment on that. I can give you a personal
  24     view, which I am happy to do. I think it is
  25     problematic, yes. That is a very personal view. I am

   1     happy to give that, if it helps.
   2   Q. What was the key imperative for the Clinical Directors
   3     as they related to you when you spoke to them, you
   4     interviewed all of them and observed them over a long
   5     period of time? What seemed to be the key imperative
   6     for them as Clinical Director?
   7   A. For them? I can tell you that very clearly, without
   8     a shadow of any doubt in my mind, and that was leading
   9     the other clinical staff, absolutely an imperative.
  10        The second thing was changing and developing the
  11     strategy for the service, which was another absolute
  12     imperative, I think, for them. I think those two
  13     things, and obviously because of the nature of the UBHT,
  14     keeping in budget, because there were very stringent
  15     financial controls, and learning to recognise that, was
  16     terribly important.
  17   Q. Was that not the key imperative for the Clinical
  18     Director, keeping in budget?
  19   A. It was not the key imperative. The key thing was
  20     leading the clinical staff, without a doubt, because who
  21     else was going to do that? You could have finance
  22     people looking after finance, but the key role for
  23     a Clinical Director, and this has been proven, you know,
  24     nationwide, is that most of their effort and energy is
  25     directed to working with their peers, with their fellow

   1     clinicians.
   2   Q. Can we go to page 58, please, still in the same
   3     document, the feedback paper. Under the general heading
   4     "Lack of experience and expertise", if you go to the
   5     very bottom of the page:
   6        "Clinical Directors are often acutely aware of
   7     their lack of particular expertise and knowledge in the
   8     management area."
   9        You give some examples.
  10        "However, the need to ensure that the directorate
  11     kept within budget was seen as paramount and at times
  12     oppressive, adding to the stress".
  13   A. Yes.
  14   Q. Does that not suggest that your research showed that the
  15     key imperative, which at times was oppressive for the
  16     Clinical Directors as they saw it, was keeping within
  17     budget?
  18   A. No, because if you look under the headings of
  19     "Leadership", I think you will find similar comments
  20     about the nature of their role vis-a-vis their clinical
  21     colleagues. What I am doing under each of these is
  22     drawing attention to particular things. I think I did
  23     mention budgets.
  24   Q. What does "paramount" mean there?
  25   A. I have no idea. Vitally important.

   1   Q. More important than anything else; is that not what it
   2     means?
   3   A. Yes.
   4   Q. So the need to ensure the directorate kept within budget
   5     was more important than anything else and was sometimes
   6     oppressive, adding to stress. Is that not what the
   7     Clinical Directors were saying to you?
   8   A. Yes.
   9   Q. So the key imperative for the Clinical Director is
  10     keeping within budget?
  11   A. Yes, but they had other key imperatives, is really what
  12     I am saying. I am not disagreeing with you.
  13   Q. Your research --
  14   A. I think that was absolutely right, because one of the
  15     big problems, after all, was Clinical Directors and
  16     things were created to actually exercise control over
  17     funding.
  18   Q. The relationship between the Clinical Directors and
  19     Dr Roylance as the Chief Executive: the Clinical
  20     Directors -- what was their attitude to Dr Roylance
  21     generally?
  22   A. What was their attitude?
  23   Q. Yes.
  24   A. I think they found him helpful. I think they found him
  25     frustrating and irritating. I think they found him

   1     a source of support. He was readily available. I think
   2     those were the kinds of words that I would use.
   3   Q. As you say in your statement, Dr Roylance responded to
   4     problems by offering support to colleagues and helping
   5     them to become more self-critical. How did he offer
   6     that support?
   7   A. He would talk to people. One of the things that
   8     absolutely amazed me, having worked with quite a number
   9     of senior managers, his entire style -- there is
  10     a saying which came out in the 1980s of "management by
  11     walking around". John Roylance is "management by
  12     talking around". As Chief Executive, his entire day was
  13     spent talking to people. His diary was always full, he
  14     was incredibly busy and worked very long hours. If
  15     I had been a Clinical Director who wanted to talk to him
  16     very urgently about something, he would have made
  17     himself available to me irrespective of whatever else
  18     was happening at the time.
  19        The frustration would come because he did not see
  20     his role as solving people's problems for them. He was
  21     not the organisation's management consultant. His style
  22     was coaching, which is an extremely irritating and
  23     frustrating for people, being coached.
  24   Q. So how did the Clinical Directors or other people to
  25     whom he was offering support react to Dr Roylance's

   1     attempts to help them become more self-critical?
   2   A. Sometimes very unfavourably, initially, because it is
   3     "jolly tough love", as they say in the States, and it
   4     is not always awfully nice, when you go to somebody and
   5     you say, "Well, I have this problem" and you expect them
   6     to say, "Oh dear", you know, "With my wealth and
   7     experience and knowledge I can sort this out for you in
   8     five minutes and therefore that is what I will do", and
   9     they actually spend an inordinate amount of time saying,
  10     "Can you see this situation from a different point of
  11     view? What does this suggest to you? Do you feel you
  12     might have handled X rather differently than you might
  13     have done?" in which case you think, "Gosh, there is
  14     another way of doing this".
  15   Q. You said that sometimes people might react by being
  16     frustrated. Was that as you understood it the usual
  17     reaction to Clinical Directors, to find these responses
  18     frustrating?
  19   A. I think so. I think sometimes that was a reaction,
  20     yes. I think they are very different people.
  21   Q. Were there any who found it not frustrating, who found
  22     it very helpful?
  23   A. Yes, I think so.
  24   Q. Who were they?
  25   A. I could not sort of just throw out names, I do not

   1     think. I think different people have different
   2     situations, so sometimes particular situations would
   3     evoke different responses in people. But I think some
   4     people did find it helpful, because in talking things
   5     through with people, you actually begin to see
   6     situations rather differently. That is a very important
   7     learning experience, because part of the ethos of the
   8     Trust was actually, it is a bit like -- I am supposedly
   9     in the education business, but it is a bit like the
  10     difference between enabling people to fish and all the
  11     other things, so you actually give them skills which
  12     they can then begin to transfer. So instead of solving
  13     problems for them, you enable them to begin to solve
  14     those themselves, but they are not in a situation where
  15     they should be floundering because there is always
  16     someone there they can talk things through with.
  17   Q. Did anyone in your research ever suggest to you that
  18     Dr Roylance gave to them the impression that he always
  19     knew best?
  20   A. In my research, with the Clinical Directors, you mean?
  21   Q. Or with anyone else?
  22   A. I think, sometimes, yes, he did say he knew best, and
  23     that was often in relation to things like the ethos and
  24     vision of the organisation, because that is what he
  25     considered his role to be.

   1   Q. That is not quite what I asked.
   2   A. That was an area in which he felt he knew best, and
   3     therefore there were some areas in which he would not
   4     necessarily brook disagreement, for example. So, for
   5     example, if you wanted -- I mean -- this is just an
   6     illustration, I think. Say you were a Clinical Director
   7     who -- and remember, a lot of them were still very
   8     untried and untested, and therefore, they still had
   9     a model of the Health Service which was not necessarily
  10     the model of the reality as it existed, which was
  11     incredibly difficult for people, because they were still
  12     doing the same jobs essentially that they had always
  13     done, but they had to reframe those intellectually.
  14     That is much more different than doing a different job.
  15     If I asked you to do the work that you are doing now but
  16     to actually think about it in a very different way, you
  17     would find that much more difficult than simply doing
  18     something different.
  19   Q. You said that Dr Roylance did say he knew best and often
  20     in relation to things like the ethos and vision of the
  21     organisation, because he considered that to be his role
  22     and there were some areas in which he would not
  23     necessarily brook disagreement, for example, in other
  24     words, would not put up with a contrary view being
  25     expressed?

   1   A. Yes.
   2   Q. I do not know whether you have seen the evidence of
   3     Mr Boardman to the Inquiry, but Mr Boardman said that
   4     there were occasions when, if you wanted to try and have
   5     a problem discussed and address an issue with
   6     Dr Roylance -- this is Day 33, page 63 from line 20 --
   7     it was difficult at times to get Dr Roylance to engage
   8     in debate in the same way you wanted to?
   9   A. Will I get this on the screen?
  10   Q. No.
  11   A. I am sorry, I will listen more carefully.
  12   Q. Mr Boardman said:
  13        "There were occasions that when you wanted to try
  14     and have a problem discussed and drafted an issue [with
  15     Dr Roylance] it was difficult at times to get
  16     Dr Roylance to engage in debate in the same way you
  17     wanted to. If I can give an example, I read the
  18     testimony of Dr Roylance [with Mr Langstaff] when
  19     Dr Roylance was asked, I think it was to describe audit,
  20     and Dr Roylance's response was to redefine the
  21     question. I think the difficulty we found -- I am
  22     sorry, I found -- was that when presenting Dr Roylance
  23     with an issue to discuss, he could at times completely
  24     redefine the question. That is what I found difficult."
  25        Is that something you had reflected to you in your

   1     research?
   2   A. I think you have to understand what the role of the
   3     transformational leader is. I think at the time of
   4     change, one of the most difficult things for almost
   5     anybody in the organisation to understand and come to
   6     terms with is that their everyday reality is actually
   7     constantly being reframed and I think part of, if you
   8     like, the enactment of the vision and a typical device
   9     for doing this is language. Language is the single most
  10     important device we have in terms of understanding
  11     change, because the rhetoric and language that we use
  12     actually illustrates and develops mindsets that people
  13     carry with them.
  14        So I think part of the frustration for people was
  15     that while lots of people kept thinking, "We need to
  16     expand our services", they said all of these notions of
  17     competition, things about expansion and all the other
  18     things, then Dr Roylance would actually begin to reframe
  19     that and say, "No, no, no".
  20   THE CHAIRMAN: May I interrupt just a second? It would
  21     help us, Dr Thorne, the question you were asked was:
  22        "Is that something which you had reflected to you
  23     in your research?" That is really what I think
  24     Mr Maclean was seeking an answer to. He may have then
  25     asked you to explain that, but may we go the steps with

   1     him, and then we will get where you and he want to take
   2     us.
   3   A. Okay. I am terribly sorry, I do apologise, but I do
   4     think that was a helpful intervention. It is a typical
   5     process of intervention. It is precisely the sort of
   6     thing I did at the UBHT, so thank you very much for
   7     that. Excellent intervention skills!
   8        So if we go back to that question -- I apologise
   9     profusely. I did warn you this morning that I may be
  10     a little discursive. I apologise.
  11   MR MACLEAN: Let us take it in stages. The frustration
  12     Mr Boardman expressed in his evidence to the Inquiry --
  13   A. I can recall your question, I think. You asked me if
  14     that ever came up in my research and the answer to that
  15     is "No".
  16   Q. The frustration that Mr Boardman expressed to the
  17     Inquiry in his evidence --
  18   A. I am sorry, that was the question I was answering.
  19   Q. This is the next question. The frustration that
  20     Mr Boardman expressed in his evidence to the Inquiry,
  21     which you have explained a moment ago: is that
  22     frustration something that you were familiar with,
  23     having been around the Trust for the period that you
  24     were?
  25   A. Yes, and it was very interesting, because at the time

   1     when the Trust was coming into being, the Chairman and
   2     the Chief Executive did a round of almost what you
   3     thought of as a "travelling circus", so they went
   4     around, the two of them together, giving input to all
   5     staff in the Trust. They must have done about 20 or 30
   6     of these meetings, which was a considerable amount of
   7     personal time, but to give everybody at every level the
   8     opportunity to ask them things. A lot of that was about
   9     trying to get people's heads -- if I can give you the
  10     kind of colloquial metaphor which might help, the
  11     language was very much about getting people's heads on
  12     the right way because everybody thought they knew what
  13     the Health Service was doing, particularly in provider
  14     units. Remember, the hospital was still there. I used
  15     to use a metaphor of the sea because at one level at the
  16     bottom everything was terribly stable but actually at
  17     the top it was waves crashing and all the rest of it --
  18   Q. We are both beginning to speak a little more quickly
  19     than we should.
  20   A. I am sorry -- but for me, it is very, very important
  21     because language and discourse are primarily the devices
  22     by which we learn, and we change the way we think.
  23   Q. So you would not be surprised to know that somebody like
  24     Mr Boardman should have had the experience of going to
  25     Dr Roylance with a problem and feel frustrated that it

   1     was being redefined, as he would see it?
   2   A. Absolutely. An everyday occurrence. Because what he
   3     was trying to do was trying to educate people to see how
   4     the new health service was going to work. It was in
   5     quite a different way. People all assumed they knew.
   6     They absolutely assumed they knew. There was an immense
   7     amount of what I was brought up to call the "arrogance
   8     of ignorance" because everybody assumed they knew what
   9     they were doing and very few people did. It was
  10     incredibly frustrating, and very difficult for the
  11     people having to repeat this stuff over and over and
  12     over again. I mean, because I went on so many of these
  13     things, I heard it hundreds of times, so I was
  14     absolutely worn out.
  15   Q. Can I take you to somewhere else in the same document,
  16     the feedback document, page 62? Just to give this
  17     a little bit of context, the heading at the bottom of
  18     the page before is "Support to reduce stress."
  19        If we go back to 62, the top of the page:
  20        "Equally important is support from the executives
  21     and colleagues. Support is seen as a combination of
  22     accessibility and backing. Accessibility is crucial,
  23     and it is the ability to talk to people, often at short
  24     notice when a problem is emerging or suddenly blows up."
  25        How accessible did the Clinical Directors relate

   1     to you Dr Roylance was?
   2   A. Could you just repeat that?
   3   Q. When you spoke to the Clinical Directors, to the extent
   4     that they reported to you on how accessible they found
   5     Dr Roylance --
   6   A. I think that was the key thing. I think that was one of
   7     the things they found most valuable, because unlike
   8     a lot of places, there was a notion that managers worked
   9     kind of 9 to 5, but they all had mobile phones and it
  10     did not much matter where they were. If there was
  11     something happening people would be called out of
  12     a meeting, they would have conversations in their cars
  13     and all the rest of it. They were immensely accessible,
  14     astonishingly so, in my view, far more so than almost
  15     any organisation I have seen.
  16   Q. From the same paragraph, a little further down, you say:
  17        "The professional background of the Chief
  18     Executive and the Medical Director are invaluable in
  19     providing a climate of trust and understanding about
  20     complex professional problems."
  21   A. Yes.
  22   Q. So the Clinical Directors welcomed and related to the
  23     fact that Dr Roylance was himself a clinician?
  24   A. Yes. That is what they said.
  25   THE CHAIRMAN: Mr Maclean, just to clarify another answer,

   1     I thought you were asking whether, in the experience of
   2     Dr Thorne, Clinical Directors found Dr Roylance
   3     accessible?
   4   MR MACLEAN: Yes. I understood the answer was "Yes, very".
   5   THE CHAIRMAN: In the answer it says "they were
   6     accessible".
   7   A. Well done. Shall I say "he was accessible"? Would that
   8     help? "Dr Roylance is accessible"? Is that what you
   9     would like in the transcript? I am more than happy to
  10     say that.
  11   MR MACLEAN: All I want is that you are content you have
  12     answered the question and I understand your answer.
  13   A. I am answering it as honestly as I possibly can, and my
  14     experience would be "absolutely".
  15   Q. It is probably my fault. I do not have the transcript
  16     running in front of me. I understood you to be saying
  17     that the Clinical Directors found Dr Roylance helpfully
  18     accessible. Is that a fair summary?
  19   A. Yes.
  20   Q. And indeed, to a surprisingly high level?
  21   A. Absolutely. Gosh, yes.
  22   Q. Was it your view that Dr Roylance's accessibility was
  23     replicated by other executive directors of the Trust?
  24   A. Yes.
  25   Q. Was it your impression that they, in being so

   1     accessible, took a lead from Dr Roylance?
   2   A. Yes, I think so, because there was this notion that it
   3     is a 24 hours a day, 365 days a year business.
   4   Q. To what extent did you undertake the same kind of
   5     research that you did with Clinical Directors on the one
   6     hand, with the managerial, the General Managers or other
   7     non-clinical staff?
   8   A. No, I did not. I would have liked to.
   9   Q. So to what extent are you able to help us with the
  10     general perception of Dr Roylance's accessibility from
  11     a General Manager's point of view?
  12   A. I think I can only base this on my experience of being
  13     around, at being amongst the managers, going regularly
  14     to a lot of their management meetings, facilitating the
  15     away-days for them and attending the management
  16     development group. In which case -- I do not think
  17     I have ever known a manager say they could not get hold
  18     of anybody if they had a problem. I am trying to recall
  19     because I want to be as honest as I possibly can be,
  20     because it is unhelpful not to be, if you can give me
  21     a second. My experience would be in all honesty that
  22     I think they would find any of the executives very
  23     accessible.
  24   Q. Did you ever have a discussion with Rachel Ferris about
  25     her relationship with Dr Roylance?

   1   A. I think only kind of informally, because I facilitated
   2     a strategic away-day for cardiac services which Rachel
   3     asked me to do for her. I cannot quite remember when
   4     that was.
   5   Q. Was that the one that took place in --
   6   A. I am trying to think where it was held.
   7   Q. Was that the one that took place in March 1996?
   8   A. It might well have been. I cannot really say.
   9   Q. Can we look at UBHT 328/134.We will come back to that;
  10     the reference is obviously wrong.
  11   A. Is that something I might have that someone sent me?
  12   Q. We will try and get that. To the extent that you had
  13     informal discussions with Rachel Ferris about her
  14     relationship with Dr Roylance, what impression did you
  15     get from her about him?
  16   A. About?
  17   Q. Her relations with Dr Roylance.
  18   A. I think sometimes she found it frustrating. I think
  19     that would be the ...
  20   Q. In a similar way to Mr Boardman, or a different way?
  21   A. That is hard for me to say, because I would never have
  22     said to her, "Do you find him frustrating?"
  23   Q. I have found the reference, UBHT 38/134 ...
  24     15th February 1996, cardiac services directorate
  25     away-day. If we look over the page to the list of

   1     copies, you are at the top of the list?
   2   A. Yes.
   3   Q. Is that the one you are referring to?
   4   A. Yes.
   5   Q. That is actually after Dr Roylance had left?
   6   A. Yes, it was.
   7   Q. We see Hugh Ross is the second person on the list.
   8        To what extent are you able to comment on
   9     Dr Roylance's accessibility or attitude towards General
  10     Managers who were medically trained on the one hand and
  11     those who were not on the other?
  12   A. I think my experience of Dr Roylance was that the bottom
  13     line at UBHT for any manager was competence. What he
  14     valued was competence, first, foremost, bottom line,
  15     however you want to define that. There were a number of
  16     people who had moved from clinical posts to become
  17     General Managers and there were a number of people who
  18     had not. I think that was fine. I think it was how
  19     good you were at what you did which was most important,
  20     or seemed to be to me. I can only speak for myself.
  21   Q. Of course. In your statement at paragraph 2.7,
  22     WIT 171/6, you say:
  23        "From a series of away-days with the Trust Board,
  24     three key areas were identified as central to the
  25     Trust."

   1        The first of those was delivery of service to
   2     patients within the resource envelope allocated?
   3   A. Yes.
   4   Q. That would apply to any Trust, would it not?
   5   A. Yes. But I think perhaps the underlying issue there is
   6     about -- it might apply to any Trust, but I think when
   7     you have a large academic Trust, which I tried to point
   8     out earlier, has immense pressures on innovation and
   9     professoriat, and all these other things, I think the
  10     way one does that may be very different in different
  11     Trusts, so I think the sentence belies a lot of things;
  12     it is a bit like the iceberg, something which belies an
  13     awful lot of discussion and views about what goes on
  14     around that.
  15   Q. So would it be fair to say that those coming from
  16     a university background would have other priorities of
  17     research and innovation, and Dr Roylance's was that the
  18     focus should be on the patient actually receiving the
  19     service?
  20   A. I think his accent was on actually enabling that tension
  21     to co-exist, because he had always seen himself very
  22     much as a teacher, was absolutely wedded to the
  23     commitment of development and therefore what he wanted
  24     to ensure was that unlike a district general hospital,
  25     UBHT should be actually at the forefront of changing

   1     services and encouraging people to question their
   2     practises but not overspend.
   3   Q. I am just trying to explore the "iceberg" a bit. It is
   4     not "above the waterline" in your statement.
   5        The first bullet point there, as I understand your
   6     evidence, is getting at that there is a tension, perhaps
   7     a healthy tension, between delivery of service to
   8     patients who are the consumers of the health care
   9     provided on the one hand, and other people involved in
  10     the Health Service at the UBHT, for example, from the
  11     University, whose priorities might lie not exclusively
  12     within patient care, but in research, innovation,
  13     development and so on?
  14   A. Which ultimately should lead to the benefits of
  15     patients, yes, so it depends how you define patient
  16     care, because it is the immediate rather than the longer
  17     term, is it not?
  18   Q. But Dr Roylance was anxious, was he, to keep the focus
  19     not on innovation for innovation's sake, or research for
  20     research's sake, but on the delivery of service to
  21     patients?
  22   A. I think that is a singularly unhelpful distinction you
  23     have drawn that I have not.
  24   Q. Thank you. Well, disagree with me.
  25   A. I am. I am trying to do it as politely as possible.

   1     I think that Dr Roylance was committed to patient care
   2     at the forefront and that was always at the centre of
   3     everything in the Trust and therefore, you know, what
   4     was the impact on patients was something which was said
   5     with monotonous regularity until it drove people crazy,
   6     but I also think that in terms of delivery of service to
   7     patients within the resource envelope, there was
   8     obviously a declining unit of resource and the
   9     purchasers in Bristol were having to sustain through the
  10     Trusts which was, you know, there was one key purchaser,
  11     so they are having to sustain three Trusts, one which
  12     had a postgraduate centre, one which had particular
  13     specialties, and UBHT, which had the University kind of
  14     attached to it.
  15        So I think there was an enormous amount of issues
  16     about how can we deliver good quality services whilst
  17     constantly cutting the cost and those issues are very
  18     similar to those we have in education. So I was quite
  19     interested in the different devices that people would
  20     use to try and change delivery patterns and so on and so
  21     forth.
  22        So I think that is what it is about: it is about
  23     how do we continue to innovate, how do we introduce
  24     service change?
  25   Q. Do you remember I asked you a minute ago about General

   1     Managers with medical background and General Managers
   2     without medical background in the context of
   3     Dr Roylance's attitude.
   4   A. Yes.
   5   Q. What about the Clinical Directors: to what extent did
   6     they value differently a General Manager with a clinical
   7     or medical background compared to one without such
   8     a background?
   9   A. I prefer the term "clinical background" because I do not
  10     think they had medical backgrounds in that sense, but
  11     from my experience, there was absolutely no difference.
  12     What they were interested in was forming a good
  13     collegial working relationship with whoever their
  14     General Manager was, because again they were
  15     a co-support group and neither could exist without the
  16     other. Good working relationships were terribly
  17     important.
  18   Q. Can I take you to WIT 171/66, your feedback paper. The
  19     bottom of the page:
  20        "The strategy of employing fellow professionals".
  21        Pausing there, what does that phrase mean that you
  22     put in inverted commas?
  23   A. It means people who have a professional background and
  24     come from a professional culture.
  25   Q. Which profession?

   1   A. Managerial.
   2   Q. Does it not mean the medical profession?
   3   A. No, one can be in quite different professions. One can
   4     be in the body of a profession. If I asked you, you can
   5     be a psychotherapist, or an accountant, even.
   6   Q. The distinction drawn in this paragraph is between
   7     professionals on the one hand and pure managers on the
   8     other; is that right?
   9   A. Yes.
  10   Q. So the pure manager might be a graduate of something
  11     else?
  12   A. Business studies?
  13   Q. Politics or economics?
  14   A. Absolutely.
  15   Q. They would be a pure manager?
  16   A. But pure managers also in this context are about people
  17     who are operating entirely as managers all day, every
  18     day.
  19   Q. Let us just look at the rest of the page:
  20        "Directorate General Managers who were
  21     specifically qualified in an area directly related to
  22     the directorate were most highly valued and seen as part
  23     of the team rather than simply managers."
  24   A. Yes.
  25   Q. Then there are two quotations. The second one:

   1        "It's important that the DGM has an NHS
   2     background. You have got to understand the process and
   3     the outputs. Our DGM is a qualified X, so although he
   4     is a manager, he is one of us."
   5   A. Yes.
   6   Q. So that is a Clinical Director saying that to you?
   7   A. Yes.
   8   Q. That Clinical Director is saying that he or she values
   9     a directorate General Manager with an NHS background
  10     more highly than a directorate General Manager without
  11     that background?
  12   A. Yes.
  13   Q. To what extent was that the general view of the Clinical
  14     Directors?
  15   A. I am not sure I can generalise.
  16   Q. Why not? You spoke to all the Clinical Directors.
  17   A. I think that in some specialties, that individuals did
  18     find it valuable. I think that is absolutely true.
  19   Q. Which specialties?
  20   A. I would not be able to recall from this because most of
  21     these things are done to maintain confidentiality.
  22   Q. Would it be fair or unfair to say that doctors,
  23     consultants, found it much easier to relate to people
  24     who had an NHS background than people who did not,
  25     because they saw such people as "one of us"?

   1   A. I think that is probably the case, yes, although I did
   2     not find any difficulty in relating to a number of
   3     clinicians, and I am the antithesis of that. So I think
   4     how it means "relating". I think, if we look at the
   5     findings here, I think in some instances, yes, that is
   6     what they are saying.
   7   Q. We have already, I think, discussed -- tell me if this
   8     is an unfair characterisation -- that the Clinical
   9     Directors saw Dr Roylance, because of his clinical
  10     background, as "one of us" as well?
  11   A. Yes, because of his medical background, yes.
  12   Q. So to what extent would it be fair or understandable for
  13     the consultants to expect Dr Roylance himself to take
  14     the same view of directorate General Managers with an
  15     NHS background as compared to those without, as is
  16     expressed at the bottom of that page?
  17   A. As far as I can replicate, I think Dr Roylance's view --
  18     and therefore this is my view of his view, if you
  19     understand the difference, which is enormous, which is
  20     quite important. I think his view of valuing the
  21     profession and the professional kind of culture, what he
  22     was trying to do was to develop people with clinical
  23     backgrounds into General Managers, and I think a number
  24     of those also had MBAs, diplomacy in management and so
  25     on and so forth, and I think, again, for a lot of people

   1     who were nurses, there was no possibility of advancement
   2     other than going into management any more, because those
   3     avenues were closed off to them.
   4        So I think that in that sense, it was perceived
   5     as, if you like, more desirable but I do not think there
   6     was any discrimination against people who did not have
   7     clinical backgrounds if they were good at what they
   8     did. Does that help?
   9   Q. Yes. How would you characterise the support that was
  10     given to Clinical Directors to support them in their
  11     transition from consultant simpliciter to Clinical
  12     Director?
  13   A. I think probably very mixed and I think one of the
  14     reasons why I wanted to do this research was to try and
  15     get a better picture, the totality. So in part, that
  16     was my kind of agenda, because having talked to them
  17     quite a lot and having been to a lot of their meetings
  18     and things, I was interested to know a lot more about
  19     it.
  20   Q. How would you characterise the amount of support given?
  21     Was there a lot of support, a little support?
  22   A. I think in some senses there was a lot of kind of
  23     structural support, because they had usually very
  24     competent and able directorate General Managers who,
  25     however they were chosen, seemed to be chosen very

   1     carefully. They also had finance people who were
   2     allocated to their directorate; they also had personnel
   3     people to pick up things and in large directorates there
   4     were a whole host of kind of associate people also in
   5     post.
   6        So I think there was that. I think they also,
   7     I think for a while, ran a series of workshops, so they
   8     did things like away-days when things were discussed and
   9     people were trying to identify issues relating to the
  10     role of Clinical Director and they also ran, I think,
  11     a series of in-house workshops to give people an idea of
  12     the context of the NHS, the changing NHS, financing,
  13     strategy, and I think personnel, three or four other
  14     things, which were, I think -- I am not sure who
  15     designed those. There were some discussions about
  16     that. I think they had people like the Director of
  17     Finance and Personnel and so on and so forth. So
  18     I think there were these kind of workshops which were
  19     run for their benefit. And I think, remember, everyone
  20     was still on a terribly steep learning curve at this
  21     point.
  22   Q. Much of your research was written up into those
  23     published papers that we saw, was it not?
  24   A. Yes.
  25   Q. Can we go to WIT 171/25? That is the first page of the

   1     paper published in the Health Service Management
   2     Research in 1997. Can we go to page 32? On the
   3     left-hand side, this is under the general heading of
   4     "Ambiguity". If we can go back one page to pick up the
   5     context, back to 31, the right-hand side, the bottom of
   6     the column:
   7        "Part of the stress of becoming a Clinical
   8     Director was induced by the ambiguous nature of the role
   9     and the lack of preparation provided to undertake it.
  10     The role was primarily seen as that of a part-time
  11     General Manager ... but the combination of
  12     decentralisation and the personalistic professional
  13     culture meant that it was interpreted and executed
  14     differently ...
  15        "Although being trusted and left alone to get on
  16     with it was important, the lack of structured feedback
  17     on their performance from the executives created
  18     a vacuum. Existing organisational measures of financial
  19     and contractual performance were seen as too simple and
  20     too narrow to capture the complexity of the role.
  21     Ambiguity was heightened by the uncertainty in the
  22     external environment ..."
  23        Was that vacuum something which, in your opinion,
  24     ought to have been filled or left unfilled?
  25   A. I think in talking to the Clinical Directors -- I think

   1     it is in the other paper, the feedback paper -- I think
   2     they were kind of "monitored" in inverted commas by the
   3     Director of Operations the Director of Finance and
   4     Dr Roylance. They looked at the kind of variety of
   5     performance indicators and went to see them, I think,
   6     I do not know, annually, I think, because in a sense
   7     what a lot of the Clinical Directors wanted to know is
   8     "How am I doing?"
   9   Q. Can I stop you there? The reference to "vacuum": that
  10     is your word in your paper.
  11   A. Yes.
  12   Q. So it was your judgment that there was a vacuum; is that
  13     right, or are you reflecting the Clinical Directors'
  14     views that there was a vacuum?
  15   A. I am reflecting the Clinical Directors' view. In their
  16     view, there was a lack of structured feedback because
  17     what they wanted to know was "How am I doing" and a lot
  18     of what they were doing was by critical incident.
  19   Q. Would it have been helpful for the Clinical Directors to
  20     have felt that there was not such a vacuum?
  21   A. I think possibly so.
  22   Q. How could that perception that they had of there being
  23     a vacuum have been filled?
  24   A. I think it is very difficult for me to answer that,
  25     because I think I could say, well, perhaps they should

   1     have had six monthly review meetings. I think also, it
   2     goes back to their own nervousness and personal
   3     insecurities which I am not making light of in any way.
   4     I think they were terribly genuine, because they were
   5     terribly committed. But I also feel that, you know, one
   6     often likes to have feedback and sometimes even quite
   7     negative feedback is better than less feedback.
   8   Q. What structured feedback, if any, could have been given
   9     that was not given?
  10   A. I do not know, because I was not present at the feedback
  11     meetings that they did have, so -- I am thinking very
  12     carefully -- therefore it is very difficult for me to
  13     say. I am not sure I can answer that honestly, so
  14     I would rather not answer it.
  15   Q. Let us look further down the page under the heading
  16     "Life after the role?" You say:
  17        "Even those relieved to give up the role [of
  18     Clinical Director] felt that the return to purely
  19     professional work would be a very difficult adjustment.
  20     Everyone valued being in the centre of things and taking
  21     a wider view of the organisation and health care
  22     issues. Unfortunately, little support was available to
  23     handle the transition or to make further use of their
  24     expertise. In the absence of any guidance, former
  25     Clinical Directors felt it was best to opt out, knowing

   1     that it would make them much better consultants in
   2     future."
   3        Opt out of what?
   4   A. "Meddling", I think, would be their expression. If you
   5     have a post where -- I am head of school at the moment,
   6     for instance, just like a Clinical Director but in
   7     a much smaller way and I think there is nothing worse
   8     than having somebody who has done the role telling you
   9     how to do the role your way. But I think from the paper
  10     and one of the things in my feedback to the organisation
  11     was that they needed to take care of succession
  12     management, and this I believe they did in a much more
  13     structured way latterly. So people who were in some of
  14     the larger directorates, I think associate directors,
  15     were almost groomed into the role which was a very
  16     different thing, but for people who come first there is
  17     no opportunity to do that because there is no-one ahead
  18     of you.
  19   Q. Let us look at your conclusions which start in the
  20     right-hand column. I want you to go over the page to
  21     the left-hand column, page 33. In the first main
  22     paragraph on that page you say:
  23        "Using any objective data for evaluation, the
  24     Trust adopted here [the UBHT] would be regarded as
  25     efficient, effective and innovative."

   1   A. Yes.
   2   Q. In what way was it innovative?
   3   A. I think in an inordinate number of ways, even quite
   4     small ways, I think. If I give one small example from
   5     the managers' point of view, in one of the exercises
   6     that we did in the management development group, it was
   7     actually about innovation so people went off and looked
   8     at the organisation and looked at all the kinds of
   9     things they could do differently to improve one aspect
  10     of patient care, for example.
  11   Q. Being innovative suggests being the first to try
  12     something?
  13   A. Yes, or to do something differently, so you may do
  14     something new, but you may do something you have done
  15     before differently, which may be a form of development
  16     people often class as innovation.
  17   Q. Was the way in which the Clinical Directors were given
  18     such scope as they were to control events within their
  19     own "box", was that one of the ways in which UBHT was
  20     innovative, compared to other Trusts?
  21   A. I think so, yes.
  22   Q. So was the degree of decentralisation of power, if that
  23     is the right word, to the Clinical Directors, something
  24     that was innovative at UBHT compared with the other
  25     Trusts?

   1   A. I think it was innovative, but a lot of people were
   2     innovating in the same way. I think that you have to be
   3     quite careful, because other people were innovating and
   4     giving away lots of things to managers rather than
   5     clinicians.
   6   Q. What about the oral culture of Dr Roylance, the way in
   7     which he reacted and interacted with his Clinical
   8     Directors by discussing things with them: was that
   9     something that was innovative at UBHT compared to other
  10     Trusts?
  11   A. Good heavens, no. It is breathing to Chief Executives
  12     to talk to people. That is almost the senior manager's
  13     role. I do not know many Chief Executives or senior
  14     managers who write a lot, because they spent a lot of
  15     their time talking. The saying is they kind of employ
  16     people to do things like that for them, they do not have
  17     time. That is not their role. Their role is to be
  18     symbolic, their role is to represent an ethos and
  19     provide leadership. Leaders do not do very often a lot
  20     of writing.
  21   Q. Let us look in the left-hand column. Do you see, about
  22     five lines into that first new paragraph:
  23        "While the introduction of Clinical Directors has
  24     played a major part in both leading and implementing the
  25     changes required to deliver more efficient and effective

   1     health care, little attention has been paid to the
   2     personal costs for those involved."
   3   A. I am sorry, can you tell me where that is? I cannot
   4     find it.
   5   Q. It is here (indicating). What is the basis for the
   6     suggestion that there was being delivered more efficient
   7     and effective health care?
   8   A. I think the kind of performance indicators that are used
   9     nationally in terms of the allocation of resources is an
  10     indication of efficiency.
  11   Q. What about "effective"?
  12   A. I think effectiveness is often very difficult to
  13     measure, but this was a Trust with a Charter Mark; it
  14     was a Trust which had set its store out, being
  15     relatively effective -- there was no evidence to suggest
  16     it was not.
  17   Q. The next couple of sentences:
  18        "Little attention has been paid to the personal
  19     cost for those involved. This research demonstrates
  20     that being a Clinical Director is a role that
  21     potentially threatens the professional identity,
  22     collegiality and autonomy of both the individual
  23     director and the group that he or she represents."
  24        Then we see what you say further down. Then:
  25        "Furthermore, the only people capable of executing

   1     the role are those already in demand because of their
   2     professional skills and competence. If the role were
   3     a substance, it would carry a government health
   4     warning."
   5        To what extent, in your opinion, did these people
   6     already in demand taking on this role affect not only
   7     themselves but the patients they treated?
   8   A. I think one of the things that came across, really very
   9     forcibly, was that Clinical Directors' views of the way
  10     in which it affected patients was extremely positively.
  11     This was at two levels, if you will give me just
  12     a couple of minutes to explain what I mean.
  13        The first level was because a lot of people who
  14     were keen to innovate -- because there are some
  15     criticisms of the medical profession being rather
  16     conservative, with a small 'c', if not a little
  17     intransigent, and therefore the ability to actually, if
  18     you like, look strategically across a range of services
  19     that you were providing and to be able to negotiate with
  20     purchasers to actually do things differently and work
  21     with colleagues to enable that to happen, for the
  22     benefit of patients, although it would not mean directly
  23     treating someone, doctors very quickly realise that
  24     improving patient care is not just a matter of their
  25     professional hands-on; it is about being able to do

   1     things differently. So I think that is the first
   2     thing.
   3        I think the second thing is that they learn such
   4     an enormous amount, and everyone said to me, even after
   5     they had stopped being a Clinical Director, that their
   6     mindset had changed quite dramatically, so they
   7     understood more about resources, they understood more
   8     about the context of the NHS, more about purchasers'
   9     needs, and much more about their colleagues.
  10   Q. Pause there --
  11   A. So it enhanced and enriched their kind of personal
  12     experience, even if it had been absolute hell.
  13   Q. I understand that being Clinical Director would mean
  14     that one would pick up a lot of knowledge about matters
  15     that one would not have had before.
  16   A. Yes.
  17   Q. Which would be enriching and one could carry forward
  18     into the future of one's career. But what about the
  19     "absolute hell" bit you are just referring to? While
  20     somebody was a Clinical Director, and suffering from the
  21     stress and the overload that you have referred to in
  22     several of these papers, to what extent did that, as far
  23     as you were aware, impact upon the Clinical Directors'
  24     care of their patients while they were Clinical
  25     Directors, while that you were under this stress?

   1   A. Actually, I do not think it did. I think that is
   2     probably why they were under stress, because they were
   3     devoting 50 per cent, 50 per cent, 50 per cent, to
   4     things. So, you know, I am not equipped to make any
   5     kind of clinical comment about that because obviously
   6     I am not medically trained and qualified.
   7        But in my discussions with them, I think one of
   8     the things that they were very clear about was that --
   9     I think if you look at the next paragraph, the kind of
  10     macho workaholic culture was very much -- it is a bit
  11     like talking about junior doctors' hours: there is this
  12     macho thing that everyone works and works and works, and
  13     that is the nature of the organisation.
  14   Q. Is that something you think is sustainable, that lots of
  15     workaholic Clinical Directors under stress and overload
  16     can sustain indefinitely?
  17   A. If you ask my view, I think it is an enormous problem,
  18     because I think you need the very best people to do
  19     these jobs, and as I said earlier, these are the people
  20     writing the papers, these are the people who are going
  21     to have the respect of their colleagues, and I think the
  22     paradox --
  23   Q. Is that a "No" or a "Yes"?
  24   A. Well, I think the paradox is, what is the government to
  25     do in terms of funding it? I think that is what I say

   1     in my paper, because I believe that the Clinical
   2     Director is the right person to lead the service because
   3     they understand the nature of the service they are
   4     leading. Therefore, if you asked me who I would want to
   5     lead a service, then I would suggest that the
   6     professionals have inordinate knowledge and expertise
   7     which should be used profitably to benefit patients.
   8        So I do not have a slick, simple answer, I am
   9     afraid.
  10   Q. In your opinion, was the position of these Clinical
  11     Directors with the stresses that you have found,
  12     sustainable or unsustainable?
  13   A. I think they were sustaining it, so I cannot say
  14     anything else.
  15   Q. Indefinitely?
  16   A. Well, it was not an indefinite role, it was two years or
  17     three years, so I do not think it was indefinite.
  18     I think people had a steep curve in, perhaps a better
  19     middle and by that time the light was at the end of the
  20     tunnel.
  21   Q. Let us look, in drawing some threads together, to the
  22     paper you produced in June 1992, UBHT 296/1. This is
  23     your document headed "Cultural analysis of the UBHT".
  24     Can you outline for me briefly what the context of this
  25     document was?

   1   A. The context of this document was that I had spent some
   2     time around the organisation and I had interviewed all
   3     of the executive directors, and this was what we call
   4     a kind of "mirroring" document, so it is what you use to
   5     kind of begin to elicit feedback from the group about
   6     what is happening, and to give some views.
   7        A lot of it is in a sense shorthand, because as
   8     a cultural analyst, part of what you need to do is to
   9     reveal you actually understand the culture yourself.
  10   Q. So this is your reflection on your experience, to serve
  11     as a discussion paper to take things forward?
  12   A. To discuss it and to hold bits up to the organisation.
  13     Again it is a kind of what researchers call
  14     "validation", so just as the other paper was about
  15     presenting it to Clinical Directors and managers as
  16     a form of cross-validation having done to work to enable
  17     them to comment on it and then use that feedback in
  18     writing something up for publication, this was used as
  19     a kind of working document.
  20   Q. Let us look at a bit of it. In that first page, under
  21     the heading "Introduction", the first paragraph under
  22     there, the third line:
  23        "Firstly, the organisation at Executive Director
  24     level is primarily an oral culture. Consequently to
  25     produce great reams of written material at this stage is

   1     counter-cultural. The counter-cultural nature of that
   2     material would give it greater meaning and
   3     "embeddedness" than I might want to convey. At UBHT,
   4     if it is written down, it is either very important or
   5     ignored."
   6        Then you divide, do you not, the period that you
   7     have been involved in into four separate sections.
   8   A. Yes.
   9   Q. If we go over the page to page 2 --
  10   A. Is this the "Cloudy vision" bit?
  11   Q. Yes. "Coming into being - a cloudy vision". If we go
  12     down the page, we see what is said there. Then "Era 2,
  13     Resistance and Dissolution".
  14        "A full provider role and shadow contracting with
  15     the purchasers was overshadowed by the appointment of
  16     the new Chairman of the DHA."
  17        Who was that?
  18   A. I think it was a man in cement or gravel or something.
  19     Was it Mr Mortimer?
  20   Q. Mr Mortimer, who replaced Mr Durie?
  21   A. Yes.
  22   Q. Mr Durie was opting out for a year while the Trust
  23     application was made.
  24        "Whilst the Trust application was formally
  25     submitted, this was the key period for consultation and

   1     an unexpected era of resistance - BMA, politicians
   2     (Labour Party members on the DHA raised the profile of
   3     resistance). Insecurity and anxiety increased but
   4     solidarity of the Trust group was reinforced by
   5     identifying a common enemy."
   6        Who was the "common enemy"?
   7   A. The "common enemy" I suppose were the resisters, because
   8     my understanding was that the idea had been started that
   9     they would go for Trust status and this was supported
  10     I think by the Chairman and the Regional Head of the
  11     South West Regional Health Authority, and therefore
  12     people were trying to go ahead with this, and I think it
  13     was something to do with the ethos of the teaching
  14     hospital that if there were going to be Trusts, then
  15     a teaching hospital should go first. We are back into
  16     the culture of innovation.
  17   Q. So Dr Roylance and the shadow team saw people like
  18     Mr Mortimer as being the enemy, did they?
  19   A. Yes. This is written to be kind of provocative and
  20     colloquial, so, yes.
  21   Q. And then we see from the next paragraph that in
  22     September 1990, when Mr Mortimer resigned, that eased
  23     things a bit?
  24   A. Because I think the feeling was that they were trying to
  25     invest an awful lot of effort and energy into this and

   1     the necessity to get things up and going was actually
   2     being deflected. So a lot of it was about workload. It
   3     was a very, very difficult period as I recall, because
   4     people were doing two or three things simultaneously.
   5     Everybody had multiple roles and it was very, very
   6     complex.
   7   Q. Over the page, at page 3, you start to identify the
   8     culture of the Trust as you were reflecting it, as you
   9     saw it. We see from the first paragraph that your
  10     methods had included in-depth interviews with all
  11     members of the group.
  12        That is the executive group, is it not?
  13   A. Yes.
  14   Q. You say at the end of that paragraph you wanted to add
  15     some small insights and draw attention to some areas
  16     where you were confused?
  17   A. Yes.
  18   Q. In the next paragraph you refer to output is an
  19     important means of understanding performance and runs
  20     counter to many process orientated organisations. This
  21     is also an oral culture and enables people to act at
  22     speed and provides a flexible interpretation of what did
  23     or should happen. There is a dislike of certainty and
  24     prescription.
  25        Does a dislike of certainty imply a like of

   1     uncertainty?
   2   A. Not necessarily.
   3   Q. What was the "certainty" that was disliked?
   4   A. I think it was a bit like, if I can -- I may have to use
   5     my hands here, so I apologise. It is a bit like a lot
   6     of my work has been done on managing change, and so most
   7     organisations that I go into are in a period of change,
   8     transition or whatever, often induced by the external
   9     environment, so not necessarily wonderfully welcomed.
  10        But I think one of the issues was, as this was
  11     coming about, there was no notion that they wanted to
  12     say, "This is how the organisation is now, it is going
  13     to that, and then it is going to be terribly certain and
  14     stable", because there was a notion that it was going to
  15     be repeatedly moving and shifting. At that stage, they
  16     did not necessarily know how or where so the important
  17     thing was to get people to accept that a degree of
  18     uncertainty is inevitable and to cope with uncertainty.
  19        Gone are the days where any manager in any
  20     organisation now wants to enable people to change from
  21     one thing to another; it is actually about helping and
  22     supporting the team to cope with this uncertainty which
  23     is almost pandemic in organisations.
  24   Q. One of the consequences of the oral culture was that
  25     although the executive directors might have an idea of

   1     what had been said and what decisions had been taken,
   2     people at a lower level had difficulty in remembering or
   3     interpreting what had been decided; is that right?
   4   A. Yes. That is what I am saying.
   5   Q. Then if we go over the page again, to the third
   6     paragraph there, you refer to the "family" or "club" of
   7     the UBHT.
   8   A. Yes.
   9   Q. You are either a UBHT type of person or you are not. So
  10     people who fit may do very well and progress rapidly.
  11     Those who do not, either move sideways down or out. Who
  12     would be responsible for moving people down, sideways or
  13     out?
  14   A. I am sorry, did you say who would be?
  15   Q. Yes.
  16   A. Presumably members in the Executive.
  17   Q. The Board?
  18   A. Well, I would have thought the executive directors,
  19     yes.
  20   Q. Are you able to help us with whether the family or club
  21     culture of the Trust as you saw it was something that
  22     was special to this Trust, or was that something which
  23     was replicated in other organisations elsewhere?
  24   A. I think it is replicated almost everywhere. I think the
  25     important thing to remember is that if you take

   1     something -- and this is taken from the work of Charles
   2     Handy. I know you are family with this, because of
   3     earlier evidence. I think if you take his kind of
   4     models, this is just one perspective, so you could have
   5     looked at this and taken the perspective roles. I could
   6     have said these are the roles of the group, but
   7     actually, at this level, having a club is not at all
   8     unusual because people need to fit, they need to be able
   9     to work together and millions of pounds are spent every
  10     year on team-building exercises all over the country,
  11     all over the world, as we sit, to actually generate
  12     a kind of team-based spirit.
  13   Q. Somebody who took a contrary view, who might be
  14     colloquially referred to as somebody who is "rocking the
  15     boat": would that be seen as an indication that one was
  16     not a UBHT type of person?
  17   A. No, because one of John Roylance's favourite things was
  18     actually turning the boat upside down, which is what
  19     caused immense frustration and unhappiness for people.
  20   Q. Did that not mean that everybody fell out?
  21   A. It depends if you were strapped in or if you were
  22     actually averse to swimming. Of course that was one of
  23     the tests so you had to be very careful about the notion
  24     of "club". I gave some supporting evidence to say clubs
  25     are not necessarily terribly cosy places. They may be

   1     a refuge, an area where people misunderstand each other,
   2     but it does not mean there is discord and conflict. The
   3     generation of conflict can be a very productive thing.
   4     I am amazed by how many organisations I go in who say
   5     "We have conflict, eradicate it". It is nonsense.
   6     Conflict can be a very productive thing.
   7   Q. What if one clinician expressed a view about another
   8     clinician's performance which was hostile and adverse:
   9     how would that have been treated inside the club?
  10   A. I have no idea. I am talking about the executive
  11     directors here.
  12   Q. How would the executive directors have reacted to one
  13     clinician suggesting that another clinician was not up
  14     to the job?
  15   A. I have absolutely no idea. You would have to ask them
  16     that.
  17   Q. To what extent was loyalty to the club important?
  18   A. I think it was important, because if I give an example,
  19     a number of chief executives I work with in the private
  20     sector would say that loyalty is the one thing that they
  21     crave, because money cannot buy it. It gives you often
  22     a level of commitment which far exceeds any role or job
  23     description because people are kind of motivated and
  24     committed.
  25   Q. Dr Roylance: what was his attitude to demanding or not

   1     demanding, requiring loyalty to him from the Executive
   2     Directors and the Clinical Directors?
   3   A. As any good Chief Executive would, I think, he would
   4     expect that when a decision had been made, perhaps at
   5     Board level, that indeed executives would support that
   6     publicly. I do not know any Chief Executives that would
   7     not expect that degree of loyalty amongst the team,
   8     because otherwise, you know, the whole place goes
   9     haywire.
  10   Q. What type of disloyalty are you referring to in the
  11     last line of that paragraph?
  12   A. Perhaps exactly that sort of thing, so, you know, if
  13     something has been agreed and the team have said, "Well,
  14     this will be our strategy" or "This is the vision", then
  15     if someone goes around trying to undermine that, I think
  16     that will be destructive and counter-productive because
  17     it is a very difficult job. I think being a Chief
  18     Executive of any organisation, I think to be undermined
  19     by one's own team is really not terribly acceptable.
  20   Q. Do you see in the middle of that paragraph the sentence
  21     beginning:
  22        "On the one hand there is a view ..."
  23   A. Yes, thank you. This pen is wonderful, thank you.
  24   Q. Then there is a quotation, "People have to change
  25     themselves", and so on. Whose quotation is that?

   1   A. I cannot say.
   2   Q. Because you cannot remember?
   3   A. I honestly cannot remember, but one of the most --
   4   Q. It must be somebody from the executive group?
   5   A. It would be.
   6   Q. That narrows it down a little?
   7   A. Absolutely. It could be one of five.
   8   Q. Would that be a view you would have thought would be
   9     shared by all of the executive group?
  10   A. Which bit are you asking me about? That people have to
  11     change themselves?
  12   Q. Yes.
  13   A. I think that would be quite commonly shared and that
  14     is why it is put here, to provoke people.
  15   Q. We know that the Clinical Directors did not have job
  16     descriptions, formal job descriptions?
  17   A. Not to my knowledge.
  18   Q. Or General Managers, as far as you were aware?
  19   A. I do not know. I think General Managers were really
  20     quite different beings. They had all sorts of things,
  21     IPRs and interviews and goodness knows what.
  22   Q. To what extent do you consider job descriptions to be
  23     important for Clinical Directors on the one hand and
  24     General Managers on the other?
  25   A. I think it very much depends what you want to do with

   1     them. I come from a professional organisation where we
   2     have in effect job descriptions for people which are
   3     very rarely enacted in the form in which they are
   4     written, so I think job descriptions may be helpful for
   5     some people who feel they need some clarity and
   6     structure. I think other people may find them
   7     inhibiting.
   8   Q. You sent a letter to Hempsons last year?
   9   A. Yes.
  10   Q. WIT 171/109: have you seen that letter recently?
  11   A. I cannot say I have seen it recently, but I will
  12     probably recall it if you put it up.
  13   Q. Are you still of the view vis-a-vis Dr Roylance now
  14     that you were then, when you wrote that letter?
  15   A. More than likely, because I would have written it in
  16     kind of all honesty, so ...
  17   Q. Would you give me one moment? (Pause). When I asked
  18     you about loyalty a moment ago, you explained to me that
  19     Dr Roylance would expect when the Board made a decision
  20     that people would abide by it?
  21   A. Yes, I think so.
  22   Q. Sort of like cabinet collective responsibility: one can
  23     have a debate around the table, but once the decision
  24     has been made, everyone falls in line?
  25   A. Yes, I think so.

   1   Q. Is that what you mean by "loyalty" in that paper? That
   2     is the kind of essence of loyalty as you were describing
   3     it?
   4   A. Yes, I think so.
   5   Q. Was there any wider concept of, for example,
   6     professional views, not about policy decisions by the
   7     Board, but if one clinician had an adverse view of
   8     another clinician's competence and said so publicly, or
   9     in a meeting of the Trust, would that be seen as
  10     disloyal to the Trust?
  11   A. I have no idea because I have never experienced that.
  12   Q. Would that be seen as breaking the rules of the club?
  13   A. Not of the club I am talking about because as I said
  14     earlier, I was producing that paper strictly for the
  15     executives who are non-medics.
  16   Q. So they are the "club" that you are referring to?
  17   A. Yes, so I did not include clinicians in that at all;
  18     that was quite a separate thing.
  19   Q. Thank you very much, Dr Thorne. That is all I want to
  20     ask you. Before we go any further, is there anything
  21     that you want to say arising out of any of the questions
  22     I have asked or any of your answers, or arising from
  23     anywhere else?
  24   A. No, other than to say that I think my experience of
  25     UBHT, watching it go from a District Health Authority

   1     into a Trust was a very unusual one and I felt very
   2     privileged about that, but I do think it is an
   3     incredibly complex issue and I think sometimes in trying
   4     to simplify it, it reduces it to something which does
   5     not adequately reflect the reality that certainly
   6     I experienced there, in terms of people having multiple
   7     roles, et cetera, so I just hope I have been some use to
   8     the Inquiry in what I have had to say.
   9   MR MACLEAN: Would you just excuse us for a moment, while we
  10     shuffle some papers? (Pause). I mentioned Mrs Ferris
  11     earlier, do you remember?
  12   A. Yes, I am sorry.
  13   Q. Can we have WIT 89/25, please?
  14   A. So you have not finished?
  15   Q. It appears not, I am sorry. Can we have WIT 89/25,
  16     paragraph 63? This is Mrs Ferris's statement. You see
  17     what she says. (Pause).
  18   A. All right.
  19   Q. Are you in a position to comment as to whether or not
  20     those involved in the Trust that you talked to perceived
  21     it to be a "culture of fear and blame" under
  22     Dr Roylance's Chief Executive-ship?
  23   A. I think that, as I read this paragraph, I mean, I come
  24     from the school of what we call "alternative
  25     management", which means that you have to deal with

   1     things as they are, not as one would like them to be,
   2     and therefore, if I read the statement, I am sure that
   3     this is the way that Mrs Ferris felt and therefore
   4     I could not deny everyone else's feelings. But if you
   5     asked me --
   6   Q. Forget about Mrs Ferris.
   7   A. I am just reading the top part of it. You asked me
   8     about, if there was a culture of fear and blame. My
   9     experience was that the culture was exactly trying to
  10     avoid fear and blame and a lot of the work that I did,
  11     particularly with the management development group, was
  12     to encourage them to actually be more open and honest
  13     about any mistakes that they made.
  14   Q. I understand it was not the object to create that
  15     culture of fear and blame; that would be perhaps
  16     slightly odd. What I am driving at is whether or not --
  17   A. No, some places actually thrive on it. It drives
  18     people.
  19   Q. What I am driving at is whether or not this view, which
  20     is Mrs Ferris's view, was a view you heard from other
  21     people you spoke to at the Trust?
  22   A. No, I can be quite clear about that: not in my
  23     experience.
  24   Q. So this view of the culture of the Trust is not one that
  25     you recognised from elsewhere?

   1   A. No. It could be quite a fun place, actually.
   2   Q. Mrs Ferris said there was a type of culture where people
   3     did not want to report things and not to address them
   4     because they were frightened of the response that it
   5     might bring.
   6        Again, is that something that was said to you or
   7     reflected to you?
   8   A. No. I mean, actually sometimes it was quite the
   9     reverse. It is interesting, because if I may just very
  10     briefly draw the parallel between the Clinical
  11     Directors' findings about vulnerability, I think one of
  12     the things, in talking to Dr Roylance about what should
  13     be encouraged with the management and the management
  14     development group was because people were often
  15     uncertain, I think it was about trying to encourage
  16     people to express their vulnerability. I think one of
  17     the papers that I submitted where I talked about the
  18     management development group that talked about
  19     flattening the hierarchy and indeed, Mrs Maisey and
  20     Mr Boardman both talked about the uncertainty and the
  21     problems they had found in changing their role, that was
  22     to encourage more junior managers to actually admit this
  23     when they had problems. The artistry and the culture
  24     was always, if you had a problem, say so very quickly,
  25     do not leave it festering. That was my experience.

   1     Because the thing was, if it was left too long, then it
   2     became problematic.
   3   Q. Now a different point. What was Mrs Maisey's role in
   4     the Trust, so far as you understood it to be?
   5   A. Well, as far as I understood it to be, she was Director
   6     of Operations and sort of Chief Nursing Adviser, in
   7     a professional capacity, which was why she was on the
   8     Board as the chief kind of Nurse Adviser.
   9   Q. As you understood it, what did she actually do? What
  10     was the context of her duties?
  11   A. I think this is where the idea of support came in,
  12     because she had moved from having this enormous kind of
  13     hierarchical management role as a General Manager to
  14     having a Board level role where she was actually
  15     supporting people and fire-fighting, beetling around,
  16     trying to help people, solve problems, identify issues
  17     before they became very problematic, et cetera. I think
  18     that was very much her role, as I understood it, as well
  19     as having a kind of professional line with the nurses,
  20     and she did have specialist meetings from what I can
  21     recall with nurses, but I never attended any of the
  22     professional nurse meetings. That is one thing I did
  23     not go to.
  24   Q. To what extent did she work with Dr Roylance, as you
  25     understood it?

   1   A. I would say quite closely.
   2   Q. More close than the other executive directors?
   3   A. No, I would say Dr Roylance had a very close
   4     relationship with the Director of Personnel because he
   5     saw personnel as the device by which the change in
   6     culture would be implemented, through people.
   7   Q. Are you able to comment from experience of other Trusts
   8     at the same time on the extent to which Mrs Maisey's
   9     role was unusual?
  10   A. No, I think other Trusts had got Directors of
  11     Operations. Each Trust would have a different
  12     constitution, because some Trusts had two finance people
  13     because the Chief Executive was a finance person, so
  14     kind of constituents of them tended to be different.
  15     Some people did not have a Personnel Director. They
  16     might have a Chief Nurse, but might then have somebody
  17     like a Director of Operations, from my experience. I am
  18     desperately trying to recall, to be helpful.
  19   Q. If it was suggested to you that the clinical
  20     directorates were semi-detached, what would your comment
  21     be?
  22   A. From what, would be my initial comment?
  23   Q. Semi-detached from one another, or semi-detached from
  24     the Trust?
  25   A. I find that an interesting remark, because my day-job,

   1     if you like, is as an organisational analyst. So a lot
   2     of stuff is about organisation structure and there is
   3     always an enormous tension between the need to kind of
   4     specialise on the one hand in terms of devolving
   5     structures and the need to integrate on the other, and
   6     from what I could see, the way that was addressed, the
   7     Clinical Directors were the kind of strategic business
   8     units and they had monthly meetings which was a means of
   9     reintegrating them, if you like. Initially with the
  10     Clinical Policy Board, which I think was chaired
  11     originally by Christopher Dean Hart, who was the first
  12     Medical Director and Chairman of the Hospital Medical
  13     Committee, and then I think it was about a year later,
  14     by Dr Roylance.
  15        So all the Clinical Directors would come together
  16     monthly and have an opportunity to raise issues and give
  17     information which was then fed directly into the Trust.
  18        So I saw that as being quite carefully remitted,
  19     particularly in relation to other organisations where
  20     Clinical Directors were kind of out on a limb and there
  21     would be senior management meetings and they had no
  22     device by which to feed up into the organisation. So to
  23     me that was a means of actually integrating the
  24     structures. Does that help?
  25   Q. So you would not recognise the language of

   1     "semi-detached"?
   2   A. No, I would see them as being quite well integrated.
   3   Q. How would you characterise Dr Roylance's connection or
   4     separation from operational matters of the Trust to the
   5     extent that he was responsible for strategy and so on
   6     and to what extent was that usual or unusual, compared
   7     to other Trusts?
   8   A. I think Chief Executives are not operational people.
   9     I think that their role is to work at Board level and
  10     I think most Board level work in my experience is
  11     invariably strategic in a sense. Having said that,
  12     I mean, if we were having an academic discussion we
  13     could be arguing about what is operational and what is
  14     strategic, actually, but I will spare you that. And
  15     I think for me, the most interesting thing was that on
  16     the one hand he may have appeared to be non-operational
  17     in the literal sense, but on the other, he was
  18     constantly involved in discussions with absolutely
  19     everybody at every level inside and outside the
  20     organisation and a whole tranche of problems.
  21     Therefore, I am not quite clear what being
  22     non-operational means, because he seemed to me to be
  23     doing things all the time, and I was quite often sitting
  24     in his office while he was doing them.
  25   Q. In your statement at page 15, WIT 171/15, you say that

   1     staff were "actively encouraged to identify how they
   2     might improve delivery of care and to seek ways of
   3     making this happen", if we just scan down the page.
   4   A. I do not think anything --
   5   Q. It is paragraph 6.3. How was that to come about?
   6   A. I am sorry, I have only just got it. What am I looking
   7     at? 6.3?
   8   Q. What I am asking is, how staff were actively encouraged
   9     to identify how they might improve delivery of care and
  10     seek ways of making it happen?
  11   A. I think a number of ways. As I gave an indication
  12     earlier, one of my own personal experiences was through
  13     the development of things, particularly for the Charter
  14     Mark and through the management development group, where
  15     people were sent away and they chose a whole range of
  16     projects. This was, I think, the top 50 or 60
  17     managers. Some people "chose" to, in inverted commas,
  18     act as people with disabilities, so they went around
  19     organisations to see whether they could improve ramps or
  20     signing, a whole range of things. I think also my
  21     experience of sitting in the Clinical Directors'
  22     meetings and indeed some of the contracting meetings was
  23     that people were constantly being asked "How can you do
  24     better?"
  25        So the impetus was coming from inside the

   1     organisation, but also, I think from the purchasers.
   2   Q. So partly internal, and partly external?
   3   A. Yes, and I think that is absolutely right.
   4   Q. Mr Boardman has given evidence to the Inquiry. He said
   5     that he thought that the general culture of the Trust
   6     would not encourage so-called "whistle-blowers". He was
   7     asked about which aspects of the culture in particular
   8     he was referring to. He said he thought it went back to
   9     the club culture where whistle-blowing was
  10     a manifestation of disloyalty because, as he put it,
  11     "What you are saying to the organisation is 'You are
  12     not doing as well as we could be'. I think to say we
  13     are not doing as well as we could be is disloyalty. It
  14     is a message which club cultures do not wish to hear."
  15   A. Yes.
  16   Q. To what extent would you agree or disagree that "we are
  17     not doing as well as we could be" is a message which
  18     club cultures in general do not wish to hear and the
  19     extent to which that is a message that this Trust did
  20     not want to hear?
  21   A. I think it goes back to, it depends on the nature of the
  22     club. I think in the club there was a constant cri de
  23     coeur of "We are not doing as well as we could be
  24     doing". Again, it appears paradoxical, because outside
  25     the Trust, UBHT was perceived as kind of arrogant

   1     because of its teaching hospital ethos, but inside the
   2     Trust, everybody kept saying "We must be able to do this
   3     better". That was just my personal experience. So
   4     people were constantly trying to do things better, and
   5     often they felt that they were failing; they wanted more
   6     resources, the age-old cry of all the clinicians I met
   7     was "We want more resources, we want to treat more
   8     people, we want to do better". That is where a lot of
   9     the frustration came from because their idea of strategy
  10     was a "wish list", really.
  11   Q. Just a couple of little points of clarification, earlier
  12     on, I think at page 28 of the transcript, you said that
  13     Dr Roylance was "immensely argumentative".
  14        Did you consider that to be a constructive or
  15     a destructive aspect of his personality for the Trust?
  16   A. I think it was just part of his personality. I think it
  17     very much depended how you responded to that.
  18   Q. Again, do you remember we were discussing Dr Roylance's
  19     response to people who go to him with problems and
  20     Mr Boardman suggested that it was frustrating to have
  21     the problem redefined?
  22   A. Yes.
  23   Q. Again, were you able to form an opinion as to whether or
  24     not Dr Roylance's attitude was constructive or
  25     destructive for the furtherance of the Trust?

   1   A. Being an educationalist, I would have to say it was
   2     constructive because it was actually about developing
   3     people. It would appear contradictory for me in my
   4     role, who performs a very similar function with students
   5     who may or may not wish to begin to see the role rather
   6     differently. So it is very much a similar function,
   7     I am afraid.
   8   MR MACLEAN: With some trepidation, those are all the
   9     questions which I or I think anyone else behind me wants
  10     to ask.
  11        Is there anything else that you want to say at
  12     this stage?
  13   DR THORNE: I do not think so, other than to say that I hope
  14     anything that I have said will be helpful to you in what
  15     I think is an extremely difficult task that you have to
  16     undertake.
  17   MR MACLEAN: Happily, Dr Thorne, I think the task is at the
  18     other side of the room. The Panel may have some
  19     questions for you. Can I thank you very much for your
  20     very helpful evidence.
  21   THE CHAIRMAN: Dr Thorne, Professor Jarman has a question or
  22     two.
  23             Examined by the Panel
  24   Q. Just to expand on the theme that you were discussing
  25     earlier on with Mr Maclean earlier on about the club

   1     culture. I think in one of your replies you implied
   2     that the "club" consisted mainly of the executive
   3     members of the Trust. Is that so -- the executive
   4     group?
   5   A. The paper that I wrote was for that group, so it was
   6     referring directly to them at the time, yes.
   7   Q. Who would you say were in the club?
   8   A. I think it was quite a large club. You have to remember
   9     that taking the notion of the club is simply one
  10     perspective that one can apply to the organisation,
  11     there are a variety of others. So I think that would
  12     include the Clinical Directors, it would include
  13     a number of the directorate General Managers, because
  14     part of the role of the Chief Executive when trying to
  15     introduce a major change which is transformational such
  16     as this is about trying to get people "on board" or "on
  17     side", as the Chief Executives' language would be.
  18   Q. And on page 23 of your statement, you also say there was
  19     constant communication among the members of the club?
  20   A. Yes.
  21   Q. Although things may not have actually been written down,
  22     people did really know what was going on for important
  23     matters?
  24   A. Yes. That tended to be my experience. There was an
  25     awful lot of communication, people would be on the

   1     phones, they were in meetings. I would spend two days
   2     there with people and I would go from meeting to meeting
   3     to meeting, so it was constantly talking about things,
   4     often the same things, with different groups. So it was
   5     terrifically educational.
   6   Q. For example, on Day 30, Mr Durie, who was the chairman,
   7     mentioned that there had been informal discussions about
   8     the Private Eye article. Would that mean the members of
   9     the club would have known about that?
  10   A. Probably, yes. I would have thought so.
  11   Q. On page 24 you mentioned that regarding the demands for
  12     loyalty and to quote you, "removing those who did not
  13     fit": if the members of the club were to have discussed,
  14     for instance something that Mr Durie mentioned to us,
  15     more widely, was there any fear that they might have
  16     been disloyal and therefore have been removed from the
  17     club?
  18   A. No, I mean, it was not a kind of punitive regime in that
  19     sense.
  20   Q. But you did mention that there was a possibility that
  21     those who were disloyal could have been -- you say in
  22     fact, "removing those who did not fit" and this was in
  23     relation to loyalty. I am quoting your words.
  24   A. No, no, I think I tried to say in a supplementary thing,
  25     when I was asked about this, that I think "fitting"

   1     is -- there is nothing wrong with the individual; there
   2     is nothing wrong with the organisation, but sometimes
   3     people just do not fit, so you might well be -- I think
   4     I gave an illustration of a Tesco's or Marks & Spencers
   5     "person", or indeed a Hewlett Packard type of person.
   6     You may flourish there but you may not flourish
   7     somewhere else. I think that was really the point I was
   8     trying to make about "fit".
   9   PROFESSOR JARMAN: Thank you very much.
  10   THE CHAIRMAN: Dr Thorne, thank you very much for coming
  11     today. It has been helpful. I repeat what Mr Maclean
  12     said, that if there is anything else you have which you
  13     would like to draw to our attention, we would be
  14     grateful to receive it, but for now, thank you.
  15        Could I impose on you, if I may, for probably no
  16     more than a couple of minutes while Mr Langstaff says
  17     something.
  18        Mr Langstaff will tell us about tomorrow. You
  19     may, because of the alteration in our schedule, wish to
  20     tell us about beyond tomorrow. That is a matter for you
  21     and you will advise me accordingly.
  22            MR LANGSTAFF: Re TIMETABLE
  23   MR LANGSTAFF: Certainly, sir. Tomorrow we hear from
  24     Dr Baker.
  25        If I can then look ahead to next week, and first

   1     of all say that Mr Wisheart, who was due to give his
   2     evidence yesterday and the day before, will now give his
   3     evidence on 19th and 20th July, which is a week on
   4     Monday and the following day.
   5        Next week, we hear on 12th July from Mr Ross, the
   6     second time we have heard from him, the Chief Executive
   7     of the UBHT, and from Mr Barrington, the General Manager
   8     of the Directorate of Children's Services at the UBHT.
   9     They will both be addressing what they have to say in
  10     respect of issue J, which is the emotive issue of tissue
  11     retention.
  12        They come on 12th July for very good timetabling
  13     reasons, principally concerned with availability,
  14     because we will not address the question of tissue
  15     retention further that week. But on 13th and 14th July
  16     we will deal with statistics.
  17        The process which we have adopted is this. As has
  18     already been anticipated in a document which some time
  19     ago was put on the Internet, the first stage is to
  20     indulge in a preliminary critical overview of the
  21     various different data sources which exist, so that you,
  22     the Inquiry panel, are put in a position to evaluate
  23     whether any data source is actually able to give any
  24     answer, and if it can, how reliably and to what extent
  25     it can give an answer, to the questions that arise

   1     simply by looking at the numbers and characteristics of
   2     the cases which passed through the UBHT, as it was, and
   3     before that the BRI and the Bristol Children's Hospital
   4     between 1984 and 1995.
   5        Those two days, which will be devoted to looking
   6     at the way in which the main data sources were
   7     collected, to looking at, as it were, the warts that
   8     there were in respect of each so that they can properly
   9     be pictured, will begin, I am afraid to say, with
  10     a short introduction by me, and I emphasise "short",
  11     because what then follows, we will hear from Richard
  12     Wilmer, the chief statistician at the Department of
  13     Health. He will be addressing the national data sources
  14     for which the Department of Health has prime
  15     responsibility. Then from Bruce Keogh, who is the
  16     individual responsible in the Society of Cardiothoracic
  17     Surgeons for the collection, maintenance,
  18     interpretation, and so on, of the cardiothoracic
  19     register, which has been in existence since 1977, and
  20     again forms a national source of data from which,
  21     possibly, some general, comparative conclusions, may be
  22     drawn.
  23        When they give evidence, there will be in
  24     attendance in the hearing chamber and in a position to
  25     comment, and indeed to interact with the witness, two

   1     experts: Dr David Spiegelhalter, an independent expert
   2     with particular familiarity with the cardiothoracic
   3     register, and Dr Paul Aylin of Imperial College who has
   4     a facility and familiarity with the national data to
   5     which Richard Wilmer will speak. So the structure will
   6     be less in terms of formal evidence, more in terms of
   7     a symposium.
   8        On the Wednesday, when the Inquiry will begin on
   9     each of those days at 9.30 but it will finish on the
  10     Wednesday no later than 1, we will hear from Mr Hooper,
  11     the health records manager at the Bristol Royal
  12     Infirmary and who was the Manager of the UBHT PAS system
  13     (Patient Admission System) and represents the local
  14     source which echoes the data available nationally which
  15     will have been spoken to the previous day.
  16        Similarly, we will have available as experts on
  17     that day, to advise and interact in the symposium format
  18     which I have described, Ann Harding, acting director of
  19     the NHS Information Authority, and again, Dr David
  20     Spiegelhalter, whose role I have already described.
  21        The purpose is, having reviewed the available data
  22     sources critically and drawn out what evidence there is
  23     as to the strengths and weaknesses of those data
  24     sources, I would hope and expect that we will be able to
  25     finish on the 14th with some evaluation of the way

   1     forward. This is not to be presented or understood in
   2     any sense as a fait accompli. The purpose of having
   3     these two days devoted to statistics at this stage is to
   4     ensure that all those who wish to make input into the
   5     Inquiry's deliberations can have a chance both to
   6     comment upon any strength or weakness that may
   7     apparently have been overlooked despite the expertise
   8     that we have available and to assist, constructively we
   9     hope, in ensuring that we take the right way forward
  10     when it comes to commissioning, interpreting and
  11     applying the available research on the basis of the
  12     various different statistical data sources that exist.
  13        I hope that does not sound too technical. Anyone
  14     who wants to read further will be assisted by a note
  15     which is entitled "A Preliminary Overview" which is
  16     being published on the Internet this week. They will
  17     see there a description of some of the main data
  18     sources, some of the less key data sources, and a gentle
  19     description of some of the more obvious strengths,
  20     weaknesses and utility, for us, of those different
  21     sources.
  22        That is rather than a longer sneak-preview than
  23     you normally get, but it is just coming up to
  24     2 o'clock.
  25   THE CHAIRMAN: That was very helpful. Not only to the Panel

   1     but of course to the wider audience. I am grateful to
   2     you.
   3        Clearly, there has been some disruption in the
   4     programme, and I apologise to all of those who have been
   5     affected by that, but I hope they will understand the
   6     circumstances.
   7        We meet again tomorrow morning at 9.30.
   8   (1.55 pm)
   9     (Adjourned until 9.30 am on Thursday, 8th July 1999)
  10
  11
  12
  13
  14
  15
  16
  17
  18
  19
  20
  21
  22
  23
  24
  25

   1                I N D E X
   2
   3
   4     DR MARIE THORNE (Sworn):
   5        Examined by MR MACLEAN...................... 2
   6        Examined by the Panel ...................... 115
   7
   8     MR LANGSTAFF: Re timetable ....................... 118
   9
  

Return to top of page

Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001