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Daily transcripts
Hearing summary
4th October 1999
Hearings this week focus on evidence from Regional Health Authority and hospital staff
commenting on the Bristol Services and the adequacy of the service provided.
Today the Inquiry heard from Catherine Hawkins CBE, former Regional General Manager,
South West Regional Health Authority (SWRHA). She described the role of the SWRHA in
relation to the setting up, organisation and monitoring of NHS services in the region. She
outlined the process of review of individual district health authorities, and later,
health authorities (purchasers) and trusts (providers). She commented on her response to
concerns raised by district general managers (later chief executives) and cardiologists
about the cardiac unit at the Bristol Royal Infirmary (BRI) at various times during the
1980s and 1990s. Ms Hawkins said that SWRHA was under pressure prom the Department of
Health and Social Security to increase throughput at the Bristol unit, despite having
raised concerns with them at review meetings. She said that she had had informal
discussions and corresponded with Dr John Roylance, former Chief Executive, United Bristol
Healthcare NHS Trust, about the performance of the Bristol cardiac unit and the potential
withdrawal of contracts from purchasers within the region. She also said that she visited
Mr James Wisheart, Consultant Cardiothoracic Surgeon, UBHT, during 1992 to discuss the
issue, and was reassured that outcomes were in line with national figures and that the age
of patients and the severity of the congenital defects that were being referred to Bristol
were factors which should be taken into account. Ms Hawkins commented on the management
style of Dr Roylance and concluded by discussing the introduction of audit throughout the
region.
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FULL TRANSCRIPT
1 Day 56, 4th October 1999
2 (11.05 am)
3 THE CHAIRMAN: Good morning everyone; good morning,
4 Mr Langstaff.
5 STATEMENT BY MR LANGSTAFF:
6 MR LANGSTAFF: Good morning, sir. Sir, I am sorry that
7 the start of today has been delayed a little. In part
8 the reasons for that, I imagine, will become clear from
9 the first few questions that I have to ask Ms Hawkins,
10 our witness for today. She, perhaps surprisingly, since
11 the Department of Health were invited by this Inquiry
12 a long time ago to make contact with her and prepare her
13 statement, is unrepresented and has had, it seems, no
14 access to documents, nor have they been made available
15 to her by the Department of Health. As I say, I shall
16 be asking some questions about that.
17 Part of the problem of course which it gives rise
18 to is that others who would wish to make comments and
19 draw our attention in asking questions to other material
20 which is pertinent have been limited in their
21 opportunity to do so, just as we have in seeing what
22 Miss Hawkins was going to say and in deciding which
23 areas would be most beneficial to this Inquiry to
24 explore with her in evidence.
25 I think, for those who might ask why is it that
0001
1 Ms Hawkins' evidence was not put back for a week or so,
2 some explanation is perhaps necessary. It is this: of
3 course we are, as I indicated when we last met, well on
4 the way to timetabling in considerable detail the
5 witnesses whom we are to hear from until Christmas in
6 this Inquiry. Timetabling is never easy because, of
7 course, a number of the witnesses are busy clinicians
8 with primary commitments to health. It is obviously
9 right that so far as this Inquiry can, it should respect
10 those commitments.
11 This applies not only to those whom we have
12 timetabled from this country, but to those whose
13 attendance is obviously desirable at this Inquiry who
14 come from far away. It is right that perhaps I should
15 say something at this stage about the scheduled
16 attendance, as it were, of Dr Bolsin.
17 We have made it clear, as perhaps would be
18 obvious, that this Inquiry regards his evidence as being
19 of very considerable importance and being likely to be
20 very helpful to us. He, of course, is a businessman
21 with both clinical and media commitments on the other
22 side of the world, and scheduling has been particularly
23 difficult. We have tried hard to get him here; we have
24 offered to fly him here; we have done our best to be
25 flexible, but try no doubt as he might -- this is
0002
1 absolutely no reflection on him, it is just the
2 difficulties of timetabling -- it looks at the moment as
3 though it is not going to be possible for him, in the
4 light of his commitments, to come to this Inquiry in
5 person.
6 However, because we are, and set out to be, open
7 and accessible, and we feel that everyone should have
8 the benefit of all the available evidence, we must of
9 course make his evidence as available as possible.
10 We are fortunate in having the technology that we have
11 at our disposal, and we have now put in hand
12 arrangements to take his evidence from Australia by
13 a video conference link.
14 Perhaps it is not ideal; it will mean timings will
15 obviously have to suit both this part of the world and
16 that part of the world, but otherwise in the light of
17 the fact that he did not feel able to attend in person,
18 given the dates and the slots that were left, and that
19 we can make available, this is a way to hear him, and
20 indeed, it is the first time that this has been done in
21 an inquiry of this sort.
22 We hope that by giving advance notice of this, we
23 prepare as many of the wider public and participants in
24 the Inquiry to the fact that the nature of his
25 attendance at the Inquiry will be rather different from
0003
1 the others, but it is of course important that we take
2 every step to get every witness who has something to add
3 a chance to say in full -- and we ask questions from
4 various different perspectives -- what they can about
5 the matters that happened in Bristol during the 1980s
6 and 1990s.
7 I have taken a little while on that because of, no
8 doubt, the interest that it will have to others. Having
9 said that, may we now please have Ms Catherine Hawkins.
10 Ms Hawkins, would you stand to take the
11 affirmation, please?
12 MS CATHERINE HAWKINS (affirmed)
13 Examined by MR LANGSTAFF:
14 Q. Ms Hawkins, you are Catherine Hawkins?
15 A. Yes.
16 Q. What I would like to show you on the screen is the first
17 page of a statement which you made last week to this
18 Inquiry, WIT 91/1. Is that the first page of your
19 statement?
20 A. Yes.
21 Q. Can you go, please, to page 5. Is that your signature?
22 A. Yes.
23 Q. We see the date, 30th September, which was last
24 Thursday.
25 A. Yes.
0004
1 Q. You stand by the contents of that witness statement?
2 A. Yes.
3 Q. Can you help me when it was that you were asked by
4 anyone in the Department of Health to produce that
5 statement?
6 A. I had a letter, I believe it was 23rd September, from
7 Simon Wilson at the Department, asking me to give
8 evidence on 4th October and if I needed any help in
9 preparing a statement, to ring them. So I went straight
10 to the telephone and rang them. I gave a brief resume
11 over the telephone, and they faxed it back to me that
12 day and then, on I think it was Monday, first thing
13 I faxed them my statement. They then rang me, I believe
14 Wednesday, to say that I could not make a statement
15 about Dr Halliday actually having gone to the unit as
16 that would be hearsay, so they would need to change it.
17 So I said as time was short, would they change it
18 and fax it back to me, which they did and they had
19 altered one or two items, the meaning of one or two of
20 the paragraphs, so I phoned them back and said that was
21 unacceptable. They then revamped it and I signed the
22 faxed copy, faxed it back so it could be sent to the
23 committee.
24 Q. So am I right in thinking from that description that
25 no-one sat down with you to find out what you had to
0005
1 say?
2 A. No.
3 Q. And no-one showed you any bundle of documents?
4 A. No.
5 Q. From what you say, 23rd September was the first time
6 you were aware that you were definitely being needed for
7 this Inquiry?
8 A. Yes. The letter I had is dated 21st September, but
9 I did not receive it until the 23rd. We have rather
10 a slow postal system in my village.
11 Q. So although we have it as a matter of record that we
12 first contacted the Department of Health solicitor's
13 office, Mr Mark Wilson, on 26th March of this year
14 asking for your contact address, and were given it,
15 you did not know anything about that; is that right?
16 A. No.
17 Q. And although this Inquiry wrote on 3rd June to Mr Wilson
18 asking if he would let us know what progress had been
19 made regarding taking a statement from you, you had not
20 heard any word at all at that stage?
21 A. No.
22 Q. Did you know that on 11th June there was a letter sent
23 to the Department of Health's solicitor's office saying
24 that we would be anxious to hear from you before the
25 summer break?
0006
1 A. The first contact I had is 23rd September.
2 Q. And it follows that a number of letters which followed
3 thereafter to the Department of Health never came to
4 your attention until last week?
5 A. No.
6 Q. Have you, in preparing your statement, found it easy to
7 remember precise dates and events without seeing
8 documents?
9 A. No. I mean, we are talking now from 1984 to the present
10 time. It is a long time to remember. Six months ago
11 I did in fact ring Region and ask was it possible to
12 have access to some of the review papers and things.
13 They did spend a day looking for them, but came back to
14 say they had either been disposed of by subsequent Chief
15 Executives at the Region or had been sent to the central
16 storage office; they were uncertain. They could not be
17 found. So I thought I might be called and I did try and
18 access any official papers I had with the Department.
19 Q. So what you are saying is that you tried but you could
20 not get anywhere?
21 A. No.
22 Q. Did you expect that you might be represented today?
23 A. To be honest, I was unsure. I did not know what form it
24 would take, being called.
25 Q. Were arrangements made for you to see a representative?
0007
1 A. Yes. The solicitor at the DHSS said that he had
2 arranged for me to see a barrister last Friday, at 2 pm,
3 but on Thursday night at 7.30 in the evening they rang
4 me to say that that was cancelled because the barrister
5 was in court.
6 Q. I should ask you this: you do not have a representative
7 here today. Are you happy to answer the questions that
8 the Inquiry has for you without having the advantage of
9 a representative to whom you can refer?
10 A. Yes, bearing in mind that I am speaking from memory and
11 to the best of my ability.
12 Q. If we get to a stage when I show you a document and you
13 want to take time, or you recollect that there are
14 documents which may yet be available to deal with the
15 point, would you please say so. Of course in the light
16 of the history which you have given us, your wishes are,
17 I imagine, subject to a ruling by the Chairman, likely
18 to be respected?
19 A. Yes.
20 THE CHAIRMAN: Absolutely.
21 MR LANGSTAFF: You have heard what I said by way of
22 introduction, and I repeat it now for the sake of the
23 wider audience: certainly from where I stand, we regard
24 it as extremely unfortunate that those who were charged
25 with the responsibility of preparing and producing your
0008
1 statement have done so so late that others who might
2 wish to feed information to me have had little
3 opportunity to do so. Can I thank those who have
4 indeed, despite the pressure of time, managed to do just
5 that. I think it needs to be appreciated, sir, and
6 I say this for the record, that there may well be
7 matters which arise in evidence which it would have been
8 desirable to indicate might arise to others, but because
9 of what you have heard, the opportunity simply has not
10 been there.
11 THE CHAIRMAN: Mr Langstaff, the Panel shares your concern
12 and would like to echo the dissatisfaction that we feel
13 about the state of affairs that has come to pass.
14 MR LANGSTAFF: At paragraph 17 of your statement, WIT 91/4,
15 you describe a number of concerns which you heard of
16 from watching television, Panorama.
17 You say that these concerns were concerns that you
18 understood from what you heard on television have been
19 expressed by the Royal College of Surgeons to
20 Dr Halliday, the Medical Officer at the Department of
21 Health and Social Security. I am right in thinking, am
22 I, it is the Royal College of Surgeons and it is
23 Dr Halliday?
24 A. Yes.
25 Q. You say in the very last sentence of paragraph 17:
0009
1 "If those concerns had been shared, we would have
2 acted promptly by suspension of operations at the Unit
3 and out of Region referrals."
4 You had in mind there suspension of operations for
5 cardiac surgery on children?
6 A. No, we actually -- the concerns that were being
7 expressed were never specific to children.
8 Q. You missed the point.
9 A. No, we would have suspended operations.
10 Q. All operations?
11 A. Yes.
12 Q. And the out of Region referrals would be what?
13 A. We would have contacted the Brompton and the Oxford
14 hospitals again and asked for out of Region contracts.
15 Q. So what you would have done would effectively have shut
16 down cardiac surgery at the Bristol hospitals?
17 A. For open-heart surgery.
18 Q. You had the power to do that?
19 A. We would have done it through Chairman to Chairman
20 contact, because the simplest way would have been to
21 suspend, not to discipline at that time, but to suspend
22 the surgeons concerned whilst an investigation was
23 carried out. The Chairman of the Bristol Royal
24 Infirmary had the power and authority to do that. The
25 Regional Chairman would have had that contact with him
0010
1 and asked him to do that, with the evidence. Any
2 concern from the Royal College would have raised big
3 spectres in our eyes.
4 Q. So again, let me have this clear. Had you known that
5 Sir Terence English had it in mind that the results, the
6 outcomes in respect of paediatric cardiac surgery at
7 Bristol, were so poor that the centre should be
8 de-designated as such a centre; if you had known that,
9 you would have taken steps to ensure that there was
10 Chairman to Chairman contact and suspension as you have
11 indicated?
12 A. Yes.
13 Q. And you would have secured a service for those in
14 Bristol and the South West by referral to other centres?
15 A. Yes.
16 Q. So it follows, does it, that at that time, at any rate,
17 the Region had a power to act?
18 A. The Region always had good Chairman to Chairman
19 networking and although we did not have direct control
20 of the executives' interests or in hospitals, and
21 particularly the United Bristol Hospital, the
22 relationship between the Chairmen was good enough that
23 if they had been given evidence by the Regional Chairman
24 that there was a big problem, they would have acted in
25 cooperation with us and they would have suspended their
0011
1 own staff while a full investigation was carried out.
2 Q. For your Chairman to act, he would need to have
3 evidence, would he?
4 A. Yes. I mean, if we had known this from the Department,
5 then we would have had direct contact with Sir Terence
6 English to find out exactly what he had been told and
7 what were his concerns, and no doubt my then Chairman
8 would have taken the Chairman of the Bristol Royal
9 Infirmary with him to see Sir Terence English.
10 Q. Did the position change in terms of the powers which the
11 Regional Health Authority had once Trust status was
12 conferred upon the UBHT?
13 A. Yes, because the control of Trusts went directly to the
14 department, so Region was not involved. Region
15 continued to oversee the non-Trust units and the
16 department had a section which managed or had direct
17 contact with Trust status units.
18 Q. Can I ask you to look on the screen at HA(A) 112/76?
19 I am going to ask you about what appears at the bottom
20 of the page. Let me show you where the document
21 starts. It begins at page 72. You see what this is:
22 Bristol and District Health Authority. My understanding
23 is that this document was a 1992 or 1993 document.
24 We can see that it is post-1992 from looking at
25 paragraph 1.2. The Bristol and District Health
0012
1 Authority came into being, did it, when Trust status was
2 conferred on the UBHT, so that began in 1991.
3 Let us go back to the page we started at, page 76.
4 "Congenital heart disease. Surgical, open and
5 closed and non-surgical interventions."
6 It deals first of all with the incidence of
7 congenital heart disease for 1,000 live births. Then,
8 in the second bullet point, it says:
9 "Follow-up data for interventions is limited.
10 Apparently good for primary closure of VSD and
11 coarctation in infancy."
12 Let us go over the page down to the third bullet
13 point:
14 "Open surgical approaches have high (20-46 per
15 cent) 30-day mortalities for truncus and great vessel
16 abnormalities, with or without [I think it means] valve
17 and septal defects."
18 The position, then, reflected by this document,
19 going back to the bottom of page 76, would suggest that
20 there was a limited amount of information available to
21 the district authority at that time.
22 Did you, in Region, at this time and before, have
23 access to what you would regard as full data on the
24 performance of cardiac surgery in the Bristol
25 Infirmaries?
0013
1 A. Not to my knowledge. Up until the time audit was
2 properly accepted by medical staff, data was not openly
3 and willingly shared. It was particularly difficult
4 around the time of contracting when they had what they
5 called "commercial confidentialities". At regional
6 level, it was extremely difficult to have very specific
7 surgeon/data aligned to one individual. Normally, if
8 data came up, it was in a block scenario so you did not
9 know who was accountable quite for what, so you could
10 have a surgical specialty with subspecialties.
11 It is one of the reasons why -- the government did
12 have a push for audit and why we did designate
13 an individual person from Region to actually begin to
14 develop the audit processes within hospitals which would
15 also give us access, as audits came forward, to make
16 good comparisons across regions and on a national
17 basis. But the collection of data was not as it is
18 now.
19 Q. When the district authority are recording here that the
20 data was "apparently good" for primary closure -- there
21 seems to have been a certain amount of doubt or
22 hesitation about it from the script itself -- what sort
23 of data, by 1992/93, would one have: still the
24 aggregated data to which you have referred, or not?
25 A. No, there should have been the beginning of more
0014
1 specific data and identification of cases, because they
2 would have been looking at specialties and
3 subspecialties too, so that surgery would not be lumped
4 as a surgical unit per se with several subspecialties in
5 it. They would have gone into subspecialty data.
6 Q. If we go over the page and look again at the third
7 bullet point down, this is the district authority
8 speaking as purchaser, is it, having its review of what
9 has been happening?
10 A. I have forgotten what the first heading of the document
11 was.
12 Q. Let us go back and show you it again, at page 72.
13 A. "Strategic Cell"? I am sorry, I do not recognise that.
14 Q. I was going to ask you for some help on that. In
15 a moment, I shall ask you about the relationship that
16 you had with the district health authorities before
17 Trust status.
18 A. Was this part of the business plan?
19 Q. I cannot help you on that. We shall have to ask
20 others.
21 A. I would have thought that the Medical Officer, Dr Mason,
22 would be able to advise you on that.
23 Q. Let us go back then to 77. If it had been thought at
24 regional level, after Trust status, that the high 30-day
25 mortalities for truncus and great vessel abnormalities,
0015
1 with or without valve and septal defects were not only
2 high in the sense of percentage chances, no matter where
3 one was operated upon, but high in comparison with other
4 units elsewhere in the country; there are two different
5 ways it might be read. If, then, Region had thought it
6 was high compared to elsewhere in the country, was there
7 anything that, at that stage, the Region could have done
8 about it?
9 A. Region would not necessarily have been involved in
10 1992/93, because Trust status went, I believe, to the
11 BRI in 1991.
12 Q. Yes.
13 A. So their documents, their business plan and their
14 monitoring was conducted by the department. So Region
15 would have heard about this possibly on the medical
16 network, but it would have come down from the department
17 if there had been a question raised.
18 Q. So what is the answer to my question? What could Region
19 have done about it?
20 A. What Region would have done about it, I suspect, is to
21 talk to its other non-Trust units and use the
22 contracting mechanism not to support this unit and to
23 raise serious questions with the Trust.
24 Q. Would Region, for its part, have made contact with the
25 DHSS centrally?
0016
1 A. Again, it depends what they would be comparing it
2 against, because I would not have any specific knowledge
3 about paragraph 3, whether that was a good comparison
4 nationally to the Brompton or the Oxford or not. So,
5 again, unless there was a good audit system going on
6 with cross-regional comparisons, it would be difficult
7 to make an assessment at that time. That might have
8 been the norm.
9 Q. If this document had crossed your desk and you had
10 looked at it in 1992, after Trust status, are you saying
11 then that what you would probably have done is put it in
12 a file marked "Not my business"?
13 A. No. I mean, there would have been a telephone call to
14 the department team that were looking after Trusts to
15 say: "Have you noticed this and have you done
16 a comparison across other regions? Is it good or is it
17 bad? You tell me."
18 Q. Then you would have left it to them, but you would at
19 least have raised the issue?
20 A. Yes, because obviously that was affecting cases being
21 referred from units that were still in our control as
22 well.
23 Q. Let me turn away from this. I will come back to the
24 whole question of concerns and what was said and what
25 might have been said and what was or was not or could
0017
1 have been done at a later stage.
2 Can I explore with you for a moment the role of
3 the Region and how it changed. In a sense it follows on
4 from the questions I have been asking about in regard to
5 what could have been done by the Regions both before and
6 after Trust status.
7 The South Western Regional Health Authority
8 existed, did it, from 1st April 1982 until 1st April or
9 31st March 1994?
10 A. No, the South West region had been there since 1974. In
11 fact, longer than that: in 1948 there had been
12 a regional authority. What had changed was that in 1984
13 general management was introduced at regional and
14 district levels. So, there had always been a regional
15 authority dealing with programmes and strategic planning
16 and financial allocation but it changed in 1984 when
17 general management was introduced, and it changed again
18 in 1991.
19 Q. Yes. There were 14 regions in the UK or England and
20 Wales?
21 A. Yes.
22 Q. Underneath the Region in this area, there were how many
23 districts?
24 A. 11.
25 Q. One of those districts would be Bristol and Weston?
0018
1 A. Yes.
2 Q. And another, Southmead, another Frenchay. So those
3 three districts would cover this geographical area?
4 A. Yes. They covered 880,000 population.
5 Q. But your responsibility, so far as region was concerned,
6 stretched beyond Plymouth?
7 A. It stretched from Cheltenham to the Isles of Scilly.
8 Q. And that was what? Avon, Cornwall, Devon, Dorset,
9 Gloucestershire, Hampshire?
10 A. No; Cheltenham, Gloucester, Avon, Somerset, Devon,
11 Cornwall and the Isles of Scilly.
12 Q. Then, in 1994, the South Western Regional Health
13 Authority was abolished and replaced by the South and
14 West Regional Health Authority?
15 A. It was replaced by an outpost of the department, so it
16 became a regional executive that then incorporated parts
17 of Dorset and Wiltshire.
18 Q. And the South and West Regional Health Authority lasted
19 until 1st April 1996, did it?
20 A. I am sorry?
21 Q. Until 1st April 1996, the South and West Regional Health
22 Authority?
23 A. No, the South West Regional Health Authority was still
24 in being when I left in 1991. In 1994 it became the
25 South and West.
0019
1 Q. Yes, that is what I was saying.
2 A. I am sorry.
3 Q. That, in 1996, ceased to exist. It was abolished and
4 the Avon Health Authority was created?
5 A. No, Avon had been there since 1974. There was an Avon
6 Health Authority because I was an area nurse on it
7 then. What happened was that the roles changed so that
8 in 1991 Avon -- I am sorry, in 1984 Avon Area Health
9 Authority was abolished and the three districts came
10 into being, but in 1991 there was an Avon Health
11 Authority purchaser.
12 Q. Yes.
13 A. And the districts were provided.
14 Q. So far as the districts were concerned, at all times
15 from 1984 to 1991, was the Bristol and Weston District
16 Health Authority one of the 11 districts under the
17 supervision of the South Western Regional Health
18 Authority?
19 A. Yes.
20 Q. Was the Bristol Royal Infirmary and the Bristol
21 Children's Hospital managed by the Bristol & Weston
22 District Health Authority?
23 A. Yes.
24 Q. There was a District General Manager of the District
25 Health Authority, was there?
0020
1 A. Yes.
2 Q. Was that Dr John Roylance?
3 A. Yes.
4 Q. Did you have much contact with Dr Roylance?
5 A. He was part of the group that we met from Region on
6 a regular basis. There was always an RGM/DGM meeting;
7 my team and those DGMs. There were meetings between
8 various of my officers like Finance Officer, Planning,
9 Medical Officer, who would all have representatives and
10 sometimes the DGM would be on that, and there were
11 informal contacts when the DGM would ask to see me on
12 various issues.
13 So there was fairly regular formal contact and
14 less regular informal contact.
15 Q. Did you know him well?
16 A. I knew him well, yes, as a person.
17 Q. Had you served with him before in a district management
18 team?
19 A. Yes. In 1979 until 1982, I served with him on the
20 district management team of the Bristol and Weston
21 district. I was the Chief Nurse and he was the Medical
22 Director.
23 Q. How good a manager was he, in your view?
24 A. I suppose I have to answer that? (Chairman nods).
25 I think it is sufficient to say that he would not have
0021
1 been my first choice for the district management job in
2 1984.
3 Q. If I can just press you a little on that, would your
4 view have been changed by your subsequent experience of
5 the management?
6 A. No. John Roylance was a brilliant doctor and a very,
7 very good Medical Director, but I did not see him as
8 a General Manager in the true sense of management.
9 Q. Did your role as the Regional General Manager involve
10 having the direct supervision of the various different
11 11 districts underneath the Region?
12 A. It was a very difficult system because the Regional
13 Health Authority had monitoring and a degree of control,
14 in italics, of its district without the actual authority
15 to affect them directly, because each district had its
16 own Chairman and non-Executive Board who actually
17 managed the districts.
18 So it was a situation where you had accountability
19 and responsibility without true authority.
20 Q. Amongst your responsibilities was the task of service
21 planning; is that right?
22 A. Yes. Strategic planning was the main function of the
23 RHA.
24 Q. So you would have a view as to what services should be
25 developed, or the converse?
0022
1 A. Yes. That was often out of synch with the national
2 priorities.
3 Q. And you would have views pressed to you, would you, from
4 districts as to their wishes as to how the services
5 should be developed, or the converse?
6 A. Yes.
7 Q. You describe in your statement a series of annual
8 reviews. Let me see if I understand what you are saying
9 in your statement. Are you saying that the DHSS had
10 an annual review with the Regional Health Authority?
11 A. We had a ministerial to Chairman review, and normally
12 the Vice Chairman attended and myself and appropriate
13 members of my team, and that was with a Minister and
14 the Executive of the Department of Health and any
15 appropriate civil servants that they thought had
16 specialty influence.
17 Q. And the Regional Health Authority, for its part, had
18 annual reviews, did it, with each of the 11 district
19 health authorities?
20 A. Yes. Again, that was a Chairman to Chairman review.
21 It was the Chairman's review, not mine, and each of the
22 Chief Executives would attend with the relevant team
23 officers, depending on what subjects were being
24 discussed at the time. Normally the Vice Chairman came,
25 or a non-executive from the RHA who had a particularly
0023
1 oversight of a district.
2 Q. And did you attend those reviews?
3 A. I attended them all, yes.
4 Q. So you attended both the DHSS reviews of or with the
5 RHA?
6 A. Yes.
7 Q. And the Regional Health Authority reviews of or with the
8 district health authorities?
9 A. Yes.
10 Q. I have used the words "reviews of or with". Which was
11 it?
12 A. It was a situation where, when I came into office in
13 1984, we were tasked by the then Minister to take
14 control of our districts who were perceived not to be
15 performing as well as could be expected and that Region
16 needed to get a grip on things.
17 I would have to say that my reputation is such --
18 you must know it well -- that I was a very strong
19 executive and although we did not have direct control of
20 districts, they did feel accountable to us. That was
21 partly style and partly the fact that I had a good team
22 at regional level who were in a position where they
23 could challenge and naturally take things forward with
24 their counterparts at district level.
25 Q. So far as the DHSS was concerned, the annual review
0024
1 meeting with them or of you by them, what was that
2 concerned to review?
3 A. That varied from year to year. It varied from Minister
4 to Minister. Some Ministers had an interest in
5 maternity, some in geriatrics, and it would be an
6 emphasis on different things with different Ministers,
7 but there was always a thread running through it about
8 financial viability and how we had performed against
9 national targets, whether we were achieving our overall
10 strategic plan and whether there were any specific items
11 of interest or concern on either side. It was a very
12 open type of meeting where you could argue back, but
13 then you would be given set targets or tasks to go away
14 and achieve.
15 Q. You mention there two things which I want to pick up and
16 just follow a little: that you would be set performance
17 indicators and targets. The performance indicators in
18 the early 1980s: to what type of item did they relate?
19 How was performance measured?
20 A. Frequently it would be against things like health
21 promotion and disease prevention: whether you were
22 closing the large mental handicap hospitals and creating
23 community care; were you getting on in partnership with
24 social services; had you actually achieved increasing
25 your numbers of good capital schemes for district
0025
1 general hospitals; were your services like cardiac
2 patients getting enough cases through units; what were
3 your contracting out of county arrangements. You know,
4 very wide-ranging items at times.
5 Q. One might summarise it by saying that it was about
6 structures and numbers?
7 A. Not always numbers, no. Often about the policies of the
8 government in and the way it was heading and how would
9 we actually get districts on board to achieve the
10 outcomes that governments expected to see, like
11 reduction in teenage pregnancies could be one, when
12 there was a female Minister at hand.
13 Q. So far as achieving the strategic goals or plans were
14 concerned, that would involve measuring progress against
15 plans which Region had proposed to the Minister on some
16 earlier occasion?
17 A. Yes.
18 Q. Would that be a general regional overview, or would it
19 be service-specific?
20 A. At the time, in 1985 when we were developing the
21 strategic plan, it was not. It was very specific on
22 mental handicap, mental illness and care in the
23 community, and on our formation of DGHs, because we did
24 have a massive need to develop new DGHs throughout the
25 Region. We had a lot of old out-of-date facilities but
0026
1 it would not have been specific to say that in Bristol
2 we had to have 100 beds for surgery. It was not like
3 that. It was a more general approach, that we would
4 need equity; we would need a DGH to serve so many people
5 and the basic facilities would be X, Y and Z.
6 Q. Can we have a look, please, at UBHT 156/236?
7 This is 1988, so we are moving a little bit
8 through the 1980s: a meeting to discuss regional cardiac
9 strategy. Can we scroll down, please?
10 One can see that a number of points were discussed
11 between the South Western Regional Health Authority and
12 the districts in terms of the strategy which the South
13 Western Regional Health Authority had in 1988 in respect
14 of cardiac services.
15 A simple question: at this stage at any rate, was
16 the strategy for cardiac services seen as a separate
17 strategy amongst others, no doubt, for different
18 disciplines?
19 A. Yes. I think at this stage it was unclear to us whether
20 we needed two units. There was a debate, in fact, I can
21 remember, on whether the huge investment that was
22 required by the department would be more effectively
23 deployed in health promotion and disease prevention and
24 in continuing extra regional contracting arrangements,
25 rather than keep heading for more and more cardiac
0027
1 surgical cases. There was a debate I remember amongst
2 medical staff at that time whether prevention might be
3 better than cure.
4 Q. I will come back to that in a moment. If we can have
5 a look, please, at UBHT 102/433, can we scroll down to
6 item 1?
7 Again, exploring, if I can, the relationship
8 between region and districts, can we just go back to
9 pick up the date: 11th June 1984. Mr Seccombe was the
10 Regional Chairman, was he?
11 A. Yes.
12 Q. He noted that the ministerial review -- that is the
13 review you have been describing between the DHSS and the
14 South West Regional Health Authority, is it?
15 A. That year we had it in April.
16 Q. "... made it plain that the Regional strategy would not
17 be regarded as sufficient if it was just a statement of
18 good intentions. There had to be a clear strategy with
19 specific plans for achieving its objectives."
20 Mr Clarke was the Chairman of the District Health
21 Authority, was he?
22 A. Yes.
23 Q. "Mr Clarke noted that the review had questioned the
24 pattern of relationship between the South Western region
25 and the districts. He said that Bristol and Weston much
0028
1 appreciated the current style of relations and the
2 opportunity to listen to advice and criticism from the
3 Region."
4 What had been said to Region about its style that
5 made it different from other regions elsewhere in
6 England and Wales?
7 A. I remember this review very well because it was my first
8 one. I joined in March as the Chief Nursing Officer and
9 it was a very difficult review. We were told -- I had
10 just joined; I think I had been there a month -- we were
11 told that the Region was so laid back that it could fall
12 off the chair. Mr Seccombe had quite a hard time, and
13 that is when we were told to stop being friends with the
14 districts, in quotes, and to get to grips with them and
15 to start making them perform well, because Region was
16 not doing that.
17 Q. So Mr Seccombe was new in post, was he?
18 A. He had not been in post very long. I suspect 1982,
19 I think, he went into post.
20 Q. Is it then the case that central government regarded the
21 South Western region really as having failed effectively
22 to supervise and manage the districts under its purview?
23 A. I would not go quite so far as that. I think they were
24 anxious that we were probably in a state where we were
25 friends with everyone and possibly not effective as
0029
1 a consequence. We were told, in no uncertain terms, to
2 sharpen up.
3 Q. Is this note suggesting that Mr Clarke was really rather
4 fond of the old way of doing things?
5 A. That would be my interpretation.
6 Q. And was that the way you saw things at the time?
7 A. On the train back, when my colleagues were very
8 depressed and so Vernon did not quite know what to do
9 about it, I can recall saying, "What we have to do is
10 get to grips with it now and perform by monitoring
11 properly, setting targets for our districts and making
12 sure that they achieved."
13 Q. What were districts not doing because of the lack of
14 effective supervision from Region at this stage?
15 A. At that review we were told that if things were -- we
16 were not getting the best for patient care because we
17 were not demanding more value for money from our
18 districts at that time; and that Region was seen to be
19 emasculated. It was just not doing as well financially,
20 getting the best value for money, as other regions
21 were. That was perceived as not the ability to do it,
22 but the style did not lend itself to actually get
23 districts to realise that Region was a force to be
24 reckoned with.
25 Q. Did you then, together with Mr Seccombe, change the
0030
1 style?
2 A. That was in April. By July, we were due to have
3 interviews for general management. We were told that if
4 we did not start achieving, we would have someone from
5 outside of the Region to actually come in and manage
6 it. So general management came in, we had interviews in
7 July, and I was appointed on 3rd August.
8 Q. And once appointed?
9 A. I changed the style.
10 Q. With success, would you say?
11 A. It was painful for quite a few people, but we did have
12 a region which was financially viable and did have --
13 it was perceived at that time -- good outcomes in most
14 services, and we did achieve quite a lot on community
15 care and mental illness and mental handicap and major
16 rebuilds with our DGHs. They gave me a CBE for
17 success.
18 Q. The good outcomes that you mentioned: is that talking in
19 terms of reducing the impact of disease across the
20 population?
21 A. I think it was the fact that we did achieve major leaps
22 in care in mental illness and mental handicap. We did
23 give good facilities and access for patients across the
24 Region to services, and we gave basically good
25 facilities for that. As a consequence, we did treat
0031
1 more cases and we did seem to keep waiting lists down
2 and we were seen to be moving in the right direction.
3 Q. In this same document, can we have a look at UBHT
4 102/434. Can we go to the top of the page? It is
5 regional services, the part that I want. The same
6 meeting:
7 "Mr Seccombe reported that the Minister had
8 expressed a desire for a rise in cardiac surgery cases
9 undertaken at the BRI to 600 a year."
10 This of course is talking of both adult and
11 paediatric, is it not?
12 A. Yes.
13 Q. "Mr Clarke noted this and said that this matter
14 epitomised the problem of a teaching district with
15 regional specialties that inevitably attracted a higher
16 percentage of patients from its own district than
17 others ..."
18 The desire that the Minister expressed for a rise
19 in cardiac surgery cases undertaken at the BRI to 600
20 per year: had you been present at the review meeting at
21 which the Minister had expressed that desire?
22 A. Yes, I believe that refers to the April meeting.
23 Q. The same meeting?
24 A. April 10th, if I recall.
25 Q. Your first one?
0032
1 A. Yes.
2 Q. What was the desire based on, as you understood it?
3 A. There was a feeling at that time, if I recall, that
4 regions should actually see more of their own cases to
5 make it easier for patients to be nearer their homes for
6 operations and recovery, and not to be travelling across
7 regional boundaries. Also, if you do not have a unit of
8 sufficient size, then it is questionable, the competence
9 of the specialists who work within it, because it is
10 like all rare conditions: unless you get enough cases,
11 maybe you are not sufficiently expert; you have not had
12 sufficient experience in actually dealing with them. So
13 higher throughputs, more cases, could actually improve
14 surgical outcomes.
15 Q. It appears from what is said in item number 3 that
16 cardiac surgery (for adults and at this stage it would
17 be all children) was a regional specialty.
18 A. Yes, in so much as I believe -- again, it is a long time
19 ago, 1984 -- the amount of children's services was
20 minimal. That probably related in 1984 to the amount of
21 expertise that was available. I believe at that time,
22 if I recall, we did do some cases at the Children's
23 Hospital. I think Miss Nibblett did some then.
24 Q. Shall we have a look, just to see the numbers that were
25 being quoted about this time, at DOH 4/28? You can see
0033
1 that this is for the under-1s. The over-1s are not on
2 this form. Concentrating on the under-1s, you can see
3 the pattern for 1982, 10; 1983, 4; 1984, 11; 1985, 14
4 open-heart surgery operations in a year, and then
5 palliative closed surgery, 1982, 24; 1983, 19; 1984, 30;
6 1985, 28; and definitive closed surgery, respectively
7 13, 11, 9 and 13. Those are small numbers.
8 A. Yes, comparatively.
9 Q. That supports what you were saying, I think, about the
10 contribution that surgery, at least on small infants,
11 made to the overall numbers of cardiac surgery cases
12 dealt with?
13 A. Yes.
14 Q. So what was in the Minister's mind at this time was
15 essentially adult care and the need to improve adult
16 care by increasing numbers of heart operations
17 performed?
18 A. Yes, particularly at the time we were sending patients
19 from Cornwall to London and of course our region was,
20 distance-wise, as far as Yorkshire is to London. So it
21 was perceived that that was a very long way for patients
22 to travel and then for relatives to visit.
23 Q. So at this stage the Cornish heart case went to London?
24 A. Yes.
25 Q. The Bristol Heart case would go to Bristol?
0034
1 A. Yes.
2 Q. The Welsh heart case?
3 A. Would go to St David's, I believe, in Cardiff.
4 Q. Cases of heart disease requiring operative treatment
5 from the north of the South Western regional health
6 authority area would go to where?
7 A. I believe the Radcliffe, it was then, in Oxford.
8 Q. Why is it, as you understand it, that those from
9 Cornwall went so far as to go to London rather than come
10 to Bristol?
11 A. That would be hard for me to say for truth, but
12 I perceive it as the fact that it was as easy for them
13 to get on a train at Truro and go directly to London
14 than it was to actually take a similar tortuous journey
15 to Bristol, and they were very happy with outcomes.
16 They seemed to enjoy it at the Brompton and come back
17 with no problem.
18 Q. So it was two things: one was ease of communication;
19 the second was satisfaction with the treatment?
20 A. Yes.
21 Q. What about those from the north of the Region?
22 A. They seemed happy too.
23 Q. For the same reasons?
24 A. Yes. I mean, Cheltenham to Oxford is not a terribly
25 long distance, and of course most of them at that end
0035
1 did have cars.
2 Q. But Cheltenham to Bristol is also a fairly easy ride, is
3 it not?
4 A. Well, their inclination at that time was towards
5 Worcestershire and Oxfordshire in services generally,
6 which was one of the reasons we changed the style to try
7 and get them up on board again with the Region.
8 Q. So the way you are talking, this is not unique to
9 cardiac cases?
10 A. No.
11 Q. This was across the board in a number of different
12 disciplines?
13 A. A variety of services.
14 Q. And just anticipating what you may yet say, you
15 attempted to bring back the throughput of patients from
16 those areas to Bristol in a number of different
17 disciplines, as you said your objective was?
18 A. It is more difficult because regional specialties were
19 very special cases. They were few and far between.
20 Prior to 1984, the patient choice had been very high and
21 it also often depended where a doctor had actually
22 trained. So you will find, I think, in Avon, a lot of
23 the GPs actually trained at the Bristol Royal Infirmary
24 and have a natural affinity. So consequently in the
25 Cotswolds, a lot of them had trained at the Oxford
0036
1 Radcliffe and had an affinity to refer back. So you do
2 find that tendency in some specialties, where medical
3 staff actually have old associations.
4 Q. When, as the years passed and you were managing this
5 situation, did you effectively secure, if I say "back"
6 I hope you know what I mean: did you secure back the
7 referrals from the north of the Region that you had
8 earlier been using to Oxford, across the whole pattern
9 of services as a general rule?
10 A. As a general rule, yes. Not only the pattern of
11 services from out of the region was not just -- we
12 actually made places like Cheltenham more
13 self-sufficient. We gave them improved facilities so
14 they could actually manage their own clients and
15 regional specialties because it was a top-slicing
16 scenario. If they still chose to send out of the
17 region, they would have paid twice for the case.
18 So money was a major factor driving the government
19 policy.
20 Q. What was true generally, was that true in the particular
21 case of cardiac surgery?
22 A. We did have a situation in some of the districts, and
23 I believe Cheltenham was one of them, where there were
24 less referrals for cardiac surgery because there was no
25 need for it and that was very hard to get over to the
0037
1 department at times: that not everybody in 1,000
2 population would automatically throw up X number of
3 cases. Some parts of our region, as it was so big, were
4 more healthy than others. I can remember having that
5 debate on many occasions. They were inclined to think
6 of numbers and not of specific places.
7 Cheltenham, if I recall, possibly because of its
8 hard water scenario, had a less need for cardiac open
9 surgery than would have been expected.
10 Q. So far as referrals were concerned, was there any
11 difference in the pattern of referral for cardiac
12 surgery than for other types of surgery which were
13 performed as specialties?
14 A. I honestly -- I could not swear to that. The Medical
15 Officer might have more information about that. We did
16 not have -- we had a lot of regional specialties at
17 Frenchay, but they were more specialised like
18 neurosciences where there are very few units that people
19 would refer to, so referral was automatic to places like
20 Frenchay. I could not swear to that.
21 Q. If we just jump forward, we have been looking at 1984
22 and I was asking you in the last few questions about how
23 referral patterns may have changed in the light of the
24 efforts you were making.
25 Can we jump forward and get some idea of how you
0038
1 saw it in 1991 by going to UBHT 38/430? It is a letter
2 I am going to come back to. This is a letter you wrote
3 on 20th November 1991 to Dr Roylance about cardiac
4 surgery. It is the second last paragraph:
5 "As a poor reputation takes an age to redress,
6 perhaps we can act now to prevent further deterioration
7 and syphoning off to Oxford and London."
8 Had there been deterioration and syphoning off?
9 A. That was a threat, now possible because contracting
10 allowed a purchaser to change his contract to another
11 provider unit, whereas before, as a regional specialty
12 with top-sliced money, the districts knew that they
13 really had to refer to the unit that Region was funding
14 because otherwise it would have to pay twice for
15 a case. Now there was a choice as a Trust (if it was
16 a Trust) to arrange a contract with another unit.
17 Q. It is the word "further".
18 A. Well, the point was that at those reviews, when one or
19 two DGMs said again they were having grumbles made to
20 them and it was a problem, and as it was an issue I had
21 raised before with this particular hospital, I really
22 felt that if we did not highlight this now, it would get
23 worse because they had had an opportunity before to
24 improve, which they seemed to have done for a while,
25 because the complaints had stopped, and now it was
0039
1 arising again.
2 Q. I will come back to the context, but what I am focusing
3 on is whether you saw there being any change with people
4 as it were voting with their feet by choosing to go to
5 Oxford or London rather than Bristol, which was
6 particular to cardiac surgery.
7 The words you use in the letter are "further
8 deterioration and syphoning off".
9 A. Yes. I have headed it "Cardiac Surgery", so I was
10 making it specific to cardiac surgery. This was not
11 a general letter to Dr Roylance.
12 Q. Does one get the view from that particular phrase you
13 used there that you had seen, in the years coming up to
14 November 1991, that there had been a deterioration and
15 syphoning off?
16 A. No, what I was highlighting there was, in fact -- maybe
17 it is badly worded, but if we did not prevent further
18 deterioration, there would be syphoning off.
19 Q. So the word "further" covers the deterioration but not
20 the syphoning?
21 A. Yes.
22 Q. The position is then, from what you were telling us,
23 that at the time that you wrote that letter -- as I say,
24 we will come back to it for its full context -- you had
25 seen no particular difference between the pattern of
0040
1 referral in cardiac surgery compared to other
2 disciplines?
3 A. If I recall, the date is November 1991. This was
4 already a Trust --
5 Q. Yes.
6 A. -- and in March, around about February, these units I am
7 talking about would be arranging their contracts. So
8 unless they acted between November and February, they
9 could find themselves in difficulty.
10 MR LANGSTAFF: Yes. Sir, I have noticed the time. Would
11 this be a convenient moment for a break?
12 THE CHAIRMAN: Thank you, Mr Langstaff. Shall we say half
13 an hour, so as to allow an element of lunch as well, and
14 reconvene, therefore, just after 1 o'clock?
15 (12.30 pm)
16 (Adjourned until 1.00 pm)
17 (1.05 pm)
18 STATEMENT BY THE CHAIRMAN:
19 THE CHAIRMAN: Mr Langstaff, before we begin this afternoon,
20 I think I would just like to say the following: that
21 from the Panel's point of view, we think we would be
22 failing in our duty if we did not repeat our concern at
23 the evidence given at the start of this morning's
24 proceedings. There may be an answer, but on first
25 impression, there is an apparent failure on the part of
0041
1 the Department of Health properly to respond to or to
2 take sufficiently seriously this Inquiry's legitimate
3 needs.
4 The Department of Health is not above this
5 Inquiry. We therefore expect, first, some explanation;
6 secondly, an assurance of full co-operation in the
7 future.
8 MR LANGSTAFF: Sir, perhaps, in anticipation that the Panel
9 might feel as you have expressed, I know that the
10 solicitor to the Inquiry is currently writing to the
11 Department of Health to ask for an explanation, if there
12 is one.
13 Q. Ms Hawkins, I have put up on the screen UBHT 156/208,209.
14 We were talking before the break about the number
15 of referrals that there may be, the referral patterns
16 and the like. What we are looking at here is a document
17 which comes from 1991, but paragraph 5.5.3 at the foot
18 of the page quotes 1987 figures.
19 I just want to see what implications, if any, it
20 would be right to draw from those figures. It says:
21 "The majority of [congenital heart disease] is
22 treated surgically by open procedures at the Bristol
23 Royal Infirmary or closed procedures at the Bristol
24 Children's Hospital. The 1987 rates were 24 open-heart
25 procedures and 10 closed-heart procedures
0042
1 per million ... population. If these rates include
2 a number of non-SWRHA residents, since the service is
3 supra-regional, the rates of 25 and 12 respectively.
4 The suggested surgical rates for children are 45 and 20
5 per million total population respectively. If all the
6 adults are included, the rates are 31 and 20. There
7 were 135 open and 88 closed cases from the whole
8 catchment area."
9 How big was the catchment area?
10 A. The Region was a 3 million population, if I recall.
11 Q. So if we go back to the foot of the last page, what one
12 would have expected for children is three times,
13 roughly, 45 and 20, per million. The rates in fact were
14 25 and 12, that would suggest that the number of
15 operations in fact being performed in Bristol was far
16 less than one might have anticipated from the population
17 size?
18 A. That is what it would indicate.
19 Q. Yet congenital heart disease, by its very nature, is
20 something which is likely to have an even distribution
21 per million population, per so many thousand live
22 births, is it not?
23 A. That is the statistical averages, yes.
24 Q. And does it follow that from these figures, one might
25 suggest that there is an element of congenital heart
0043
1 disease which was not actually being treated within the
2 Region, but was being treated elsewhere?
3 A. I really could not comment on that without having access
4 to figures. I presume that the Finance Department would
5 have been aware of that, because we would have been
6 requested money.
7 Q. You would have been requested money for the
8 supra-regional service?
9 A. They would have had a contract arrangement, and I think
10 our own Finance Department contracting section would
11 have been made aware that there were extra-contractual
12 referrals.
13 Q. This is looking at 1987 rates, of course, and in 1987
14 there was no internal market, was there?
15 A. No, but we were beginning to address contracting within
16 our Region. We were the first Region to actually begin
17 to investigate contracting, so we were beginning to
18 develop the costing of services so that we could
19 actually devolve down to districts the appropriate
20 financial allocations.
21 In that, we would have been looking at what the
22 cross-boundary flows would have been.
23 Q. It is right, I think, to say that so far as heart
24 transplants in the infants and neonates were concerned,
25 that is not work which Bristol ever did?
0044
1 A. No.
2 Q. So to that extent, if congenital heart disease required
3 treatment by transplant, it would not be done here; it
4 would have to be done there, wherever "there" was?
5 A. Yes.
6 Q. That might narrow the gap between the two rates. One
7 would have to obviously investigate the number of
8 transplants that were done and whether it could explain
9 the --
10 A. I would have thought they were minimal.
11 Q. Yes. So, on the face of it, one would be looking for
12 some explanation, would one not, as to why rates which
13 ought to be relatively constant in a given population
14 did not come for treatment in accordance with what one
15 might have expected?
16 A. A limiting factor might have been, of course, that this
17 was not a free-standing children's unit; it was part of
18 an adult unit, and maybe bed occupancy -- again, I am
19 making a supposition, but maybe bed occupancy with
20 adults actually limited the numbers of children that
21 went through.
22 Q. We have, I think, explored this on an earlier occasion
23 with Dr Roylance. I cannot put my finger on it for the
24 moment but I recollect that the answer we were given was
25 that the children did not suffer as a consequence of the
0045
1 adult throughput. That is the effect of it. I think
2 there are one or two anecdotal cases which go to the
3 contrary, but they are only anecdotal and do not detract
4 from the overall proposition.
5 So on the face of it, one has an unexplained gap,
6 has one, probably?
7 A. On my behalf, yes. I mean, I would not have been aware
8 of these figures on a personal basis. The RMO and the
9 finance man would be monitoring statistics at that stage
10 and only coming to me if there was a severe problem.
11 This is a supra-regional specialty, so doubts would have
12 been referred back up to the department, in fact.
13 Q. Do I take it that you personally did not get involved in
14 the detail of figures of this sort?
15 A. On a day-to-day basis such as that.
16 Q. On what sort of basis?
17 A. Waiting lists, outpatients against national targets,
18 whether there were identified problems, if there was
19 a very high death rate, if there was poor discharge rate
20 or referrals back in.
21 Q. At the very first review by the DHSS of Region, a point
22 was made by the Minister about the number, the
23 throughput, of cardiac surgical operations at Bristol,
24 you have already told us. Was it a consequence of that
25 that you took particular interest in the number of
0046
1 operations done thereafter?
2 A. We have to put cardiac services into the context that as
3 an RGM, my role was mainly strategic and financial
4 allocation and overseeing the general performance.
5 Specific figures like this would have been in
6 relation to a district's overall performance. Certain
7 specialties were a departmental issue. The basic
8 cardiac surgery unit adult cases would have been our
9 concern and were we actually hitting the targets that
10 had been funded; we would have got into those issues.
11 Only if there was a severe skewing or if in fact
12 districts had said to my Medical Officer or someone,
13 "We are not going to send there, so your figures will
14 be down; we are sending elsewhere", would the issue have
15 been raised with me on a day-to-day basis, because the
16 interactions of a Chief Executive at regional level is
17 totally different to that at district level.
18 Q. Can I take you back, in the light of those answers, to
19 1984, and can you please have a look at HA(A) 29/222?
20 I am sorry, that is the wrong reference, I will
21 have to come back to that; my apologies.
22 In 1984, before the service for neonates and
23 infants was made a supra-regional service, did you have
24 any knowledge of the numbers, the throughput of cases?
25 A. No, not on a specific basis.
0047
1 Q. Your statement suggests that you talk generally about
2 cardiac services without distinguishing adults from
3 paediatric?
4 A. Yes.
5 Q. When you talk about the need to increase numbers, you
6 say not only in relation to the 1982 review but also at
7 paragraph 7, which is page 2 of your statement, you are
8 referring to more than one review at which you were
9 asked to increase cardiac surgical numbers?
10 A. Yes.
11 Q. The view was, then, that throughout the 1980s the
12 numbers were too low, generally?
13 A. Certainly in the beginning of the 19 -- in the middle of
14 the 1980s. At that 1984 review the department suggested
15 that we should have, I believe it was a doubling of
16 throughput through the cardiac unit, but that would mean
17 a major capital investment.
18 In a subsequent one or two years, they were not
19 hitting the numbers that we expected, in spite of the
20 investment that was being made. We accepted at that
21 time that there may need to be a gradual build-up of
22 those numbers; that you could not hit them in Year 1 or
23 2.
24 Q. What sort of investment are you talking about?
25 A. The unit that was there in 1984 was not appropriate for
0048
1 a higher throughput, so we actually had a capital
2 project which rearranged the facilities there so that
3 there would be better nursing outlooks and allowed for
4 better nursing care and for more patients to be cared
5 for.
6 Q. And a major capital investment would suggest there was
7 alteration to the premises?
8 A. Yes.
9 Q. You use the word "review" in the plural, "reviews".
10 A. Yes.
11 Q. For how long did this practice of asking the Region to
12 increase cardiac surgical numbers at the BRI go on?
13 A. There were at least two reviews I can recall, because
14 I can remember a change of executive at the Department.
15 Q. So what individual was asking you, at Region, to
16 increase the numbers?
17 A. That would have been Len Page at one time, who was the
18 second Chief Executive of the Department.
19 Q. Len Peach?
20 A. That is right, Len Peach.
21 Q. And Victor Page?
22 A. Victor Page was not there in 1984, not at that review,
23 I do not think. He would have been at the 1985,
24 I think.
25 Q. So was it him, who is now Sir Leonard Peach?
0049
1 A. I suspect it would have been 1985/86 at least, those two
2 reviews, because that was the time of Martin Reynolds,
3 the then RMO, I recall. Yes, he was there two years.
4 We were having the debate about whether health
5 promotion/disease prevention would give better returns
6 in the end than spending money increasing the cardiac
7 unit. He was a very good community physician and
8 actually was trying to look at the longer term
9 consequences of any money that was expended.
10 Q. So, again, putting faces to job titles, the RMO you have
11 identified at the start of the period we are talking
12 about as Dr Reynolds. Who succeeded Dr Reynolds?
13 A. Dr Freeman.
14 Q. Who succeeded Dr Freeman?
15 A. Dr Alistair Mason.
16 Q. They are the individuals, are they, to whom any detailed
17 consideration of outcome statistics would have fallen?
18 A. Yes, because they would have been involved in the major
19 planning role at regional level.
20 Q. Can I ask you to go back to page 1 of your statement?
21 Scroll down, please, to paragraph 5 and paragraph 6.
22 First of all, paragraphs 4 and 5; let me see if
23 I can identify the document that you are talking about
24 here. It is 1989, so we will have to come back to it
25 because it does not quite fit into the chronology. Can
0050
1 we look at HA(A) 6/19?
2 That is Strategic Statement number 2, it is
3 a draft. Is that part of the series of service
4 strategic statements that you are referring to, or not?
5 A. No. The draft would not be the final document.
6 Q. Obviously.
7 A. So that would have been on the medical network.
8 Q. The medical network is what?
9 A. We revamped the Regional Medical Advisory Committee so
10 that it had representatives from every district serving
11 on it, as well as the Regional Medical Officer, and
12 I was a member, at that time, for the decision-making
13 meetings.
14 Each time we needed to look at acute or other
15 services, then the subject was given to the Regional
16 Hospital Medical Advisory Committee who would form
17 a sub-committee for the specialty under review, and they
18 would put together a strategic outline of the services
19 that were under review. They would take it back to the
20 main committee, who would take it to their districts and
21 when they signed up, it would form the strategic
22 statement for the Region. So all districts and all the
23 specialty people had been involved in developing the
24 service strategy.
25 Q. So we are looking at part of the process along the way
0051
1 to producing the service strategy?
2 A. Yes.
3 Q. You were speaking there of both the Regional Hospital
4 Medical Advisory Committee and the Regional Medical
5 Advisory Committee. Are they one and the same thing?
6 A. Yes. One changed into the other, because we then
7 subdivided. I believe prior to 1984, they had had an
8 Advisory Committee which was a mixture of primary and
9 secondary services, so we split it so it was definitely
10 hospital services and community services, so that the
11 GPs became involved in the development of primary care
12 services.
13 Q. Can I go back from the screen to page 1, where we were?
14 You have answered, I think, the question I had in
15 relation to the description you give in paragraph 3.
16 It was indeed, from what you say, the Regional Hospital
17 Medical Committee which became the Regional Hospital
18 Medical Advisory Committee?
19 A. Yes.
20 Q. So the "A" got added?
21 A. Yes.
22 Q. Again, so that I can follow, if we look at page HA(A)
23 6/22, if we just read paragraph 22, for a moment.
24 (Pause). Let us split the screen, please. We will
25 enlarge it in a moment for you. It is WIT 91/1,
0052
1 paragraph 5.
2 If we look at paragraph 5, item 20 recommends, and
3 if we look across, it is paragraph 22 in the draft which
4 presumably became item 20 in the finished report, did
5 it?
6 A. Yes, that is the same.
7 Q. If you can, at some time convenient to yourself, and
8 I hope with the assistance of the Department of Health,
9 put your hands on a copy of the finished product rather
10 than the draft --
11 A. I have one at home.
12 Q. You have?
13 A. Yes.
14 Q. Would you please send it through to us in due course?
15 A. If you are seeing Dr Mason, I am sure he could bring
16 one.
17 Q. Yes, please. Can we move from this back to the whole of
18 WIT 91/1? You talk at the bottom of the page of basic
19 statistics which have come into the hands of the RMO,
20 and appeared to show less good outcomes from surgery at
21 the BRI than other acute units.
22 Again, so we are clear what you are talking about,
23 is this all surgery? Is it cardiac surgery? Is it
24 paediatric cardiac surgery? What, in general?
25 A. That was a general comment made to me about surgery
0053
1 per se at the BRI. They could not at that time identify
2 which subspecialty it might be in, or whether in fact it
3 was all across the board in surgery.
4 Q. And the RMO that is talked about here, that is
5 Dr Reynolds, is it?
6 A. No, it is Dr Freeman, but I have been in touch with her
7 and she cannot remember that because it was a throw-away
8 remark at the time because they were not absolutely sure
9 about these figures, but at the time they were doing
10 a review of the cancer registry as well, so they had
11 looked at general statistics and that seemed to throw up
12 a blip in the BRI.
13 Q. So although it was something which she mentioned to you
14 as a throw-away remark, it is something you obviously
15 remembered?
16 A. Yes, because it is not very often you are told by an RMO
17 that a major teaching hospital may not be what it was
18 credited to be.
19 Q. And did you ask for any further enquiries to be done?
20 A. Yes. She was trying to pursue that at the time.
21 They were going to try and reanalyse statistics, but as
22 I have said before, it was very, very difficult in fact
23 to disaggregate statistics which were lumped together in
24 deaths and discharges. In fact, at that time, you did
25 not know when people left hospital whether they were
0054
1 dead or alive.
2 Q. The process now of knowing of outcomes through clinical
3 audit is very different, is it, from the process that
4 you had in the early and mid-1980s?
5 A. Yes.
6 Q. If we take up the way in which one might, in the 1980s,
7 have come to grips with the figures, can we perhaps have
8 a look at what was happening in 1989 and cast some light
9 back on what had happened before? It is UBHT 68/1.
10 That is the document we are going to look at, which you
11 recognise, I think: "The Regional approach to medical
12 audit."
13 Can we look at page 8, paragraph 2, "current
14 position ..."
15 There appears to be at this stage, 1989, as we
16 have seen, a variety of approach and practice. You are
17 nodding. I have to say that because that nod does not
18 go down on the transcript.
19 A. Yes.
20 Q. How accurate a description is paragraph 2 of what the
21 position was?
22 A. That is accurate based on the feedback we would have had
23 from our Regional Medical Advisory Committee who would
24 be in a position, as they represented their districts,
25 to come forward and say we do not have formal meetings,
0055
1 or we have formal meetings in geriatrics but we do not
2 in surgery, and also some had begun to have discussions
3 with colleagues where they would actually work together
4 and identify their own cases; others had said no they
5 would only work together if it was a lump sum for the
6 specialty.
7 So it was the Regional Hospital Medical Advisory
8 Committee who was able to advise us of what was actually
9 going on amongst medical staff in their own districts.
10 Q. Can we just scroll down the page 8?
11 "Basic requirements for medical audit include the
12 provision of timely, accurate and complete listings of
13 diagnosis, procedures and deaths within each hospital."
14 Drop down five lines:
15 "Currently available listings of procedures and
16 dealing noises are scarcely adequate for the RAWP
17 [Resource Allocation Working Party] let alone for
18 medical audit, as they are generally 6 months in
19 arrears, inaccurate and incomplete."
20 The reason is given for that: that they were
21 developed by people who are removed from the actual
22 clinical operations or procedures to which they relate?
23 A. Yes. They were not computerised.
24 Q. So this is a general picture, again, as opposed to
25 specific to cardiac surgery?
0056
1 A. Yes.
2 Q. But this would mean, would it, that in 1989 there simply
3 was no reliable information that one could have at
4 regional level as to how a hospital was performing in
5 terms of the results for the patient?
6 A. I think that is fair comment.
7 Q. Which would make it difficult from a regional
8 perspective to know whether a specialty was or was not
9 performing as it ought to?
10 A. That is true.
11 Q. You tell us in your statement words to the effect that
12 for some time before 1989 you had heard or had some
13 concern that cardiac surgery in Bristol was not up to
14 scratch.
15 A. It was a fact that at district reviews in the north and
16 the south of the county, DGMs advised us not always
17 formally in a meeting but sometimes at lunch afterwards
18 that they had cardiologists who were not happy with the
19 Bristol unit. Part of that, they thought, might be
20 historical because people had been used to sending
21 patients to the Brompton and to Oxford, but partly they
22 thought that there was a general dissatisfaction with
23 outcomes, whether operations were done in time, whether
24 the patients waited too long, but they could not be
25 specific and their cardiologists would not come forward
0057
1 to make statements.
2 Q. Can I put flesh on this? These were conversations that
3 you had not just in the formal review but around it?
4 A. Yes.
5 Q. Because if one looked to the formal review, was the
6 formal review minuted?
7 A. If it was raised as an issue, if we were having
8 a dialogue about cardiac surgery and a concern was
9 expressed, then it may well have been minuted, but
10 again, in those days, it was very difficult, unless you
11 had evidence, to name or shame a doctor.
12 Q. At least the general position, appreciating that cardiac
13 surgery may be slightly unusual because of the
14 cardiothoracic register, but the general position was
15 that you would know that you had not got chapter and
16 verse to go on because that was the defect in the
17 information systems at the time?
18 A. Yes. We had a hint that -- we had hints, but we also
19 had a situation where cardiologists who were
20 dissatisfied were still referring.
21 Q. So, when were the district reviews at which or around
22 which these concerns were expressed?
23 A. That varied in time. It is very hard for me to
24 remember. I know that they were raised in -- I know for
25 sure they were raised in 1990 from one particular
0058
1 district.
2 Q. Exeter?
3 A. Yes. Before that, I believe it was about 1987.
4 Q. Do you remember from where?
5 A. I have a feeling that that is Cheltenham, but the DGM
6 has died since, I am afraid, but I think it was
7 Cheltenham.
8 Q. Who else would have been present at the meeting that
9 might remember?
10 A. My Finance Officer was always there. The other officers
11 varied, depending on what was being discussed. Exeter,
12 definitely the finance man was there. He was present at
13 all reviews.
14 Q. And he was --
15 A. Mr Arthur Wilson.
16 Q. So going back to what you can recollect about
17 Cheltenham, probably 1987, thereabouts, you are not
18 quite sure, do you recall the way it was put to you?
19 A. That was not in a formal context; that was over lunch
20 where Mr Hammond said, "You know, we are not really
21 happy with referring to the BRI; we would rather go to
22 Oxford". Asked why, again we had this, "Well, we are
23 not absolutely sure but they are not too happy with the
24 performance of the unit". We did ask them to be more
25 specific.
0059
1 Q. Specific as to the performance?
2 A. As to what the real anxieties were about because unless
3 you had that sort of evidence, you could not go back and
4 challenge the DGM and his consultants, who were not part
5 of the regional staff unless you had something very
6 specific to hang on to. You could convey the concerns,
7 but you could not say what those concerns actually were.
8 Q. The cardiologist who would have inspired the DGM's
9 expression of concerns to you would probably be an adult
10 cardiologist, would he?
11 A. Yes.
12 Q. So are we to take from that that probably these concerns
13 related to adult rather than children's services?
14 A. I have never had an official or informal hint about
15 paediatric service.
16 Q. Neither formal nor informal?
17 A. No. Not to me personally.
18 Q. You were quoted, I think, on Newsnight. I do not know
19 if you saw the programme and heard the quotation that
20 was ascribed to you?
21 A. Vaguely.
22 Q. Can I read it out to you as what was said:
23 "Newsnight can reveal that it was some ten years
24 earlier when serious misgivings about Bristol's record
25 for adult heart surgery were voiced by the woman in
0060
1 charge of the health service in the west to the
2 Department of Health. Catherine Hawkins was Chief
3 Executive of the Regional Health Authority from 1984 to
4 1992. She declined to be interviewed on camera, but has
5 told Newsnight of her considerable concerns about the
6 role played by the Department of Health. A letter to
7 Newsnight says that in the late 1980s there was pressure
8 from both District Health Authority and Whitehall to
9 expand the cardiac service, despite warnings that all
10 was not well.
11 "'At many of our District Health Authority
12 reviews, we find a reluctance to encourage referral by
13 the cardiologists to the BRI because of, and I quote,
14 unsatisfactory outcomes, close quotes. These views
15 caused me sufficient disquiet to actively resist the
16 rapid expansion of the service.'
17 "She also told Newsnight that in 1988 her own
18 Medical Officer warned her of a high death rate for
19 adult heart surgery. Ms Hawkins says she raised this
20 matter with officials from the Department of Health on
21 several occasions", and again there is a quotation:
22 "'Civil servants were hell bent on the numbers
23 game. They were not bothered about the outcome of the
24 operations; they just wanted to be able to quote a big
25 increase in the number of operations being undertaken.'"
0061
1 First of all, are those quotations accurate in the
2 sense that they come from a letter or from what you said
3 to Newsnight?
4 A. The majority.
5 Q. The first of those quotations:
6 "At many of our District Health Authority
7 reviews, we find a reluctance to encourage referral by
8 their cardiologists to the BRI because of, and I quote,
9 unsatisfactory outcomes, close quotes."
10 Did you say that to Newsnight, either in writing
11 or orally?
12 A. Yes, because that, in the 1980s, was the feedback we
13 were getting.
14 Q. You say: "At many of the District Health Authority
15 reviews".
16 A. Yes. Well, two or three I consider many.
17 Q. Because so far you have told us of Exeter in 1990 and
18 Cheltenham in 1987. Was there any other you can recall?
19 A. When we first started raising the issue of the fact that
20 we would have to develop the BRI, we did have feedback
21 then that they did not want to refer; they wanted to
22 continue with Oxford and Brompton. That was not Avon,
23 because Avon had always referred to the BRI, but the
24 other districts did not want to go along that line.
25 Q. You asked for the reason for that?
0062
1 A. Yes, and as I say, part of that could have been the fact
2 that they were used to the pattern of referral and they
3 told us patients were happy with that but we still had
4 them saying, off the record, the cardiologists, that
5 their doctors, in quotes, were not happy with referring
6 to the BRI.
7 Q. The words ascribed to you by Newsnight were, "and
8 I quote, unsatisfactory outcomes ..."
9 In other words, those words, unsatisfactory
10 outcomes, were being used to you in the course of one or
11 more of these discussions, were they?
12 A. Yes.
13 Q. So DGMs were telling you that their cardiologists were
14 unhappy about unsatisfactory outcomes?
15 A. They may not have said "cardiologists" specifically, but
16 they referred to their "doctors".
17 Q. So you had expressed to you reluctance to allow the
18 expansion of the BRI, cardiac surgery generally, adult
19 cardiac surgery. Did you ask your RMO to investigate?
20 A. In that scenario, again, without very specific evidence
21 or what he would be investigating, that was extremely
22 difficult to do. In a situation where we would have to
23 ask the individual doctors concerned for their specific
24 cases, could we look at all their records, also, we did
25 not have the manpower for that at that specific time, so
0063
1 I referred the matter back to the DGM, who should have
2 done that.
3 Q. So you could, could you, have asked your RMO, or indeed,
4 even yourself asked the unit at Bristol to provide
5 comparative statistics such as they had of their
6 performance as contrasted with national performance?
7 A. To my knowledge, you could not have done that because
8 units were reluctant to give up their figures. I spoke
9 to the RMO before about that, and he said, well, you
10 would never get a comparison because they do not want to
11 give their statistics.
12 Q. So although you as Region were responsible for the
13 performance of the unit, and although your Chairmen
14 could talk and achieve results with the Chairmen of the
15 unit, you would not have been able to find statistics of
16 outcomes even if they had them?
17 A. We were not responsible for the performance of the unit;
18 we were responsible for monitoring it, but the BRI was
19 responsible for the performance of the unit.
20 Q. Let us stick with monitoring. Monitoring involves
21 getting figures and seeing how they compare against some
22 standard?
23 A. I think in hindsight that is easy to say. If you were
24 there at the time, in the 1980s, that was not easy to
25 do.
0064
1 Q. Did you or your RMO try to get the figures from the BRI?
2 A. I would have to say no, because I would not have had the
3 evidence to go in and demand such figures. A reluctance
4 on the part of districts who were very content to refer
5 out of region and not to the BRI, without being able to
6 identify what they meant -- what did they mean by
7 unsatisfactory outcomes -- was not a reason to put in
8 two or three people to try and identify and collate
9 statistics by hand, which is what it would be. There
10 was no computerised record at that time.
11 Q. In 1991, as we have seen, in the letter I said I would
12 come back to, and I shall, you wrote to the Trust as it
13 then was and said, "We have had concerns, not very
14 specific concerns, expressed in Exeter", and you wrote
15 to alert them of that fact in order to gee them up to
16 make sure that there was no further deterioration or
17 syphoning off.
18 If you could do that in 1991 when the relationship
19 between the Region and the hospital was not as direct
20 perhaps as it had been before 1991, why could it not
21 have been done in the 1980s?
22 A. I suspect, if you find the review between Bristol and
23 the Region, you will find that it is a formal item on
24 the agenda, and they were asked to go and investigate.
25 I am pretty sure that happened.
0065
1 Q. So the answer may be that figures were asked for by that
2 route?
3 A. No. I do not recall asking specifically for figures.
4 What we would have been asking for is for the DGM to
5 investigate why there were problems there, and were
6 there problems there.
7 Q. And the DGM would be the DGM of the Bristol & Weston
8 Health Authority?
9 A. Yes.
10 Q. Do you recall yourself, or do you understand that your
11 RMO ever spoke to Dr Roylance about these concerns?
12 A. If I recall, there is somewhere on 1980's, in quotes,
13 reviews, an item on that subject with the Bristol
14 authority. I have spoken to him informally about
15 problems there.
16 Q. Do you recollect when it was that you spoke to him
17 informally, roughly?
18 A. Roughly? It must have been, I think, round about 1987.
19 Q. Once or more than once?
20 A. It would have been more than once because I would have
21 had some feedback on it. If I had said to him, "Have
22 you got a problem", I would have expected him to come
23 back and tell me what the problem might be.
24 Q. Do you recall as best you can how you raised it with
25 him, what sort of thing you said?
0066
1 A. I would have told him that we had had bad feedback from
2 other districts and that it looked as though there might
3 be a problem, did he think there was and if he did,
4 could he go and investigate.
5 Q. Do you recollect the feedback that you got?
6 A. Yes. He told me that they had identified an individual
7 that they thought might be the problem, and that they
8 were going to change that situation in the unit and
9 another consultant was being appointed and things should
10 get better.
11 Q. You can answer the next question "Yes" or "No". Did he
12 identify the individual, the particular doctor who was
13 thought to be the problem by name?
14 A. Yes.
15 Q. Was he a surgeon in cardiac surgery?
16 A. Yes.
17 Q. So far as you are aware, did he retire shortly
18 afterwards?
19 A. Yes.
20 Q. After that, do you recall any further expression of
21 concern by DGMs of districts other than Bristol
22 & Weston?
23 A. I really cannot recall that --
24 Q. Until the time you came to Exeter?
25 A. It seemed to go quiescent until round about late 1990.
0067
1 I believe in 1990 we held reviews in December.
2 Q. I know you have been answering from memory, but if we go
3 back to page 2 of your statement and go to the foot of
4 it, the third paragraph in paragraph 11, you have
5 identified the additional consultant who was to make
6 a difference and that was, as it turned out, to be
7 Mr Dhasmana.
8 A. Yes.
9 Q. We know he was appointed in 1986, so the time that
10 you were looking at must have been a little bit earlier
11 than 1987?
12 A. Yes, roundabout then.
13 Q. Can you help with whether you ever raised with the DGMs
14 elsewhere whether things now seemed to be better or all
15 right or words to that effect?
16 A. It sounds -- I mean, that would have been done on an
17 informal network, because I did have AGMs who were
18 responsible for individual districts, and that would
19 have been done when they actually sat with them to see
20 what should be coming up as agenda items at our
21 reviews. I mean, cardiac surgery was a very small part,
22 as I have tried to explain, of the total acute and other
23 services in the Region, so it was not high on my agenda
24 every single time I sat down with a DGM.
25 Q. If one scrolled up to paragraph 7 on the same page,
0068
1 maybe you have just given the reason why you put it this
2 way, you desire:
3 "The main catchment area for the BRI .... Local
4 cardiologists did not state dissatisfaction ..."
5 It is a double negative. Did you put it that way
6 because they were saying they were dissatisfied?
7 A. No, there was never any issue from the cardiologists
8 from the BRI or around Somerset that there was a problem
9 with the unit.
10 Q. Because inevitably you will be more concerned about
11 complaints than simply having someone give you a pat on
12 the back?
13 A. Yes.
14 Q. Was it part of the style that existed before you came to
15 your appointment, the 'being too friendly' approach that
16 you described earlier, that management would not follow
17 up matters that needed to be followed up, or see whether
18 problems had actually been resolved?
19 A. I mean, at that review, Ministers did not describe in
20 intimate detail what they considered. I had only been
21 there for a month. I had come from district where we
22 actually thought Region was very nice, but you could get
23 away with it if you wanted to.
24 Q. That is what you had to set out to change?
25 A. Unfortunately, yes.
0069
1 Q. Was it a case, then, looking back, that it had been the
2 "old pal's act": if you got on well with someone, then
3 things were assumed to be okay instead of proved to be
4 so, or what?
5 A. Well, Region was very supportive if you were having
6 difficulties. I recall that very well but they did not
7 challenge you very often. They did not set you firm
8 goals. I suppose, yes, if it seemed all right, you were
9 left to get on with it, which was good in one way, but
10 it did not stretch you in other ways.
11 Q. You had to be challenged rather than comfortable?
12 A. It is very easy to think you are doing well all the time
13 when you may not be, and it is only an outsider who can
14 actually tell you that, sometimes.
15 Q. If you had been asked to do so, how would you have
16 challenged the style of management which you saw being
17 adopted in the Bristol & Weston District Health
18 Authority after 1985?
19 A. That has been very difficult, because the management in
20 the BRI adopted a style that had been utilised in Exeter
21 with a specific DGM who had been very well regarded by
22 the department. I suspect that the BRI management may
23 have modelled themselves on that style. It may worked
24 in Exeter, but it was different in a teaching
25 authority.
0070
1 So Dr Roylance did come very often to discuss
2 various problems and issues that were confronting him.
3 He did come to see me and I did try to steer him through
4 that but I could not shake his belief that the style he
5 was operating might actually run away with the
6 management at the end of the day. But I do suspect that
7 he did model it on somebody who had been successful with
8 it.
9 Q. How would you describe -- I want you to be as
10 even-handed as you can about this -- the advantages and
11 disadvantages of the style that you saw him adopting?
12 A. I believe he had the confidence of the medical staff,
13 which is a very good thing for an NHS manager to have.
14 He had a very good brain, so he could argue very
15 cogently with his peers and he did have a belief that if
16 you gave a specific budget to someone, they had to live
17 within it come what may.
18 I believe his weakness was that he did not fully
19 appreciate the politics in a teaching hospital with
20 a big and a small "p" and that, because he tried to be
21 so even-handed, he was not always seen to be in charge.
22 And his style cascaded down through some of the senior
23 management. That meant there were some loose cannons.
24 Q. When you say his style cascaded down, you mean some of
25 his senior managers adopted it?
0071
1 A. Yes.
2 Q. That meant that others who should have been restrained
3 were free to do as they please?
4 A. I think also the other side of that coin was maybe some
5 of the people who would have liked things to be under
6 tighter control actually held back from expressing those
7 views because they thought that the power bases were
8 actually stacked up against them.
9 Q. Can we go back from that discrete topic to the question
10 of the concerns that you heard being expressed and the
11 way in which you approached them? Newsnight record you
12 as saying -- I will remind you of the quote again
13 because I do not have it in a document and cannot
14 therefore put it up on the screen for you:
15 "At many of our District Health Authority reviews
16 we find reluctance to encourage referral by their
17 cardiologists to the BRI because of, and I quote,
18 unsatisfactory outcomes. These views caused me
19 sufficient disquiet to actively resist the rapid
20 expansion of the service."
21 That last sentence:
22 "These views caused me sufficient disquiet to
23 actively resist the rapid expansion of the service."
24 Is that a faithful reproduction of what you told
25 Newsnight?
0072
1 A. Yes. It is what I told the Department. I resisted them
2 on one or two years.
3 Q. So it is true that is what you did, is it?
4 A. Yes.
5 Q. How did you actively resist the rapid expansion of the
6 service?
7 A. We would not put the capital investment in.
8 Q. So region had funds which it could have allocated to the
9 development of cardiac services but chose not to do so?
10 A. No. The point was that we could make it a top priority
11 and let something else go for that year, but while
12 we were actually investigating whether it was the best
13 place to expand, then we spent capital monies on
14 developing other DGHs.
15 Q. Where else would you have expanded, if not at the BRI?
16 A. At Derriford in Plymouth.
17 Q. Did you subsequently in fact expand at Derriford, or
18 not?
19 A. I believe it happened just after I had left, in the
20 early 1990s.
21 Q. You said that:
22 "While we were actually investigating whether
23 it was the best place to expand, we spent capital monies
24 on developing other DGHs."
25 What investigations were undertaken to see whether
0073
1 it was the best place to expand?
2 A. My capital planner did a detailed planning option and
3 a cost benefit analysis.
4 Q. Just looking, therefore, at the costs on the one hand
5 and the benefits on the other; how were the benefits
6 measured?
7 A. It was trying to do a comparison with number of cases
8 that might be referred from the south of the region, how
9 it would affect the unit at Avon, and whether in fact
10 Somerset would switch allegiance and go down and whether
11 there would be enough cases going through that unit to
12 make it one of expertise.
13 Q. You say that -- this is paragraph 9 -- that you did
14 advise the DHSS that you had a preference for another
15 unit in Derriford?
16 A. Yes.
17 Q. And you say while you were evaluating whether that would
18 prove more beneficial for patients -- you are talking
19 again about adults here?
20 A. Yes.
21 Q. Would it have been part of the other unit, that you
22 would have anticipated it dealing with children over the
23 age of 1?
24 A. Yes. If there had been sufficient numbers, and from
25 statistics it looked as though there would have been.
0074
1 Q. Was not one of the risks that you would end up with two
2 small units, both of which were too small to be
3 effective and to achieve, rather than one larger unit?
4 A. Yes. That came out in the cost benefit analysis, that
5 to start with, the two units would be too small so we
6 would need to expand the Bristol Royal Infirmary first
7 and then look at another unit.
8 Q. You say in paragraph 9:
9 "The DHSS placed it as a requirement to increase
10 the BRI unit".
11 A. Yes.
12 Q. Therefore you were trumped, as it were, by higher
13 authority?
14 A. Yes. You can resist the Department for so long.
15 Q. Who told you to get on with it?
16 A. It was then set on my personal objectives as a task.
17 Q. By whom?
18 A. It would have been the Chief Executive.
19 Q. You describe the response that the north and south of
20 the Region gave to that. How was that expressed?
21 A. Again, a general disquiet. I mean, it is a problem that
22 people were not specific but again, you do not know
23 whether that was based on historical alliances.
24 Q. Again, in paragraph 10 we have something which may be
25 the passage of time, but it is inevitably perhaps vague:
0075
1 "Some DGMs gave vague indications that
2 cardiologists felt BRI outcomes could be better but
3 could not be specific in their concerns."
4 There are about five vague words in that
5 sentence. Can you help us to put more detail on that?
6 A. If I recall, some of the issues were that because
7 throughput was not very good, then if they referred,
8 patients may wait too long and therefore they would be
9 happier to send them somewhere elsewhere they knew they
10 would be seen in a shorter space of time.
11 Some felt that they could actually do all the
12 tests that were required but if they sent them to the
13 BRI, very often tests were redone and they did not seem
14 to have a working protocol between them, which meant
15 that may be the selection of cases was not being
16 adequately addressed. Those sorts of issues.
17 Q. From which part of the Region did Mr Seccombe come?
18 A. You mean where was he based? Where did he live?
19 Q. Yes.
20 A. Mr Seccombe was Cornish.
21 Q. Was he personally nearer Plymouth than Bristol?
22 A. Yes, he lived just over the bridge, over the Tamar.
23 Saltash.
24 Q. To what extent did that perhaps natural local alliance
25 that he may have had play any part in the view that
0076
1 there needed to be a centre at Plymouth as in Derriford?
2 A. No, Mr Seccombe never had Cornish "hang-ups" in that
3 way. He looked at the region as a region. He did feel
4 that Derriford would run a very good unit, but that did
5 not affect his judgment.
6 Q. Can I move forward from the mid to late 1980s, the
7 period which you have been covering thus far in your
8 statement, and ask you if you would to look at HA(A)
9 24/6. This is the Regional Health Authority, District
10 Health Authority Review 1991. Can we go over to the
11 second of the pages, page 7, and scroll down, please?
12 "Heart disease/cardiac services:
13 "The DHA meets adequately the Region's targets for
14 open-heart surgery for children and for valve
15 repair/replacement. It meets approximately two thirds
16 of the target for coronary artery bypass grafting ...
17 the authority has not been able to increase investment
18 in cardiac surgical or cardiological services."
19 This is 1991. Is this the Regional authority that
20 has not been able to increase investment?
21 A. No, 1991 would be the responsibility of the Trust from
22 March, and I would have thought that that relates to the
23 increase in medical staff because, from my recollection,
24 the unit could have handled up to 1,100 cases in a year
25 and should have been gradually building up to that, but
0077
1 they were requiring more and more medical staff to do
2 that.
3 Q. It goes on. Since we are on this document, let us
4 notice it now, that the next two sentences are dealing
5 with getting numbers for audit which plainly, if it is
6 describing collaboration taking place, suggests that
7 there had not been a sufficient reporting back on
8 numbers and outcomes before then?
9 A. Yes. As I said, you had to have the agreement of
10 doctors to do audit; it was not something you could
11 impose on them.
12 Q. And that was very difficult, was it?
13 A. It was difficult enough that we actually gave
14 a dedicated individual from Region to get the processes
15 going in at all acute units.
16 Q. Can we go back to your statement? Page 3,
17 paragraph 12. "RTO" is what, Regional Team Officer?
18 A. Yes.
19 Q. And who would attend a Regional Team Officer meeting?
20 A. Myself, the Finance Director, the Medical Officer, the
21 human resource director, the capital planner and the
22 service planner.
23 Q. So in essence, the senior management team?
24 A. Yes.
25 Q. And you set out the four points that would have led you
0078
1 to conclude that Derriford was preferable. Item D:
2 "The DHSS was insisting we increase cases
3 undertaken, in spite of the fact we had raised concerns
4 on outcomes with them on a consistent basis."
5 A. Yes.
6 Q. We have dealt thus far with people reporting concerns to
7 you in the way in which you best remembered. If the
8 word is "we", I think that means the Region, does it?
9 A. Yes.
10 Q. How did the Region raise concerns with the DHSS?
11 A. Initially, when we were resisting the increase in the
12 middle 1980s, we would have raised that in the review
13 process in conversation and we would have done it also
14 with our regional liaison officers because we had
15 a gentleman from the department who came periodically to
16 see us and discuss items of particular interest and also
17 to prepare items for the ministerial RHA reviews.
18 Q. Were the ministerial RHA reviews minuted?
19 A. Yes, but not everything discussed was minuted.
20 Q. Would something like this be minuted?
21 A. Not necessarily. If it was something that you could not
22 prove, it would not necessarily be recorded.
23 Q. In what terms do you recollect it having been raised
24 with whoever it was from the DHSS?
25 A. We would have told them that we had had hints from the
0079
1 districts that they were not happy with the services
2 that were being provided.
3 Q. With the services, or with the outcomes?
4 A. You know, it is the same thing, because if you have
5 an input and a bad output, then the service is not
6 satisfactory. The service per se is not satisfactory.
7 Q. But one could talk in terms of quality of service by
8 meaning waiting lists, quality of hospital services,
9 hotel services and so on?
10 A. Well, again, recollecting we would not necessarily have
11 been specific to the last detail, we would have told
12 them the service is not necessarily the best; we would
13 like to have continued with Oxford or the Brompton. The
14 Brompton we were very happy with.
15 Q. Do you recall anyone actually using the word "outcomes"?
16 A. We would have quoted what was said to us, but again, we
17 would have been asked the question, what is the outcome,
18 and we would have to say they could not identify that.
19 Q. Do you recall anyone actually asking you that, what was
20 the outcome? What are the outcomes?
21 A. I could not be that specific at this point in time.
22 That is a long, long time ago but I would be, knowing
23 the individual I am, I am pretty sure I would have
24 quoted it.
25 Q. Let us be hypothetical for a moment. Suppose somebody
0080
1 had said to you: "What are the outcomes?", you would
2 have said: "I do not know because they will not tell
3 us", or, "we cannot find out".
4 A. I would have said to them, they do not seem to be happy
5 with the results, and we are not in a position to
6 identify that because either they will not say or we do
7 not know what those outcomes are, because we do not know
8 the cases involved.
9 Q. And there it would have rested, would it, at that time?
10 A. We would have expected them to go away and discuss that
11 in their medical division. We would have expected that.
12 Q. Do you remember anyone from the medical division in
13 particular to whom you spoke?
14 A. No. There was always a medical officer at the review.
15 Q. So it would have been him or her?
16 A. It would have been him, because the two chief medical
17 officers were always him. It might have been a her;
18 Dr Wolford came sometimes.
19 Q. You say at the bottom of paragraph 12, that you took the
20 matter to the Regional Health Authority:
21 "It was agreed to invest capital monies in the
22 BRI. The project was completed."
23 The project was what, the expansion?
24 A. It was the redevelopment of the ward area, upgrading it
25 and improving it, and theatres.
0081
1 Q. There is a typo which follows, I think, because you mean
2 the unit was able to double, rather doubt, its
3 throughput?
4 A. Yes, I am sorry. Yes.
5 Q. When next, after this, was it that you heard further
6 concerns expressed?
7 A. I think that must have been late 1990.
8 Q. So what you say, at the top of paragraph 13, just scroll
9 down, although no doubt the best of your recollection
10 when you wrote your statement, is not quite your
11 recollection now. Your recollection I think now is that
12 it was not the latter part of the 1980s, it was actually
13 the very early 1990s?
14 A. Yes. It certainly was the late reviews in 1990.
15 We held them very late because they were going to be
16 Trusts in 1991, so it must have been December time,
17 I think, 1990.
18 Q. And some DGMs, again, relayed some concerns of some
19 cardiologists?
20 A. Yes.
21 Q. You have only told us so far about Exeter. Who else?
22 A. If I recall, Plymouth was not too happy. But again,
23 they had not got the unit that they had wanted.
24 Q. So this might be local pique?
25 A. It was very hard to tell in those days.
0082
1 Q. You are obviously aware of the politics in a teaching
2 hospital; you would know of the politics amongst the
3 districts. Did you see politics as playing a part in
4 this?
5 A. I have to say that politics, I thought, was playing
6 a part in it, but I also had reservations.
7 Q. And why did you have reservations?
8 A. Because I do not think, if you get grumbles coming and
9 then fading and then coming again, and then fading,
10 coming again, it is like a rumbling appendix, something
11 is wrong; something is not quite right. You may not be
12 able to put your finger on it or discover it, but it
13 needs monitoring and watching.
14 Q. So you had this unease and you conveyed the unease to
15 the DHSS, did you?
16 A. I would have conveyed that to the Trust team from the
17 Department, who were assessing at that time whether
18 these acute or community units should go forward for
19 Trust status, and I would not have thought it was
20 something to stop them going forward to Trust status,
21 but it would have been something to register with them
22 because they were going to be monitoring them.
23 Q. So you let them know so they could keep an eye on it?
24 A. Yes, because Trusts were not finalised or agreed until
25 the end of March 1991, but they needed to be aware that
0083
1 maybe there was something that needed to be kept an eye
2 on -- not the least that if other districts decided to
3 move their cases from there, then part of that unit
4 would not be liable. That had big financial
5 implications.
6 MR LANGSTAFF: We have reached the time I think of our next
7 break. May we now have a short break.
8 THE CHAIRMAN: Yes, 15 minutes, around a quarter to 3.
9 (2.30 pm)
10 (A short break)
11 (2.45 pm)
12 MR LANGSTAFF: Before I pick up the theme of concerns
13 expressed to you by DGMs, let me just ask you: in
14 respect of the DHSS, to whom had you expressed your
15 concerns, "you" being Region? You told us first thing
16 this morning that in your original draft you had
17 included a reference to your understanding as to when
18 it was that Dr Halliday came down to look at Bristol.
19 What was the context in which you said that,
20 hearsay though it may be?
21 A. The point is that while we were at DHSS reviews and
22 we were saying we are not absolutely sure that it is the
23 right thing to invest in the unit at the BRI, or at
24 a later stage where we would be saying we have had one
25 or two hints that things may not be satisfactory there,
0084
1 we would have expected, if the Panorama programme had
2 been correct in its portrayal, that if a Medical Officer
3 of the department knew from the Royal College that
4 concerns had been expressed about a very specific unit
5 and service in our region, that they would have informed
6 us, even if it was a supra-regional service children's
7 cardiac surgery; even out of courtesy, they would have
8 told us, if not me specifically, then my Medical Officer
9 on the medical network.
10 To my knowledge, that never happened.
11 If it had happened, then I believe the dialogue
12 we would have had with the department would have been
13 very different indeed.
14 Q. How would it have changed?
15 A. We would have asked, I think, that there should be
16 a situation where the Region and the department together
17 carried out a formal investigation and that could have
18 been with RHA members, not the executive but
19 not-executive directors, taking specialist opinion.
20 So I admit, I felt slightly aggrieved after seeing
21 that programme that they appear to have known something
22 was wrong at the time when we were uneasy, but did not
23 communicate that to us.
24 Q. Dr Halliday told us that he understood that the problem
25 with Bristol was the throughput of numbers and that all
0085
1 he heard about the quality of outcome was that Bristol
2 was not the best until, that is -- leave aside the
3 events of 1991/92.
4 Did the Department ever express a concern to you
5 about the throughput of cases in the neonatal and infant
6 category?
7 A. To my knowledge, no.
8 Q. Did they ever express the view that they had heard in
9 the corridor or through the back door that however good
10 or bad the results might appear on paper to be, their
11 view was that Bristol was not one of the best?
12 A. I can say no because if they had, I would have had
13 sleepless nights.
14 Q. Going back to your statement which is on screen, you say
15 in paragraph 13 that there were changes made in the
16 consultant staff at the BRI. I think that is
17 a reference to the retirement of the gentleman we talked
18 about earlier?
19 A. And the joining of another, yes.
20 Q. There were no problems referred to Region, and you
21 think, on reflection, having had a moment to think about
22 it, that the reference to the latter part of the 1980s
23 is really the early part of the 1990s?
24 A. Yes.
25 Q. You say:
0086
1 "Some DGM ..."
2 If you turn over the page, this is WIT 91/4,
3 paragraph 17:
4 "... at the 1990s reviews, Exeter in particular
5 asked if they could refer back to another hospital once
6 contracting from purchasers was introduced."
7 A. I think that would have been December 1990.
8 Q. What other DGMs relayed any concern to you about what
9 their doctors were saying at that time?
10 A. I believe again that that was around the Plymouth/Devon
11 areas.
12 Q. What sort of thing were they saying?
13 A. What they had said before: that they were not happy with
14 the service; they thought outcomes could be better, but
15 again, non-specific, but it was the same type of
16 complaint that we had before there had been changes in
17 the unit.
18 Q. Can we go back, then to the letter which we have at UBHT
19 38/430? Just up the top of the page, please, for the
20 date: 20th November 1991.
21 What was it that inspired this letter?
22 A. It is the comments that we have had when doing the
23 district reviews in relation to the fact that we were
24 moving into Trust status; contracting was a major issue;
25 they were not happy with the handling of their
0087
1 contracts; they were not happy with the service being
2 provided, they thought they would get better services
3 elsewhere; they really felt that when they had moved
4 into purchaser/provider separation, their purchasers
5 would want to shift away from the Bristol Royal
6 Infirmary.
7 Q. 20th November 1991 is of course some, what, six months
8 or so after the BRI became part of the UBHT. So, it was
9 already a Trust at this stage?
10 A. Yes.
11 Q. The meeting that you had at Exeter was the end of 1990?
12 A. Yes, as a purchaser. They were purchasers.
13 Q. Had there been any other round of meetings before
14 writing this letter?
15 A. What would have happened was that the AGM for those
16 areas would have been coming back to talk with my
17 officers about what should go on the agenda for
18 discussion, so there would have been informal contacts
19 about "When I was discussing this, I picked up ..."
20 So that would have been happening round about October
21 time.
22 Q. You say you had just finished the interim reviews?
23 A. Yes.
24 Q. October time, that is the interim review time, is it?
25 A. Yes.
0088
1 Q. So what had come back to you from the interim reviews
2 that made you write this letter?
3 A. What I have said: that the contracting was not
4 satisfactory, services they did not feel very happy with
5 and that they were considering moving contracts at the
6 first available opportunity.
7 Q. The contract would be a sum of money for a particular
8 throughput of operation. Am I right or wrong to suggest
9 that the essentials of it were cost and volume?
10 A. Initially, yes.
11 Q. And this, November 1991, is at an initial stage?
12 A. Yes, and the first contracts would have been arranged by
13 Region, which is why we would have been reviewing at
14 this stage whether they were satisfactory or not,
15 because districts had not set up a contracting
16 mechanism. They were doing that during 1991, ready to
17 take over in 1992.
18 Q. So 1992 was going to be the first time the districts
19 themselves exercised their autonomy?
20 A. Yes. In consultation with them, we had set the first
21 set of contracts.
22 Q. The second paragraph:
23 "Without exception the business managers were
24 identified as ' problems' in the negotiation."
25 That is the business managers of the Bristol
0089
1 Trust?
2 A. Yes.
3 Q. And what was the problem with the business managers?
4 A. If I recall, at that time they would have wanted more
5 the -- the cases to cost more than they actually could
6 get in other contracts for a similar service.
7 Q. So, it is the cost side of the cost/volume --
8 A. There would be difficulties about negotiating that; it
9 would not just be a simple one meeting; it would be
10 an ongoing dialogue for a while. If they were being
11 obstructive, then you could not process the
12 contracting. So they were going to hit deadlines not
13 having achieved the contracting time.
14 Q. So the dissatisfaction was with the process of
15 contracting and the difficulty of getting a price and
16 agreement out of the business managers?
17 A. Yes, because involved in that discussion would also be
18 a degree of case mix.
19 Q. Thus far, nothing about the quality of outcome?
20 A. Not that particular -- the business managers would not
21 have been involved with that.
22 Q. It is the business managers you begin to home in on in
23 this letter.
24 A. In that particular paragraph, yes, in relation to
25 contracts.
0090
1 Q. You go on to say and the third paragraph appears in the
2 language, does it not, to follow on from the second:
3 "As currently, we ... are reviewing cardiac units
4 and our needs and the fact we have invested in Bristol
5 to serve the Region, not just Avon, I would more than
6 welcome your comments and action if you feel you are not
7 in sympathy with the current rate and quality of
8 performance of the cardiac unit."
9 This letter is signed by you. Are those your
10 words?
11 A. Yes, but what we have to bear in mind is that just
12 before I sent this letter, I had had a dialogue with
13 Dr Roylance.
14 Q. Just before?
15 A. Yes, because it was at that meeting that I told him.
16 I mean, I would not just send him a letter out of the
17 blue. We did actually have a discussion about what
18 I found. I said to him, I am going to write to you
19 officially and I want you to take it to Mr Wisheart to
20 draw his attention to the fact that this unit is not
21 performing satisfactorily on all fronts.
22 Q. On all fronts?
23 A. Yes, because part of this in here, drawing his attention
24 to it, is about the quality of performance of the
25 cardiac unit and that is in totality, not just on
0091
1 contracts. I would have said the quality and
2 performance of your contracts.
3 Q. So let me just get the chronology right. In November
4 1990, you speak to Exeter and other DGMs?
5 A. Yes. My AGMs would have been doing that.
6 Q. And the feedback you get from your AGMs would come back
7 to you fairly quickly thereafter?
8 A. Yes.
9 Q. So by the end of 1990, you had a sense that Exeter,
10 perhaps Plymouth, perhaps Devon, were less than happy
11 with the service they were getting from Bristol, but you
12 did not write, at that stage, to anyone about it?
13 A. That would have been within a few days of this letter
14 going out. I would have -- as soon as I had all that
15 evidence, I would have had John over to talk to him and
16 quickly followed it up with a letter, because that was
17 agreed between him and I, that I would send him
18 a letter.
19 Q. Are you clear on the dates, because this letter, just
20 going back to the top of it, is 20th November 1991 and
21 you were telling us of the meeting with Exeter and your
22 report back from the AGM in 1990?
23 A. No, the 1990 related to formal reviews, so we would
24 already have had a discussion at formal reviews of
25 purchasers and providers, because they were providers at
0092
1 that stage, in 1990, in December and I would have told
2 the Department in 1990 that we were not too happy.
3 This review is in relation to the following year,
4 which is the purchasers, not the provider units, the
5 purchasers. We would have had a meeting with the health
6 authorities who were making contracts with purchasers.
7 Q. So can I go through the chronology again so I have it
8 right: 1990: formal review with Exeter, amongst others?
9 A. Yes.
10 Q. At which concerns are expressed to you about cardiac
11 surgery generally at Bristol?
12 A. Yes, and could I say, at that time Exeter were managing
13 their acute services.
14 Q. And you take those concerns to the DHSS?
15 A. To the team that are looking at Trust status for
16 specific units.
17 Q. But you did not raise those concerns at that stage with
18 Dr Roylance?
19 A. They would have been a part of his review as a provider
20 unit. Because they would have been still District
21 Health Authority controlled in 1990, they would have
22 still had a formal review with us.
23 Q. So that would have been raised with him at your review?
24 A. Yes.
25 Q. Do you recall whether it was or was not raised at that
0093
1 review?
2 A. I cannot recall, but I cannot possibly believe that
3 I have had that information and not conveyed it to him
4 at a review.
5 Q. So you cannot remember doing it but you must have done
6 it because that is the sort of information you would
7 deal with?
8 A. You pass it on, yes.
9 Q. Then you have the interim reviews of what are now the
10 purchaser units?
11 A. Yes.
12 Q. In 1991 you get the feedback from those and immediately
13 after getting that feedback, you think to yourself,
14 what, that the problem has not gone away since the
15 previous year?
16 A. It seems to be the same, and that, you know, this is now
17 a situation where they could become unviable financially
18 if this unit closes.
19 Q. There is nothing in the letter -- let us have a look at
20 the whole text -- about your having spoken to
21 Dr Roylance earlier about this issue?
22 A. No, because I told you, he and I met informally on
23 several occasions and that would have been one of those
24 types of meetings. The Region was in Kings Square
25 House. The BRI was literally 100 yards away.
0094
1 Q. And you meet him again informally prior to sending this
2 letter?
3 A. Yes, we discuss it.
4 Q. And you tell him what you are going to say, what you are
5 going to give him the impetus to do. This letter is to
6 inspire him or the basis for taking action, is it?
7 A. It is the basis to have a full and frank discussion with
8 Mr Wisheart.
9 Q. So what were you seeking to achieve by this letter?
10 A. What I was seeking to achieve was to raise the fact with
11 Mr Wisheart that not only was contracting an issue, but
12 that the general quality of performance of this unit
13 appeared to leave something to be desired, and were
14 there explanations for that that he could actually
15 quantify to Dr Roylance. Because if we had that,
16 we could either go back and reassure purchasers, or the
17 unit themselves could have done that in their
18 contracting scenarios. And of course, it is a fact that
19 if your business manager is not doing the best for the
20 unit, then the Medical Director should be having a say
21 in that. That is what Clinical Directors were for.
22 Q. Would it be right or wrong to suggest that this letter
23 was written by you in a supportive way as your way of
24 trying to help to resolve adult contracting?
25 A. It was written to support Dr Roylance in a difficult
0095
1 situation because he had been, to my knowledge, trying
2 to sort the problems out within that unit over a period
3 of years and it appeared that it still was not quite
4 right. So it was actually in support of the Chief
5 Executive.
6 Q. Because you understood from what he had said to you that
7 he was making efforts to sort out a difficult problem?
8 A. With the demise of one consultant, taking on another,
9 looking for a Chair of Cardiac Surgery and trying to get
10 investment, and with a paediatric pathologist on the
11 cards, all those things he had been trying to achieve:
12 very difficult in a teaching authority where money is
13 short, but he was trying.
14 Q. So, back to the letter. If we look at the words
15 themselves:
16 " ... more than welcome your comments and action
17 if you feel you are not in sympathy with the current
18 rate and quality of performance of the cardiac unit."
19 The words are somewhat Delphic, are they not?
20 A. If in fact he investigated and he was not satisfied with
21 what he heard, I expected him to come back and say,
22 "I believe that the current rate and quality of service
23 is bad and it is for all these reasons ...", and then
24 we would have picked it up in a different way.
25 Q. If it was to be suggested that those who dealt with the
0096
1 letter and responded to it viewed this as a letter about
2 contracting and not about the quality of outcome of
3 surgery, how would that strike you?
4 A. I would have said it was a clever sidestep.
5 Q. From what you are saying, Dr Roylance was well aware of
6 the motive behind the letter; indeed, you say you wrote
7 it to him to help him to deal with the problem that
8 he had. Did you ever speak to Mr Wisheart about it?
9 A. When I had a reply from Dr Roylance, I believed it was
10 not addressing the real issue, although I cannot
11 remember what the reply was.
12 Q. Again, so we are not at cross-purposes, if you had to
13 describe in a phrase the real issue, what is it?
14 A. The real issue is that there seemed to be general
15 dissatisfaction in a major part of the region which the
16 unit Medical Director appeared to be disregarding.
17 Q. It is three units out of the 11 that have expressed some
18 dissatisfaction.
19 A. As I have said to you, the point being that cardiac
20 surgery was not high on everyone's agenda but questions
21 were being asked; if we do not like certain units, can
22 we move? Implicit in that is the fact that they would
23 have been looking at services like cardiac services.
24 Q. The reply is UBHT 38/426. Can we scroll down, please?
25 It mentions that Exeter has voiced concerns directly to
0097
1 Bristol and repeats what James Wisheart has said to
2 Mr Roylance. This is from Dr Roylance. It deals with
3 the volume and that appears to answer any problem about
4 the rate, does it not?
5 A. Yes.
6 Q. He deals with the cost there, which I suppose is
7 an answer, is it, to the business manager point?
8 Overleaf, "Quality (Medical)", what you would
9 expect nationwide, and then "Quality of Care", and it is
10 quality in that sense, waiting times, which is then
11 focused upon.
12 Why do you say this reply did not deal with the
13 real issue?
14 A. Because it was statements actually saying that
15 everything was all right when in fact what was being
16 conveyed back was that it was not, and therefore we were
17 at a dichotomy between two opinions. That did not sit
18 easily with me because it did not seem to address what
19 the final outcome of treatment was all about. It is all
20 right to have a throughput, but I was not absolutely
21 confident that we were getting the best results,
22 particularly if people were waiting a long time to go in
23 for operations.
24 Q. If the outcome, at the top of the page, was "at
25 a quality level similar to that expected nation-wide";
0098
1 if, in other words, you could look at the UK Cardiac
2 Surgical Register and compare the results at Bristol
3 with that, then your doubts about the length of time
4 that children or others, adults, may have waited for
5 an operation would be resolved, would they not?
6 A. If a cardiologist tells you that he is not happy, even
7 if it is through a third party, that he is not happy
8 with the outcomes, then there is something wrong in that
9 service because he appears to be happy with other units.
10 Q. But other units he has not sent his cases to?
11 A. That he used to send his patients to.
12 Q. Why should the customer always be right?
13 A. I do not think in that sense I would perceive the
14 cardiologist as the customer. I think he was the agent
15 acting for the customer.
16 Q. What he may seem to be saying is that, because these
17 concerns had been expressed, they had to be right; no
18 smoke without fire?
19 A. No, I think they had to be thoroughly investigated, and
20 I was not at ease with this, that it had been properly
21 investigated.
22 Q. So what investigations followed?
23 A. I actually did not feel confident in this and I wanted
24 to speak to Mr Wisheart myself to see what he had to
25 say. So I did go to the unit myself.
0099
1 Q. When was that?
2 A. It was shortly after receipt of the letter.
3 Q. If you look at paragraph 18, it is page 4 of your
4 statement:"Following receipt of the letter from the
5 BRI ...", is that the letter I have just shown you?
6 A. Yes.
7 Q. "... I visited the unit again."
8 You use the word "again".
9 A. I had been there before as the RMO, but also when
10 the capital project had been completed, to go and see
11 our handiwork.
12 Q. You spoke to Mr Wisheart. Do you recall when exactly
13 this was, because the letter from the BRI to you was
14 dated 3rd January 1992.
15 A. No. I know it was one afternoon. I have not got my old
16 diaries, I am afraid.
17 Q. Roughly how long after getting the letter?
18 A. It would have been within the week, I think.
19 Q. What was said?
20 A. Mr Wisheart showed me around the unit and I spoke to
21 nurses and technicians and a few of the patients. Then,
22 when we finished, I said to him that I was concerned by
23 the fact that cardiologists, through their DGMs, were
24 actually raising concerns about outcomes. We did
25 discuss -- he did tell me that some of the cases that
0100
1 they had were very difficult. Some were being referred
2 too late and that age-related situations could affect
3 good outcomes.
4 I did say to him that he needed to be more
5 discerning in the type of cases that he attempted; that
6 obviously he needed to be competent, and confident, that
7 the cases he was treating would produce the best
8 outcomes; that he was having problems with referral, he
9 needed to speak to cardiologists to make sure that
10 referral rates and timings were much more appropriate to
11 the type of treatment to be given.
12 Q. Did he say anything about the overall figures and how
13 they compared with elsewhere?
14 A. He thought that they were performing satisfactorily, and
15 I said that with the best will in the world, you may
16 think that within a unit like this, where you might all
17 be reinforcing your own opinions, but if external agents
18 who are going to contract with you perceive that you are
19 not doing well, a reputation lost is very hard to get
20 back and therefore you need to get on board with your
21 purchasers to ensure that you deliver the service that
22 they require.
23 Q. So he essentially was denying the problem, was he?
24 A. I think he was saying that it was not a big problem.
25 Q. You said a moment ago that he said that they were doing
0101
1 satisfactorily at Bristol. In your statement you say in
2 the second sentence of the last big paragraph on page 4:
3 "He admitted they [the outcomes] could be
4 better ..."
5 How do I reconcile those two statements?
6 A. Because of the fact that he said at the time that they
7 were having too-late referrals, age could make
8 a difference, be it at the young end of the scale or the
9 other end of the scale. If they got patients that were
10 too old, for example, that that could have a bad outcome
11 and that could be affecting outcomes and that is when we
12 entered the dialogue about, then, you need to be
13 discerning about age relation, that you get them in time
14 and that people are referred properly and that you
15 change this perception that purchasers have.
16 Q. Did he actually say anything about the outcomes being
17 such that they should or could do better?
18 A. I recall that he said, yes, they could be better if
19 these things were changed.
20 Q. So in other words, the results were satisfactory for the
21 cases they were dealing with, as opposed to the results
22 were not satisfactory and in any event, there were these
23 problems?
24 A. Yes, against the fact that he thought that they were
25 having much more difficult cases than many units had and
0102
1 therefore the outcomes were reasonable, set against
2 those sorts of criteria.
3 Q. Was there anyone else with you on that visit?
4 A. No, I went on my own because I felt that if we needed to
5 speak within four walls, then we should have that
6 opportunity.
7 Q. Can we just turn over the page?
8 Mr Wisheart, for his part, does not recall this
9 visit, or any such visit, after the letter. Are you
10 sure you are right about that?
11 A. I know what I know happened.
12 Q. If you look at the paragraph at the top:
13 " ... I recall advising him [Mr Wisheart] that if
14 the BRI shortly achieved Trust status and districts did
15 not value the quality of the service the unit offered,
16 they would shift their cases elsewhere."
17 Is that what you recall telling him during the
18 course of this conversation?
19 A. No, that is a misquote, actually. It is the gist of
20 what I did tell him that the districts, in contracting,
21 would shift their contract and he would actually lose
22 money for their service.
23 Q. What about the words "if the BRI shortly achieved Trust
24 status"?
25 A. No, that should actually read "the BRI having achieved
0103
1 Trust status" that the purchasers would now be able to
2 shift whereas before they could not, because the Region
3 actually controlled the contract.
4 Q. I appreciate things were done at a rush when you made
5 your statement.
6 A. Yes.
7 Q. Did you check your statement over, though, before you
8 signed it?
9 A. I checked it quickly off the fax and phoned back with
10 five amendments.
11 Q. Because the BRI in fact achieved Trust status in April
12 1991.
13 A. Yes.
14 Q. So if this conversation took place in 1992, it could not
15 have taken place as described in your statement?
16 A. I remember it happening because 1992 is the year I left
17 and I was actually tying up ends before I was going to
18 go.
19 Q. And this is one of the ends, is it?
20 A. Well, when you have purchasers who are going to be
21 a major threat to a major unit within a teaching
22 hospital, it is not something that I wanted to leave for
23 somebody else.
24 Q. You were inclined to accept the explanation that he was
25 giving you?
0104
1 A. I am not a cardiac surgeon so I was not in a position to
2 judge, but it sounded feasible that if you actually get
3 late referrals and the age is a problem and the case is
4 very difficult, then you would not have as good outcomes
5 as if everything else was put in a correct order.
6 Q. So not being a cardiac surgeon, did you take any further
7 advice on it?
8 A. I actually felt, from our talk, that he did intend to
9 address those issues, particularly talking to the
10 cardiologists in trying to sort the problem out.
11 Q. So you thought it required no further action on your
12 part?
13 A. Having had the conversation with Dr Roylance and with
14 Mr Wisheart, having had a reply from them, having put
15 an audit person in there to begin to sort audit out,
16 I really felt that we were on the road now to being able
17 to evaluate, in fact, what the real outcomes were.
18 Q. Did you leave a minute of any of this for your
19 successor?
20 A. Most of my personal papers I understand were destroyed
21 by the subsequent RGM.
22 Q. No, that is not the question. Did you tell your
23 subsequent RGM of this discussion, of this issue?
24 A. I invited the RGM to come and talk to me about a variety
25 of issues, but that offer was declined.
0105
1 Q. So is the answer that you did not?
2 A. I never talked about it because she never came to see
3 me.
4 Q. And you did not leave any note of work in progress for
5 her?
6 A. If I told you I did, you would not be able to prove it
7 because all my personal papers were subsequently
8 destroyed.
9 Q. I am asking you: did you?
10 A. I left a note in personal files but they were destroyed
11 because my secretary rang me and said, I have to tell
12 you, all your personal papers have just been destroyed.
13 Q. So if I can just again get it clear: you did leave
14 a note for your successor about this particular issue on
15 your personal files?
16 A. Yes.
17 Q. And we obviously cannot get the note now because your
18 personal files have been destroyed, but that is what
19 you did?
20 A. Yes, but not just on cardiac surgery, on one or two
21 issues.
22 Q. I am not suggesting this was on its own. It would be,
23 one might suggest, a natural thing to do across the
24 board on various issues.
25 In that note for your successor, did you actually
0106
1 mention the meetings you had had with Dr Roylance and
2 Mr Wisheart? Obviously your letter may have been on the
3 file, but did you mention the meetings?
4 A. I do not believe I did, because any subject raised on
5 a formal basis would have been in the official review
6 notes. Informal meetings with Dr Roylance were
7 confidential so I would not have been noting that at the
8 time.
9 Q. Although they were part of your work, you treated them
10 as being something which not only was not recorded but
11 should not be recorded?
12 A. If a DGM asked to see me on a confidential basis, it was
13 confidential because people had access to my files.
14 I mean, the office was not locked. Anybody could go in
15 and look at my files.
16 Q. You have told us how you were content to leave the
17 matter with Dr Roylance and Mr Wisheart following
18 Mr Wisheart's explanations to you of how it might come
19 about that the outcomes were not, perhaps, as good as
20 they could have been had other things been different.
21 A. Well, again, there was nothing specific you could hang
22 a hook on and I had already raised concerns with the
23 DHSS team when they were made Trust status. I had
24 raised it now. I had left a note. They appeared to be
25 trying to deal with it. Purchasers had the leverage.
0107
1 I was not responsible for that Trust any more, to be
2 able to ring up and say, "Can I come and be welcomed in
3 there", and everything else was not -- I was not in
4 a position of authority to actually take control of
5 that --
6 Q. You told us --
7 A. -- or disprove what he was saying to me.
8 Q. You told us about an hour or so ago that one of the
9 matters which gave you particular concern was the fact
10 that these grumbles came back and surfaced again rather
11 like a grumbling appendix. That is what made you think
12 that there was some real problem underlying what was
13 happening.
14 You recall saying words to that effect?
15 A. Yes.
16 Q. If that is the way you felt about it and here
17 the problems had grumbled to the surface again, why were
18 you content to leave matters on the assurance that
19 Dr Roylance and Mr Wisheart would sort things out when,
20 in years gone past, they had not?
21 A. I would have to say to you that in years past, for
22 a period they appeared to have sorted it because things
23 did go quiescent for a while, so this could have been
24 another blip in a situation where purchaser/provider was
25 coming into the fore and I was not in a position to
0108
1 challenge statements made by a cardiac surgeon who was
2 head of his unit.
3 Q. Did you speak about what you had said or the gist of the
4 conversation with your RMO?
5 A. That I honestly cannot recall.
6 Q. Do you recollect whether, having implied to him that he
7 needed to be more discerning in the work undertaken,
8 he made any suggestions as to how matters might be
9 improved?
10 A. Again, I mean, that is a general discussion and it was
11 up to him. I mean, clinical freedom; you cannot dictate
12 to a doctor what type of cases they are going to deal
13 with, but it was -- if it was in fact the case that
14 he was getting more difficult cases too late in the day
15 at the wrong age group, then a dialogue needed to go on
16 between referral agents and himself to ensure that that
17 pattern was altered.
18 Q. Let me turn away from this. There are one or two other
19 matters I need to round up with you.
20 What responsibility did you see Region having for
21 supra-regional services?
22 A. We were not in control of supra-regional services.
23 Q. No: what responsibility did you have in respect of
24 them?
25 A. If they formed part of -- if they overlapped into our
0109
1 regional services, it was obviously our duty to inform
2 the department if we had concerns about them, so they
3 could address them.
4 Q. Can we have a look on the screen, please, at UBHT
5 61/293?
6 This is a meeting after you left. It is 9th March
7 1995, so I do not suggest it is anything to do with your
8 own tenure of office, but what interests me is this: you
9 see that it is a meeting between representatives of the
10 NHS Executive and what was then the South and West
11 Regional Health Authority and the UBHT on 9th March
12 1995. Can we scroll down, please? The subject matter,
13 paragraph 3:
14 "Mr McKinley said that the Trust was facing
15 a complex issue .... Concern had been expressed for
16 some time about paediatric cardiac services ..."
17 He talks about events that had come to a head in
18 early 1995.
19 What I want to ask you is why, as you see it,
20 after some publicity had arisen in early 1995, was it
21 that the Region had any role to play in discussing how
22 to deal with the situation or to understand the
23 situation?
24 Can you help from your knowledge of regional
25 responsibilities to elucidate that for us?
0110
1 A. It depends who called the meeting.
2 Q. Suppose concern was expressed in the media about the
3 performance of a particular unit in the Region, but it
4 is a supra-regional unit which the --
5 A. If anything hit the press, the department would be down
6 with us in no time at all, to share anything.
7 Q. So the mere fact of geographical location would be
8 sufficient?
9 A. What they would have wanted was a -- what I believe they
10 would have wanted was a combined front against media
11 coverage.
12 Q. For your part, can we look at SLD 2/5?
13 This is Private Eye, you probably recognise that
14 sort of cartoon. The left-hand column:
15 "In America, the mortality rate for arterial
16 switch, an operation to connect congenitally transposed
17 arteries from the heart is now 0 per cent. In
18 Birmingham, it is 3 per cent. In Bristol, it is 30 per
19 cent ..."
20 This is 3rd July 1992, so it is a little while
21 after the meeting that you had had with Mr Wisheart,
22 a little while after the concerns are expressed to you,
23 and it was after you had left, was it?
24 A. No, I left in the October.
25 Q. So you were still in post?
0111
1 A. Yes.
2 Q. Is this the sort of news clip that would come your way?
3 A. I do not buy Private Eye. I believe this one was shown
4 to me by the RMO.
5 Q. So you saw it?
6 A. Yes, and raised the question, if it had been
7 whistle-blown, why had he not come to tell me, because
8 I had not had any information, and he said he had not
9 either, if I recall.
10 Q. In the discussion you had, did you think of doing
11 anything to follow it up?
12 A. The RMO was, I believe, going to investigate that and
13 visit the unit and talk to the department.
14 Q. Who was the RMO at that stage?
15 A. Alistair Mason.
16 Q. Because in a sense, this was perhaps another grumble at
17 the appendix?
18 A. I do not know. Private Eye is not known for its
19 accuracy.
20 Q. The other matters I want to ask you about are about
21 audit generally. There are just a few matters to get
22 your comments, if I may.
23 Can we have UBHT 26/83? Can we look at the first
24 paragraph? There is a copy here to your RMO dated
25 3rd June 1992 and it is talking about the funding of
0112
1 medical audit. The last sentence:
2 "The fragmentation of funding arrangements and the
3 consequent lack of clarity over the responsibilities of
4 the Regional medical audit adviser, local audit
5 committees and the DHAs has led to some confusion."
6 Is that an accurate reflection of what was
7 happening in the early 1990s?
8 A. Yes, because funding was coming from a variety of
9 sources and each unit either had no audit procedures in
10 operation, or committees, and the one that did had
11 different approaches and there was no common agreement
12 at that stage on how audit should be conducted.
13 Q. At this stage, I suppose, it was not necessarily clear
14 who was in charge of audit?
15 A. Well, if I recall, the medical staff themselves were
16 supposed to be responsible for audit.
17 Q. What we, I expect, will in due course hear from
18 Dr Keiran Walshe, is this: that it may be suggested that
19 there was, in the 1980s, much suspicion and a great deal
20 of sensitivity from the professions such that the
21 prevailing idea was that the regional tier of management
22 was the most appropriate level at which to roll out
23 initiatives on audit.
24 Would you agree or disagree with that?
25 A. I would agree with that, because with the revised
0113
1 regional hospital medical advisory committees, the
2 Region had gained the confidence of consultant staff and
3 they felt that under the auspices of the Regional
4 Medical Advisory Committee, that they would not be made
5 vulnerable.
6 Q. So it was the structural change from the Hospital
7 Medical Committee to the Hospital Medical Advisory
8 Committee --
9 A. To be made a regional committee.
10 Q. -- that enabled the pushing through of audit?
11 A. And the fact that we did introduce Dr Charles Shaw to be
12 the RHA representative in assisting local units and
13 consultants to develop their processes. He had done
14 very good audit in community hospitals, so he had
15 a proven track record in audit.
16 Q. Can I move from that to pick up two little points from
17 your statement. Can we go to page 3 of your statement?
18 At the foot you, refer to:
19 "... the RMO assigning a doctor on his staff to
20 the task of promoting the process of audit".
21 Was that Dr Shaw?
22 A. Yes. He had been in Cheltenham. He came on to the
23 regional staff to be the audit promoter.
24 Q. Can we go to page 5 and the very last paragraph:
25 "In April 1991, Bristol Royal Infirmary moved out
0114
1 of RHA supervision to become a Trust under direct DHSS
2 monitoring."
3 Just to explore what is meant by that, if we have
4 a look, please, at UBHT 26/100? You recognise this,
5 I have no doubt, as EL 92/21 of 2nd April 1992.
6 A. Yes.
7 Q. If we see that it is addressed "Regional General
8 Managers", it deals with medical audit and the
9 allocation of funds. We can scroll down and go over the
10 page. This suggests that the Region retained, at the
11 very least, a part to play in the financing and
12 supervision of audit?
13 A. Well, audit was supposed to cut across all boundaries,
14 so Region would be used in that context on a devolved
15 responsibility basis from the Department.
16 Q. So when we read paragraph 19 of your statement, going
17 back to page 5, we have to read that as not excluding
18 the role of the Regional Health Authority in financing
19 and supervising audit?
20 A. Periodically there would be devolved responsibilities
21 from the department and the National Executive which
22 would -- because in 1991 there was a situation where you
23 had, in this region, 25 units were Trusts; the rest were
24 non-Trusts, so things like audit would apply equally to
25 all of them and therefore, to have a split between
0115
1 responsibilities for certain subjects between the Region
2 or the National Executive would cause unnecessary
3 complication.
4 So, in the case of audit and other things, you
5 would have devolved responsibilities so that you would
6 control your directly-managed units and on behalf of the
7 National Executive, the DHSS, the Trust for that
8 specific responsibility.
9 Q. Again, although in April 1991 the UBHT was created, you,
10 nonetheless, spoke to Mr Wisheart in 1992; you wrote to
11 Dr Roylance in 1992. You did so out of the sense of
12 responsibility for the Trust, did you?
13 A. No. In 1992, I did not leave until October and there
14 was still a relationship with DGMs whereas as the RMO,
15 which I was, I could visit units anyway on
16 a professional accountability basis.
17 Q. So when you spoke to Mr Wisheart as you have described,
18 what hat were you wearing?
19 A. When I spoke to Mr Wisheart in 1992, it was in the
20 capacity of an external agent trying to identify that
21 there could be problems for a Trust which the Region had
22 been committed to because they could only go forward
23 with our permission, and that we had purchasers who were
24 part of the RHA's responsibility who were not happy with
25 that unit. So I was speaking on behalf of purchasers at
0116
1 that stage, based on evidence that they were passing up
2 through reviews.
3 Q. Did you actually work that out formally, or did you just
4 go and talk to him without thinking about which hat you
5 were wearing?
6 A. No, the concerns I had related to purchasing and the
7 quality of the service that was being purchased. Beside
8 the fact that, as I say, with Dr Roylance there was
9 a personal relationship anyway, that I could ring him up
10 and say, can I come and visit a unit or look at this,
11 that or the other and never have I known a consultant
12 refuse to show his unit or his work to you.
13 Q. Just two more matters I want to raise with you and can
14 I take you back to page 1 of your statement? It is what
15 you say underneath, having detailed your previous posts
16 from April 1994, and I think you mean before April 1984,
17 probably?
18 A. Yes.
19 Q. You set out the posts and underneath that:
20 "The Regional Medical Officer also had oversight
21 of the Avon districts as part of duties I assigned
22 because of the teaching hospitals and the importance of
23 University liaison and the medical school."
24 What particular duties did you assign to the RMO
25 in respect of the Bristol teaching hospitals?
0117
1 A. The situation was, as RGM in a very big region and
2 a very large budget in the billions, there was no way
3 that I could have a dialogue with DGMs or important
4 officers on every single occasion. There was also in my
5 mind the fact that every now and again one would have to
6 be quite rigorous with the DGMs in order to achieve the
7 change of style and that could be more than
8 confrontational in the early stages and was something to
9 try and be avoided and to come in as the reinforcer and
10 not the enforcer.
11 So I set up a system where I had four major
12 officers at regional level; the Finance Officer, the
13 Human Resources Officer, the DMO and the Capital
14 Planner. So each one of those was assigned basic
15 responsibilities overseeing certain districts. The RMO
16 was assigned the Avon districts: Frenchay, Southmead,
17 Bristol & Weston, because Southmead and the BRI were
18 teaching hospitals and there was a lot of University
19 liaison and medical teaching.
20 So that the RMO could be the first point of
21 contact by a DGM who would say, "We would like to do X",
22 or "We do not want to do Y", "What will the RHA make of
23 it", "What will Catherine do?", or "We have a problem up
24 there, come back and let me know and we can get together
25 with Catherine and the team and try and sort something
0118
1 out".
2 So, they were the first point of contact and had
3 the first oversight of the district: anything of
4 importance, they were supposed to come and keep me
5 informed, not for me to dabble in it unless they needed
6 that assistance, but to deal with things; to prepare
7 a district for the review, give us feedback for the
8 departmental reviews. So the RMO had oversight of Avon.
9 Q. And so he would know, inevitably, more in detail about
10 what was going on than you would because you had
11 filtered through what was most important to you?
12 A. Yes, unless it was so serious, then the DGM would come
13 to me directly.
14 Q. The only other matter which I think I want to take up
15 with you is that you said almost first thing this
16 morning that if you had known then what you learned from
17 the Panorama programme about the problems, the worries
18 that others had about the results at Bristol, you would
19 have taken action which would have meant the suspension
20 of the unit and the referrals elsewhere and the
21 suspension of operations would mean the suspension,
22 would it, of the clinicians taking part in those
23 operations?
24 A. Yes. Again, if it had been identified that it was
25 a very specific part of that service, if, for example,
0119
1 it had been open-heart surgery and not closed-heart
2 surgery, then one would have been able to address that
3 with the Chairman. But if it was the service in
4 general, then we would have been in a position to
5 seriously not want to continue operations per se.
6 Q. If you were going to decide to suspend the clinicians,
7 under the processes that were available at the time,
8 the Region would hold the consultants' contracts, would
9 it?
10 A. No. We held the contracts for all consultants except
11 those in the teaching authority. They held theirs, so
12 that was why we would have to have had the dialogue with
13 the Chairman, the Vice Chairman, even the DHA itself
14 with the RHA to tell them of the problems, to involve
15 them and to get them to suspend operations.
16 Q. And it would have involved the management of the
17 teaching hospital taking action under those contracts in
18 order to stop the consultant continuing to operate?
19 A. Yes, and suspension is not discipline.
20 Q. So there would have to be, presumably, very clear
21 evidence, material, upon which to act?
22 A. Yes. For that serious action to take place, yes.
23 Q. Despite the level at which you understand now concerns
24 to have been expressed, given everything that you have
25 said about the difficulties of audit, the difficulties
0120
1 of information and the fact that Mr Wisheart, when you
2 spoke to him, appeared to have a satisfactory
3 explanation in terms of the difficulty of operations and
4 such like, you think that it is probable that that
5 information would have been available?
6 A. I think if the Royal Colleges have had a member of their
7 College in effect complain about service delivery in
8 a specific unit, then that information should have been
9 shared to allow an investigation as to whether that was
10 a valid complaint or not, and if it was, then action
11 should have been taken.
12 Q. So the step would actually have been not suspension and
13 referral elsewhere, but investigation first, see what
14 the investigation produces, and then if necessary --
15 A. Yes, but that depends on the seriousness of the
16 complaint, because one has to ask oneself what is the
17 price of a life?
18 Q. Yes, thank you.
19 I have asked you a lot of questions, Ms Hawkins.
20 There may, nonetheless, be something that you would wish
21 to add or to respond to or some area of your evidence
22 where you do not think that your answers may have been
23 clear enough. In particular, since you have not been
24 represented today, this is your opportunity to say
25 whatever you would wish to add. May I also say that you
0121
1 will be given an opportunity I have no doubt by the
2 Chairman, or reminded, that you can at any stage before
3 we cease taking evidence, supplement what you have said
4 in writing, and you should not feel at all inhibited
5 from doing so. But if there is anything which occurs to
6 you as you sit there now, please add it.
7 A. It is just the fact that I have to apologise because it
8 was at short notice and I did not have access to
9 documents, so my memory -- I am 15 years on now, so
10 I may not have been quite as accurate in dates, but I do
11 not have doubt about what I have said to whom and why.
12 THE CHAIRMAN: Mrs Howard?
13 Examined by THE PANEL:
14 MRS HOWARD: May I take you back to quite early on your
15 evidence, at about page 22 in the transcript, for those
16 who are interested in following that. You talked for
17 a short period about your views of Dr Roylance as
18 a General Manager and you actually used the words,
19 I think, "I did not see him as a General Manager in the
20 true management sense."
21 Could I ask you to comment on whether, as a "good
22 and committed doctor", as I think you referred to him,
23 that this was in any way a conflict of interest for
24 Dr Roylance in his role as a General Manager?
25 A. I do not personally believe it was a conflict of
0122
1 interest, because he was in the same position as I was,
2 with a professional hat and a managerial hat. What I do
3 believe is that it was more difficult for him as
4 a doctor managing doctors, and therefore, because he had
5 been there for quite some time, it was very hard for him
6 to appreciate the real role and function of a manager as
7 opposed to being one of the colleagues in a set-up of
8 a teaching hospital, which is a very different climate
9 to a non-teaching authority.
10 So I think what actually got in the way was that
11 he did not fully understand the role of a General
12 Manager. He did the best he could, to the best of his
13 ability, but he was not a trained manager in the real
14 sense.
15 MRS HOWARD: Thank you.
16 THE CHAIRMAN: Professor Jarman?
17 PROFESSOR JARMAN: Regarding the concerns expressed to you
18 by the DGMs which we have been talking about today, in
19 paragraph 17, page 4, you said that you had been
20 advising the DHSS officers at reviews of these
21 concerns. You also say that what was discussed at those
22 annual reviews varied from Minister to Minister?
23 A. Yes.
24 Q. Does it mean that the Ministers would have been aware of
25 your concerns at the reviews?
0123
1 A. Not necessarily, because sometimes conversation ensued
2 when Ministers left for one reason or another, or were
3 called out for something. Sometimes it occurred over
4 lunch. As you know, sir, a lot of business goes on in
5 an informal session as well a formal one, so they would
6 not always have been there.
7 Subsequently, after the first few reviews, the
8 National Executive team then started to hold reviews
9 without Ministers. Once a region was doing well, they
10 did not always feel that a Minister needed to be there.
11 Q. I am talking about the earlier time. Were you aware of
12 whether Ministers knew or not?
13 A. I would have to think back and think which Minister,
14 because in the first three years I saw three Ministers.
15 I would have to think which one.
16 Q. I do not mind; any of them, really.
17 A. The April review was Mr Patten, not John Patten, the
18 other Patten, the barrister gentleman. Who was the
19 grey-haired Patten? It was not him, it was the other
20 Patten.
21 Q. I know Mr Waldegrave was one.
22 A. John Patten was one. Baroness Trumpington was another
23 one. Ken Clarke was later. The lady, what was her
24 name, the Minister? Virginia Bottomley was another
25 one. I think we had William Waldegrave once.
0124
1 Q. But among all those, do you happen to know whether any
2 of them were aware of the concerns?
3 A. I suspect, if any, it would have been Baroness
4 Trumpington. I think it was that review when we talked
5 about health promotion, disease prevention, and whether
6 there was better value for money in that, the cardiac
7 services.
8 Q. The second question is, you say in paragraph 18, page 4,
9 that in April 1991 the BRI moved out of RHA supervision
10 to become a Trust under direct DHSS monitoring.
11 Does this mean, so far as you were concerned at
12 the region, that you had no further responsibility for
13 monitoring the quality of the service and this then
14 became the responsibility of the DHSS from 1991 onwards?
15 A. There was a shift of emphasis on monitoring which would
16 move away from the providing of the service to the
17 purchasing of the service, because we would be working
18 through the purchasing DHAs, whereas the performance
19 monitoring of the provider was the DHSS if they were
20 a Trust.
21 Q. My question was, as you said that the DHSS was the
22 monitoring agent, did you consider that the DHSS was
23 responsible for monitoring from 1991 onwards?
24 A. For the provision of service, yes.
25 Q. And that would include the cardiac surgery at the BRI?
0125
1 A. Yes.
2 PROFESSOR JARMAN: Thank you.
3 THE CHAIRMAN: Ms Hawkins, I have no questions. May I thank
4 you for spending today with us. I am anxious to repeat
5 what Mr Langstaff said to you: that if you want to let
6 us have any further observations, whether it be in the
7 form of clarification of what you have said or other
8 matters that you think we ought to know, we will be very
9 pleased to receive them. But for the moment, thank you
10 very much for coming and talking to us today.
11 MR LANGSTAFF: Sir, before Ms Hawkins leaves, may I say for
12 the record, as I said at the outset, that we were
13 incommoded by having her statement so late, in the
14 circumstances which she testified to at the start of her
15 evidence. May I pay tribute to those who have done
16 their best to get comments to me? I have done my best
17 to put those in the questions that I have asked of
18 Ms Hawkins.
19 One person who has not been able yet to give any
20 input is Dr Roylance. I do not, of course, know what,
21 if anything, he would wish to say or to dispute. I just
22 mention that so that anyone who looks at this transcript
23 from a distance will appreciate that it has to be read
24 subject to any further evidence that we may receive from
25 those who have not yet had as good an opportunity to
0126
1 respond as time will later provide them.
2 THE CHAIRMAN: I echo that. The procedure we are adopting
3 does depend upon the timely production of statements and
4 it is not to our advantage or to the Inquiry if we are
5 in any way inconvenienced in the way we have been
6 today. I echo your tribute to those behind you and
7 elsewhere, but I also regret the circumstances we have
8 had to deal with.
9 MR LANGSTAFF: Sir, tomorrow we have Joyce Woodcraft,
10 a senior sister formerly at the ITU in the Bristol
11 Children's Hospital. She is unable to come to us before
12 11.30, so for those who are used to having an early
13 outing and being here by 9.30 on a Tuesday, I am sorry
14 to disappoint them, and to promise them an 11.30 start.
15 THE CHAIRMAN: Thank you, Mr Langstaff. So we adjourn now
16 and reconvene at 11.30 tomorrow.
17 (4.10 pm)
18 (Adjourned until 11.30 am on Tuesday, 5th October 1999)
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2 I N D E X
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5 STATEMENT BY MR LANGSTAFF ......................... 1
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7 MS CATHERINE HAWKINS (affirmed)
8 Examined by MR LANGSTAFF .................... 4
9 Examined by THE PANEL ....................... 122
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11 (Statement by the Chairman at page 41)
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001