|
|
|
|
 Home
Page
Search
Final
Report
Interim
Report
Evidence
- Transcripts
- Witness Statements
- Submissions
- CCNR Report and associated
documents
- Statistical Reports and associated
documents
- Background Papers
- Expert Papers
Inquiry
Seminars
About
the Inquiry
Help
|
 |
Daily transcripts
Hearing summary
13th October 1999
The Bristol Royal Infirmary Inquiry oral hearings focus for the
remainder of this week on the subject of medical and clinical audit.
Today the Inquiry heard from Kieran Walshe, Senior Research
Fellow, Health Services Management Centre, University of Birmingham, and
one of the Inquiry’s Expert Group of witnesses. He began by defining
what audit is. He then concentrated on discussing the contents of a briefing
paper which has been prepared for the Inquiry entitled "Medical
and Clinical Audit in the NHS". He explained the development
of medical audit into multi-disciplinary clinical audit during the 1980s
and 1990s. Mr Walshe said that in 1989 audit practice was variable around
the country with some national initiatives taking place e.g. the National
Inquiry into Maternal Deaths, highlighting good practice. He commented
on the reaction amongst the medical profession to 1989 recommendations
that all doctors should engage in medical audit and explained the reservations
regarding confidentiality of data. He described the role of regional and
district health authorities and hospital managers in promoting and managing
audit and explained the allocation of funding and monitoring of how those
funds were used. He concluded by identifying the elements of a successful
audit programme.
Dr Trevor Thomas, Consultant Anaesthetist, St Michael’s Hospital, Bristol and
first Chairman of the Medical Audit Committee also gave evidence today. He described the
development of audit within the Bristol Hospitals and the role of the Medical, and later,
Clinical Audit Committee in promoting, assisting and monitoring audit within the United
Bristol Healthcare NHS Trust (UBHT). He discussed the series of annual audit reports
prepared for the Regional Health Authority (RHA) and subsequent reports sent from RHA to
the Department of Health. Dr Thomas told the Inquiry about the inclusion of audit
requirements into service contracts with purchasing health authorities after 1991. He
commented on the amount of time clinicians spent on audit activities and changes in the
reporting structure from the Audit Committee to the Trust Board.
|
FULL TRANSCRIPT
1 Day 62, 13th October 1999
2 THE CHAIRMAN: Good morning, everyone. Good morning,
3 Miss Grey.
4 MISS GREY: Good morning, sir. Before starting on today's
5 evidence, may I deal with one matter arising out of the
6 evidence given yesterday by Professor Angelini?
7 Professor Angelini has written a letter to the Inquiry
8 following his evidence, which will of course be
9 published as part of that evidence, but it is right
10 I should perhaps read it into the transcript as well at
11 this stage.
12 THE CHAIRMAN: It was written with the knowledge that it
13 would be published?
14 MISS GREY: Indeed. Well, it was written as a letter to
15 you, sir, and therefore is in the public domain.
16 LETTER TO CHAIRMAN FROM PROFESSOR ANGELINI
17 MISS GREY: Professor Angelini writes:
18 "Dear Mr Chairman,
19 "I would like to clarify an aspect of my evidence
20 given today, 12th October 1999.
21 "I refer to the comment by Mr James Wisheart to
22 Dr Roylance that the results of the paediatric surgery,
23 with the exception of one surgical procedure, were
24 comparable or above average.
25 "I believe it is incorrect that these results were
0001
1 incomparable or above average especially in relation to
2 the AV canal results. I do apologise for saying that
3 Mr Wisheart's comments was a lie", that is as the letter
4 was written, "and I do not make that accusation against
5 Mr Wisheart.
6 I would be grateful if this letter was placed on
7 record, together with my oral evidence."
8 THE CHAIRMAN: Miss Grey, thank you very much indeed.
9 MISS GREY: Sir, can we now pass, please, to the evidence of
10 Dr Walshe, if he would like to come up and take the
11 stand, please?
12 Dr Walshe, we have been taken evidence on oath or
13 affirmation. Could I invite you to stand to affirm?
14 DR KIERAN WALSHE (AFFIRMED):
15 Examined by MISS GREY:
16 Q. Dr Walshe, could you give your full name to the Inquiry,
17 please?
18 A. Yes, my name is Kieran Michael Joseph Walshe.
19 Q. You are a Senior Research Fellow in the Health Services
20 Management Centre at the University of Birmingham?
21 A. That is correct.
22 Q. We do not have available to the Inquiry, scanned in as
23 yet, a curriculum vitae for you. Could I therefore
24 invite you to tell the Inquiry of your record and the
25 work that you have been involved in, and please do not
0002
1 be modest?
2 A. I am happy to provide a CV if that would be helpful for
3 the record.
4 Q. It would, thank you very much.
5 A. As you said, I work at the University of Birmingham as
6 a research fellow in the Health Services Management
7 Centre there. Before working there I was at the King's
8 Fund in London, again as a senior researcher. I have
9 been a researcher for 11 years. Before starting
10 a research career, I was a manager in the Health Service
11 for three or four years.
12 In my research career, my main interests have been
13 approaches to assessing and improving the quality of
14 health care and approaches to measuring clinical
15 performance. I was involved in the late 1980s in early
16 work done in Brighton Health Authority, funded by the
17 Department of Health, to pilot a number of quality
18 assurance measures in an acute health care
19 organisation.
20 In the late 1980s and early 1990s I was involved,
21 whilst working at the King's Fund in some other projects
22 for the Department of Health, one that particularly
23 looked at adverse events in health care and the way that
24 detecting and monitoring adverse events could be used as
25 a way of assessing and improving quality.
0003
1 Perhaps particularly germane to today's issues for
2 the Inquiry, in the early 1990s I led a quite large
3 project over two and a half or three years for the
4 Department of Health, evaluating the development of
5 medical and clinical audit in the NHS in England, which
6 resulted in a series of reports for the Department, and
7 the data from which was used also in the National Audit
8 Offices' "Value for Money" study on clinical audit in
9 England.
10 Q. Is that the research that is known as the CASPE
11 research?
12 A. That is right, yes. Subsequent to that I worked in 1995
13 and 1996 in the NHS Executive on developing a framework
14 for managing and monitoring clinical audit in provider
15 organisations, aimed at improving effectiveness in
16 clinical audit programmes in health care organisations.
17 Q. You had not been asked to provide a statement for the
18 Inquiry, but I think it is right to say that you are
19 familiar with a paper which has been published by the
20 Inquiry Secretariat on medical and clinical audit in the
21 NHS if we could just have that on the screen, please, it
22 is INQ 11/1, please. That is simply the title page, but
23 I think it is right you have seen that paper; is that
24 correct?
25 A. Yes, I have, yes.
0004
1 Q. Perhaps we ought to start any discussion of audit by
2 asking you to define what audit means? It may perhaps
3 help to look at page 9 of this paper, where a definition
4 is offered, but would you like to comment on what you
5 understand audit to entail? Can we just scroll up
6 through the page a little, please?
7 A. I think the definition offered in the Inquiry's paper is
8 a helpful one. The Department of Health, in its early
9 policy papers issued in 1989 when it first required the
10 introduction of medical audit in health care providers,
11 defined it as the "systematic critical analysis of the
12 quality of medical care."
13 I think the definition you have offered in this
14 paper is in some ways more helpful because it makes it
15 clear the process involves both gathering information
16 about the quality of practice and performance,
17 identifying problems and opportunities for improvement
18 and then taking action to remedy those problems or
19 difficulties, to bring about change.
20 There are ways in which you can make
21 differentiations -- and the paper referred to
22 distinguishes between medical audit, clinical audit and
23 organisational audit and quality assurance and TQM and
24 CQI. There are lots of definitional discussions you can
25 have. What brings all those definitions altogether is
0005
1 that they are all about systematically attempting to
2 identify problems with the quality of care, and then
3 taking action to understand their causes and bring about
4 changes that make improvement in the quality of care
5 take place.
6 Q. Perhaps we should go back to that early paper that you
7 referred to. If we look, please, at WIT 323, please,
8 page 15, this is a section from the Working Paper on
9 medical audit. If we scroll down towards the bottom of
10 the page, a 1989 paper, as you mentioned. That is the
11 definition that you produced from memory.
12 Does the contrast between that fairly short
13 definition and the more extensive discussion in the
14 Inquiry's paper help us to understand anything about the
15 development of the understanding of audit over the years
16 since it was introduced?
17 A. Yes, I think it does. I think the paper you have, which
18 came out, I think I am right, in late 1989, a little
19 while after the publication of the White Paper itself,
20 represents the Department of Health's thinking about
21 medical audit and quality assurance in health care at
22 that time, but it reflects the level of understanding at
23 that time.
24 I think it would be true to say that the
25 Department's proposals for medical audit in the NHS at
0006
1 that point in time could be criticised with hindsight as
2 not being particularly directive, not if you like
3 mandating a particular process, not requiring the
4 organisations to undertake audit in a particular way and
5 for also perhaps not putting in place particularly
6 strong incentives or requirements for people to engage
7 in this process.
8 However, I think you need to read the paper and
9 that definition understanding that at the time this was
10 part of a set of policy reforms, some of which were
11 being opposed very strongly by the medical profession,
12 the nursing profession and by others. But the
13 department was very nervous about imposing this process
14 on the professions because in the past, in the early and
15 mid-1980s, there had been considerable professional
16 resistance at the highest level, I think, to the idea of
17 systematic quality assurance or quality improvements in
18 health care.
19 And I think there was real uncertainty in the
20 Department of Health about the best way to do this so
21 mandating a particular process was difficult if you did
22 not know what the best kind of process would be.
23 So I think the definition was as good as it could
24 be at the time, and subsequent policy guidance changed
25 and modified that definition considerably.
0007
1 Q. So to have themes or threads you have identified there:
2 firstly a nervousness of professional reaction to the
3 idea of having audit imposed upon them, and secondly,
4 central nervousness of requiring a particular approach
5 in the absence of knowledge as to what the best approach
6 would be.
7 Can you tell us what the state of knowledge was at
8 the time of different forms or approaches to audit?
9 A. I think there was probably a much better developed
10 understanding of how the process might work elsewhere in
11 the world, in other countries, particularly perhaps in
12 the US where there was a much longer history of
13 systematic efforts to improve quality in health care
14 than there has been here.
15 I think in the UK we had a very limited
16 understanding of how, given the organisational context,
17 given the way our health service was structured and the
18 way different professions interrelated and so on, how we
19 would put into place a programme of quality improvement,
20 and our ability to look outside of the health service
21 at, for example, developments in the US or indeed at
22 developments in industry, because there was a great deal
23 of activity in the 1980s in non-health care sectors in
24 the UK in quality assurance, was in part limited by some
25 of the differences in the way we run the Health Service
0008
1 and the way other non-health care organisations run, and
2 indeed the way that health care organisations in
3 countries like the US are organised. There are
4 difficulties that make transferring some of the
5 structures and processes others have developed
6 difficult, although much of the learning about how these
7 things work is certainly transferable.
8 Q. If we were to look across to the United States at the
9 time of this paper in 1989, what would we have found,
10 broadly, in terms of the development of audit or quality
11 assurance in that country?
12 A. In brief, the United States has had systems for the
13 external accreditation or inspection of hospitals in
14 some form or other since the 1980s, in a fairly rigorous
15 form certainly since the 1960s and it first mandated
16 quality assurance, introduced federal legislation that
17 required it effectively in I think 1973. So we would
18 have found a very long history of this kind of work, and
19 lots of efforts with different approaches to attempting
20 to measure quality, different kinds of measures and
21 different ways of structuring and doing this, so a great
22 deal of experience.
23 We would have found a huge amount of activity.
24 Every hospital we visited then and indeed now, would
25 have had a well-developed internal quality assurance
0009
1 programme, with staff, structures, processes and things
2 like that in place. They would also have had programmes
3 for risk management and utilisation review, looking at
4 the use of resources, and then we would also have found
5 a number of external programmes, payers for health care,
6 examining the quality of health care provided by
7 hospitals and health care providers.
8 I think it would be right to say you would also
9 have found far from a consensus about how useful that
10 very substantial investment had been in bringing about
11 quality improvement and in fact in the late 1980s, the
12 US health care system began to move away from its
13 traditional approaches to quality assurance and to
14 embrace what is sometimes called "whole system"
15 approaches to continuous quality improvement and TQM,
16 and that movement in the US has continued.
17 Q. You said that it might be difficult to draw lessons or
18 transfer information across from the US to Britain at
19 that time. Does your answer suggest that there may be
20 two main reasons for that: firstly that the system of
21 quality assurance or audit within the US was in large
22 measure imposed from the outside, or required from the
23 outside by externally imposed or required regulatory
24 systems, and secondly, that there was a lack of
25 consensus as to the benefits that had been produced by
0010
1 those approaches?
2 A. I think I would agree with both those reasons. Yes, it
3 had been required and mandated by federal legislation
4 and by payers of health care who required providers to
5 do this. That was not necessarily the way this was
6 working here. Also there would be a second point.
7 I think I would add perhaps that there are big cultural
8 differences between the way that US health care
9 organisations had traditionally been run and British NHS
10 Trusts or health care organisations had been run, big
11 differences in the employment status of doctors in the
12 degree of medical involvement in the management of those
13 organisations, and big cultural differences that affect
14 the transference of an organisational approach to
15 quality improvement from their context to ours.
16 THE CHAIRMAN: Forgive me if I interrupt just a moment. It
17 is only to remind Dr Walshe that the person sitting
18 immediately to your right is perhaps the most important
19 person in this room because she is taking a note --
20 DR WALSHE: I am speaking too fast.
21 THE CHAIRMAN: Not too fast, but it may help sometimes,
22 because we use technical terms, to keep an eye on how
23 things are proceeding on your right, and slow down
24 sometimes. I apologise for interrupting.
25 MISS GREY: Not at all. It is actually my responsibility,
0011
1 Dr Walshe, to keep an eye on that, I had not been doing
2 so and I will try and do so.
3 You talk there about "large cultural
4 differences". Can you explain a little bit more what
5 you mean by those?
6 A. I think the sorts of differences I would point to would
7 be that in the US it has been much more accepted for
8 much longer that the quality of clinical practice is
9 a consideration for the organisation and not just for
10 individual clinical teams and that would be one thing
11 I would point to. So every US hospital you would visit
12 would have quality assurance mechanisms, would have
13 surgical review and medical review committees, would
14 have corporate structures designed to identify and deal
15 with quality problems. Those systems have been there
16 for in some cases decades, so the acceptance, if you
17 like, that the organisation has not just a legitimate
18 role but a central role in understanding and dealing
19 with quality problems is much greater than it
20 traditionally has been here in the UK.
21 I think there is also a difference in our approach
22 to measurement and the US approach to quality
23 improvement has been highly adversarial, kind of quasi
24 judicial in the way it has worked, and I know that in
25 1989 and before that, people from the Department of
0012
1 Health and from organisations in the UK have been over
2 to the US to look at the way that quality in health care
3 was managed and improved, and have taken from that some
4 important lessons about how it can be done, but also
5 real concerns about not emulating a system which has, in
6 the US, become very bureaucratic, quite expensive and
7 about which to this day there is still much debate about
8 whether it really produces improvements in quality
9 concomitant with its costs.
10 Q. So if we went back to 1989 in the UK, what audit would
11 we have found in clinical practice at that time? What
12 was the background to the introduction of this paper?
13 A. Before the White Paper, I think you would have found
14 a very varied and patchy pattern of clinical audit.
15 I was involved in working with one Health Authority
16 quite closely, and less closely with a number of others
17 at that time, and in most hospitals you would have found
18 a small number of clinical professionals, particularly
19 doctors, who were gathering data about their own
20 practice, who were, if you like, audit enthusiasts and
21 who were engaging in a process of clinical audit for
22 themselves.
23 You would have found, I think, in most parts of
24 most organisations, relatively little activity. There
25 would have been some traditional mortality and morbidity
0013
1 meetings or death and complication meetings going on, at
2 which problems to do with the quality of care perhaps
3 got reviewed, but you could not have said that in
4 I think almost any health care organisation at that time
5 in the NHS there was a systematic programme of quality
6 assurance or quality improvement in place.
7 You would also have found some important national
8 initiatives which were focused on particular areas of
9 care and were important in those areas but were somewhat
10 isolated in that they did not have a wider remit or
11 impact. Examples would be the Confidential Enquiry into
12 Maternal Deaths and the National Confidential Enquiry
13 into Peri-operative Deaths, work done by the Royal
14 College of General Practitioners on standards for
15 general practice, and things like that.
16 So there were important initiatives, but there was
17 no system that covered even a large minority of the care
18 being provided.
19 Q. So against that background, can you describe the driving
20 force or reasons why this paper and the government's
21 reforms, not to mention, of course, the initiatives from
22 the various professional organisations, the Royal
23 College of Physicians, the Royal College of Surgeons and
24 so forth, were developed?
25 A. Yes. I think it is hard to point to a single driving
0014
1 force. I guess your enquiry about why the policy
2 documents included this focus on medical audit could
3 also be directed to some of the policy makers at that
4 time.
5 I think there are three things that had happened.
6 One was the rise of general management during the 1980s
7 and the arrival of individuals, some clinically
8 qualified, some not clinically qualified, but
9 individuals who had general management responsibility
10 and authority for health care services, and had more of
11 a remit and a legitimate right to ask questions about
12 the quality of care.
13 Second was the rise of concerns about quality of
14 performance across public services, and indeed private
15 services. It was a theme in government in the 1980s and
16 a focus on the role of managers and managerialism and
17 a concern about the power of the professions running
18 across education and health and social services, and
19 other sectors. I guess I would also point to the fairly
20 positive experience of those initiatives I have
21 described going on in the 1980s, seen as examples of
22 good practice that perhaps we should be trying to
23 emulate and roll out on a wider scale.
24 I do not think I could point to one particular
25 event or set of circumstances which led the government
0015
1 then to say "We have to have systems of medical audit".
2 It was a combination of things.
3 Q. I think if we looked at the Inquiry paper again, we
4 would see a whole string of factors mentioned, all of
5 which culminate perhaps in the initiative in 1989.
6 If a bystander had come along and said, "Well, is
7 this initiative going to guarantee safe clinical
8 practice across the United Kingdom?" would those behind
9 the reforms have said, "Well, yes", or would they have
10 said, "That is not quite what we are hoping to achieve",
11 or "It is too early to hope to achieve that"?
12 A. We were asked to evaluate the development of medical and
13 clinical audit in, I think, 1992, three years after the
14 process had been put in place. I remember engaging in
15 some sort of post hoc attempts to work out what the
16 objectives had been at the time. It was difficult to
17 discern those objectives. I think the purpose in 1989
18 was much more about putting a process and systems in
19 place than necessarily about delivering either huge
20 improvements in the quality of care or necessarily
21 ensuring that significant problems could not happen or
22 would be less likely to happen in the future. The
23 objective was, I think, more modest. It was to engage
24 the professions, particularly the medical profession in
25 a system or a process for quality improvement that would
0016
1 lead in the future to those sorts of objectives and
2 ends, but I do not believe the policy makers at that
3 time thought that the introduction of medical audit was
4 going to be something that would bring short-term gains
5 and would deliver those sorts of improvements
6 straightaway. I think they recognised that it was
7 a long-term issue involving cultural change in the
8 service that would take time to work through.
9 Q. If we can look briefly at the reaction of the medical
10 profession to the introduction of audit, it is touched
11 on in the Inquiry's paper if we go back to INQ 11/13,
12 please.
13 We see, towards the bottom of that paper,
14 paragraph (ii) on the reaction from the medical
15 profession, which suggests that against a background of
16 general concerns or hostility to the proposed reforms in
17 1989, the reaction to audit on behalf of the medical
18 profession was strikingly positive, but that there were,
19 nevertheless, if we turn over the page, please, a series
20 of concerns about how it would actually work in
21 practice, even if the broad thrust was surprisingly
22 welcomed.
23 Can I ask you, what main threads did you see in
24 the reaction to the introduction of audit?
25 A. I think it is important to note that the positive
0017
1 responses from organisations such as the Royal Colleges
2 and the BMA and others were distinctly different from
3 the sort of evidence they had given ten years earlier to
4 the Royal Commission on the NHS when they had seen no
5 case for systems of medical audit in the NHS. So it was
6 a real step forward. I cannot think of one of the
7 professional bodies which did not respond in positive
8 terms to the White Paper's proposal for medical audit.
9 In that sense, the Department of Health strategy
10 of, if you like, a softly-softly approach, which was not
11 directive and did not mandate and did not require but
12 built gradually on things that were already there, was
13 perhaps justified.
14 I would distinguish though, between the reaction
15 of the professional bodies, the Royal Colleges and
16 others and the great and the good, and the profession on
17 the ground. I think your paper cites a study that
18 suggested that on the ground the profession was perhaps
19 less enamoured, less convinced, than professional bodies
20 and organisations. That is reflected in some of the
21 papers recruited from individual clinicians, saying
22 "Whilst we sign up to the aims of this, we are not sure
23 it is really going to work and deliver improvement" or
24 whatever.
25 Q. The paper mentioned a number of reasons for concern from
0018
1 clinicians, such as bureaucratic committee structures,
2 adequate time for audit, and concerns about the use of
3 resources. But what in particular I would like you to
4 address, if you would, is whether confidentiality could
5 really be maintained. That was a concern. Can you tell
6 us a little more as to the elements of that concern?
7 A. Yes. At the time I think many clinicians --
8 I encountered this in work I was doing at that time in
9 the South-east Thames region and I was involved in
10 drafting with others in that region a policy on the
11 confidentiality of medical audit, clinical audit data.
12 I think the concern of clinicians was primarily
13 about the confidentiality of data that referred to
14 individual clinicians, or indeed, to clinical teams and
15 they had two concerns: (1) that information would be
16 disclosed outside the clinical team to others, perhaps
17 particularly to non-professionals or to managers, who
18 would misunderstand it, who might misuse it for whatever
19 purpose and who would therefore draw conclusions that
20 should not be drawn from that data, or take actions
21 which should not be taken. That was one concern. The
22 other concern that clinicians had was that data that
23 they collected for clinical audit would be discloseable
24 to patients, or to patients' representatives in actions
25 for clinical negligence, and at the time, in those two
0019
1 areas in the first area many hospitals developed
2 guidelines that were designed to reassure clinicians
3 that data, particularly data about individual
4 clinicians, would not be passed willy-nilly around the
5 organisation, but would only go to those who needed to
6 know and had a legitimate right to know.
7 Q. What would that unit be?
8 A. That varied according to the level of concern and the
9 local context. In the work I was involved in
10 developing, the model we worked out was that data about
11 individual clinicians should primarily stay with those
12 clinicians in the clinical team and the Clinical
13 Director for that service. Data about clinical teams
14 would be shared more widely with the Management Board of
15 the health care provider. That was the compromise we
16 evolved to try and reassure individual clinicians that
17 they would not see information about them in Trust Board
18 minutes or whatever.
19 Q. I am sorry, you were talking of concerns about civil
20 litigation and I interrupted you.
21 A. Yes. That was the second concern. That concern
22 remained unresolved. There was some discussion with the
23 Department of Health at the time about whether that data
24 could have some kind of privilege, some kind of immunity
25 from disclosure, as indeed information collected for the
0020
1 Confidential Enquiry on Peri-operative Deaths and the
2 Confidential Enquiry on Maternal Deaths, which both had
3 PII certificates and the Department of Health was not
4 enthusiastic about attempting to pursue that, and it was
5 not pursued and it seemed to go away as an issue.
6 Q. It went away when, or why?
7 A. I think gradually, as people -- this was part of the
8 initial abreaction, if you like, the initial concern
9 about the whole idea. Gradually, as people engaged in
10 medical and clinical audit into the 1990s, their worries
11 about the confidentiality of the process tended to
12 decline. I cannot think of a single example that I have
13 come across of data from clinical or medical audit
14 having been misused in the way that it might have been
15 suggested, and although I have had a number of
16 discussions with defence lawyers involved in medical
17 litigation for health care organisations, I am not aware
18 of any real examples of that data being then picked up
19 and used by the plaintiffs in litigation. So I think it
20 was a set of concerns that were not particularly real,
21 although they felt very real to the individuals who
22 raised them.
23 Q. Does the position --
24 THE CHAIRMAN: I just wanted to explore a little bit more --
25 I may be asking something you were going to ask,
0021
1 Miss Grey, if so, forgive me, but the notion of
2 confidentiality as used here is not the traditional
3 notion of confidentiality we are used to hearing about,
4 namely as between patient and doctor, which is
5 established; it is, as it were, a claim to privacy or
6 secrecy, or, if you like, confidentiality as regards
7 a new lot of data which is going to be generated. Would
8 that be accurate?
9 A. Yes. I do not think most people saw a big issue about
10 the confidentiality in patient terms, because if you had
11 a set of data about, for example, a series of cases, it
12 was easy to anonymise without removing the key issues to
13 do with what the quality problems were or whatever.
14 I think the debate about confidentiality
15 reflected, if you like, an underlying theme to do with
16 who owned the audit process: was it owned by individual
17 clinicians in the clinical team, or did it belong to the
18 organisation? Whose data was it? That changed between
19 1989 and 1995 quite significantly.
20 MISS GREY: Two questions: did the attitude of the
21 Department of Health or the legal position in the UK
22 about such data not attracting public interest immunity
23 or any other form of confidentiality within civil
24 litigation differ from the stance taken in other
25 countries?
0022
1 A. Yes, it did. In the United States, something like 47 or
2 48 of the States have legislation which gives some kind
3 of qualified immunity or privilege to information that
4 health care providers collect for quality assurance
5 purposes. Not all States have that, but the great
6 majority do. Some people pointed to that as an example
7 and said clearly that is needed to allow audit or
8 quality improvement to be established.
9 That has to be seen in the light of levels of
10 litigation for medical negligence which are an order of
11 magnitude higher at least in the US, so a very different
12 situation.
13 Interestingly, more recently, I think I am right
14 Australia has introduced some legislation which gives
15 some qualified privilege to information that providers
16 there collect for the purposes of quality improvement.
17 Q. How can one evaluate whether that immunity makes any
18 difference to the effectiveness of the audit process?
19 A. I do not think we can really answer that question. You
20 could argue in practical terms. It clearly has not been
21 necessary in Canada, it has not been necessary in other
22 European countries and it does not seem to have been
23 necessary here, but we cannot prove the counterfactual,
24 had we had that legislation, things would be different
25 today.
0023
1 Q. Because there are too many other confounding factors to
2 be able to evaluate it. Going back to your discussion
3 of the model of who obtains information about the
4 performance of an individual clinician and the
5 suggestion that at least in one team that you were
6 working, the organisation that you were working with,
7 the solution was found that that sort of information
8 should stay at the level of the team and the Clinical
9 Director, what was the justification for saying that it
10 was in effect the responsibility of the team and/or the
11 Clinical Director to address concerns about an
12 individual clinician's performance or record or whatever
13 aspect of the data gave rise to concern?
14 A. I think, in thinking about how we developed those
15 guidelines in the South-east Thames region, it was
16 essentially a pragmatic justification. We were trading
17 off overcoming clinicians' concerns and worries about
18 confidentiality, and hindering or even hampering the
19 process of clinical or medical audit and its results.
20 The concern we had was that if you drew too tight
21 a set of confidentiality guidelines, then information
22 about quality problems would not be able to flow to the
23 people who needed to know about them, or who had perhaps
24 had the capacity to do something to then change
25 practice. So confidentiality, we were concerned, could
0024
1 be a bar to actually producing effective medical or
2 clinical audit.
3 On the other hand, we were responding to the very
4 real concerns of clinicians, and this compromise we
5 worked out, we distinguished between data about
6 individual clinicians and the clinical team. We said
7 that information about teams should be much more widely
8 shareable. Data about individual clinicians would stay
9 within the team and the Clinical Director, so that the
10 Clinical Director had a key role there. That did not
11 mean that if that Clinical Director had concerns about
12 a particular individual, they would not then be able to
13 raise those concerns, and indeed, they would have a duty
14 to raise those concerns with those higher up in the
15 organisation. But it was our kind of pragmatic response
16 to try and find a middle way between the concerns of
17 clinicians and the effectiveness of having an effective
18 audit process.
19 Q. The answer you are giving there implies there was some
20 formal discussion and agreement on how data should be
21 shared within the organisation; is that correct?
22 A. We developed these guidelines for Brighton Health
23 Authority, and Brighton Health Authority and the
24 clinicians involved in audit there endorsed them and
25 used them. They then got picked up by the South-west
0025
1 Thames region which used them themselves, the Regional
2 Health Authority endorsed them, and in fact several
3 other regions picked those up and a number of other
4 Trusts around the country took copies of our guidelines
5 and then used them or modified them. I think there is
6 in the papers a set of similar guidelines or a set of
7 guidelines on confidentiality for UBHT, and most Trusts
8 around the country at that time wrote some sort of
9 a paper describing how they would try to manage
10 confidentiality in the audit process and tread this
11 middle way between keeping clinicians reassured and
12 making sure that problems with quality could be raised
13 and dealt with effectively.
14 THE CHAIRMAN: May I ask another question? Again, perhaps
15 just proceeding the way Miss Grey is going to go.
16 Would this compromise you talked about work as
17 well if you included in the audit process what Professor
18 de Leval mentioned when he was here, namely near-miss
19 examinations, not merely mortality and morbidity but
20 near-miss, where you might need to have more specific
21 information than just the unit, that you may identify
22 one particular individual. Could that compromise work?
23 How would one manage that, if it were desirable?
24 A. I think the compromise we came up with places a lot of
25 responsibility on the clinical team to deal with the
0026
1 sorts of problems that arise, not just near misses but
2 significant adverse events of one sort or another.
3 I do not think I would feel comfortable with
4 a Trust following that compromise today. It was very
5 much a compromise of its time. It dealt back in the
6 early 1990s with the worries that clinicians had.
7 MISS GREY: Can I just go back to an answer you gave
8 earlier, when you mentioned that the Department of
9 Health was reluctant or would not grant PII
10 certificates, or immunity for data produced in the audit
11 process.
12 Can I just ask you for further details of how that
13 information came to light, or you know of it?
14 A. I would have to look back to papers at the time, but
15 I know I had discussions with people who were in the
16 Medical Audit Unit at the Department of Health about the
17 issue, having been involved in producing some guidelines
18 on this, and other organisations produced sets of
19 guidelines on this. I think the BMA issued some
20 guidance and I think the Royal College of Physicians did
21 too, and it was raised by a number of individuals with
22 the Department. I think I am right that I have
23 somewhere on file a letter from the Department's
24 solicitors, I might struggle to find it now, because
25 I know they did get legal advice on the confidentiality
0027
1 of that data.
2 THE CHAIRMAN: I think it is being urged that if you do have
3 any such material, we would be very grateful to see it,
4 if you could let us have it in due course?
5 A. I will endeavour to find it, yes.
6 MISS GREY: If I could leave the topic of confidentiality,
7 unless there are any further questions arising out of
8 it, and pass back to the structure that was set up in
9 1989 to develop audit: firstly, can you tell us a little
10 bit about the role of Regional Health Authorities in the
11 system, as it was developed from 1989 onwards, to 1995?
12 A. The situation in 1989 -- it was actually I think 1990
13 and early 1991 when the policy began to roll out into
14 practice -- was that the Department of Health allocated
15 sums of money that were ringfenced for the purposes of
16 medical audit and it allocated those sums to regional
17 health authorities and regional health authorities went
18 on to allocate them to district health authorities, and
19 a variety of formulas were used to do that, mostly based
20 on the numbers of consultants in those organisations or
21 areas.
22 Every Regional Health Authority established some
23 kind of a function, a regional audit committee or
24 a regional audit co-ordinator to manage this process, to
25 allocate the resource and also to follow up how that
0028
1 resource was used to make future decisions about
2 movement of that resource and so on.
3 So every region established some kind of
4 a function.
5 Q. Is it right to say that the regions devolved that money
6 down to the districts, or did they at least in some
7 cases distribute it directly to hospital Trusts
8 themselves?
9 A. That changed over time. Initially, they distributed
10 that money to districts, and I think the circular that
11 came out in 1990 described a process of having
12 a District Audit Committee. This was a time when NHS
13 Trusts were being created and so gradually, between 1990
14 and 1992, regions began to allocate that resource more
15 to individual provider units or Trusts rather than to
16 districts.
17 But in that process of allocating the resource,
18 district health authorities tended to play a very
19 limited role. The resource went largely from Regional
20 Health Authorities and their Audit Committee to
21 a District Audit Committee at district level to
22 a hospital or to a provider unit audit committee at
23 provider level, with the Health Authority often seeming
24 to act as not much more than a sort of post-box for the
25 funding as it went down and for the report that would
0029
1 then come back up on an annual basis.
2 Q. I think if we look at the documents from the UBHT, by
3 1992, at any rate, the line of reporting went from the
4 Trust directly to the Region, rather than via the
5 District Health Authority. That would be in no way
6 atypical, would it?
7 A. No, some regions were more interventionist than others.
8 Some regions for example, their regional audit function
9 undertook visits to Trusts to assess what they were
10 doing with their audit resource, to advise them, try to
11 encourage them to take particular directions and so on.
12 Others were much more hands-off and simply allocated
13 a resource and then waited for an annual report. But
14 the position of the Health Authority here, in not
15 playing an important role in the process, is far from
16 atypical. We did some research about that time that
17 looked at the role of health authorities and suggested
18 that most health authorities had a fairly limited role.
19 There is a report on that that I can provide, if that
20 would be helpful.
21 Q. If we look back at WIT 323/18, we are back in the
22 Working Paper of 1989 on medical audit. At this stage,
23 at items (c), (d) and (e) we can see the role envisaged
24 for management in the audit process.
25 I think firstly it is a fair comment perhaps that
0030
1 at this stage the detail of the level of scrutiny or
2 involvement from management that was envisaged is not
3 particularly clear?
4 A. Yes, I think that is true. You should remember that at
5 this time managers in the Health Service had a fairly
6 substantial change agenda, the creation of NHS Trusts,
7 the development of contracting, one or two other things
8 to deal with, and most managers sat at best as
9 a spectator rather than a player in local clinical
10 audit. I note that I think the Audit Committee for the
11 UBHT had a manager in attendance rather than a manager
12 as even a member of the Audit Committee. That was far
13 from being atypical; that was a common model: the
14 committee was entirely clinical or almost entirely
15 clinical.
16 One of the things we examined in our research was
17 the reporting relationships of those committees, so if
18 you have a local Audit Committee, to whom or how does it
19 report? What became clear was that many did not see
20 a particular reporting relationship to their
21 organisation; if anything, it was to the Region.
22 The process was kind of semi-detached. It was
23 certainly not corporately owned. Ringfencing of the
24 resource had an effect here because --
25 Q. Can I just slow you down? You were saying that
0031
1 ringfencing ...
2 A. Ringfencing had an important effect here too. Because
3 the money was dedicated to clinical audit, many managers
4 seemed to simply say, "This is not our concern, we will
5 leave it to the Audit Committee". It was actually when
6 ringfencing of the resource ended in 1994 and it became
7 a local funding issue for health authorities and Trusts,
8 that managers began to get much more involved because
9 they were then accountable for and could influence the
10 spending of that resource.
11 Q. So do you see, then, a development in the involvement of
12 management and its agenda throughout the period of the
13 Inquiry?
14 A. Yes. Managers moved from being spectators to being
15 players. As policy on audit evolved, as the process
16 began to mature and people began to understand it better
17 in provider units or Trusts, and as the funding process
18 for it changed and it became locally a process that
19 health authorities funded through a contract with their
20 provider units, you saw much greater management
21 involvement in the process.
22 Q. What shape or form did that management involvement tend
23 to take? I know I am asking for generalisations, but
24 you can perhaps help us at least?
25 A. I think it worked at several levels. It meant there
0032
1 started to be more management input into audit
2 committees with a manager or a number of managers taking
3 a role. We started to see an executive lead for audit
4 quite often, so quite commonly the Medical Director or
5 Nurse Director of the Trust being clearly identified as
6 the Executive Director who had responsibility for
7 clinical audit and in the process of auditing
8 directorates, you began to see more managerial
9 involvement. This was at a time when Clinical
10 Directorate structures were developing, and it was
11 becoming more common to have Clinical Directors with
12 a busy manager working with them to manage a clinical
13 area, and increasingly, those business managers were
14 involved in audit processes within their directorates.
15 Q. What does that mean in concrete terms? For instance,
16 does it have an effect on whether or not managers feel
17 able to specify topics for audit, or guide that process?
18 A. That became commoner. In fact, the guidance from the
19 Department of Health on the evolution of clinical audit
20 issued in about 1993 or 1994 began to suggest that
21 a proportion of audit topics should be determined by the
22 local health authority; a proportion should be
23 determined by the Trust; and a proportion should be
24 determined by clinicians. That I think is an explicit
25 recognition of the fact that there are other people who
0033
1 have an interest in the process.
2 In some ways, that was not necessarily that
3 productive, because it was often the people in the
4 service who were best placed to see what the quality
5 problems were and to identify an agenda. What it did do
6 was at least make health authorities and Trusts engage
7 more in identifying what topics for audit should be
8 addressed; much more than they had done in the past when
9 it was entirely an issue in most places for the local
10 clinicians.
11 THE CHAIRMAN: May I ask another question? You talked about
12 the parallel development of clinical directorates. Do
13 you have any insight as to whether, if audit was
14 developed along with clinical directorates and was
15 particular to that area of activity, there might be
16 a price to be paid in terms of being able to audit
17 across directorates to see, for example, whether there
18 were a number of directorates involved in stages in the
19 care of a particular patient?
20 A. Yes. I think it might be helpful to refer to some of
21 the research in the evaluation that we did here. One of
22 the things that we looked at in our survey of all Trusts
23 in 1993 was whether Trusts had devolved the process to
24 directorates and devolved the resource as well to
25 directorates, or whether they had a central function.
0034
1 I think we found from memory about 10 per cent of
2 Trusts had chosen to devolve the process wholly or
3 largely to directorates. The great majority had
4 established some kind of central audit function, quite
5 often with a link then to directorates, so individual
6 audit staff would serve particular directorates, for
7 example. In that report -- I can provide it for the
8 record -- we argued that the devolved model was not
9 a good way to go, for a number of reasons: because it
10 fragmented the resource across areas, it made it much
11 more difficult to do anything across directorates; it
12 was hard to monitor and there was some evidence from our
13 survey that directorates did not necessarily use the
14 resource for clinical audit as it was intended to be
15 used, and it led to some very isolated audit and quality
16 improvement staff. So we felt that a centrally led
17 model, particularly in the early days of clinical audit,
18 was much more appropriate.
19 THE CHAIRMAN: Could I ask where that research was
20 published, where and when?
21 A. It was published in a research report from CASPE
22 Research for the Department of Health in 1993, I think,
23 but I will provide the report. That was widely
24 circulated. That report was sent to all the Trusts that
25 had taken part in the survey, for example.
0035
1 MISS GREY: Can you just tell us a little more about the
2 methodology of that work, because I think you visited
3 a number of Trusts in order to do your research?
4 A. Yes. There were two parts to it. We did a very
5 detailed survey of all health authorities and all
6 Trusts, and we used data from that survey to identify
7 29 Trusts, chosen to be broadly representative of the
8 different sorts of Trusts, broadly representative
9 geographically of England, and also broadly
10 representative, from the data we had in our survey, of
11 progress in clinical audit. So we were not just looking
12 at the leading edge or the trailing edge but looking
13 across the spectrum of clinical audit.
14 We chose 29 Trusts whom we then visited -- I am
15 working from memory here -- across 1994. I think it was
16 the first few months of 1994 that we did most of that
17 work. Each Trust we visited for about two days. We did
18 confidential interviews with a range of staff at each
19 Trust, including leads for audit, chief executives,
20 medical directors and others. We held an open meeting
21 at which people came and talked about what they were
22 doing for clinical audit. We reviewed their documents,
23 their audit reports, minutes of meetings and we also
24 collected data on a sample of audit projects at each
25 Trust.
0036
1 MRS HOWARD: Dr Walshe, may I interrupt again. You talked
2 about 29 Trusts and gave a wide spread. Out of memory,
3 can you remember whether Bristol was actually one of the
4 Trusts?
5 A. No, it was not. I think I am right there were two in
6 the South West region. I am 99 per cent -- can you
7 confirm, Eleanor?
8 MISS GREY: That is my understanding from the
9 documentation. Were there any Trusts of a size
10 comparable to the UBHT that were included in the study?
11 A. Yes, we looked at some very large acute Trusts and also
12 some smaller acute Trusts. We looked at community
13 Trusts and combined Trusts that combined medical health
14 and acute services.
15 Q. I think the argument that might be advanced for
16 a devolution model in a Trust the size of the UBHT would
17 be that really its size drove that particular policy and
18 to impose centralised control would have been
19 counter-productive and stifle local initiative, as it
20 were?
21 A. Yes. I am quite cautious about imposing a particular
22 shape to the process on a Trust, because one of the
23 things the research suggested was that it was very
24 dependent on the local context; it was hard to prescribe
25 that "this is the best way" of organising and auditing
0037
1 an organisation. We published four reports on Trusts we
2 thought were very good at doing clinical audit. One of
3 those was North Staffordshire Royal Infirmary, a very
4 large acute Trust which we thought developed a very
5 effective clinical audit programme. I am happy to
6 provide that report for the record. There they had
7 a central audit function, a clinician and physician who
8 led the process and an audit team of about 9 or 10 audit
9 staff working across the Trust. It was an example of
10 a model that we thought had worked well.
11 Q. You in fact identified, through your research, the
12 elements of a successful audit programme?
13 A. Yes.
14 Q. If we look at INQ 11/17, please, towards the bottom of
15 the page we can see -- perhaps we should scroll up
16 a little for the full information. Firstly, there is
17 a paragraph there which says at (i) that a successful
18 audit programme is defined firstly as one directed to
19 quality improvement, valued and respected by
20 stakeholders, it covers the full range of provider
21 services, departments and professions, and produces
22 documented demonstrable improvement in the quality of
23 care.
24 Then this summary reports you as having found that
25 there were really only a very few providers whose audit
0038
1 programmes would genuinely be said to be achieving most
2 or all of those benchmarks. So one had, as it were, to
3 lower one's ambitions in order to find successful signs
4 of improvement or development in audit.
5 If we go on, then, and scroll down the page to
6 (iii), please, they set out there seven critical success
7 factors for clinical audit programmes. Can you just
8 talk us through the summary of the seven that we find
9 there: firstly, clinical leadership?
10 A. Yes. We found that these were the seven key
11 determinants of whether audit had worked, or would work
12 in an organisation. Whilst the presence or absence of
13 any one was not necessarily a determinant in the sites
14 we visited, being able to say that these things were
15 present seemed clearly associated with greater progress
16 in clinical audit.
17 Clinical leadership emerged from the qualitative
18 research that we did as the most important single
19 determinant of whether audit worked, having the right
20 clinical leader for the audit programme, the chair of
21 the audit committee or whatever. In some places we
22 visited, the person put into that role was the most
23 junior consultant, or one of the most junior consultants
24 in the organisation. In some places they had no time to
25 fulfil this role. In some places they were not
0039
1 interested, or had been given the role because nobody
2 else would take it; they had no real enthusiasm for it.
3 In others, the clinical leader was someone who had
4 authority, who had perhaps played other roles within the
5 organisation, was respected clinically by doctors and by
6 others, who was genuinely interested in quality
7 improvement and demonstrated that by their own practice
8 of clinical audit, and who had the management skills and
9 the interpersonal skills to make the programme of change
10 involved in implementing clinical audit work.
11 That seemed the most important single determinant,
12 having the right person as the clinical leader.
13 Q. Just to clarify, presumably these benchmarks, as it
14 were, would be being assessed either at the level of
15 a centralised audit committee in a centralised
16 structure, or perhaps at a devolved level if audit was
17 taking place, say, at the Clinical Directorate level?
18 A. Yes. I think you could use the framework of the seven
19 areas that we suggested, both to think about a Trust and
20 to think about performance in a Clinical Directorate.
21 Q. If we go on, you talk about vision, strategy, objectives
22 and planning, and perhaps not surprisingly, it helps if
23 one is clear about all of those things.
24 A. Yes, researchers often come up with the blindingly
25 obvious. The point was that in some places we visited,
0040
1 there was no clear idea of what audit was meant to be
2 doing, so it became taken over by individual agendas of
3 individual clinicians, or indeed other individuals who
4 wanted to do something in particular, and you ended up
5 with a very uncoordinated and rather incoherent
6 programme of quality improvement, if at all.
7 In others, they had a clearer shared view that the
8 Chair of the Audit Committee had communicated to
9 clinical colleagues that this is what audit is about,
10 and there was then much more coherence and where that
11 was linked to having someone perhaps as the audit
12 co-ordinator or manager who was good at delivering the
13 objectives, translating that into an action plan and
14 making sure that those actions happened, then it worked
15 much better.
16 Q. And those set of objectives, they had tended to emerge
17 how? Through discussion? Through debate?
18 A. Every Trust was obliged to have a forward plan for
19 clinical audit, and also to produce an annual clinical
20 audit report, particularly in the time of ringfenced
21 funding to receive their ringfenced funding, but those
22 plans varied very much. Some of them were not much more
23 than a statement of the guidance, with some information
24 about local activity, and others were much more a real
25 plan, setting out what the objectives were and how they
0041
1 were going to be achieved.
2 Usually, those objectives and the planning process
3 emerged from chairs of audit committees and chairs of
4 audit co-ordinators as the driving force behind them.
5 Q. Going on to audit staff and support, if we just turn
6 over the page?
7 A. Yes. Especially at the start of clinical audit, the
8 perception amongst many clinicians was that they needed
9 people to help them collect data, so quite often Trusts
10 appointed a raft of audit assistants to help gather
11 data, to put it into computers and so on.
12 I think what soon emerged was that data collection
13 was not necessarily the problem. They needed more help
14 with the quality improvement process, with helping them
15 to identify opportunities for improvement or policy
16 problems, and manage a clinical audit project that would
17 result in recommendations that would then bring about
18 a change in practice, and Trusts gradually moved to have
19 more senior people involved. For example, people who
20 had a clinical background, working as an audit
21 facilitator, who are much more able, if you like, to
22 punch their weight with the clinicians they were talking
23 to, who understood the clinical issues much better and
24 were more able to provide real advice and support, not
25 just collect data.
0042
1 Q. Do you mean that at the beginning there was too much
2 attention paid to collecting data, without adequate
3 thought given to how it would be used, or be useful?
4 A. Absolutely. One of the findings from our survey was
5 that at the time of this survey I think about 25 per
6 cent of the ringfenced funding for clinical audit was
7 being spent on IT. In some Trusts, some of the ones we
8 visited, it was much more than that. We raised concerns
9 about the value of much of that investment because it
10 produced lots of information systems and the gathering
11 of a huge amount of data, much of which was never really
12 used in clinical audit.
13 Q. If we go on, then, please, to structures and systems --
14 A. In a sense, it is like the point about vision and
15 strategy and objectives in planning. The people who
16 were running audit, chairs of audit committees, were
17 almost all consultants, and some of them had never
18 managed staff, for example, before apart from their
19 junior medical staff. Suddenly in a place like UBHT,
20 you would have responsibility for a budget of œ300,000
21 for perhaps five, six or seven audit staff, and some
22 were much more able to get to grips with the process of,
23 you know, setting up structures for a department,
24 managing staff appraisal, dealing with all the issues
25 concerned with managing this new function. And some
0043
1 audit departments were just much better managed than
2 others. They had systems, for example, for deciding
3 which audit projects they would do, which audit projects
4 they could support for prioritising, for timetabling,
5 for monitoring what was going on. Others were much less
6 well developed.
7 Q. The entirety of that answer is, I think, largely
8 premised upon the 9 per cent of the larger departments
9 with large budgets, deployment of staff and so on.
10 Presumably you might say that had an application
11 nonetheless again at Clinical Directorate level, albeit
12 that smaller programmes would be run at that level?
13 A. Yes, indeed. If you talk to Clinical Directorates, or
14 to directors and consultants about how audit was managed
15 in their directorate, some would have a system for, for
16 example, identifying what topics they would address.
17 They would say, "Once a year we sit down together and we
18 discuss what topics we want to do over the coming year
19 and we plan out a programme". Others would say, "We
20 each take it in turn to run an audit meeting and it is
21 up to whoever runs the audit meeting to choose a topic
22 to present".
23 Q. It would follow if that model were adopted, it is likely
24 that the whole process of audit would be collapsed into
25 one single meeting?
0044
1 A. Yes, absolutely, and one of the perverse effects of the
2 Department of Health's policy on audit and the way it
3 monitored the process of audit was that there was
4 a focus on having audit meetings as being a major part
5 of the audit activity. So consultants were very much
6 encouraged to establish meetings where they had
7 regularly talked about audit. Some Trusts established
8 an audit half day where all consultants would spend time
9 talking about audit, but that encouraged a wrong-headed
10 view that audit was all about sitting down and having
11 audit meetings and once you had been to the audit
12 meeting, you had done audit. Much of what was important
13 about audit -- identifying problems, collecting
14 information, putting into practice change -- had to take
15 place outside those meetings.
16 Q. Training and education: I think that if we look through
17 the regional reports to the Department of Health from
18 the South West Regional Health Authority during the
19 period of our Inquiry, we would find comments that
20 little money was spent on training clinicians in audit.
21 That was a theme, then, that you found repeated in your
22 research?
23 A. Yes. Very much. Very few of the providers we visited
24 had done more than run a few ad hoc workshops to equip
25 clinicians with skills in quality improvement. The
0045
1 assumption was that they had those skills because they
2 were already doctors or nurses or whatever.
3 If you look at other sectors, if you look outside
4 of health care, effective quality improvement programmes
5 invest a lot of money in equipping people with the
6 skills in teamwork, in problem identification, in change
7 management, that they need to make quality improvements
8 happen and we thought this was an important failing
9 here.
10 I would also say that those Trusts who did invest
11 a lot in training, and Brighton Healthcare was one
12 I worked with a lot in the 1993/94 period on training
13 clinicians in clinical audit, struggled sometimes to get
14 clinicians to see that they had a need for training,
15 struggled to persuade particularly doctors that they
16 should take a day away from clinical practice and spend
17 that in a seminar on clinical audit or quality
18 improvement.
19 Q. How much guidance or help was coming on that issue, on
20 the need for training, because presumably your study and
21 its publication might have identified that as a failing;
22 but before such work was coming out of the evaluation of
23 audit, how much recognition of the problem would there
24 have been?
25 A. I think quite limited. It was not really a strong theme
0046
1 in the policy documents, earlier or later. Because
2 although they talked about audit as being fundamentally
3 educational, it was more about educating people about
4 clinical practice than about educating them about how to
5 do effective clinical audit.
6 THE CHAIRMAN: May I ask a further question? In your
7 reference to the preparation of clinicians and training,
8 what provision was made, and presumably it would be
9 financial, for the engagement of locums or others to
10 take over those duties that the clinicians would
11 otherwise be doing?
12 A. That was a local issue for Trusts. They had their audit
13 resource and they spent it how they chose. And not just
14 for Trusts but also in primary care, where I think it
15 was even more of a problem for the primary care audit
16 groups, in getting GPs and others to take time away from
17 the workplace to engage in training.
18 MISS GREY: Did they make use of locums, that you saw?
19 A. Not very much. I think where training was organised,
20 often it was orientated around those audit meetings that
21 I described, so if a Trust had a regular audit half
22 a day once a month, they would try and organise training
23 workshops and things like that. The Audit Department
24 would focus its training activity on times when it knew
25 clinicians were able to make it.
0047
1 Q. Presumably it might say that it is not easy to find
2 a replacement for a senior consultant surgeon, for
3 instance, you cannot find a locum to substitute for such
4 a person?
5 A. Indeed, but I think it was treated within Trusts very
6 much as absences for other purposes from the clinical
7 workplace would be treated, absences for other
8 directorate meetings, for other meetings within the
9 organisation, for continuing professional development,
10 where the workload would get reorganised but it would be
11 unusual, I think, often to hire a locum to cover a day's
12 session.
13 Q. If we move on, then, to understanding and involvement,
14 you say that "successful participation in audit
15 programmes also depended on resources, time and
16 appropriate incentives and sanctions."
17 What use was made of incentives?
18 A. Many Trusts used the ringfenced audit money itself as an
19 incentive. They used the distribution of that resource
20 as a way of encouraging participation in clinical
21 audit. It was used to kind of oil or grease the wheels
22 and encourage people to take part.
23 Very few Trusts had other incentives that they
24 could rely upon, other than the sort of encouragement
25 and support of, you know, the audit chair and others,
0048
1 and I cannot think of any Trusts who had real
2 sanctions. I mean in our research we interviewed what,
3 29 chairs of audit committees, and I remember one
4 telling me that in his year or so as the Chair of the
5 Audit Committee, he had made himself more unpopular than
6 he had in 20 years of clinical practice. It was
7 a difficult role to fulfil in raising with colleagues
8 issues such as "Why is your directorate not doing any
9 clinical audit?"
10 The result of that was that clinicians or chairs
11 of Audit Committee tended to raise the issue once or
12 twice, but they did not bang their head against a brick
13 wall, because they had few other sanctions they could
14 take. Quite often, what chairs of audit committees
15 would do is include in their annual audit report the
16 fact that orthopaedics was not doing any audit because
17 there would be a blank page for orthopaedics, but they
18 would not do more than that. It was hard to see what
19 more than that they could do, quite often.
20 Q. If we go on to the organisational environment, the
21 summary again comments that the those organisations
22 likely to be most in need of audit and quality
23 improvement were probably the least able to be able to
24 make it happen.
25 A. Yes, good organisations are good at implementing change
0049
1 and the introduction of clinical audit was another
2 change, so it was clearly the places where managerial
3 and clinical relationships were good, and not just at
4 a Trust level but at a directorate level, where, for
5 example, the clinicians got on, met regularly, there
6 were good relationships between doctors and nurses, who
7 were more able to engage in setting up a clinical audit
8 process.
9 I can think of places I visited where groups of
10 clinical staff did not talk to each other, individual
11 clinicians just did not get on, and establishing an
12 audit programme in that rather hostile environment is
13 clearly much more of a challenge.
14 Q. Are you saying then that audit functions as a sensitive
15 indicator for other more deep-seated problems, or that
16 it may do so?
17 A. Yes, we argued in the conclusions from our research,
18 that audit was a useful kind of proxy for deeper seated
19 organisational problems and that by pointing to Trusts
20 who had struggled to establish any kind of audit
21 programme, or to directorates within a Trust who had
22 struggled to establish any clinical audit, you could
23 often point to places where there were deep-seated
24 clinical problems that had implications for the quality
25 of clinical care widely.
0050
1 THE CHAIRMAN: When you say audit was a useful proxy, you
2 mean, do I take it, the existence or effective use of
3 audit, rather than the results of the audit?
4 A. No, the process. I think having done the research,
5 I would be much reassured as a patient to be treated in
6 a directorate or department where I knew they had
7 established an effective set of arrangements for
8 clinical audit, and I would worry if I knew they had
9 struggled to do so and failed to do so.
10 THE CHAIRMAN: I am grateful.
11 MISS GREY: If I may leave, then, the indicators of
12 a successful audit programme and just ask you to discuss
13 briefly the shift from medical to clinical audit during
14 the latter period, if we are looking at the period 1991
15 to 1995.
16 We know from various papers before the Inquiry
17 that in around 1993, to put it broadly, the Department
18 started to encourage and then indeed to require of
19 clinical audit programmes as against purely medical
20 audit programmes.
21 Was that replacing medical audit, or was it common
22 to find the two beginning the operate in tandem?
23 A. It generally replaced and it was part of the wider shift
24 towards for example more managerial involvement, that
25 there was this move towards a more multi-professional
0051
1 approach to audit and quality improvement.
2 The department had established, back in 1990,
3 a separate nursing and therapies audit programme run by
4 a separate part of the Department of Health, part run by
5 the Chief Medical Officer's section and part by the
6 Chief Nursing Officer's section. In 1993 they
7 recognised, as did others, that that division did not
8 make sense and they brought the two together and
9 encouraged Trusts to bring the systems together.
10 What usually emerged within a Trust was a Clinical
11 Audit Committee with a more multi-professional
12 membership, although the membership of those committees
13 tended to be quite medically dominated.
14 Q. So was there no clinical role for a medically orientated
15 form of audit?
16 A. I think it depended on the specialty, the area and the
17 quality issues that you were addressing, but I think
18 most people would agree that most quality problems do
19 not belong to an individual profession. When you start
20 to examine why a particular problem or difficulty
21 exists, it quickly rolls out, given the complexity of
22 the process of care, into the territory of other
23 professional groups.
24 So clinical audit seemed much better fitted to
25 dealing with the very multi-professional nature of most
0052
1 areas.
2 Clearly there are some specialties who tend to
3 work much less multi-professionally than others, and
4 there was no purpose in having a multi-professional
5 process if the issue simply, you know, affected the
6 anaesthetists. But the default, I think, was meant to
7 be that these processes should be multi-professional,
8 because most of the time that was what was needed.
9 Q. And if we are looking at 1995, how well-developed was
10 that form of audit by that time?
11 A. Here I have to rely more on anecdote, because I do not
12 have research data to refer to, but anecdotally, it
13 changed gradually. Initially, it was a clinical audit
14 process, but still very medically led, with both at
15 Trust level and directorate level doctors dominating the
16 process and also having most of the resource for
17 clinical audit in terms of support and so on.
18 That changed gradually and quite often what you
19 found was that the Nurse Director for a Trust would
20 become the person responsible for quality, including
21 clinical audit, and the shape of the clinical audit
22 committee would be changed to make it less medically
23 dominated and to make it involve managers, therapists,
24 nurses and others much more. So gradually it did shift,
25 and I think most Trusts today would have fundamentally
0053
1 a clinical rather than a clinical and medical audit
2 programme.
3 Q. I am touching on a number of themes very briefly, but
4 just to complete that process, can I touch on something
5 that we mentioned briefly earlier but did not explore in
6 any detail, which was the issue of the lessons or
7 experience to be gathered from other industries,
8 experience in introducing quality assurance programmes.
9 Do you think that the NHS learned as much as it
10 could have done from that experience, and if it did not,
11 what were the obstacles to it?
12 A. With the benefit of hindsight, I have no doubt we could
13 have learned much more from the experience of quality
14 improvement, both in other industries and in health care
15 in other countries, than we did. You can attribute that
16 to a kind of parochialism in which we tend to think of
17 things invented in the NHS as being much more important
18 and useful than things invented elsewhere.
19 I think there were important lessons we adopted at
20 least in part. There was for example some very useful
21 research that compared the use of total quality
22 management in pilot TQM hospitals in the NHS with its
23 development in a number of non-health care
24 organisations, Post Office Counters, a water company,
25 a building society, and so on, and highlighted some of
0054
1 the differences in culture and context that made it
2 harder, they argued, in a health care organisation to
3 implement TQM than it was in those non-health care
4 environments.
5 Q. Can you summarise those factors?
6 A. Yes. I mean, I think there are three things, perhaps,
7 they pointed to. One was the professional culture,
8 which did not fit well with the fairly corporate and
9 planned approach that TQM demanded and sort of implied,
10 so the tradition of having a strong professional base
11 and professionals who were not conventionally
12 accountable in a non-health care sense to people was one
13 issue they identified.
14 The second issue was the difficulties of making it
15 work more broadly in public sector organisations, where
16 the incentives are not always as clearly aligned with
17 improving quality as they are in the private sector.
18 You can argue that in a building society, if you
19 improve quality you stand to increase market share, to
20 improve return, and there are a number of measures you
21 might look to. In the public sector, measuring
22 performance is sometimes more difficult. Deciding what
23 the goal is if it is not profit is more difficult, and
24 the incentives to improve are sometimes not really there
25 in the way that they are in a private sector
0055
1 organisation.
2 The other point they pointed to was the complexity
3 of hierarchy in health care organisations, the fact that
4 all the non-health care organisations they worked with
5 have fairly simple hierarchies, and it was much easier
6 to make decisions at the top that rolled down to the
7 bottom, to gather data from the bottom that went up to
8 the top. The hierarchies and structures in health care
9 organisations, partly because of the professional
10 culture but also because of the nature of health care,
11 were so much more complex.
12 MISS GREY: Thank you. Dr Walshe, we have covered a great
13 deal of ground in an hour and a half, and some of it, of
14 course, will be further supported by further papers and
15 research which you have very helpfully offered to
16 provide to us.
17 Is there anything else for this morning's session
18 that you would like to highlight as being an important
19 theme or development in the development of audit in the
20 NHS, across the period of our terms of reference.
21 DR WALSHE: I do not think there is anything I would like to
22 add.
23 MISS GREY: There may be some questions from the Panel.
24 THE CHAIRMAN: We want to know whether Dr Walshe is going to
25 be with us for some time, because we may have some
0056
1 thoughts, but we would like to reflect on them.
2 MISS GREY: The answer to that is that Dr Walshe is able to
3 be with us today, so he will be, I hope, available for
4 further discussion at the end of today's session.
5 THE CHAIRMAN: That is excellent, thank you.
6 MISS GREY: In that case, could I suggest a break for
7 a quarter of an hour?
8 THE CHAIRMAN: Let us break now. I thank you now, but we
9 will converse further later. We will reconvene at
10 11.20.
11 (11.00 am)
12 (A short break)
13 (11.20 am)
14 MISS GREY: Sir, we are now to hear from Dr Trevor Thomas,
15 please. Dr Thomas, could I you to stand, please to
16 swear or affirm?
17 DR TREVOR THOMAS (AFFIRMED):
18 Examined by MISS GREY:
19 Q. Dr Thomas, you have provided a statement to the
20 Inquiry. If we look, please, at WIT 323/1, is that the
21 first page of the statement?
22 A. Yes, it is.
23 Q. If we turn, please, to page 7, is that your signature
24 which appears at that page?
25 A. Yes, it is.
0057
1 Q. Are the contents of this statement true to the best of
2 your knowledge and belief?
3 A. To the best of my knowledge, memory and belief, yes.
4 Q. If we turn to page 2 of that statement, you have
5 helpfully provided to us your abbreviated curriculum
6 vitae and we see there that you are a consultant
7 anaesthetist within the UBHT and that in particular,
8 since 1991, you have been the Associate Director of
9 Obstetric Anaesthesia within the UBHT, and this would
10 be, then, in addition to your duties as Chair of the
11 Medical Audit Committee from 1991 to December 1993?
12 A. Yes, that is correct.
13 Q. It appears, if we turn down through the CV, scroll down
14 the page, please, that your principal responsibility for
15 the last 24 years has been the provision of safe and
16 effective anaesthesia and analgesia services within the
17 hospital maternity unit.
18 Did that involve developing and participating in
19 systems of audit?
20 A. Yes, I think I have been involved in audit in a number
21 of ways during my time as a consultant in the United
22 Bristol Hospitals. I suppose that I could say that the
23 system of medical records that we introduced for
24 obstetric anaesthesia in 1975 might be one of the
25 aspects of audit, because it is a starting point for any
0058
1 of our assessments of what we do.
2 I also have had a role for quite a substantial
3 period of time as the regional assessor in anaesthesia
4 to the confidential inquiry into maternal deaths.
5 Q. You mention that in your CV: since 1978, you say?
6 A. Yes.
7 Q. Can you tell us briefly what the pattern of audit would
8 have been within your division or unit before 1989/90?
9 A. When you say "my unit" you mean in the obstetric
10 anaesthesia unit?
11 Q. I mean the clinical unit with which you were most
12 directly concerned.
13 A. In obstetric anaesthesia, we developed, in 1975, and
14 continued to develop thereafter, a system of recording
15 our activities and bridging between them and midwifery
16 and obstetric records, so as to be able to use data
17 which were being accumulated by the other two
18 disciplines when producing denominator figures.
19 MISS GREY: Could I just break off for a moment, there,
20 please, because it appears to me, sir, I have been
21 guilty of an unintentional discourtesy in that I failed
22 to introduce Mr Hoyte to you. Dr Thomas is today
23 represented by Mr Hoyte, and I do apologise for having
24 failed to make that introduction at the outset.
25 THE CHAIRMAN: I am sure Mr Hoyte will forgive you. I, for
0059
1 my part, am impressed by the telepathy that sometimes
2 takes place between you and me, Miss Grey, because I had
3 just sent a note asking who was the legal
4 representative. So I am very grateful. I am sure you
5 are forgiven; you are by me.
6 MISS GREY: I am sorry, Dr Thomas, you were describing the
7 system that had been introduced?
8 A. Yes ... I am slightly dislocated.
9 I think that our intention was to accumulate
10 sufficient information for us to be able to assure
11 mothers who came into the unit that we could provide
12 safe anaesthesia and pain relief, and where we found
13 that we had a deficiency of some sort, or where we found
14 that our practice was not as good as national figures
15 might suggest it should be, then we would be able to
16 address the problem.
17 An easy example, I suppose, is the incidence of
18 something called an inadvertent dural tap, which is
19 a complication of epidural pain relief. That is quite
20 commonly used across the country to judge the quality of
21 the service, and it was one of the pieces of information
22 that we actually accessed.
23 Q. You have described a system of recording your activities
24 and bridging between them and midwifery and obstetric
25 records, so as to be able to use data accumulated across
0060
1 those units to monitor care. You have also just
2 described a particular factor which you would examine to
3 see whether there were particular problems.
4 Can you tell us a little more what the system
5 consisted of, because from your last reply, it appeared
6 it might be some form of critical instant reporting or
7 near misses or something along those lines. I may be
8 entirely wrong.
9 A. It was a composite. When we began in 1975, we began in
10 a new building. The Maternity Hospital had been built
11 at the top of the hill above the BRI, and the unit moved
12 from its old site to this new building.
13 So the opportunity presented itself for us to
14 start pretty well from scratch with most of our
15 practices, and quite a lot of our record-keeping.
16 So we introduced at that time a computerised
17 record. The first version of that was a clumsy affair
18 which, well, I use the word loosely, for the time
19 I suppose was quite advanced, but looking back now it
20 seems to have been quite a clumsy affair, which was
21 based on punch-cards and mainframe computing.
22 However, I had a colleague who had a lot of
23 interest in computer affairs and he introduced a number
24 of versions of those records through a period I suppose
25 of some, I do not know, 15 years, and the system
0061
1 underwent changes until finally it met the Regional
2 Health Authority initiative for medical data indexing,
3 and that MDI system was something which, at the time,
4 the United Bristol Hospitals wanted to implement.
5 So we tried to blend the two systems together.
6 I think the result -- we are living with it now -- is
7 less than happy and there are a lot of improvements that
8 could be made, given the appropriate financing.
9 Q. We will come back, I am sure, to the MDI system, but
10 what I was trying to understand was, what was it that
11 you were actually scrutinising?
12 A. We stored a very, very large amount of information and
13 we had a retrieval programme which addressed that
14 information and pulled out correlations between a number
15 of activities and results. One I have already
16 mentioned. Another was a simple scoring system of how
17 many general anaesthetics versus regional anaesthetics
18 were given for Caesarean section; what was the forceps
19 delivery rate in patients; the epidurals, and so on and
20 so forth. We looked at the data on an annual basis with
21 a view to modifying our retrieval of information to fit
22 in with current concerns, whether they were our local
23 concerns or concerns that had been voiced nationally by
24 national associations, or whatever.
25 So it was a changing spectrum of data that we were
0062
1 looking at. We were trying to provide a good service
2 and assure ourselves that is what we were doing.
3 Q. If we can turn, then, to page 3 of your statement, you
4 say there that you were a member of the Medical
5 Information Working Group which in turn, when it was
6 disbanded, became the UBHT Medical Audit Committee. You
7 were, I think, the first Chair of that committee?
8 A. Of the District Audit Committee.
9 Q. Of the District Audit Committee, subsequently the
10 UBHT Medical Audit Committee?
11 A. Yes.
12 Q. When discussing the creation of the Audit Committee,
13 Dr Roylance gave evidence as follows -- it is not
14 scanned in so I will read it to you, if I may:
15 "When medical audit was introduced, it was
16 introduced on the professional line, not the managerial
17 line. The then Regional Medical Officer, in conjunction
18 with the Regional Hospital Medical Advisory Committee,
19 made a series of proposals directly to the divisions,
20 which was the medical consultant advisory machinery, not
21 to management, to develop audit. So it started on that
22 axis. Slowly, the responsibility of management emerged
23 to facilitate that professional activity."
24 The point that Dr Roylance is clearly making there
25 is that the initiation of the process of audit began
0063
1 along a professional line of responsibility and
2 accountability, rather than a managerial one, and was
3 addressed in the first instance to the divisions rather
4 than to any managerial structure.
5 Would you agree with that as a description of the
6 history of the audit process?
7 A. Yes, I think I would.
8 Q. Can you tell us how you remember the origination of the
9 development of audit at that time, that is, prior, even,
10 and around 1989?
11 A. Medical audit as we now look at it is different from
12 medical audit in the early years between 1989 and
13 roughly 1993/94, which I think, in itself, differed from
14 what was being done before 1989.
15 The introduction of medical audit that you have
16 just described and that Dr Roylance was referring to
17 I believe was in response to Working Paper 6 of the
18 White Paper, and that Working Paper is something that we
19 used quite extensively when we were considering what we
20 should do in order to implement medical audit as
21 described in that White Paper.
22 Q. Dr Roylance went on to make the point that audit was not
23 introduced at a Trust level and then devolved, or
24 perhaps one might say at a hospital level, because this
25 was still the period prior to the inauguration of the
0064
1 UBHT. It was not introduced at a hospital level and
2 then devolved, rather it began with the medical
3 divisions in the first place.
4 Would you help us on that distinction?
5 A. I am not entirely clear what he meant by that, but my
6 perception of the introduction of audit was that in the
7 first instance there was a regional interest in
8 beginning the process of audit. That regional interest
9 was accelerated by Working Paper 6, which also, of
10 course, laid down a deadline by which hospitals, health
11 authorities and so on, had to have audit in place in
12 a recognisable form.
13 So during 1990, the Medical Committee discussed
14 the way forward and I had just completed a term of
15 office as the Chairman of the Medical Committee, and so
16 I was asked if I would produce a constitution which
17 might address the problem.
18 I did so, and the Medical Committee approved that
19 constitution, and I was invited to chair that committee
20 in the first instance, which I agreed to do for three
21 years.
22 Q. When you speak of the Medical Committee, you mean the
23 Hospital Medical Committee?
24 A. Yes, I do.
25 Q. So what was the relationship -- looking now still at the
0065
1 period in 1989/90, prior to 1991, between audit and the
2 divisions?
3 A. The basic function of audit, as we understood it at that
4 time, was that it would be for educational purposes and
5 that it would be carried out by various groupings of
6 clinicians and would be led clinically and would
7 function as a form of peer review within that clinical
8 group.
9 There was already in existence a culture of
10 devolvement within the hospital, partly because of the
11 size of the unit -- it is quite a big unit and if you
12 add all the big hospitals together, it had nearly 1,000
13 beds, and there were slightly more than 150 consultants
14 on the staff.
15 So it was a large unit and it was perceived that
16 it would function best if the specialties were allowed
17 to develop their own audit and their own audit topics,
18 because they understood their particular aspect of
19 medical care, its risks, its problems, its quality and
20 so on, far better than anybody else.
21 Q. If we look at UBHT 273/1, please, we should see there
22 the first, I think, report produced by the UBHT's
23 Medical Audit Committee.
24 If we turn, please, to page 7 of the report and
25 scroll down a little, you can see there the last
0066
1 paragraph on the page:
2 "The committee has adopted the philosophy that
3 medical audit activities should be the responsibility of
4 specialty divisions or departments and not necessarily
5 the responsibility of directorates. The committee
6 maintains a watching brief in order to determine whether
7 any changes along directorate lines are necessary."
8 That, I think, is a summary of the process or the
9 decision you have just been describing; is that correct?
10 A. Yes, that is right.
11 Q. What sort of debate took place before that decision was
12 taken? Was there a consensus that this was the right
13 approach? Was there a debate or disagreement about it?
14 A. From my memory, I think that all shades of opinion were
15 voiced. People were, I think, worried or concerned
16 about the prospect of audit being undertaken in a way
17 which did not allow them to guide it or to be the owner,
18 if you wish, of the process and the information.
19 We looked at the Regional Health Authority's
20 pronouncements and the Working Paper 6 for guidance and
21 it seemed to us that if we were to reassure colleagues
22 and actually persuade them to pursue audit and gain the
23 benefits from it, that we had to actually allow them to
24 build their own audit process within their specialty.
25 That, we felt, would assuage their concerns quite
0067
1 considerably, but there is no question in my mind that
2 concerns continued for the whole of my time as the
3 Chairman of the audit committee, and there was
4 a constant need to reassure people that confidentiality
5 would be protected in all the ways that Dr Walshe spoke
6 of earlier this morning.
7 Q. Can I just stop you there? Firstly you say that people
8 were concerned?
9 A. Yes.
10 Q. By that you mean individual clinicians, do you?
11 A. Yes, I do.
12 Q. And you say that concerns continued: that is concerns
13 over the ownership and nature of the audit process, or
14 what?
15 A. Yes. I think concerns over the ownership of audit.
16 Q. Was there any discussion of what might be dubbed the
17 "alternative model" of audit?
18 A. Could I just go back, before you ask that question, and
19 say that it might be helpful if the Inquiry remember
20 that within the United Bristol Hospitals, the District
21 Health Authority -- if you do not mind, I will say
22 United Bristol Hospitals as the catch-all phrase --
23 there had been attempts previously to audit in the
24 widest sense, not as we now know it, but audit and the
25 Medical Information Working Group was formed because the
0068
1 authority had formed, previously to that, a Performance
2 Assessment Committee which had been less than tactful in
3 its treatment of information and medical staff.
4 So there was a considerable air of suspicion about
5 any process that looked in any way like the Performance
6 Assessment Committee.
7 I am sorry, I just thought that was helpful.
8 Q. It is, thank you. I was going to ask you, in any event,
9 about something which I think is a reference to the same
10 point in your witness statement.
11 If we can perhaps go back to it now, since we have
12 raised it, WIT 323/3.
13 In the most substantial paragraph, the third
14 paragraph, you wrote in that statement that the Medical
15 Information Working Group was formed to assist the
16 Performance Assessment Committee of the Health Authority
17 by interpreting technical medical information and that
18 it was formed following misinterpretations and
19 misunderstandings between the PAC and members of the
20 medical staff of the United Bristol Hospitals.
21 Is that a reference to the same point you have
22 just been making?
23 A. Yes, it is.
24 Q. Can you help us a little further, then, about the nature
25 of those misinterpretations and misunderstandings?
0069
1 A. I suppose it would be easiest if I quoted a couple of
2 examples which, if you will allow me, I will cloak to
3 a certain extent in anonymity, because it would be
4 pejorative to do otherwise.
5 The Performance Assessment Committee were very
6 keen to ensure that the hospitals functioned as
7 efficiently as possible. In order to assure the Health
8 Authority that that was happening, they examined a lot
9 of work-related figures, and I suppose the simplest
10 example is that there was a failure to understand that
11 surgeon A, who operated on major cases, would do fewer
12 operations in an operating session than surgeon B whose
13 workload comprised mainly minor surgery. That may seem
14 surprising to you, but that difference was not readily
15 appreciated.
16 In addition, there were approaches made by the
17 Performance Assessment Committee through the Health
18 Authority demanding to know where medical staff had been
19 when they were, as far as the PAC was concerned,
20 supposed to be doing a list. That particular example
21 sticks in my memory because the person who was so
22 denigrated in fact was not at fault at all and was on
23 leave at the time.
24 I am sorry to give you simple examples, but this
25 sort of thing happened quite frequently. It did lead to
0070
1 a certain amount of difficulties.
2 Q. Was that an issue that had anything to do with the
3 composition of the Performance Assessment Committee?
4 A. Yes. I think that is what I was referring to when
5 I said that the committee was formed of lay members of
6 the Health Authority. It had no professional members in
7 the first instance and so information went directly from
8 hospital activity analysis sources to a group whose
9 insight into medical activities was limited to their
10 time on the Health Authority.
11 Q. If we go back to a different document, it may be that
12 there is a thread here we can trace. UBHT 25/170,
13 please. Can we go to 169, please?
14 MRS MACLEAN: Can we ask one small point? Could you give us
15 a date for the setting up of the PAC; an approximation,
16 if not an exact date?
17 A. No. I think --
18 Q. We are anxious to make sure we have things in their
19 proper order.
20 A. I cannot give you a date for the setting up of the
21 Performance Assessment Committee. I cannot remember
22 when it was set up.
23 Q. The mid-1980s?
24 A. I would think so, but I would wish you not to put any
25 reliance on that figure. Actually, I think it was
0071
1 earlier than that, to be honest with you. I think it
2 was at the beginning of the 1980s.
3 MISS GREY: What we appear to be looking at is a dispute or
4 a memory of a dispute that coloured the introduction of
5 medical audit in 1990 or thereabouts?
6 A. Yes.
7 Q. So it was sufficiently live in people's memory to still
8 have an influence?
9 A. Yes, because the process of looking at performance
10 figures, which you understand were totally different
11 from audit as it was perceived in 1989/90, nevertheless,
12 the fact that people had been reviewed, as it were, to
13 see whether they were seeing enough patients or whether
14 they were doing enough operations, it lingers in the
15 memory of clinicians, I think, and certainly did in the
16 UBH.
17 Q. Those were then throughput and workload efficiency type
18 scrutiny that was being attempted?
19 A. Yes.
20 Q. The document now on the screen is what I wanted to refer
21 you to, but to get the context we should go back to the
22 first page, the annual report of the District Audit
23 Committee, 1990/91. [UBHT 25/168].
24 Before we discuss that further, I am being
25 helpfully reminded by those behind me that according to
0072
1 Pamela Charlwood's statement, the PAC was formed in
2 August 1985. Would that accord with your memory?
3 A. I would have set it earlier, but I would not dream of
4 arguing the date.
5 Q. We have here the Audit Committee report for 1990 to
6 1991. This is the predecessor body to the Hospital
7 Medical Audit Committee; is that right?
8 A. Yes.
9 Q. Just to finish with this point, if we please go back
10 over the page to page 169, in the last paragraph there
11 is a reference to previous experience with the
12 Performance Assessment Committee, and a reference to
13 misunderstandings and recriminations, and as a result of
14 that, the committee recommends -- I am looking up the
15 paragraph -- that the audit information currently being
16 demanded by purchasers as they strike contracts with
17 providers should be provided by the Audit Committee.
18 Is that a correct link to make, that that
19 recommendation arose out of that past experience?
20 A. Yes. In my memory, that is correct. Can I say that if
21 you go to the previous page, we might as well correct an
22 error on it and say that the first paragraph says that
23 the committee first met on 5th December 1991. It is, of
24 course, 5th December 1990.
25 Q. Thank you. We were discussing the relationship between
0073
1 audit and the divisions as well as audit and any central
2 committee structure. Can I ask you, when the committee
3 started to put in place a network of audit
4 co-ordinators, to whom did those audit co-ordinators
5 respond?
6 A. They responded to the committee via one or other of its
7 members.
8 Q. And the committee responded, or reported to what? To
9 the Hospital Medical Committee?
10 A. Yes.
11 Q. Were there also lines of communication to the Steering
12 Committee of the Chair of divisions?
13 A. Yes. That basically was the route through which the
14 Medical Committee was reached, because the Steering
15 Committee was a Steering Committee of the Hospital
16 Medical Committee.
17 Q. Because the Hospital Medical Committee met only fairly
18 rarely, so the Steering Committee was the --
19 A. No, the Hospital Medical Committee met monthly. The
20 steering committee was formed in order to assess and
21 prepare information for the Hospital Medical Committee's
22 discussions. It met in two forms. A Steering Committee
23 alone and a Steering Committee with Chairmen of
24 Divisions, and those meetings alternated so they
25 occurred at two-monthly intervals. It seemed to be
0074
1 quite an effective way of not troubling people with
2 unnecessary information, and yet, at the same time,
3 allowed the specialties access to their colleagues for
4 discussion of any matters that were causing them
5 concern.
6 Q. We have heard a certain amount during the course of the
7 Inquiry about the Clinical Directorates that were
8 established in the UBHT and their evolution.
9 Can you tell us a little about what might be
10 called the medical side of that particular coin, the
11 divisions, and their continued life and existence from
12 1991 onwards?
13 A. Yes, I suppose I can give you my perception of what
14 happened. I think that it was generally felt that the
15 introduction of Trust status demanded the formation of
16 directorates, clinical directorates, and that those
17 clinical directorates would be responsible for
18 organising the services that the specialty provided;
19 that they would be the contract-making organisation
20 where contracts were made.
21 However, it was perceived that that was only part
22 of the activity and responsibility of specialty groups,
23 and that there was a continuing need for, if I may call
24 it a professional network which addressed problems of
25 education, interfacing with Royal Colleges, and the
0075
1 like.
2 So, for some time, and indeed, in some instances
3 there is still a divisional system within some
4 specialties. Some specialties, I know, felt that that
5 was inappropriate and did away with their divisional
6 structure very early on -- I cannot give you dates, but
7 very early on.
8 Q. But in others, the structure continued to have life, did
9 it?
10 A. Yes.
11 Q. Until the end of our period, 1995?
12 A. Yes.
13 Q. Are you able to help us as to what the position was
14 within the Department of Cardiac Surgery, within the
15 field of cardiac surgery?
16 A. No. I do not know.
17 Q. You describe in your statement the creation of the UBHT
18 Medical Audit Committee. If we could look back, please,
19 to first of all the District Audit Committee, its
20 predecessor, at UBHT 25/157, and go back another page to
21 156 -- I will have to come back to that, I am sorry.
22 We can see, however, from this particular
23 document, that Mr Wisheart was a member of the committee
24 from its outset; is that correct?
25 A. Yes, that is correct.
0076
1 Q. Can you help, he succeeded you ultimately as the Chair
2 of the Medical Audit Committee for a period of time as
3 a caretaker, I think it can be said. You have spoken in
4 your statement about new initiatives tending to be
5 viewed with great suspicion by staff. Can you help us
6 on Mr Wisheart's attitude to audit and its
7 introduction?
8 A. No, I do not think I can. I think you would have to ask
9 him. Guide me a little, Miss Grey.
10 Q. You were his colleague. You worked with him on this
11 committee. It is apparent, we have heard it from
12 Dr Walshe this morning, that some clinicians at least
13 were concerned, worried, by the introduction of medical
14 audit in 1989/90.
15 Was this Mr Wisheart's attitude, or was he more
16 welcoming and helpful?
17 A. His appearance, to his colleagues, would have put him in
18 a neutral position. He was not one of the enthusiasts
19 that Dr Walshe talked of earlier, but neither did he
20 seem particularly bothered about the prospect of
21 pursuing the audit process. I think he understood, and
22 probably shared, the concerns that you and I have
23 already discussed this morning, because I think those
24 concerns were common to the medical staff in the UBHT.
25 So I do not think he was any different in that respect.
0077
1 Q. But there are those who remain fixed within concerns,
2 and there are those who seek to overcome them, and to
3 answer concerns. What was Mr Wisheart's contribution to
4 the work of your committee?
5 A. He functioned as he was required to, as the
6 representative of the Medical Committee on the District
7 and then Trust Audit Committee. He functioned in that
8 role because he was, by this time, the Chairman elect of
9 the Hospital Medical Committee.
10 I cannot say that Mr Wisheart was resistant to the
11 idea of audit being pursued, but equally, as I said
12 a moment ago, he was not an enthusiast. He knew, as we
13 all knew, that medical audit was an important function
14 among the educational functions within the hospital, and
15 I am sure that he supported that educational function of
16 audit.
17 You will undoubtedly come on to something which
18 I will mention now, but audit in cardiac surgery was
19 going on from the very beginning of the life of the
20 District Audit Committee in 1990, and you will see from
21 references that I have made in my statement that the
22 District Audit Committee were aware of the contractual
23 content of some of the discussions being held between
24 the purchaser and cardiac surgery. We are now speaking
25 a little bit beyond 1990, but nevertheless, I think I am
0078
1 talking about March 1991, something round about that
2 time.
3 At that time there was a clear undertaking being
4 given by cardiac surgery to the purchaser that they
5 would provide, to the purchaser direct, figures of
6 mortality. As far as the Audit Committee were
7 concerned, those figures were passed and we were not
8 given any information that they were not passed. They
9 did not go through the Audit Committee, much to our
10 regret, because we believed that that should be
11 a function of an Audit Committee. We were defeated on
12 this matter by both the purchaser, by the directorate,
13 by the management, and so on and so forth. You will be
14 aware of the entries in the minutes of the committee to
15 indicate that.
16 Q. Had you been aware of the negotiations regarding that
17 particular contract?
18 A. No.
19 Q. At what stage were you made aware of the fact that there
20 was this contractual obligation which bypassed the
21 committee?
22 A. I cannot give you a date. I think it was March 1991.
23 But the first document that we saw or information that
24 we received that such an agreement was being undertaken
25 was in a draft service agreement. When we saw the
0079
1 draft, we commented on it. However, our recommendation
2 that the Audit Committee would have been an appropriate
3 conduit for the transmission of that information, our
4 recommendation was not accepted. That was a pity,
5 because it would have given the Audit Committee itself
6 some sight of that information and the process that was
7 going on.
8 Q. Perhaps we should pick that up whilst it is being
9 discussed with the various document references. We will
10 go back, please, to page 170 of this document first.
11 I am sorry, can you try 169, please? We have seen there
12 already that the recommendation was that, as purchasers
13 demanded audit information, information should be
14 provided by the Audit Committee. That continued as your
15 recommendation, did it?
16 A. Yes.
17 Q. If we look then, please, to HA(A) 10/1 this is the cover
18 sheet of the Bristol & Weston Health Authority service
19 agreement for 1991/92, so the first year of full
20 contracts, as it were.
21 If we look at page 9 of that contract,
22 paragraph 8.3 in particular, we can see there that
23 firstly the confidentiality of any data provided to the
24 District Health Authority is recognised and then it
25 suggests that any information concerning clinical
0080
1 activity required by the purchasing authority will be
2 released to the Director of Public Health Medicine, so
3 they are recognising the medical channel of reporting;
4 is that right?
5 A. I am not clear which Director of Public Health Medicine
6 they are talking about. I think it is the purchasing
7 authority's director, actually.
8 Q. I think it is a reference to the individual in post
9 would have been Dr Ian Baker, I understand?
10 A. You may be right about that. 1991 was the time when the
11 person in that post changed, I think. In 1992 Dr Baker
12 started, and then Dr Morgan took over. I think. I am
13 not sure.
14 Q. In any event, I think we can agree that the Director of
15 Public Health Medicine envisaged there is that person
16 occupying that position within the Health Authority, and
17 the suggestion is that this will be authorised by the
18 appropriate Clinical Director, who may wish to consult
19 with colleagues, or with the Audit Committee. So the
20 Audit Committee has been given an advisory role at the
21 discretion of the Clinical Director only.
22 Is that an agreement that you were made aware of
23 at the time?
24 A. No.
25 Q. Was there any discussion, then, of the difference in the
0081
1 recommendations, the role envisaged for itself by the
2 Audit Committee and that which appears to have been
3 agreed by the Trust with that particular Health
4 Authority?
5 A. I would imagine that the inclusion of the Audit
6 Committee in that paragraph would have followed our
7 recommendation to the then UBHT Board. I suspect that
8 that was seen as a way of accommodating our view.
9 Q. In reality, in practice, did you get, brought to you as
10 an Audit Committee, issues of information required by
11 purchasers and the propriety of those requests?
12 A. Not to my memory, no.
13 Q. And that would be true, would it, of purchasers other
14 than the local health authority?
15 A. Yes. I am casting back in my memory to see whether
16 I can recall any particular figures that came through
17 the Audit Committee and the nearest example I can come
18 to you with is that in I think early 1992, our general
19 practitioner representative, Dr Whitfield, came to
20 a meeting and said he felt that the Audit Committee
21 should have a more proactive role.
22 We discussed that suggestion. In order to pursue
23 it to the best of our ability, given our terms of
24 reference and the limitations that were on us as far as
25 budget and so on -- we did not have a budget, nor did we
0082
1 have any staff with which to pursue anything. The best
2 we could do at the time was to approach the Directorate
3 of Ear, Nose and Throat Surgery and ask them if they
4 would be prepared to undertake a commission from the
5 Audit Committee in liaison with the relevant general
6 practitioners. I cannot remember the topic that was
7 proposed at the time, but I think it was glue ear, but
8 I am not absolutely sure about that. I do not know for
9 sure. That approach, to my memory, bore no particular
10 fruition. It came to no fruition. I think it fell away
11 for lack of interest, but possibly from general
12 practitioners and from the ENT surgeons themselves.
13 Q. You just referred there to the fact that you did not
14 have a budget. Can you describe to us, in your words,
15 the role of the District Audit Committee that then
16 became the Medical Audit Committee and its remit?
17 A. You will have seen, in the annual reports, the
18 responsibilities that the committee took to itself but
19 if you wish to look beyond them or behind them, then
20 I would say to you that the committee felt that its
21 principal objective was to set up and embed within the
22 culture of the UBHT the audit function.
23 We were aware that that audit function might well
24 change, but that until we could persuade people that
25 audit was indeed a valuable process and that they should
0083
1 not fear it, we would get nowhere. Given the fact that
2 we had no budget specific to the committee nor any
3 staff, that was what we thought we might be able to do.
4 There were a number of functions that we believed we
5 could undertake to assist that process of embedding the
6 culture. Dr Walshe referred to them, I thought slightly
7 scathingly earlier on, when he said that large sums of
8 money were spent on hardware, computer systems and the
9 like. However, I think that to be honest with you, we
10 pursued a policy whereby we set up the hardware and the
11 staff and then did the training. That seemed a logical
12 progress, to us. You may say you are surprised we did
13 not actually achieve that within a very short time-span,
14 but it is quite a difficult thing to achieve. I think
15 that certainly by the end of my chairmanship we had done
16 that and we did have staff in post, equipment they could
17 use, in some instances information systems which they
18 could use, and we had done our best to ensure that staff
19 were trained.
20 You may like me to develop that a little bit in
21 two different forms of staff because of Dr Walshe's
22 comments earlier on.
23 Q. If we can, we will come back to the issue of staff and
24 training. Can I come back to your words when you used
25 words such as "persuade" staff to start audit, to
0084
1 encourage them "not to fear", you said, audit.
2 Can you help us further on the climate in which
3 the requirement of the introduction of medical audit
4 came in 1989/91?
5 A. I think I would go back to my earlier comments, and
6 indeed, those of Dr Walshe earlier this morning, that it
7 was a common finding across the country that the
8 profession were wary of the White Paper in general, and
9 I suppose, therefore, any components of it. That was
10 the sort of ambience within which we were working.
11 There was no power within the Medical Committee to force
12 people to do audit, and indeed it would have been very
13 counter-productive had we tried to do so, because audit
14 can only be pursued if people are prepared to be honest
15 about what happened, accurate in producing figures to
16 support the discussions that they were having, and so on
17 and so forth. And in 1989/90, to do other than try to
18 persuade people that this was a good initiative that
19 would in fact result in better patient care, we only had
20 one way forward.
21 Q. So your way forward was persuasion?
22 A. Yes.
23 Q. You did not have a budget?
24 A. No.
25 Q. But nevertheless, you have described the introduction of
0085
1 hardware, staff and training?
2 A. Yes.
3 Q. How are those two statements reconciled?
4 A. Miss Grey, you may not actually have the money, but if
5 your committee members have the influence, then they can
6 persuade people which equipment to buy, what sort of
7 personnel they should have in post and how they should
8 be trained.
9 I believe that the membership of the Audit
10 Committee was such as to achieve that, and the
11 directorates themselves had little experience in
12 securing hardware, personnel or training, so we were
13 able to advise them and to divide them.
14 Q. Because the directorates themselves had been allotted
15 the audit money; is that correct?
16 A. Yes, they had.
17 Q. How was that allotted? On the basis of consultant
18 numbers?
19 A. Yes.
20 Q. Looking back on it, is that a creative way, do you
21 think, of allocating audit funding?
22 A. I am not sure what you mean by "creative".
23 Q. How does it compare with the model of funding audit on
24 the basis of bids or schemes for audit?
25 A. I think you could only allocate money in response to
0086
1 bids or plans or schemes if, in the first instance, you
2 own the money. That was never the case. The money came
3 from the Regional Health Authority into the Treasurer's
4 Department and was allocated on that basis, of
5 consultant numbers. The underlying premise was one
6 which I think you will find appears in Working Paper 6,
7 which says that each individual consultant should be in
8 a position to audit. I paraphrase that, I am not sure
9 of the exact words, but I believe that that phrase is in
10 Working Paper 6. If I misquote it, it may be in
11 a Regional Health Authority document, but that was the
12 underlying principle: that whatever or wherever, each
13 individual consultant would be given the financial
14 wherewithal to pursue audit. That was not the whole
15 story, of course, but that was the resource allocation,
16 and that is why it was done.
17 Q. I can see that that was the policy decision that drove
18 that particular form of resource allocation, but how
19 effective a policy do you think it was in encouraging
20 audit to start?
21 A. I suppose quite effective, actually. No individual, no
22 specialty, no directorate, could claim that they had not
23 been provided with the appropriate resource. They
24 therefore would be expected to carry out audit unless
25 they protested that they were unable within the
0087
1 resource, so the expectation was present, the
2 expectation that they would carry out audit in whatever
3 form they thought was appropriate for their specialty,
4 and they knew that they would then be asked to give some
5 evidence of having done so.
6 So I think from the point of view of actually
7 persuading people to carry out audit, I do not think it
8 was a problem. I do not think that that was an
9 inappropriate way of disseminating resource.
10 Q. If we go back again to UBHT 25/170 -- I will see if the
11 reference is correct this time -- no. Back to 169,
12 please.
13 At the top of the page, it says:
14 "The main hindrance to prosecuting audit is felt
15 to be a lack of time for consultants to carry out
16 individual audit, either as members of the District
17 Audit Committee, or, more importantly, as audit
18 co-ordinators. That is exacerbated by an apparent lack
19 of audit assistants in many specialties."
20 Firstly, is that an accurate statement on the main
21 hindrance to prosecuting audit at that time?
22 A. May I look at page 168, please?
23 Q. Please do. Can we scroll down the page, please.
24 A. Yes, okay. Can we go on now to 169, please? The
25 segment is to be read as it appears on the page, that
0088
1 this was a feeling that people expressed. The pressure
2 of clinical demand was such that they were reluctant or
3 unable in some instances to allocate sufficient time to
4 the creation of an audit process, and that is why, in
5 the second part of that sentence, I said more
6 importantly as audit co-ordinators, because I thought
7 then, and I still think that given the system of
8 specialty audit, the co-ordinator is very important. He
9 or she is the person who will guide the whole process.
10 They need time to do that. They need time to create the
11 project, to do the appropriate background reading and
12 produce the necessary bibliography or whatever, and the
13 lack of time -- I am still quite sure in my memory that
14 the lack of time was something which bothered people
15 a lot at that stage, and I think that that problem did
16 not go away entirely for the whole of my time as
17 Chairman of the Audit Committee. We only persuaded the
18 Trust right at the end of my tenure that they should
19 officially state that time should be given specifically
20 to audit and that that time should match the
21 recommendations that had been made by the Regional
22 Hospital Medical Advisory Committee some three years
23 before.
24 Q. Which was a commitment of how much time?
25 A. The regional recommendations, in my memory, were that it
0089
1 should be one notional half day per month.
2 Q. If we look at UBHT 24/72, we should have the first
3 page of the 1993 report. This was the report produced
4 for the last year in which you were the Chair of the
5 committee; is that correct?
6 A. Yes, that is right.
7 Q. If we go to page 80, please, first of all if we look at
8 it there is the modifications that are forthcoming to
9 produce a committee responsible for clinical audit.
10 Then, if we scroll down, please --
11 A. Are you looking at the last three lines of that
12 paragraph, or the penultimate line?
13 Q. I am looking at the last five lines of the second
14 paragraph:
15 "While there has been general agreement from
16 purchasers and providers across the South West Region
17 that half a day per month is an appropriate expenditure
18 of time on audit, it has taken the UBHT three years to
19 accept this recommendation of its Medical Audit
20 Committee."
21 So does that record, firstly, an agreement by the
22 end of the year 1993 or thereabouts, the time this
23 report was produced, that that amount of time should
24 formally be set aside for audit?
25 A. An agreement on the part of the UBHT?
0090
1 Q. Yes.
2 A. Yes.
3 Q. What level of support do you think that management have
4 given to you in taking three years to accept that
5 recommendation?
6 A. There is a complex answer to that. In the beginning,
7 management was perceived as not being part of the
8 medical audit processes. Managers attended meetings
9 because we felt that it was important, in particular the
10 Director of Operations, and there was a standing
11 invitation to the Chief Executive, to Dr Roylance to
12 come whenever he wished.
13 So to some extent you could say that they felt it
14 was none of their business, I suppose. That is a crude
15 phrase and it is unfortunate. However, I think it would
16 be fair to say that for the whole of the three years
17 there were divergences of opinion between difficult
18 specialties as to exactly how much time was needed for
19 audit and exactly how that time might be best set
20 aside. I think that those differences of opinion were
21 appreciated by managers who might have preferred not to
22 take part in that debate. They may have preferred to
23 wait until the profession worked it out for itself.
24 Q. But it was appreciated from the very start -- I am
25 looking back now by that phrase to the Working Paper in
0091
1 1989 -- that it was the responsibility of management to
2 ensure that resources were available for audit to take
3 place.
4 Did that not include a responsibility to ensure
5 that adequate time was set aside for audit?
6 A. In my mind, yes: resource, I mean, of money at that
7 time, it was useless.
8 Q. Did the extent of the clinical disagreement as to how
9 much time was needed for audit explain a failure to
10 commit half a day per month?
11 A. Commit UBHT to a policy? Well, I come back again to
12 this history, the Performance Assessment Committee, and
13 the sensitivity of individuals concerned with the
14 District Health Authority and later the Trust to
15 protestations that absence of personnel from clinical
16 areas might jeopardise the fulfilment of contracts and
17 the pursuance of clinical activities to the detriment of
18 another specialty.
19 My perception is that that is ridiculous and that
20 there is sufficient flexibility in most organisations to
21 allow the sort of time period we are talking about to be
22 set aside quite easily. If we were to pursue the
23 philosophy, however, of allowing audit to take place in
24 such a way that bridges could be created between
25 specialties so as to allow them to share an audit time,
0092
1 an audit meeting, whatever, then that might be
2 a different argument. That might be more difficult to
3 do.
4 Q. Because the dispute amongst clinicians, one might have
5 thought, would have been more to do with the latter
6 point, the timing of sessions and the difficulty of
7 co-ordinating it, rather than an argument as to whether
8 half a day was required or not?
9 A. Yes.
10 Q. Is that a fair summary of the position, or not?
11 A. Yes, I think it is.
12 Q. I am having difficulty, Dr Thomas, if you could help us,
13 on the logical link between a dispute or difference, an
14 opinion, a disagreement amongst clinicians as to when
15 audit could take place and how to bridge gaps between
16 specialties, and using that as a reason not to make
17 a formal commitment to have a half a day a month, say,
18 set aside for audit?
19 A. You are asking me to argue a case for managers, and
20 I have difficulty doing that. I believe that it was
21 their perception -- you understand, this is what
22 I believe, I do not know that it is so. I believe it is
23 their perception that audit could be pursued as it were
24 "out of hours" and if it were not pursued out of hours,
25 then it would jeopardise the performance or the
0093
1 efficiency, if you will, of the Trust. I think that
2 that management view was produced by those clinicians
3 who we have already mentioned in the last few moments.
4 I think it is an erroneous view.
5 Q. Can I just say, Dr Thomas, I am not seeking to make you
6 argue any case, I am seeking to explore and understand
7 the evidence you were giving on that perception.
8 A. I am sorry if I am being opaque or difficult.
9 MISS GREY: Sir, I am conscious of the time. I wonder
10 whether in fact this ought to be the moment where we
11 break, perhaps, for half an hour, or a little longer,
12 for lunch?
13 THE CHAIRMAN: Yes. Thank you, Miss Grey. I think we
14 should take a break. Why do we not say 35 minutes? It
15 is now a feature of the transcript, my inability to add
16 up, but I think that is about 25 past 1 or thereabouts.
17 MISS GREY: All I can say is that I can now put on
18 transcript the fact that your watch does not accord with
19 mine!
20 THE CHAIRMAN: How diplomatically you put it! I think it is
21 a quarter past 1, my fault.
22 (12.40 pm)
23 (Adjourned until 1.15 pm)
24 (1.15 pm)
25 MISS GREY: Perhaps we could start by going back to the
0094
1 document which I was having trouble locating earlier,
2 UBHT 98/195. It is now on the screen. It is the
3 meeting of the audit review group, the Hospital Medical
4 Committee Steering Committee, which in fact effectively
5 set up, or planned to set up, the District Audit
6 Committee.
7 If we could just scroll down the page, please, to
8 paragraph 5, can you assist us on what was meant by the
9 phrase "District Audit Committee" at that time, because
10 the title implies that it is a Health Authority-wide
11 organisation, but its evolution into the Hospital
12 Medical Audit Committee suggests otherwise?
13 A. My apologies, I had forgotten about this small group.
14 Paragraph 5 refers to the fact that the district,
15 as it then was, comprised the United Bristol Hospitals,
16 plus Weston-super-mare, and the certainty in our minds,
17 I think, was that Weston would not wish to use the same
18 audit committee as the United Bristol Hospitals. That,
19 I think, was very reasonable. They were separated from
20 us geographically by 25 miles and they had a very
21 different practice and set of activities going on in
22 Weston General Hospital. So it made much sense to
23 separate the two.
24 Q. So the hospitals that were comprised within the District
25 Audit Committee were the same, were they, as those which
0095
1 subsequently became the UBHT?
2 A. I think the absolutely correct answer is "No". But to
3 all intents and purposes, the answer is "Yes". I am
4 sorry to be difficult about that, but when the Trust was
5 formed, there were some changes made in the hospitals
6 that made up the Trust. For instance, there was
7 a Bristol Homeopathic Hospital which was sold. I just
8 use it as the easy example. You are going to ask me
9 what other hospitals fell out of the Trust envelope.
10 I am trying to remember the name of it.
11 Q. I think we do not need the precise detail. I think what
12 I would ask, however, is that the name "District Audit
13 Committee" might imply there was some interest or
14 involvement in primary health care or extra-hospital
15 health care for which the district would have
16 responsibility.
17 Was this any part of the remit of this District
18 Audit Committee at any time?
19 A. Yes. It may not have formed explicitly part of the
20 remit when we wrote it down, but it was always in our
21 minds that we needed to have an interface of some sort
22 with general practitioners, for instance, and obviously
23 it depended on the specialty that was carrying out the
24 audit. Some specialisms had no interface with the
25 community at all in the shape of general practitioners,
0096
1 but others had quite a substantial interface.
2 Q. If we turn over the page, please, we should see there
3 the proposed constitution. We can see that it includes,
4 for instance, the district nominee to the Regional Audit
5 Committee, the RHMAC, who would have been who at that
6 stage?
7 A. That was me.
8 Q. What difference did the creation of the UBHT make to the
9 structure of this committee, because you talked about
10 liaison or interface between GPs and the hospital. What
11 I am asking is whether there was any responsibility at
12 any earlier stage for primary health care, or whether
13 this was solely a group concerned with the auditing and
14 practices of the hospital, despite its name "District
15 Audit Committee"?
16 A. My memory is that it was concerned almost entirely with
17 within-hospital activities and that the interface that
18 we sought with general practitioners was limited to an
19 interface where the two practices were actually dealing
20 with a similar condition or the same patient, or where
21 they had a shared interest and we had no intention of
22 casting the audit net more widely into primary care.
23 Q. Which is why, presumably, you talk about this body
24 evolving or transforming itself into the Hospital
25 Medical Audit Committee after the creation of the UBHT.
0097
1 It did not have to shed any Health Authority functions
2 in order to make that transformation, did it?
3 A. No. I think not.
4 Q. We have spoken about the development of that audit
5 structure. At the end of the period of your term as
6 Chairman of the Medical Audit Committee, the evolution
7 into a Clinical Audit Committee began and took place
8 eventually in mid-1994. I think that is right?
9 A. Yes.
10 Q. If we look, please, at UBHT 98/13, this gives us the
11 context, a meeting of the Steering Committee with
12 Chairmen of Divisions held on 5th January 1994. You are
13 in attendance. If we go on, please, to page 17, there
14 is a discussion there of clinical audit and you are
15 reporting back on the government's intention that Trusts
16 should move towards multidisciplinary clinical audit.
17 Then there is a second sentence:
18 "However, there was concern that medical audit
19 will be marginalised under the pressure from clinical
20 audit. The Chairman pointed out that we must be
21 perceived to be carrying out the national guidance lest
22 we lose audit monies. We must also maintain medical
23 audit as a valuable educational and peer review
24 activity."
25 How was the interface between medical and clinical
0098
1 audit seen within the Trust at that time, that is, early
2 1994?
3 A. I am not sure I can answer your question
4 satisfactorily. I can give you a view that I held at
5 the time, that might have been informed by meetings that
6 I attended, but if you say what is an average Trust
7 view, I cannot actually give you that.
8 Q. My question was loosely phrased. I am asking for your
9 evidence as to how the interface should operate.
10 A. In that case, the answer to your question is that the
11 short history of medical audit set up a system which was
12 being used as an educational system, and that the new
13 form of audit, clinical audit, was going to be a much
14 more widely-based type of audit; it was not going to be
15 limited to educational purposes, and it was going to
16 address problems of resource allocation, throughput and
17 so on and so forth in a much wider sense and with
18 a different emphasis.
19 Q. Did that mean that medical audit should continue
20 alongside clinical audit, that there was a continued
21 role for it?
22 A. I believed that there was and there were indications --
23 again, I am afraid I cannot quote the document
24 precisely, but there were indications in I think both
25 the government documents of the time that medical audit
0099
1 should indeed continue. I think that there were
2 substantial reservations about the progress that had
3 been made because -- and I speculate here, you
4 understand -- I believe that in government circles they
5 had anticipated that progress would be much more rapid
6 than it was.
7 Q. Progress in medical audit?
8 A. Yes, and they also anticipated that medical audit would
9 embrace the wider sphere of information-gathering, which
10 I suspect was sought in the first place.
11 I think that those anticipations of rapid progress
12 were ill-founded and had the government chosen to listen
13 to advice, it would have realised that setting up such
14 a system as they had proposed in the White Paper was
15 actually going to take a substantial amount of time, and
16 not just a couple of years. It was not just a simple
17 thing to put in place.
18 May I say one other thing which I omitted when
19 I was responding? There was, among most of the
20 documents at the time, an emphasis on bringing
21 non-medical, paramedical, whatever you wish to call
22 them, members of the hospital staff, the teams and so
23 on, into the audit process. It is my memory that we had
24 already done that to a limited extent in the
25 directorates, not in the audit committee, but in the
0100
1 directorates. But that was another aspect of clinical
2 audit.
3 Q. You mean that at a directorate level, some overlap had
4 been taking place?
5 A. Yes.
6 Q. Some participation amongst non-medical staff in the
7 audit process?
8 A. Yes.
9 Q. Are you able to help us on how widespread that was?
10 A. I cannot tell you how widespread it was, but the
11 directorates that spring to my mind, as directorates
12 where I was aware that that was happening, were medicine
13 in general, although that was made out of separate
14 subgroups, but general medicine, rheumatology and so on,
15 ophthalmology and the dental services.
16 Q. You implied by your answer as to the length of time it
17 took to develop and set up a medical audit programme
18 that the reason for continuing with medical audit,
19 notwithstanding the introduction of clinical audit, was
20 that it needed more time to develop a proper and
21 effective programme?
22 A. No, I am sorry, I did not mean that. If I gave that
23 impression, I apologise.
24 What I meant was that in my mind, at any rate, the
25 function of education was a very important function.
0101
1 That particular function was served by medical audit and
2 I believed at the time that it might not be so well
3 served by clinical audit.
4 Q. Why would it be jeopardised by allowing other
5 professional groups into the process?
6 A. It is not a question of letting other professional
7 groups into the process, it is a question of how people
8 perceive the time and the opportunity. So, for
9 instance, I might, as I said this morning, wish to
10 explore the complications of epidurals in pain relief.
11 On the other hand, if you enlarge the group beyond me as
12 a medical person and bring in somebody who may, perhaps,
13 manage the resource of the Trust, they might be more
14 interested in how I was going to use the money that they
15 were prepared to let me have to buy kits or whatever.
16 So the emphasis within the meetings was going to
17 change and that might well have damaged educational
18 processes, I thought.
19 Q. Is that purely a management versus clinicians, broadly
20 defined, debate, or were there concerns also that if,
21 say, doctors were joined by nurses or perfusionists or
22 other such disciplines, the process, the potential
23 agenda, would be too wide?
24 A. I suspect it is the former. Yes. I suspect it is
25 doctor versus manager rather than anything else. There
0102
1 is very little problem with having nurses at these
2 meetings. That does not interfere with the educational
3 process at all. That is fine. So I think you are
4 right, it is management that I worry about.
5 Q. We had this morning the view of Dr Walshe that many of
6 the issues that might be raised by audit would very
7 rapidly trespass or come to involve other non-medical
8 groups, such as nurses, for instance?
9 A. Yes. Well, he is absolutely right. For many --
10 although I suppose not all groups, specialty groups,
11 their activities are overlapped with the nurses most of
12 the time. The two groups work in the same area at the
13 same time within the same patient care episode or
14 whatever, so that is not ...
15 Q. In the event, in 1994 and 1995, did clinical audit and
16 medical audit both proceed in tandem, as it were, or did
17 one devolve into the other?
18 A. I think the one devolved into the other and medical
19 audit became clinical audit.
20 Q. Dr Roylance again was asked questions about the
21 introduction of clinical audit. He gave a long passage
22 of evidence which I will, if I may, read out to you
23 section by section. He said:
24 "A number of things changed with the introduction
25 of clinical audit. It was no longer, as somebody said,
0103
1 a pursuit by consenting adults in private. In other
2 words, it was no longer a matter for the medical staff
3 to pursue in private. It had now become
4 a multidisciplinary process ..."
5 So far, would you agree with that description?
6 A. Yes. I think I would not have chosen those words, but
7 the sentiment is there, roughly, yes.
8 Q. "... and therefore could not reside, if I may say so, in
9 the professional advisory structure of the Medical
10 Committee, the Steering Committee and through the
11 Chairman of the Medical Committee to the Trust Board.
12 It now had to be on a management basis because it was
13 multidisciplinary and we had to get it up and running."
14 Again, would you agree with that description of
15 the change in the line of reporting?
16 A. That is an accurate description of the change that took
17 place, yes, if that is what you mean.
18 Q. Is it also an accurate description of the reasons why
19 the change took place, that once --
20 A. Yes, because the changes were not within, for instance,
21 my gift. I might have thought otherwise, but they
22 certainly were within Dr Roylance's gift. His decision
23 was that that was the changing culture and because of
24 that and because of the changing culture of Trust
25 status, it was more appropriate for the audit function
0104
1 to report through a different channel, a different
2 route.
3 Q. Can you explain to us what you mean by the change in the
4 culture of Trust status?
5 A. I suppose I should start before 1989, almost. You
6 understand that in what I am going to say I will be
7 representing some ideas that I have as a person and that
8 do not necessarily reflect the ideas of an Audit
9 Committee, of which I was a member. But having worked
10 in the Health Service since 1972, as a consultant and
11 prior to that as a trainee, I perceived it as a service
12 that the individuals within it felt was theirs.
13 Everybody knew that was not true but they had a sense of
14 ownership and that is why they were prepared to knock
15 themselves out to get the job done to work late or
16 whatever.
17 The culture at the end of the 1980s and the
18 beginning of the 1990s changed and became, if you like,
19 more business-like, and so a commercial flavour entered
20 into what was being done and it was being done for
21 money, contracts, whatever.
22 So it is that sort of flavour and that change in
23 flavour that I think underpinned or overlay, whichever
24 way you put it, the decisions that were made.
25 Q. And in particular, the decision to make the reporting
0105
1 structure upwards to the Trust Board and the management?
2 A. No, we had always reported to the Trust Board anyway.
3 We had always sent them the annual reports and we had
4 anticipated that since we had non-executive directors
5 attending the meeting, that there were no secrets and
6 the information flowed freely from us to them just as it
7 did to the Medical Committee.
8 Q. I am sorry, I should have repeated more accurately
9 Dr Roylance's comments on shifting the line of reporting
10 from the professional advisory structure to the
11 management structure.
12 A. Right.
13 Q. It is that change you would see as a culmination or link
14 to the change in culture that you were describing?
15 A. Yes.
16 Q. Dr Roylance continued:
17 "I think Dr Thomas had a number of concepts of how
18 this should go. He was worried about immediate medical
19 audit disappearing. He wanted it to continue and so on
20 and he had anxieties about this new initiative. As
21 I remember, he resigned as Chairman of this committee
22 [the Medical Audit Committee] after a while, because it
23 did not seem to be doing what he wanted it to do."
24 Is that an accurate description of the reasons for
25 your resignation?
0106
1 A. No. I had, from the very beginning, said I would chair
2 the committee for three years, at the end of which time
3 I would cease to be Chairman and that is what I did.
4 Q. Did you have concerns about the way in which the
5 committee was going at the time you left it?
6 A. Yes. We have just explored them.
7 Q. He then continued:
8 "We eventually, after much discussion of which
9 this is a small part, made the Clinical Audit Committee
10 report through the Patient Care Advisory Committee and
11 through that committee to the Board. The Chairman of
12 the Clinical Audit Committee was invited to attend that
13 committee to shorten the lines of communication."
14 That is the change in reporting structure we have
15 just been discussing, is it not?
16 A. I believe so, yes.
17 Q. He then continued:
18 "I think Trevor Thomas -- I do not want to malign
19 him and you may be able to ask him, but I think he,
20 having chaired the Medical Audit Committee, wanted to
21 control medical audit outside management as
22 a professional thing and himself being in charge. That
23 could no longer be appropriate. What the Clinical Audit
24 Committee had to do was to monitor the activities now of
25 management and of audit activity and report in the
0107
1 manner I have said to the Trust Board and to me to
2 assure us that that was continuing."
3 Again, if we leave aside the comment about
4 yourself being in charge and confine ourselves for the
5 moment to Dr Roylance's comments, as he said that he
6 thought that you, having chaired the Medical Audit
7 Committee, wanted to control medical audit outside
8 management as a professional thing: is that an accurate
9 comment on your attitude to --
10 A. No. The word "control" is inappropriate. The whole
11 point about audit is that it is not controlled in that
12 central way. At least, that is my perception.
13 Dr Walshe may have a different view as to what is the
14 right way forward, but I was still of the view that
15 clinical specialty groups should have the responsibility
16 to educate themselves by carrying out audit projects.
17 I did not think that that should disappear.
18 So that is the difference of view, not that Trevor
19 Thomas wanted to control anything, which would not have
20 been possible.
21 Q. I think it must follow from that that you would equally
22 well, and for the same reasons, disagree with the
23 comment that Dr Roylance made when he said that you
24 wanted to retain the existing Medical Audit Committee as
25 it was, with yourself being in charge?
0108
1 A. No, not at all. My term of office had come to an end.
2 I had said I would do three years as the Chairman and
3 that was the end of it.
4 Q. If we could look, please, at UBHT 24/76, this is
5 a report of a visit of the Regional Audit Team which
6 took place after you had come to the end of your formal
7 term of office but whilst you were still the "caretaker
8 chairman", if I may call it so, which is a role you took
9 until mid-1994; is that right?
10 A. I cannot give you the exact data, but approximately,
11 yes. The Trust had some difficulty, I believe, in
12 finding a replacement Chairman.
13 Q. You say the Trust had some difficulty in finding
14 a replacement Chairman. Do you know why?
15 A. No. I think you would have to ask the person who
16 replaced me, because they may have given an answer more
17 accurately.
18 Q. Why did the Regional Audit Team come to visit the UBHT?
19 A. The Regional Audit Team visited all the units. It was
20 UBHT's turn.
21 Q. If we scroll down, please, through the report, we can
22 see that it took place at a time when there was debate
23 on the future role and constitution of the Audit
24 Committee as the shift towards clinical audit was being
25 discussed.
0109
1 Then, at the bottom in the last paragraph, there
2 is a description of the organisation and the direction
3 and development of audit within the UBHT, and it is said
4 to have been significantly different from that of all
5 other Trusts within the Region.
6 Is that accurate?
7 A. Yes.
8 Q. We heard this morning from Dr Walshe the difference
9 between a centralised structure and a devolutionary
10 model. Did the other Trusts in the region therefore
11 follow the centralised model?
12 A. As I remember, yes.
13 Q. Set out in that paragraph are the beginnings of a series
14 of conclusions on how the structure has worked. It
15 comments firstly that the control of audit therefore
16 lies ultimately with the Clinical Directors. Do you
17 agree with that?
18 A. Yes, I think I do. Effectively they had the
19 responsibility, they had the resource, and therefore it
20 was their control that dictated what could or could not
21 be done.
22 Q. The report then says:
23 "The Audit Committee is not however constituted of
24 Clinical Directors, which means its role has been
25 relatively powerless."
0110
1 Can you comment on that?
2 A. Well, I agree with it.
3 Q. "The tight directorate structure and approach operates
4 at all levels and for most issues and has therefore led
5 to a confusion for the Audit Committee over its role."
6 A. I do not think there was any confusion in our minds
7 about what we might be able to achieve. We had, as we
8 said this morning, no budget, no staff and therefore the
9 only way in which we could influence people was by
10 persuasion, by cajoling them into doing things which we
11 thought were valuable. Sometimes they agreed with us,
12 sometimes they did not. We knew that we would be able
13 to influence people over such things as hardware,
14 staffing and training, because the members of the Audit
15 Committee had information which was not available easily
16 to the Clinical Directors. So we could pass that
17 information on to them and persuade them to take the
18 steps that we thought were wise.
19 There was, I suppose, the other element to the
20 equation, and that was that they knew at the end of the
21 year they would have to account for how they had
22 expended their money. Certainly when things started the
23 Audit Committee was required to put its seal on those
24 items of accounting and say, "Yes, that is what
25 happened".
0111
1 Q. Would putting Clinical Directors on the Audit Committee
2 have assisted matters?
3 A. I am not sure I can answer that question. I suspect it
4 would have made little difference. I do not know, but
5 I suspect it would have made little difference.
6 Q. Why so?
7 A. Because I think that the directorates viewed the
8 resource as theirs and at any meeting to discuss what
9 audit was to be done, that would have coloured people's
10 judgment.
11 The success of Dr Walshe's alternative, the
12 centralised audit committee that responded to requests
13 or projects, would have ignored directorate interests
14 and parameters.
15 So given the devolved structure and the fact that
16 the money was going to devolve anyway, I think having
17 the Clinical Directors there would have made little
18 difference to what was done.
19 Q. Is it your view, then, that the devolutionary model that
20 was adopted within the Trust was a sensible response to
21 its structure?
22 A. In a general sense it was a very logical way to
23 proceed. It maintained the contact between like
24 clinicians who had similar problems and could therefore
25 explore them. One of the problems of audit was always
0112
1 how does the single-handed practitioner audit, and that
2 was always difficult to do and had to be done on
3 a cross-district or cross-region or whatever basis.
4 So if you bring people together with a common area
5 of interest, then that is perceived as concentrating
6 your skills into a group that can improve its practice,
7 can identify problems and so on and so forth.
8 Q. What about the problem of cross-speciality audit? How
9 do you tackle the need for, for instance, surgeons and
10 anaesthetists to tackle topics of common interest?
11 A. It is quite difficult and was, I think, done not very
12 successfully over that three-year period of 1991 to
13 1993. No, I take that back. That is not fair because
14 there were some groups who did it very successfully,
15 particularly among the medical specialties. I think
16 where it was not done particularly successfully was
17 between anaesthesia and surgery. That is why I gave you
18 the first answer, because you must remember my
19 background is as an anaesthetist, and it does colour my
20 comments sometimes.
21 Q. What were the particular difficulties with anaesthesia
22 and surgery that led to that failure?
23 A. I think two main difficulties. One is that if you look
24 at the generality of anaesthesia and the generality of
25 surgery, there are subgroups who have their own
0113
1 particular interests. Because of that, there will be
2 difficulty in agreeing a project, a report, an
3 investigation or whatever, that will be of interest to
4 the whole group. When you think about it, we are
5 talking about -- I cannot remember, if you add all the
6 anaesthetists and all the surgeons together, I think it
7 is 50 or 60 people.
8 Q. But many people have specialties of their own, cardiac
9 surgery, cardiac anaesthesia, for instance?
10 A. They do and there is no reason why they should not do
11 their own particular audit within the limit of an audit
12 session, if you wish. There could be a bit of it on
13 obstetrics, a bit of it on cardiac surgery. That could
14 be done. It was not done and one of the bones of
15 contention was time.
16 Q. The Regional Audit Team's report set out a series of
17 criticisms based on the proposition that the Audit
18 Committee was relatively powerless, and therefore had
19 not had a strong central influence.
20 Do you think that the committee was effective,
21 notwithstanding that?
22 A. It was effective in doing what it set out to do. You
23 may say we should have had higher expectations, but
24 I think that we recognised that what we could do --
25 I think I said this this morning -- is that we could
0114
1 encourage a system of audit, an audit philosophy, if you
2 will, among all the clinicians in the district and in
3 the Trust, and that was something which could be done by
4 persuasion rather than requiring power.
5 Q. Could we go back, please, to UBHT 67/81? This is
6 a meeting of the Medical Audit Committee, 10th June
7 1992. If we go, please, to page 83, we can see there
8 a reference to a discussion about purchasers' access to
9 audit information.
10 A. Yes.
11 Q. You are minuted as referring to the constant pressure
12 from the purchasers to have some access to audit
13 information, but you were reluctant to accede to their
14 request, particularly their suggestion that they should
15 receive copies of the committee's annual report.
16 Why was that a request that you were reluctant to
17 accede to?
18 A. I cannot answer your question. I do not know because
19 the annual report had a very wide circulation and went
20 across the Region. I suppose that I was responding to
21 their wish as purchasers to have free access to
22 information which the Audit Committee did not have and
23 had it had that information, it might not have chosen to
24 share it with the purchaser. A provider, fine, because
25 that is within the envelope of the organisation.
0115
1 So I will, if you like, take you back to what
2 I said shortly after lunch: that the philosophy within
3 the Health Service had changed quite markedly from
4 a service to a business. Part of that change of culture
5 involved a change of attitude towards many things,
6 including information. Information then became
7 commercially sensitive. This was one of the reasons why
8 I, and I think the UBHT, were resistant to sharing
9 processed information.
10 It was, if you like, "What is the recipe for
11 Marmite, because if we know what it is, we might be able
12 to make it cheaper". That is the commercial view. That
13 was the sort of attitude that was beginning to creep
14 into those discussions, and information was regarded as
15 sensitive and not to be shared in a way that would make
16 it accessible to competitors.
17 Q. Is that, then, what lies behind the next sentence:
18 "At the meeting, Mr Wisheart had referred to the
19 confidentiality of audit and was concerned that the
20 purchasers were requesting more detailed
21 information ..."
22 You reassured him you would resist any attempt by
23 a purchaser to breach any confidentiality.
24 Should we read "confidentiality" as being
25 a reference to patient confidentiality or commercial
0116
1 confidentiality, or neither?
2 A. I think you must interpret the word in its wider sense,
3 in the way it was being used at the time. It was the
4 confidentiality of our original remit which had not
5 changed. That was the confidentiality which we had
6 established and which was part of the foundation for
7 confidence being built up among clinical staff in the
8 audit process.
9 If we had been seen -- this is what I believe --
10 to waiver in our commitment to that, then I believe that
11 we would have lost the confidence of some or possibly
12 the majority of those who were taking part in audit
13 within the Trust.
14 Q. Dr Walshe this morning referred to the fact that
15 problems of patient confidentiality within the audit
16 process were fairly readily dealt with by anonymisation
17 and that the sensitivity of confidentiality therefore
18 centred around a scrutiny of individual clinicians'
19 performance in particular.
20 Was that a sensitivity within the UBHT?
21 A. As it was within any hospital. I do not think there was
22 any particular difference at that time. I am not sure
23 I would entirely agree with Dr Walshe, because I know
24 I sat through a number of meetings, audit meetings, not
25 of the Audit Committee but as a consumer of audit,
0117
1 I suppose, as an anaesthetist, and the issue of patient
2 confidentiality did not go away in people's minds. I am
3 sure he is right that there are few, if any, instances
4 of patient confidentiality being breached and then being
5 used in a litigation action, but it was a constant worry
6 and I remember people being fairly heavily criticised
7 for using patients' initials in reports that they made.
8 So people were very sensitive about patient
9 confidentiality, as well as clinician confidentiality.
10 Q. What about clinician confidentiality, then? Was any
11 understanding reached within the Trust as to the level
12 at which complaints, concerns or issues about an
13 individual clinician's performance would be raised or
14 shared following the audit process?
15 A. Concerns about individual clinicians and their abilities
16 or performance or suitability for a particular task,
17 there were a number of routes open to any group or any
18 individual who wished to make that sort of complaint.
19 The Trust maintained the older "three wise men"
20 approach to many of the complaints and that is the
21 channel that was used, not the Audit Committee.
22 Q. But was there any explicit discussion of how issues that
23 had specifically arisen out of an audit process that
24 might cast doubt on performance or raise an issue as to
25 performance of a clinician, could or should be handled
0118
1 as part of that process?
2 A. No, I do not think so. I think that at that time any
3 observation of that nature would have gone through the
4 same channels because that channel was dedicated not
5 just to addressing problems of, for instance, the sick
6 doctor, but also to problems of levels of performance.
7 Q. But that was a relatively high level mechanism, if I may
8 describe it as such. It perhaps might have been thought
9 to be appropriate for serious concerns, serious
10 worries. Was there nothing more informal or closer to
11 a junior consultant's, say, perspective, where an issue
12 arising out of the audit process could and should have
13 been taken?
14 A. Within the Trust as it was set up, the path that would
15 have been pursued by the sort of junior consultant you
16 describe would have been in the first instance, if it
17 was appropriate, to discuss the problem with the
18 individual concerned; in the second instance, to have
19 discussed it with either the Chairman of Division, if
20 one still existed, or the Clinical Director.
21 Following that discussion, the individual would
22 have taken his or her concerns to the Medical
23 Director -- no, possibly to the Chairman of the Medical
24 Committee, still, in those days, I think. Yes, to the
25 Chairman of the Medical Committee, I am pretty sure.
0119
1 Q. You have mentioned the Clinical Director and the
2 Chairman of Division?
3 A. Yes.
4 Q. Are either of those interchangeable or is there any
5 difference in the approach of speaking to them?
6 A. Not really. Both tended to be people who were regarded
7 with respect by their colleagues, and who were felt had
8 good judgment, and so either could have been approached,
9 and the approach might have been predicated on who the
10 individual regarded as most friendly, most approachable,
11 most whatever. There are all sorts of shades of
12 reasoning why they would choose the one or the other.
13 Q. Did the Audit Committee ever get information in the form
14 of the annual reports or any other reports that it was
15 receiving on the audit process in such a form as to
16 raise doubts about clinical performance of any
17 particular practitioner?
18 A. No.
19 Q. So the issue of how the Audit Committee would in turn
20 have dealt with that situation never arose; is that
21 correct?
22 A. No.
23 Q. It never arose?
24 A. It never arose.
25 THE CHAIRMAN: May I ask one question about
0120
1 confidentiality? Was there ever any formal arrangement
2 made between consultants and the Trust, as its
3 employees, that material for audit would be kept in
4 a manner where it would not be released or revealed
5 beyond that purpose of audit?
6 A. You mean -- may I quote an example and tell me whether
7 I am going in the right direction? You mean that
8 information might be derived from an audit project, but
9 then might be used for contract negotiations with
10 a purchaser?
11 Q. No, simply if it was something that it was thought other
12 people should learn about, they should be told about.
13 A. You are asking whether there was any formal agreement.
14 Q. I am trying to get to the heart of the confidentiality,
15 whether it was, as it were, something that was assumed
16 or agreed informally, or whether there was some more
17 formal agreement between the employer and the
18 consultant?
19 A. To my knowledge and memory, I think there was no formal
20 agreement between the employer and the consultants and
21 the issue of confidentiality derived from two principal
22 sources, one of them being the Working Paper 6 from the
23 government and the other being the Regional Health
24 Authority's paper on confidentiality which had a very
25 wide circulation.
0121
1 MISS GREY: And which I think you have attached as an
2 appendix to your witness statement?
3 A. Yes, it is.
4 Q. We have looked here at a discussion of confidentiality
5 and whether or not information should be provided to the
6 purchasers. If we go back, please, to page 81, we can
7 see there that apologies for absence were received from
8 Dr Kammerling. Dr Kammerling was a representative of
9 the District; is that correct?
10 A. Yes.
11 Q. Did his absence make any difference to the form in which
12 this discussion took place at that meeting?
13 A. I would think not. The group exchanged views very
14 easily and freely. Dr Kammerling might have had
15 a different view had he been there, but my view would
16 not have stifled his view and his view would not have
17 stifled mine. It was a forum, as any reasonable
18 committee should be, for discussion.
19 Q. Was anyone articulating the case for purchasers to have
20 access to this situation?
21 A. No.
22 Q. How long did Dr Kammerling remain a member of the Audit
23 Committee?
24 A. Oh dear, I cannot remember, I am afraid. It is in the
25 documents and I know that we discussed -- Dr Kammerling
0122
1 said that he felt that his loyalties were sorely tried.
2 He did not say that, but he felt that he had divided
3 loyalties and that he should therefore resign from the
4 committee in order to pursue his activities for the
5 Health Authority.
6 We were in some difficulty to know whom we should
7 invite as our public health representative in his place.
8 I believe that it was a suggestion of Mrs Maisey
9 that we should ask the University department for
10 a nomination, which we did, and Professor Colley pointed
11 out that Dr Charles Shaw was in fact within the Region
12 and was working within Professor Colley's department and
13 would be available, so we invited him to come instead.
14 Q. So Dr Charles Shaw, as the person who had been employed
15 by the Region to assist in the development of audit
16 across the Region, effectively replaced Dr Kammerling
17 as, as it were, an outside voice on the Audit Committee;
18 is that correct?
19 A. Yes, that is right.
20 Q. If we could go to UBHT --
21 A. Can I just go back a moment, because I just worry a wee
22 bit here. You said, I think -- correct me if I am
23 wrong -- that Dr Kammerling was a representative of the
24 District Health Authority? Am I correct?
25 Q. Yes.
0123
1 A. Can I refine the answer a little bit. The District as
2 it was to begin with -- you understand the District
3 Health Authority then became the purchaser, which was
4 when Dr Kammerling found he had difficulties.
5 Q. So he had been on the committee prior to April 1991?
6 A. He, I believe, was a member of the committee from the
7 beginning.
8 Q. It was after the purchaser/provider split that the dual
9 role he was playing became troublesome?
10 A. Yes.
11 Q. If we could go to UBHT 1/219, there is a meeting there
12 of the Hospital Medical Committee Steering Committee,
13 1st July 1992. It is not a meeting that you were
14 yourself present at. Could we, however, turn
15 nonetheless to page 221, and to a discussion there about
16 an issue relating to audit and the possible conflict
17 between fulfilling the obligation to audit and
18 fulfilling the contract with the purchaser, and there is
19 an agreement being reached that the two obligations
20 should be seen as complimentary.
21 I appreciate you were not at this discussion, but
22 does the debate raise any memories with you?
23 A. No, it does not.
24 Q. If we could move on then, please, to the issue of -- we
25 have talked about incentives or sanctions for the
0124
1 failure to conduct audit, and if we look at the UBHT
2 Audit Committee report, 66/107, the 1992 report, and
3 over the page at 108 there is an index to the report
4 which tells us where the reports are coming from.
5 The point I would make about this report,
6 Dr Thomas, is that there is no report of audit
7 activities in cardiac surgery or in paediatric
8 cardiology.
9 I can take you through the report if that needs
10 confirmation, but I think it is a fair comment, both on
11 this report and also in the following year's report in
12 1993.
13 Can you tell us, firstly, was this omission
14 something that the Audit Committee was aware of?
15 A. Yes.
16 Q. What happened, then, to comment or rectify that
17 omission?
18 A. You will understand that responses from clinical groups
19 came to the committee over periods of time. In my
20 memory, I think we probably sent out certainly one,
21 probably two reminders to audit co-ordinators that they
22 had not yet filed their report with us.
23 The route to cardiac surgery from the committee
24 would have been via the co-ordinator for surgery. That
25 was Professor Farndon. The reason that that was the
0125
1 route was because we had a specific number of members of
2 the committee and to have divided the major specialties
3 into their integral subspecialty groups would have
4 produced such a profusion of co-ordinators for the
5 committee members to liaise with that it was not
6 practicable.
7 So Professor Farndon was our contact point with
8 surgery. Certainly, he would have received the letters
9 that went out asking for reports and he would have
10 received the reminders. However, I would make two
11 comments about cardiac surgery: I, as the Chairman of
12 the committee, and Mr Wisheart as a committee member,
13 had a conversation on a couple of occasions in which
14 I pointed out that we had not yet received the report
15 from cardiac surgery. In my memory, as I recall, he
16 said, "Well, the quality of patient care is improving in
17 cardiac surgery". I said, "Well, in that case that
18 makes it even more important that a report is received
19 so that throughout the Region people will know that that
20 is the case".
21 However, we did not receive a report and
22 I regretted the fact that they had been unable to
23 produce one for us. There was some reassurance, I felt,
24 in that we knew that cardiac surgery were carrying out
25 basic audits on mortality outcomes as part of their
0126
1 contract with the purchaser and that they were returning
2 figures to the Central Cardiac Surgery Registry, the
3 national registry.
4 So although I regretted the fact that they had not
5 been able to produce a report, I was reassured that
6 audit was in fact being done, and I believe that that is
7 the case: it was being done.
8 Q. So ultimately, the only means you had of ensuring that
9 reports were made to the committee was one of persuasion
10 and exhortation?
11 A. Oh, yes. I had no big stick with which to beat people
12 into giving me a report.
13 Q. A failure to provide a report to the committee: did it
14 produce any adverse effect for the department concerned?
15 A. Not really, no.
16 Q. When Mr Wisheart said to you that the quality of care
17 was improving, what did you understand that to mean?
18 A. I understood it to mean exactly what he said, that the
19 unit was producing a better quality of care year on
20 year, which was an entirely good outcome as far as I was
21 concerned, and knowing that his unit were returning
22 figures to a purchaser who was responsible for either
23 giving or denying money to a unit, I felt that the audit
24 was being done, the figures were being produced, they
25 were going to a suitable body to deny any further money
0127
1 if the figures were not good, and so I accepted what he
2 said.
3 Q. But it might be thought that if someone says, "Well, it
4 is improving", that that implies that it has problems.
5 Did you take it in such a sense?
6 A. The unit had not got a good reputation in general terms
7 across the Region. I think you have spoken with
8 Miss Hawkins, because I saw her appear on the television
9 not long ago, and she will have told you that there were
10 concerns about the quality of care in the Cardiac Unit,
11 and her concerns related, I think -- please, I do not
12 know what she told you because I have not looked to see,
13 but her concerns almost certainly will have been that
14 patients were being referred out of the Region for
15 treatment and that would have been a drain on regional
16 resources; and that she would have preferred them to be
17 treated within the Region.
18 Q. When you say that the unit did not have a good
19 reputation across the Region, what factors had led to it
20 having such a poor reputation?
21 A. I do not know. I genuinely do not know, but it did not
22 have a good reputation. I know that was true because
23 I was a member of the Regional Hospital Medical Advisory
24 Committee and my colleagues on that committee, from time
25 to time, would say that they did not feel that the
0128
1 cardiac surgery was all that good in Bristol. Mind you,
2 I suppose some of them had a reason for saying it
3 because they wanted to have a second cardiac unit in
4 Plymouth, but --
5 Q. You can say something is not all that good because there
6 are problems of managing waiting lists, for instance,
7 and meeting demand, or you may say it because you have
8 a concern that the outcomes are less than good. Do you
9 know which lay behind that comment?
10 A. I cannot differentiate between the two for you. I know
11 that the unit was unable to accommodate the number of
12 patients that the Region would have liked it to
13 accommodate.
14 I am dredging my memory here a little bit, but
15 that limitation on size of the unit was one of the
16 factors that encouraged the Region to increase the
17 resource allocation for the unit in the BRI. That is my
18 memory. You may find that people at Region would
19 disagree with that, I do not know.
20 Q. Again, in describing the reputation that was enjoyed by
21 Bristol, was there any difference made between adult
22 cardiac surgery and paediatric cardiac surgery?
23 A. No: that was not a factor that they mentioned
24 specifically.
25 Q. Can I just go back to the discussion you were having
0129
1 about Dr Kammerling, please, because we should put up
2 UBHT 271/312. That is a letter to you?
3 A. Yes.
4 Q. Which I think is a letter which reflects the evidence
5 that you were giving -- can we scroll up the page,
6 please -- about the concern that he was expressing in,
7 as it were, having a double role on the Medical
8 Committee?
9 A. Yes.
10 Q. Disciplines reported to you as the Chair of the Medical
11 Audit Committee, they reported to the committee about
12 the content of audit. Was there any attempt made by the
13 committee to assess and then to offer guidance on the
14 content of the audit that was being performed in the
15 hospital?
16 A. I think the committee assessed the content because we
17 received reports which gave us an indication of content,
18 of what topics were being discussed. Beyond assessing
19 what was being returned to us, we did not go. For
20 instance, we did not suggest that group A should pursue
21 an audit into, I do not know, glue ear, except on the
22 one occasion when we attempted to set up a joint GP/ENT
23 initiative.
24 Within the two months or so following the meeting
25 between the UBHT and the purchaser where audit was
0130
1 discussed -- you will know the reference much better
2 than I, it is in the paperwork, in the documents --
3 Q. We will come back to that in a minute. For the moment,
4 if I may, you were required, I think, to report to the
5 Regional Health Authority on the audit work as part and
6 parcel of accounting for the funds received; is that
7 right?
8 A. Yes.
9 Q. If we look at UBHT 66/316, please, this is just the
10 title page, to give us the context. It is the report
11 "Progress in Medical Audit" from the South West
12 Regional Health Authority, which would have been sent,
13 I believe, to the Department of Health.
14 If we go over the page to page 322, we can see, if
15 we scroll down, please, on the discussion of
16 expenditure, that for the purposes of the discussion,
17 units which had not provided a report have not been
18 included, neither has the UBHT because of the way
19 funding is distributed and then accounted for in the
20 year end report, and it is not possible to identify the
21 specifics of where funding has been spent as the total
22 allocation is divided amongst directorates.
23 If we go through the remainder of the report, we
24 would see that there is no financial data included for
25 the UBHT in the analysis of how Trusts and other
0131
1 organisations had spent their money.
2 How did this situation arise?
3 A. Please will you be specific? Because you are aware that
4 those two exclamation marks you see on the page and the
5 correction of spelling are mine. You know that this
6 report I found very irritating indeed, because we had
7 provided substantial amounts of information to the
8 Region to show them what was being done. We had
9 provided them with specific instances where audit had
10 resulted in changes being made to practice. Radiology
11 had achieved a huge amount with their audits and they
12 had qualified for, I cannot remember the name of it, but
13 a national award. Contributions had been made to
14 identify hazards in patient care and so on and so forth.
15 The fact that Miss Cowie decided not to accept the
16 assurances that we gave her and that were contained in
17 all the annual reports from the UBHT or the committee on
18 how money had been spent, I found difficult to accept.
19 Q. Had you been asked to provide financial data in
20 a particular form?
21 A. I believe that they provided us with a format. We were
22 unable to adhere to that format because of the
23 devolvement of money to directorates, and so we could
24 not match their particular format that they wanted
25 matched. I mean, it was not possible for us to do
0132
1 that. Nevertheless, I found it difficult to accept
2 this, and as you know, in the paperwork there are
3 letters from me to Miss Cowie and to Dr Roylance,
4 remonstrating with the format, and asking the latter if
5 he would not mind speaking up on our behalf.
6 Q. If you were unable to provide the financial data in the
7 format it was requested in that year, 1992/93, were you
8 able to provide it in the format that was required by
9 the Region in any future year?
10 A. Nothing changed in -- let me think. I cannot remember
11 the date of this particular document. Could you refresh
12 my memory?
13 Q. It is 1992/93.
14 A. When did it appear?
15 Q. We do not get a date, I think, from the document.
16 A. I believe that this document appeared at the end of 1993
17 and might even have appeared in the early part of 1994.
18 I may be wrong about that, but that is what is in my
19 memory because I remember the letters that I wrote were
20 written towards the end of my tenure of office, as
21 Chairman of the Audit Committee.
22 Q. Is the point you are making that any change in the
23 breakdown of funds came after your period as Chair?
24 A. Yes.
25 Q. Or are you able to seek to any changes or not?
0133
1 A. I cannot give you an assurance one way or the other
2 about how returns were made after I left the Audit
3 Committee.
4 Q. But did you perceive any need to change the system of
5 financial reporting in order to satisfy the Region's
6 requirements?
7 A. No.
8 Q. Why not?
9 A. It was my view that Region were being petty and they
10 were asking for information to be produced in
11 a stereotyped form, which they knew perfectly well we
12 were almost unable to do because of the very way in
13 which audit was devolved within the UBHT. It would have
14 cost them nothing to have put in a separate statement.
15 THE CHAIRMAN: Would another way of describing the concern
16 of the Region be that they simply wanted to know where
17 the money was going?
18 A. Well, sir, that was a concern that I had for the whole
19 of the three years that I was actually sitting in that
20 committee. I think Dr Walshe may agree with me, I do
21 not know, I hope he will, that that is a concern of
22 audit committees around the country. Certainly that was
23 a point made in the Royal College of Physicians' survey
24 of audit committees that appeared in 1992 -- 1993?
25 1992/93, that many audit committees had some difficulty
0134
1 in maintaining the ring, the fence, around audit money.
2 So it was a matter of great concern to us and it
3 was the source of discussions that we had with the
4 Treasurer's Department on a number of occasions, and
5 indeed, even invited the Treasurer to come to a meeting
6 to explain exactly what was going on, in 1992, I think.
7 Q. Your concerns may have existed, but they may reflect the
8 concerns of the Region. To tell the Region when they
9 ask where the money is going, "We are worried about that
10 as well" may not be entirely satisfactory to the
11 Region? I put it as an argument.
12 A. Well, I understand that, sir. You are right, of course,
13 to say that. However, the Regional Audit Committee and
14 those who assist in it were very well aware of how audit
15 was pursued within the UBHT. They knew that the Audit
16 Committee at the UBHT was assiduous in its attempts to
17 verify the use of the money and indeed, we oversaw some
18 of the uses of the money almost directly.
19 My indignation shows, does it not? I should be
20 more dispassionate, I am sorry.
21 Q. I do not want to pursue the point too far, but if I was
22 sitting before the Public Accounts Committee having had
23 money given to me, I would not feel comfortable being
24 only able to say, "As far as I know, they are all good
25 people doing the best they can". I would have thought,
0135
1 just for the sake of argument, I would have wanted to
2 get some information.
3 A. You would be right to say so. I believe that we had
4 done that, but not in the format that they wished us
5 to.
6 MISS GREY: If we go back to your statement at WIT 323/3, we
7 can see, if we scroll up the page, please, and further
8 down, please, you say in the last sentence that
9 paediatric cardiac surgery did not form a subject for
10 report to or discussion to any of the committees
11 concerned with audit in the Trust at the time with which
12 you were concerned with them.
13 Is that correct?
14 A. I cannot remember it doing so.
15 Q. Did the articles in Private Eye on paediatric cardiac
16 surgery come to your attention?
17 A. I was aware of them. I think everybody in the hospital
18 was aware of them.
19 Q. Was there not a case for discussing those in the Audit
20 Committee?
21 A. No. I do not think there was. The articles in Private
22 Eye were almost invariably scurrilous, and they had no
23 currency in proper information for much of the time. In
24 fact, all of the time they appeared, and set that sort
25 of reporting against the fact that we were assured that
0136
1 properly derived figures were being sent. I refer now
2 to the period between 1989 and 1993, were being sent to
3 other bodies who one might have expected if there had
4 been something astray with the figures, would have
5 actually said "Excuse me, there seems to be something
6 astray".
7 Q. You mean the UK Cardiac Surgical Register?
8 A. No, the purchaser I was talking about. I think the
9 Registry might not have been actually in a position to
10 say that. I do not know enough about the Registry to
11 know.
12 Q. So your impression at the time was that purchasers were
13 receiving mortality statistics for paediatric cardiac
14 surgery; is that correct?
15 A. For the whole of cardiac surgery.
16 Q. Are you able to say in truth whether they received them
17 or not?
18 A. No, I am not.
19 Q. Because in fact I think it is the evidence of Dr Baker
20 that they were never received?
21 A. Right.
22 Q. But you are not, I am sure, able to comment on that?
23 A. No.
24 Q. We have learned or heard that certainly during the
25 course of 1993, if not earlier, there were disputes
0137
1 within the department of paediatric cardiac surgery on
2 figures, on outcomes and on the results of audit and
3 that by January 1995, at any rate, some members of the
4 Department of Anaesthesia, when reporting to Dr Hunter
5 and Professor de Leval when they came to the UBHT, felt
6 that they had not been given proper access to figures to
7 enable them to decide about outcomes.
8 Firstly, to your recollection, was this subject
9 matter never brought to the Audit Committee's attention?
10 A. To my memory, we had no approaches from anybody along
11 the lines of, "Excuse me, this is not right".
12 Q. Why do you think the committee did not function as
13 a channel for concerns if there was a concern at the
14 directorate level that audit was not being properly
15 carried out, or there was not proper access to figures?
16 A. There are two questions, Miss Grey. If somebody had
17 said that audit was not being carried out, then that
18 would have been a matter properly addressed by the Audit
19 Committee, because that is what we were charged with
20 doing.
21 I do not believe that that was what was said.
22 People were not saying that audit was not being carried
23 out. The arguments were about whether or not the
24 figures were correct, or whether they were accessible to
25 Dr X or Mr Y. From what you have said to me, that seems
0138
1 to have been the bone of contention, not whether audit
2 was being carried out. We understood that audit was
3 being carried out and that that audit was continuing and
4 that it served the purpose of medical audit, in other
5 words, education, and also, we believed it served the
6 purpose of contractual obligation.
7 Q. Did you understand it to be scrutinising outcome figures
8 and in particular, mortality statistics, so as to be
9 able to determine whether or not those were acceptable?
10 A. I cannot answer the second part of the question. The
11 first part, the draft contract that the Audit Committee
12 saw stated quite specifically that mortality figures
13 were to be made available and I cannot now quite
14 remember which mortality figures they were, but I think
15 they were deaths within hospital, deaths within 30 days
16 and there was a --
17 Q. Perhaps I can assist you by bringing it up. It is
18 HA(A) 10/94, please, and 15.2 is the relevant paragraph.
19 A. Yes, that is it.
20 Q. This is from the 1991 service agreement that we have
21 already looked at.
22 A. Yes.
23 Q. It was not, however, a contract that was repeated in the
24 same form in the following years. Are you able,
25 therefore, to help us on your extent of knowledge of the
0139
1 contractual arrangements between cardiac surgery and
2 purchasers after the date of this contract?
3 A. No. No, because contracts were perceived as following
4 a different route from audit and the sort of schism
5 between the two was quite clear. In the Trust's mind
6 and in I think the Audit Committee's mind as well, the
7 contract negotiations would proceed and would only
8 involve the Audit Committee if the Trust asked the Audit
9 Committee to be a conduit for the passage of information
10 from the directorate to the purchaser.
11 Q. So when you say that you thought that the cardiac
12 surgery department was fulfilling its contractual
13 requirements and that those included reporting on
14 measures such as 30-day mortality, that was based upon
15 having had sight of a 1991 contract?
16 A. Yes.
17 Q. But therefore, no further involvement in the contractual
18 process?
19 A. That is correct.
20 Q. Is that an adequate basis for that understanding?
21 A. We believed it to be so at the time: we knew that audit
22 meetings were occurring and we knew we were assured that
23 returns were being made to the national Registry.
24 Q. Who assured you of that?
25 A. I knew you were going to ask that. Before I said it,
0140
1 I was trying to remember who had said it. I cannot
2 remember, but I suspect it might have been Mr Wisheart.
3 Q. Equally well, when you received an account of what audit
4 was taking place within the cardiac surgery department,
5 notwithstanding the absence of annual reports for 1992
6 and 1993, would that information also have reached you
7 from Mr Wisheart?
8 A. Not necessarily, because Professor Farndon, I think,
9 would probably have been in a position to reassure me as
10 well. Certainly I spoke to him about surgical audit on
11 a substantial number of occasions.
12 Q. Dr Bolsin and Dr Black became members of the Clinical
13 Audit Committee in around June 1994. But again, they do
14 not appear to have raised any concerns with the
15 committee at that stage.
16 Are you able to help us on how the committee
17 perceived that that should be the case?
18 A. You are asking me to put myself in Dr Black's and
19 Dr Bolsin's shoes really, here, because it is their
20 perception of the committee that would govern whether or
21 not they brought data to the committee. I think --
22 again, you will have to ask them about this, but I think
23 that they were pursuing a separate audit process.
24 That is all right. If you go back to the origins
25 of the Audit Committee, and indeed, go back to the
0141
1 Working Paper 6, it specifically makes provision for
2 independent audits to be carried out at the behest of
3 a number of authorities. There is no reason why an
4 audit should not be going on along separate lines, which
5 did not necessarily involve the Audit Committee.
6 Q. Is that an accurate parallel, if we look at HOME 3/130,
7 please, this is another reference for the same document
8 you have put as an appendix, back to the Working Paper.
9 Scroll down to (e), please. There the concept of an
10 independent audit is set out, but it is in a very
11 different context to the one we have just been
12 describing, is it not?
13 A. No. I do not think so. It says quite specifically
14 where necessary management must be able to carry out
15 a function, and although this Working Paper was written
16 before Trusts came into being, it obviously had them in
17 mind because they formed part of one of the other
18 working papers.
19 Q. I think the point I was making is that you suggested
20 that Dr Bolsin's and Dr Black's audit was of a nature
21 envisaged by this document. This document envisages
22 that it was initiated by management?
23 A. I take that point. I suppose in that point, it is
24 initiated differently.
25 Q. You said "That is okay".
0142
1 A. I think that having additional audits being conducted is
2 acceptable. There is nothing wrong with that. It comes
3 back, I suppose, to this business of control and power.
4 It is something you quoted Dr Roylance about. I do not
5 think we felt we had to control every audit function
6 within the UBHT. It was not practicable to do so, and
7 I am not sure it would have been right to do so.
8 I would not have dreamt of trying to control people who
9 wanted to go and do audit using a separate basis,
10 a separate system, a separate funding. As far as we
11 were concerned it was to be applauded.
12 Q. So concerns were never raised with you, but so far as
13 you understood it, audit was being properly pursued
14 within the department. Did you have any contemporaneous
15 knowledge of Dr Bolsin's or Dr Black's independent or
16 other audit?
17 A. No. The only contemporaneous view or contact point that
18 I have would date back to 1990. I cannot give you the
19 month, but you will undoubtedly give it to me.
20 Q. Can we look perhaps at that letter that I think you are
21 referring to, UBHT 61/19. This is a letter to
22 Dr Roylance from Dr Bolsin, if we scroll through to the
23 bottom of the page, dated 25th July. Firstly, can
24 I ask, am I right to bring this document up in this
25 context?
0143
1 A. Oh, yes.
2 Q. What involvement did you have in its production?
3 A. I saw a first draft of this letter at around this time,
4 just a short while before 25th July. It was a letter
5 which Dr Bolsin was writing principally to point out
6 deficiencies or errors in the application for Trust
7 status.
8 That was the primary purpose of the letter.
9 I know that Dr Bolsin had been disappointed in not
10 getting some equipment which he mentioned specifically
11 in the letter, so he brought me the original to look at.
12 Q. He brought you the original in the shape of, you said
13 a draft earlier?
14 A. I am sorry, a draft that he had put together prior to
15 writing the letter itself. He showed it to me and said
16 he was going to send it to the Chairman of the Health
17 Authority, and did I think that was right or an
18 appropriate destination for it.
19 I advised him on that draft. I changed the
20 English a little and I said that since he was primarily
21 concerned with the Trust status application, the letter
22 should go to Dr Roylance who was the Executive and who
23 was in the process of putting together the application
24 or who had put together the application for Trust
25 status.
0144
1 Q. If we scroll down the page, please --
2 A. May I finish, and say that I also advised him that he
3 should send a copy to the then Chairman of the Health
4 Authority, Mr Mortimer, because he had included as his
5 final paragraph or sentence, a comment on the mortality
6 of paediatric cardiac -- could you scroll down, please?
7 Yes, the mortality for open-heart surgery on
8 patients under 1 year of age.
9 Q. "One of the highest in the country" and he says that the
10 problem should be addressed?
11 A. Yes, that is right.
12 Q. So you advised him to send it to --
13 A. Both Dr Roylance as the -- he was then district General
14 Manager, of course, but Dr Roylance and the Chairman of
15 the Health Authority were appropriate people to send
16 a copy of that letter to.
17 I also advised him that he should discuss that
18 particular factor with colleagues within the unit, which
19 he said he had done.
20 Q. He said he had done?
21 A. Yes. I said "Well, in that case, you should copy your
22 letter to them as well so that they know you are writing
23 it".
24 I think -- I cannot be sure about this -- I also
25 said to him that he should be in a position to show
0145
1 figures to support his contention, which I think he was
2 not. I cannot remember whether I said "Have you got
3 figures to support this and can I see them". I do not
4 remember that bit of conversation very clearly.
5 Q. Is it possible that your memory of that event is
6 coloured by later discussion of when he went away and
7 gathered figures?
8 A. It is possible.
9 Q. But it says, this letter, that the mortality is one of
10 the highest in the country. Did you not yourself think
11 that you had any duty to either investigate it further
12 or to pursue the matter further to ensure that it had
13 been properly addressed?
14 A. Well, addressing it properly involved exactly the path
15 that he was pursuing in that he was discussing it with
16 colleagues. He was alerting the District General
17 Manager and the Chairman of the Health Authority, and so
18 the people who could address the problem had been
19 informed of it.
20 Q. Dr Thomas, one of the allegations that has been made
21 about events in Bristol is that the pattern of events
22 may have something to do with the issue of Freemasonry.
23 Can I ask you, therefore, are you, or have you
24 ever been, a Freemason?
25 A. No, I am not a Freemason, and I have never been
0146
1 a Freemason. I am amazed that that has been suggested.
2 Q. Those are the questions I would like to ask you. It may
3 be that Dr Walshe has further questions, or the Panel.
4 THE CHAIRMAN: Dr Walshe, please?
5 QUESTIONS FROM DR WALSHE
6 DR WALSHE: There were a couple of points I wanted to embark
7 on. Miss Grey has asked you about the devolved
8 arrangements for managing clinical audit and the
9 complete devolution of responsibility to clinical
10 directorates, and you have described how it worked.
11 Would you accept that it was an unusual structure?
12 I think you said it was the only Trust within the Region
13 with that structure and there were few others like that
14 in other regions. Is that so?
15 A. That is so, and I will accept that, yes.
16 Q. Is that still the structure within the UBHT, or is there
17 now a central function for quality today for clinical
18 governance?
19 A. There is a central function for quality. You are going
20 to ask me whether that forms part of the Audit Committee
21 function, and I am not sure I can answer your question.
22 I do not know. But there is a central quality assurance
23 function.
24 Q. So the Trust now has a central function in some form for
25 monitoring and managing all the quality --
0147
1 A. I cannot promise you it is part of the Audit Committee.
2 I am not sure about that.
3 Q. Are you aware of any other Trust that still has
4 a structure of the kind that you describe?
5 A. No.
6 Q. You had said that cardiac surgery did not have a good
7 reputation -- your words -- and you discussed how for
8 two years in succession there was no audit report in
9 your annual audit report to the Region for paediatrics
10 or for cardiac surgery.
11 You also said that that issue had not been
12 discussed at the Audit Committee. Was that right?
13 A. I do not think I said it had not been discussed.
14 I cannot remember whether it has been or not, whether it
15 was or not. I suspect it might well have been, because
16 the committee reviewed the annual report before it was
17 finalised and they usually identified those who had not
18 responded. I cannot remember, to be honest with you,
19 whether we actually specifically addressed cardiac
20 surgery, the absence of the report and in particular,
21 paediatric cardiac surgery -- we would not have
22 addressed paediatric cardiac surgery as a separate thing
23 anyway, it would have been cardiac surgery.
24 Q. Nothing sticks in your mind?
25 A. No, save my conversations with Mr Wisheart where I urged
0148
1 him to get his audit co-ordinator in cardiac surgery to
2 produce a report. That was a separate line of
3 communication from the official one, which would have
4 been via the member of the Audit Committee responsible
5 for surgery, and Professor Farndon. That would have
6 been Dr Stansbie to Professor Farndon, on to the audit
7 co-ordinator for cardiac surgery and that was Mr Hutter.
8 Q. Given that the remit of the Audit Committee was to
9 review the reports of individual audit groups to ensure
10 that effective audit is being undertaken within the
11 limitations of suitable confidentiality of individual
12 data -- it does not have a reference, but the District
13 Audit Committee's annual report for 1991.
14 Given that was the position, do you think the
15 Audit Committee was fulfilling its remit?
16 A. Yes. You are identifying one small unit in a 1000-bed
17 hospital with innumerable subspecialties, and so by and
18 large, I would say that the Audit Committee was.
19 Q. But in this instance?
20 A. In this instance, we knew there was no report there. We
21 were not able to do anything about it, apart from asking
22 repeatedly for it, which we did, and beyond that, there
23 was nothing for us to do except to print the report out
24 of that particular subspecialty report.
25 Q. Would it have been appropriate for you to raise this
0149
1 issue with the committee to whom your committee
2 reported, which I think was the Hospital Management
3 Committee; is that right?
4 A. No, the Hospital Medical Committee.
5 Q. The Hospital Medical Committee, I apologise.
6 A. Since Mr Wisheart was probably by this time the Chairman
7 of the Hospital Medical Committee, and since I had
8 raised it with him, I think that the answer to your
9 question is, yes, and it was done, perhaps not
10 officially in writing and discussed in open Hospital
11 Medical Committee meetings, but certainly the matter was
12 discussed with the Chairman of the Medical Committee.
13 Q. Can I ask one further question, which is: you describe
14 the arrangements for maintaining confidentiality of
15 data, and I think you have outlined that this was
16 a continuing concern for clinicians through to 1993/94.
17 Do you think that focus on confidentiality and
18 that concern in retrospect acted as a bar or a barrier
19 to identifying and dealing with quality problems -- not
20 in this case particularly in cardiac surgery, but within
21 the Trust?
22 A. It is a difficult question to answer. "A bar to quality
23 matters"? That really was not what audit was about, do
24 you see? It was about what underlay quality. It was
25 about education. If you say to me, did it impede
0150
1 education, the answer would have been no, it did not.
2 Then you will say, did it impede the transmission of
3 a message from education into the area of quality and
4 quality assurance? The answer is, yes, it might have
5 done that. Do you see what I mean?
6 Q. Let me try and clarify. I was really asking whether
7 being unable to discuss openly the fact that particular
8 problems with the quality of care or problems with the
9 way a service was delivered exists, being able to
10 discuss that openly for example with managers because
11 they fell outside the boundaries of your policy on
12 confidentiality, was that a barrier to doing something
13 about those problems?
14 A. No, I do not think it was, because it was entirely
15 within the remit of any directorate to address a problem
16 which it identified. So, for instance, if valves were
17 falling off machines, the directorate who was
18 responsible for the machine was perfectly able to
19 address that problem and had a responsibility so to do.
20 So far as the specifics that we have been
21 addressing just recently in cardiac surgery,
22 responsibility of the directorate quite clearly was if
23 it identified a problem, then it should address the
24 problem.
25 MISS GREY: Sir, I was rising to interject, that I think
0151
1 there are certain questions that I should ask arising
2 partly out of what Dr Walshe has been asking, but also
3 more generally. I do not know whether this is
4 a convenient time to do so, or how you would like to
5 handle matters, sir.
6 THE CHAIRMAN: I personally would prefer to press on. You
7 have some questions? There are some questions from the
8 Panel, both to Dr Walshe and to our witness. Why do we
9 not first take your further questions, and then we will
10 proceed from here.
11 MISS GREY: Thank you.
12 FURTHER EXAMINED BY MISS GREY
13 Q. Can I take you back firstly to a debate that we touched
14 upon, Dr Thomas, but I think we did not really follow
15 through? If I take you to a reference, please, it is
16 HA(A) 9/119. This is a meeting with the Bristol and
17 District Health Authority at which you were one of the
18 attendees from the UBHT. If we scroll down the page,
19 please, there was a discussion taking place on the
20 Trust's approach to audit and progress.
21 If we turn over the page, please, we can see that
22 there is a discussion going on here about process and
23 outcome measures with broadly speaking the district
24 arguing that process was a legitimate area of activity
25 for the Health Authority, whereas Dr Roylance was
0152
1 arguing that outcome was for the Health Authority, but
2 process was not.
3 Can you help us a little further on the matters
4 that lay behind that particular debate?
5 A. I think we touched on it earlier this afternoon, perhaps
6 it was this morning. Process and outcome are two
7 separate areas. I am sure that they overlap, but
8 nevertheless, they are separate. Process in health
9 care, as I said to you earlier, was considered as
10 commercially sensitive information. Outcome was
11 something that was a matter for the purchaser to
12 consider, so that if they perceived the outcome provided
13 by in this case the UBHT to be less good than they would
14 wish, they had a number of alternatives as to how they
15 approached that problem.
16 So outcome was definitely something the purchasers
17 needed to be aware of, and to consider when deciding
18 what contracts to strike.
19 However, the process, the way by which that
20 outcome was achieved, was considered in a separate
21 light, and it was considered to be the affair of the
22 Trust and its medical employees.
23 Q. If we turn, please, to the follow-up letter from the
24 Health Authority, this is HA(A) 9/114, from Dr Kieran
25 Morgan, Director of Public Health, if we scroll down,
0153
1 please, what we see there is that there is a report in
2 the third paragraph of this particular discussion and
3 the UBHT is reported as saying that they were adamant
4 that "they did not wish to generate and stick to
5 clinical process standards and would wish to concentrate
6 on outcome measures only. Whilst we all agreed this was
7 in fact the correct course, we did not accept that
8 process measures had no place. As usual, the UBHT will
9 not budge."
10 Can you help us there, as to the reasons why the
11 comment might be made, "as usual"?
12 A. I think you would have to ask Dr Morgan why he said "as
13 usual".
14 Q. The impression one gets from that, is it not, is that
15 the district had difficulties in dealing with the UBHT
16 because on occasion it found it stubborn or impervious
17 to argument?
18 A. Yes.
19 Q. Well, would that be a fair comment on the style of
20 negotiation adopted by the UBHT with the District during
21 that period?
22 A. I have no idea. I was not party to the sort of
23 negotiations that the UBHT had with the District on its
24 contracts, except in this one instance where it wanted
25 to talk about audit.
0154
1 Q. Arising out of that particular meeting, do you get the
2 impression that that comment might have been justified,
3 given the stance of the UBHT at the meeting?
4 A. Well, I think the stance of the UBHT at the meeting was
5 in fact correct, and Kieran Morgan in that letter says
6 that he, too, believes that it is correct and that
7 outcome was in fact the important factor to consider.
8 But, Miss Grey, I cannot comment on the negotiations
9 that the UBHT had with the District. I mean, I was not
10 party to them.
11 Q. So are you able to help us as to whether or not there
12 was any change in the dealings of the District with the
13 UBHT, or the stance of the UBHT in contractual
14 negotiations during the period of the terms of our
15 Inquiry?
16 A. I do not believe I can help you with that.
17 Q. If we could go on, please, to a letter at UBHT 65/159,
18 this is a letter to you from Dr Shaw, 10th June 1994, so
19 at this point you were retiring from the Audit
20 Committee. You are updating Dr Shaw about your
21 successor, Mr Wisheart.
22 If we look at the bottom of the second paragraph,
23 you say there that you "told James that you are happy to
24 continue coming to Audit Committee meetings. He has
25 gone away to think about that particular offer. I fear
0155
1 he has become part of the rather introspective
2 organisation of UBHT management and that he may find
3 that he will not wish to take you up on that particular
4 offer."
5 What did you mean by the "rather introspective
6 organisation of UBHT management"?
7 A. I meant that the organisation of the Trust was not an
8 outward looking organisation, and that certainly as far
9 as audit was concerned, I had felt that the rather
10 slavish pursuit of devolvement had not helped us.
11 I believe that that was what was in my mind when I wrote
12 that.
13 Q. Because if one takes that together with the minute we
14 have just been looking at from Dr Morgan, both pieces of
15 comment, one from you, one from a source outside the
16 UBHT, might suggest that the UBHT and its management as
17 a culture were resistant to suggestions of change or
18 innovation.
19 Would that be a fair characterisation of the
20 culture, or not?
21 A. Yes. Yes, I think it probably would be.
22 Q. To what extent do you think that Mr Wisheart was
23 identified with that culture, as your letter suggests
24 that he may be?
25 A. You understand, I was writing the letter about audit,
0156
1 not about cardiac surgery. As far as audit was
2 concerned, I believed that Mr Wisheart felt as
3 Dr Roylance did and that audit was going to continue as
4 a devolved process without allowing any sort of role for
5 an Audit Committee. Because you must remember that --
6 again, this was my view -- it was my view that we had,
7 in that three-year period, done what could be done to
8 establish the necessary frameworks for medical audit to
9 occur.
10 Q. Can I just take you back to an answer which you gave at
11 an earlier stage? You were being asked by me about the
12 pressure on the Audit Committee for further
13 information. You said:
14 "At that time there was a clear undertaking being
15 given by cardiac surgery to the purchaser that they
16 would provide to the purchaser direct figures of
17 mortality. As far as the Audit Committee was concerned,
18 those figures were passed; we were not given any
19 information that they were not passed. It did not go
20 through the Audit Committee, much to our regret, because
21 we believed that that should be a function of an Audit
22 Committee. We were defeated in this matter by both the
23 purchaser, by the directorate, by the Manager, and so on
24 and so forth."
25 Can I ask you, why did you say that you were
0157
1 defeated on that matter by the purchaser as well as by
2 management and the directorate?
3 A. Because the purchaser had shown at that stage no
4 interest in having the District Audit Committee involved
5 in the passage of that information.
6 Q. It had shown no interest in it, but had it expressed
7 a view either one way or the other as to whether it was
8 received information from the directorates or from the
9 Audit Committee?
10 A. Not to my knowledge.
11 Q. So as far as you were aware, the purchaser was
12 indifferent?
13 A. I suppose so. My earlier reply may have included them
14 when it should not have.
15 Q. One final matter, and it is a final matter. Could
16 I take you back to the regional reports to the
17 Department of Health? This is HA(A) 167/1. This is
18 1993/94. Firstly, did you see this report at the time
19 it came out?
20 A. I do not think so. I do not recall seeing it.
21 Q. Did you have any involvement in the process of providing
22 information to the Region to generate the information
23 that is contained in this report?
24 A. I am sorry, I cannot help you because I am not familiar
25 with that report and I do not know, is the answer to
0158
1 your question. I do not know.
2 Q. You recollect, obviously, an exchange of letters with
3 Nicola Cowie over the previous year's report and its
4 omissions?
5 A. Oh, yes.
6 Q. No recollection of a similar exchange this year?
7 A. I do not believe so.
8 Q. If we look, please, to page 44, we can see there that we
9 have a repetition in effect of the problem experienced
10 in the previous year of a lack of information from the
11 UBHT on such matters this time as the number of meetings
12 and the percentage attendance at them.
13 That contrasts with the previous year where it was
14 financial information that was lacking?
15 A. Yes.
16 Q. Are you able to help us as to the fashion in which this
17 situation had arisen?
18 A. Yes. I still believe -- let me put it a different way.
19 I have no memory of this particular document. However,
20 I suspect that it was produced and appeared late in
21 1994 -- am I correct?
22 Q. I believe you are, yes.
23 A. That would fit with the sort of financial year that was
24 reported.
25 The annual report from the Medical Audit Committee
0159
1 for 1993 -- because we used calendar years rather than
2 financial years -- the 1993 report was much delayed.
3 The Audit Committee lost its only support and there was
4 a considerable difficulty in retrieving information.
5 One of my colleagues spent a huge amount of time in
6 actually rediscovering it and eventually the 1993 report
7 appeared, but it was much delayed. You will want to
8 know the date. I cannot tell you when it appeared, but
9 certainly it would have been in the summer of 1994. It
10 would have been in the summer of 1994, and so by that
11 time I suspect this would already have been finalised.
12 Q. So your answer is that from the best of your surmise, if
13 I may put it like that, it appears that the Region did
14 not get the information in time for its annual report?
15 A. That is correct.
16 MISS GREY: Thank you very much, Dr Thomas. I have no
17 further questions.
18 THE CHAIRMAN: We have some questions from the Panel both,
19 as I said, for Dr Walshe and for yourself. Mrs Howard?
20 Examined by THE PANEL:
21 MRS HOWARD: Dr Walshe, we have heard quite a good amount
22 this afternoon about the interface between the purchaser
23 and the provider and I think Miss Grey's last questions
24 were particularly resting on that.
25 Do you have any comment to make about whether the
0160
1 difficulties we have heard, perhaps some of the concerns
2 we have heard with regard to the Bristol interface are
3 unique, or whether there was an issue between the
4 purchasers and the providers across the country?
5 DR WALSHE: When the approach to funding clinical audit
6 changed from ringfenced funding distributed essentially
7 by regions through districts to Trusts, to an approach
8 in which that money was rolled into individual Health
9 Authorities' budgets and health authorities struck
10 contracts with Trusts for clinical audit, the emphasis
11 shifted much more towards health authority involvement,
12 understandably. Health authorities were then much more
13 explicitly responsible for those funds. Many health
14 authorities began to stretch their muscles a little and
15 to exert their influence by, for example, seeking to
16 influence the agenda of audit to determine some or all
17 topics and some health authorities were much more
18 directive than others, but all began to be more involved
19 in the process.
20 A lot depended on how good or poor the
21 relationships between a health authority and its local
22 Trusts were, but where those relationships were poor and
23 perhaps there was a history of a Trust asserting its
24 independence and being unwilling to accept that the
25 health authority should, in inverted commas, "meddle" in
0161
1 its business, then you got a clash between the health
2 authority that wanted to exert some control on clinical
3 audit and know that the investment it was making was
4 worthwhile and a Trust that was sometimes unhappy about
5 disclosing what was going on, or even providing much if
6 any information to the Health Authority. That was
7 something that happened in many places.
8 Q. You used the past tense. Is the suggestion that that
9 has changed significantly? If that is so, can you put
10 a date on that?
11 A. I did use the past tense. I think things have moved on
12 a lot in all sorts of ways since 1994/95, and in fact
13 the current reforms which do not form part of the remit
14 of this Inquiry have changed the agenda yet again.
15 I think health authorities learned a lesson. As
16 they began to exert influence, they often began by
17 saying "We want audits on these topics" and they soon
18 realised it was very hard for them to work out what were
19 the areas where audits needed to be undertaken and they
20 developed more sophisticated approaches to try and work
21 with providers to determine a combined or a joint audit
22 agenda rather than trying to dictate it from afar and
23 simply, Trusts got more used to it and began to
24 recognise that, yes, the money came from the Health
25 Authority and as I think John Roylance said in some of
0162
1 the quotes that Miss Grey used, therefore the Health
2 Authority had a legitimate interest in the process.
3 MRS HOWARD: Thank you.
4 MISS GREY: Sir, I know that we break new procedural ground
5 every day in this Inquiry, but may I suggest in fairness
6 to Dr Thomas and also Mr Hoyte, it may be appropriate to
7 remain on a slightly more conventional format and for
8 the Panel to direct their questions to Dr Thomas first,
9 allow Mr Hoyte to continue with any re-examination and
10 then to direct any further questions to Dr Walshe?
11 THE CHAIRMAN: It is my fault. You read my mind. I should
12 have intervened earlier. Mrs Howard?
13 MRS HOWARD: Dr Thomas, I have one question which is really
14 for clarity for myself. You talked in your evidence
15 about during 1993, acknowledged disputes about some of
16 the cardiac surgery audit that was taking place in terms
17 of the numbers.
18 What I would really like to know is, did that
19 audit have any status in respect of the Audit Committee,
20 particularly because you referenced forward plans, for
21 example, so at any time, had the clinicians involved in
22 collecting that data talked to the Audit Committee for
23 support or just had any sort of discussion with them
24 prior to commencing that data collection?
25 A. No. As I said, the contact that I had with Dr Bolsin
0163
1 was in 1990 over the matter of the letter that he was
2 writing principally about the application for Trust
3 status, and his throwaway line, if you like, at the
4 end. But following that, I think -- again, memory plays
5 tricks so I am unclear as to exactly when I became aware
6 of different aspects of the Bolsin/Black audit, as
7 Miss Grey pointed out to me. I became aware of it as
8 a member of the Department of Anaesthesia, but I think
9 I became aware of it at quite a late stage in its
10 progress, because by that time the audit had acquired
11 numbers to it. The numbers were in dispute, but they
12 had acquired numbers.
13 I am in some difficulty as to exactly when that
14 was. Miss Grey will probably correct me if I am wrong,
15 but I suspect that was round about 1994. I think that
16 is when they came up with a result. I am not sure.
17 MISS GREY: Dr Thomas, I cannot assist you on the dating of
18 your recollection of when you came to know of this
19 audit.
20 DR THOMAS: Touche, Miss Grey!
21 THE CHAIRMAN: Professor Jarman?
22 PROFESSOR JARMAN: Dr Thomas, Miss Grey read to you earlier
23 a quotation from Dr Roylance -- page 63, line 10 of
24 today's hearing -- in which Dr Roylance had said that
25 management's role was to facilitate professional audit
0164
1 activity. Do you remember that, earlier today?
2 A. Yes.
3 Q. Later on, you discussed the conflict between the time
4 needed for audit by clinicians and the time needed to do
5 clinical work.
6 A. Yes.
7 Q. In this facilitating role that management had, are you
8 aware that they did actually fund, say, locums to
9 provide doctors to enable clinicians to carry out audit,
10 or not?
11 A. No, I do not think so. I have no recollection of any
12 locums being secured for that purpose. And in truth, it
13 would be difficult to do, to produce a locum at
14 relatively short notice to fulfil the role of
15 a consultant, a specialist in whatever, be it diabetes
16 or cardiac surgery or anaesthesia. Locums are not that
17 easy to come by. If you want to hire a locum in order
18 to fulfil a contract for 12 months or 2 years, 3 years
19 or whatever, that is a different matter, but to cover an
20 afternoon for 50 or 60 people, that is difficult to do.
21 Q. So did management actually facilitate audit by providing
22 some means of dealing with the conflict between clinical
23 and audit demands?
24 A. No. As I said, I think they stood aside and waited for
25 the clinicians to come to a conclusion.
0165
1 Q. The second question is, you were discussing the remit of
2 the Audit Committee to review the report of individual
3 groups and your difficulty of getting a report about
4 cardiac surgery.
5 Did you actually see the annual report of the
6 paediatric cardiology and cardiac surgery unit which is
7 at UBHT 55/68? It is for the year 1989/90.
8 A. Yes, but --
9 Q. They may put it on the screen.
10 A. I believe I remember it.
11 Q. UBHT 55/68. That is the front of the report. Then if
12 we go to UBHT 55/81 you will see on the fifth line down,
13 for open-heart surgery under 1 year, the fourth column,
14 the percentage deaths in 1989 for UBHT is given as 37.5
15 and the UK figure for the previous year is given as
16 18.8. Did you see that report?
17 A. No. The answer to your question, sir, is no, I think
18 not, and I do not believe it forms part of any of our
19 Audit Committee reports. I would have to go through
20 them again, but I do not believe it does.
21 PROFESSOR JARMAN: Thank you.
22 THE CHAIRMAN: Thank you. Mr Hoyte?
23 MR HOYTE: I have nothing to ask. Thank you very much.
24 THE CHAIRMAN: I am grateful. I do beg your pardon,
25 Professor Jarman now wants to ask a question of
0166
1 Dr Walshe.
2 MISS GREY: Unless they are interconnected, perhaps we could
3 thank Dr Thomas and allow him at least to be released?
4 THE CHAIRMAN: They may be interconnected and the decision
5 as to whether they are will rest upon the question,
6 Miss Grey. But I take your point. I am told they are
7 not. So may I, Dr Thomas, thank you very much for
8 coming to talk to us today. There are a couple of
9 things which arose during conversation as I recall where
10 there might be the possibility of your assisting us
11 further, if you were able to lay hands on pieces of
12 information. If you are, we would be very grateful.
13 DR THOMAS: Could somebody give me an indication of what
14 I am looking for?
15 THE CHAIRMAN: Someone will find out where they are, yes.
16 It was my memory that there was a reference to something
17 on which you may be able to help us further. If I am
18 wrong, then please ignore what I have just said. But in
19 any event, if there are other things that you do think
20 would help us, we would be always grateful to hear from
21 you further, but for today, thank you very much indeed.
22 (The witness withdrew)
23 THE CHAIRMAN: Professor Jarman to Dr Walshe, please.
24 PROFESSOR JARMAN: I wonder if you have seen the paper in
25 the BMJ by Berisford and Evans this year, called "Legal
0167
1 Safeguards for the Audit Process", BMJ 1999, volume 319,
2 page 654?
3 A. Yes, I have.
4 Q. They point out, and I quote:
5 "In Britain audit activities are protected neither
6 by statute nor by case law", and go on to say the
7 problems concerning confidentiality, because it is
8 multidisciplinary, and patients can discover documents
9 for litigation. They suggest the system they say is
10 used in Australia and the United States about legal
11 protection.
12 I just wondered what is your view with regard to
13 their opinion?
14 A. I wrote back actually to them and to the BMJ, and wait
15 to see whether they carry it. It is on the BMJ's
16 website. I am trying to recall what I said, but
17 essentially I disagreed. I do not really think that
18 legal protection in our legal environment with the level
19 of clinical negligence, litigation and other issues that
20 we have, is necessary. In fact, I felt that they were
21 pursuing an argument that we discussed this morning
22 about the importance of confidentiality to protect
23 individual clinicians from the misuse or abuse of data,
24 which experience during the 1990s with clinical audit
25 suggested was more an argument rooted in people's fears
0168
1 and beliefs than in the reality of their experience.
2 So I would not agree with them that there needs to
3 be some legal safeguard.
4 PROFESSOR JARMAN: Thank you.
5 THE CHAIRMAN: May I just follow that up? Professor
6 Jarman's question, if I may say so, touches on a very
7 important area. You talk of it being a perceived
8 problem rather than a real problem, but are not
9 perceptions as important as the reality in this context
10 and how do you respond to that perception, except by
11 waiting along for a long time through education, or by
12 doing something rather pointed rather quickly?
13 A. I think we have the advantage now that we can point to
14 our experience and we can say, "Well, we have had
15 systems of clinical audit for five years or so; it is
16 very hard to find anyone who can point to examples of
17 that data being misused".
18 You could argue, it has not been misused because
19 we have had such stringent arrangements for
20 confidentiality, but those arrangements have I think
21 relaxed as people have become more comfortable with the
22 use of data, as health authorities began to play much
23 more of a role in determining the audit agenda, and so
24 on, and in particular, the current reforms, the
25 development of clinical governance, imply a much greater
0169
1 corporate ownership of that information about the
2 quality of clinical care than was true in the past.
3 So I recognise that the worries are very real;
4 I just do not think that there is actually an empirical
5 problem there.
6 THE CHAIRMAN: Thank you. If I may flag something for some
7 distance from now in terms of time, I am sure we shall
8 return to this topic and if there are those not in this
9 phase of the hearing, undoubtedly when we consider wider
10 matters, and if there are those who have such experience
11 as you talk about and would wish to get in touch with us
12 we would be very grateful and no doubt we will pursue
13 such people.
14 Thank you very much, Dr Walshe. Is there anything
15 you would like to add in addition to everything you were
16 able to help us with this morning, as a final comment,
17 or are you, as it were, satisfied that you have said
18 what you wanted to say?
19 DR WALSHE: I think I have nothing more to add, but thank
20 you.
21 THE CHAIRMAN: Speaking on behalf of the Panel, we are
22 enormously grateful to you for your contribution this
23 morning, because it was very, very clear and very
24 helpful. And I am sure that is also true of what our
25 leading counsel describes as the "wider audience". On
0170
1 behalf of all of us, may I thank you very much indeed
2 for coming and helping us today.
3 MISS GREY: Sir, we adjourn today and resume again tomorrow
4 at 9.30, when we shall hear from Dr Alan Bryan of the
5 UBHT.
6 THE CHAIRMAN: Thank you. I think, Miss Grey, there was
7 a suggestion that we may begin slightly earlier than
8 that.
9 MISS GREY: It has not filtered through to me, sir.
10 THE CHAIRMAN: It is entirely my fault, since it turned upon
11 whether I would accede to the request to start at
12 9 o'clock. I am happy to do so, if that will help other
13 arrangements. So shall we say we adjourn now and begin
14 at 9 o'clock tomorrow morning?
15 (3.40 pm)
16 (Adjourned until 9.00 am on Thursday, 14th October 1999)
17
18
19
20
21
22
23
24
25
0171
1
2
3
4 I N D E X
5
6
7
8 LETTER TO CHAIRMAN FROM PROFESSOR ANGELINI ....... 1
9
10 DR KIERAN WALSHE (affirmed) ...................... 2
11 Examined by MISS GREY ...................... 2
12
13 DR TREVOR THOMAS (affirmed) ...................... 57
14 Examined by MISS GREY ...................... 57
15 Questions from DR WALSHE ................... 147
16 Further examined by MISS GREY .............. 152
17
18 DR THOMAS AND DR WALSHE
19 Examined by THE PANEL ...................... 160
20
21
22
23
24
25
0172
Return to top of page
Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001