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Daily transcripts
Hearing summary
27th April 1999
Mr Alan Angilley, of the Finance Directorate of the NHS Executive and former
Administrative Secretary to the Supra-Regional Services Advisory Group (SRSAG) 1987-1992,
gave evidence to the Inquiry today. He described the aim of Supra-Regional Centres to
encourage high-quality treatment and economies of scale in the provision of highly
specialised services, and its role as an advisory body to the Secretary State for Health.
He recalled the concern that the number of centres providing neonatal and infant cardiac
surgery was considered greater than required. As SRSAG Secretary, his work included
monitoring activity levels and the financial costs allocated to designated centres. He
stated that the SRSAG Medical Secretary was responsible for liasing with clinicians. He
said, that before 1991 the quality of the service, in terms of outcome, of supra-regional
centres providing neonate and infant cardiac surgery, was not formally monitored by SRSAG.
He explained that after that date, copies of the centres’ annual returns to the
Cardiac Surgical Register were submitted to SRSAG, giving details of surgical procedures
and death rates broken down by type of operation.
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FULL TRANSCRIPT
1 Day 12, 28th April 1999
2 (9.30 am)
3 MR LANGSTAFF: Good morning, sir. Today we have the benefit
4 of hearing from Mr Owen, who, as with Mr Angilley, is
5 represented by my learned friend Mr Pirani.
6 Mr Owen, would you come forward, please?
7 MR STEVEN OWEN (Sworn)
8 EXAMINED by MR LANGSTAFF:
9 Q. Mr Owen, your full name is Steven Owen, is it?
10 A. Steven Paul Owen.
11 Q. Could we have on the screen, please, WIT 57/1. Is that
12 the start of a statement which you made for the purposes
13 of this Inquiry?
14 A. Yes, it is.
15 Q. If you turn to page 57/8, please, is that your signature
16 at the end of the statement?
17 A. Yes, it is.
18 Q. Is the statement true and accurate?
19 A. Yes.
20 Q. As you will appreciate, because I think you were here
21 yesterday when Mr Angilley gave his evidence, the
22 statement will broadly be taken as read. I may ask you
23 some questions arising out of some of the paragraphs of
24 it for clarification, and for further exposition, but
25 essentially, we have that as your evidence.
0001
1 What I am going to ask you about is in relation to
2 what you can tell us arising out of your work as the
3 Administrative Secretary in succession to Mr Angilley of
4 the Supra Regional Services Advisory Group from I think
5 the beginning of January 1992 until, what, February
6 1986, was it?
7 A. Yes.
8 Q. So you cover the period during which the continued
9 designation of neonatal and infant cardiac services fell
10 for consideration by the group?
11 A. Indeed.
12 Q. You were there as the Administrative Secretary during
13 the time that the service was de-designated?
14 A. Yes.
15 Q. What I wanted to ask you about would fall under a number
16 of headings. I will tell you what they are so that you
17 can follow where the questions are directed. I want to
18 explore with you the continued designation for a time of
19 the service, in particular in so far as it related to
20 Bristol; secondly, the process of de-designation.
21 I want to ask you about the quality of the service, that
22 is the systems that were in place, if any were, for
23 looking at, evaluating and monitoring quality.
24 I want to explore with you the contracts which
25 were entered into, because your term of office came
0002
1 after the National Health Service reforms had just been
2 introduced, I think. You are nodding. You will
3 apologise if I say you are nodding, but that goes down
4 in the transcript for those who cannot see you live.
5 I want to explore with you, towards the end of the
6 questions that I have to ask, the issue of how clinical
7 freedom on the one hand inter-related with the scope and
8 purpose of national provision on the other.
9 It may be that as with Mr Angilley, there are
10 a number of questions which you cannot answer because
11 they are properly within the remit of a clinician or
12 medical advice and if that is so, please do not feel shy
13 to indicate, and tell us to whom our questions might be
14 directed. I imagine it may well be Dr Halliday, but if
15 we come to that, you tell us.
16 A. I will.
17 Q. Can I look at the designation issue first? We had
18 yesterday explained for us the principles by which
19 a service was designated, and you set them out, I think,
20 in your statement, if we just look at it for a moment,
21 at the foot of 57/2, paragraph 5:
22 "In assessing bids for designation of
23 services ..."
24 Can you clarify one point for me? Plainly what
25 you are talking about is new bids for the designation of
0003
1 services that had not previously been designated?
2 A. Just so, yes.
3 Q. The process that the Supra Regional Services Advisory
4 Group went through was to have three meetings a year at
5 least?
6 A. Yes.
7 Q. And in the course of those meetings, they would consider
8 bids for designation of a service or a unit; is that
9 right?
10 A. Yes.
11 Q. They would also consider bids for continued designation?
12 A. Yes.
13 Q. Is it right, as I think some of the documentation coming
14 from the group suggests, that designation was therefore
15 reviewed annually?
16 A. No, I do not think that is quite right, not explicitly,
17 anyway. Perhaps I can try and explain.
18 As you said earlier, the Advisory Group tended to
19 meet three times a year. It could meet more often, but
20 it never met for less than three times. Usually those
21 meetings were in February, July and September of every
22 year. The February meeting was almost invariably
23 concerned with considering bids for new services to be
24 designated, or for new units to be designated for an
25 existing designated service.
0004
1 Questions about reviewing existing designated
2 units or services to see whether or not their continued
3 designation was warranted or necessary, arose really
4 organically; it was not an annual process in the way
5 that perhaps you imagine. You could certainly argue,
6 I suppose, that continued designation for each
7 individual unit and therefore service was assessed
8 annually through the revenue considerations that applied
9 in July and September meetings. There would be no
10 point, for example, in agreeing to fund a unit if your
11 decision was to de-designate them. But de-designation
12 decisions and considerations tended to arise when issues
13 arose, so, for example, if I can give an example, during
14 my time as Administrative Secretary, I think I am right
15 in saying we de-designated four services -- I am sorry,
16 three services, and got very close to de-designating
17 a fourth, which occurred shortly after I left.
18 The reasons we de-designated those services were
19 various, but the impetus to start the process of
20 considering whether those services would continue to be
21 designated or not arose either from suggestions puts to
22 the group by the Secretariat, or suggestions put to the
23 group by its own members.
24 So it was not a formal annual exercise to look at
25 everything you had and say, "Okay, yes, I am content, we
0005
1 will now confirm the designation for the next 12
2 months".
3 Q. So it was not a question of having, as it were,
4 a check-list?
5 A. No.
6 Q. Rather like the car is MOT'd each year and saying "It
7 fails in these boxes, therefore it fails"?
8 A. No.
9 Q. There had to be some reason for reversing the original
10 decision to designate?
11 A. Yes, that is right.
12 Q. What I think that suggests is that your experience
13 during your time as Secretary appears to be very much
14 the same as that which Mr Angilley told us of yesterday:
15 effectively, once you were designated you were there,
16 unless there was a good reason for you to be dismissed
17 from the club?
18 A. In practical terms, that is right, yes, although I think
19 I would slightly take issue with the term the "club".
20 I do not think it quite had that connotation.
21 Q. I do not mean it pejoratively. It is simply a crude way
22 of making the point, nothing more than that.
23 Do you think you might bring the microphone
24 a little nearer?
25 I have asked you about the bids for designation of
0006
1 services, paragraph 5. If we look up page 57/3, the top
2 of the page, you deal with services. You then deal with
3 units. This again is obviously units for the first time
4 being designated?
5 A. Yes.
6 Q. You identify, I think, six matters there: first the
7 existing level of provision from already designated
8 units. In other words, you wanted to see what the
9 competition is like. Again, I am using a crude phrase
10 to make the point. Is it a fair reflection or not?
11 A. Not quite. As we saw on the previous page, one of the
12 fundamental points about supra-regional service units is
13 that they were providing services for very small numbers
14 of patients. The whole point of the arrangements of the
15 funding scheme was designed to prevent proliferation of
16 that service. If your existing designated units for
17 a particular service were indeed already mopping up the
18 vast majority of those eligible patients, or indeed all
19 of those eligible patients, then there clearly would not
20 have been an awful lot of point in designating an
21 additional unit.
22 I think that is what I meant there.
23 Q. Secondly, the facilities, and I think it is probably
24 a separate point, and the service personnel available,
25 in the candidate unit?
0007
1 A. Yes.
2 Q. So the facilities: that presumably is a question of
3 seeing whether they have the operating theatres, the
4 equipment, the wards, things of that sort?
5 A. That is right.
6 Q. Service personnel: that would be both numbers,
7 presumably, and qualifications?
8 A. Yes, and the relevant experience.
9 Q. Fourthly: their track record of experience. Does the
10 "their" relate to the personnel or the unit?
11 A. It could in fact relate to both. If, for example, you
12 had a unit that had been performing the designated
13 service, even though it was not itself a designated
14 unit, they would have some sort of track record. It
15 could also be, however, that the unit had not indeed
16 performed that service at all, but the clinical staff,
17 perhaps recently appointed -- I know of one instance
18 where this occurred -- of a unit that was not involved
19 at the time I am talking, in liver transplantation, but
20 had recently employed a surgeon and a couple of other
21 clinical managers from another transplant unit and their
22 experience was relevant in the consideration of that
23 unit's experience.
24 I am sorry, have I made that clear?
25 Q. I think you have, yes. The expression you used may be
0008
1 thought somewhat tautologous. "Their track record of
2 experience", and "track record" is generally speaking
3 experience?
4 A. Yes.
5 Q. But "track record" may suggest there is something
6 documented as opposed to something perceived by those
7 who were looking at it. Was that the case?
8 A. We are talking about the personnel here, are we, or the
9 units?
10 Q. It could be either, as you said.
11 A. Indeed. If it is the unit, there would be some sort of
12 record of the numbers of cases they were dealing with,
13 some outcome data no doubt; there would be data
14 available to the various Royal Colleges and the
15 professional organisations who played a key role in
16 designation matters, as we know, with the individuals
17 I think that would apply, you would have their CV,
18 perhaps references from their previous organisations.
19 They would certainly again be known to the Royal
20 Colleges.
21 Q. So what you are saying is, when it came to designating
22 a new unit, the Advisory Group, it may be through the
23 clinical advice, it may be directly to you, but it would
24 look for something on paper, if you like, as to verified
25 experience of personnel or the unit?
0009
1 A. Well, they may. What would inevitably happen with a bid
2 for designation would be that the Advisory Group would
3 commission the advice of the relevant Royal Colleges,
4 and we would be looking for their assessment and their
5 recommendations.
6 In reaching their assessment and their
7 recommendations, they would have recourse to whatever
8 information sources they had. Some of that may be paper
9 records or not. It would be unlikely, I think --
10 I cannot remember an instance of this occurring
11 necessarily, where the Advisory Group would ask for
12 paper records of an individual surgeon's experience,
13 although, in the designation bid, the unit may indeed
14 have referred to that. But all of that would have been
15 assessed again by the Royal Colleges.
16 Q. Because the process would be that the unit would put
17 a designation bid in?
18 A. Yes.
19 Q. And that would be a paper bid?
20 A. Yes.
21 Q. And the expectation was, was it, that that paper bid
22 would identify the personnel and their relevant
23 experience?
24 A. Yes.
25 Q. It would identify the relevant experience of the unit?
0010
1 A. Yes.
2 Q. And you said no doubt it would look at clinical data as
3 to outcome?
4 A. Well, if available. If it existed. If the unit had
5 indeed been engaged in the service they were seeking
6 designation for.
7 Q. So I think the impression you may be giving -- I want to
8 make sure this is right -- is that there was no
9 formalised system of checking, or audit, if you like, of
10 performance before you qualified; it was a question of
11 what was available, tailor-made to the particular unit,
12 or ad hoc, if you like, depending upon the particular
13 circumstances?
14 A. To an extent that is true. I think the formalised
15 process came in the referral of the bid to relevant
16 medical colleges, for their comments and recommendations
17 as to firstly whether the service needed to be
18 designated or whether this particular unit needs
19 a designation.
20 Q. Again I appreciate we are talking in general terms about
21 a range of services here, but if one were looking at the
22 proposed designation of a service in order to find out
23 what was considered in terms of the acceptable numbers
24 and the acceptable outcomes, one would have ultimately
25 to ask the Royal Colleges as to what they made of
0011
1 a particular bid?
2 A. Yes.
3 Q. The next matter you identify is geographical coverage.
4 That, I think, speaks for itself. It is presumably the
5 service, the catchment population that is relevant?
6 A. Yes, all other things being equal, one of the things the
7 Advisory Group were quite keen to do was to ensure, not
8 equal but equal and relatively easy access to units.
9 That clearly was not always possible. We had designated
10 services that were provided by a single unit, for
11 example: very convenient if you lived around the corner,
12 but not if you lived 500 miles away. If you had
13 a service that was likely to be provided in a number of
14 different units, then geography would be an issue that
15 the Advisory Group would consider.
16 Q. The Advisory Group was for England and Wales, and not,
17 therefore, for Scotland?
18 A. No.
19 Q. To what extent did the group take into account the fact
20 that similar services to those they were considering
21 designating might have been provided north of the border
22 as well as south, and the relevance might be if one were
23 considering a bid for Carlisle or Newcastle?
24 A. We are getting into slightly confusing territory, but
25 I will do my best to clarify.
0012
1 The supra-regional service arrangements were for
2 England.
3 Q. And Wales?
4 A. No, they were for England. Because of the funding
5 quirk -- and I understand Mr Angilley has undertaken to
6 provide a paper on this -- essentially there was an
7 understanding and agreement that patients from Wales
8 could be treated in English units without any
9 cross-funding matters being undertaken. That also
10 operated for Scotland, but that is almost by the bye.
11 Scotland and Wales were entirely free to provide
12 whatever health care facilities they chose for their own
13 patients in whatever infrastructure and formation they
14 decided was best for their patients.
15 To try and answer the question directly, if we
16 were looking at designating a unit in Carlisle, I think
17 you said, it would be certainly relevant and normal to
18 consider the impact upon that Carlisle unit of
19 a Scottish unit, a close Scottish unit, providing the
20 same service.
21 So it would be considered, certainly, because it
22 could well have an effect upon the likely catchment area
23 of the Carlisle unit, which, in extremis, could threaten
24 its viability.
25 Q. "Protected costs", I think, probably speaks for itself.
0013
1 Mr Angilley described the supra-regional services
2 designation process as being essentially a funding
3 process. Was that something you would agree with?
4 A. Yes, I think so.
5 Q. So much then for new bids. Continued designation you
6 have dealt with to an extent, which you took over in
7 early 1991 --
8 A. 1992.
9 Q. I am sorry, 1992, you inherited a situation in which the
10 continued designation of the neonatal and infant cardiac
11 services was under threat?
12 A. That is right, yes.
13 Q. And what I want to do is take you back to documents
14 which began in 1990. I appreciate that they were not
15 during your particular Secretaryship, but no doubt when
16 you became Secretary you looked back through the minutes
17 to see what you were inheriting?
18 A. There was a certain degree of doing that, yes,
19 certainly.
20 Q. And ongoing issues, you would need to understand.
21 I will show you the particular documents which I have in
22 mind, and invite your comments as to how much of that
23 had filtered through to you in 1992.
24 Can we begin, please, with Department of Health
25 2/205? So we can put it in terms of time, this is
0014
1 February or shortly after February 1990. It is the
2 first meeting of 1990, the minutes. Under heading 4:
3 "NHS review: the future of supra-regional
4 services, SRS(90)1, that is a reference to a briefing
5 paper?
6 A. It would be a reference to a paper that had been
7 prepared for the group, yes.
8 Q. Can I go through with you:
9 "The Chairman noted that members have previously
10 expressed concern over the future of supra-regional
11 services...", this is generally, not any particular
12 service?
13 A. Yes.
14 Q. "... following the publication of the NHS review white
15 paper. At his request a small meeting had taken place
16 in January", and it identifies those attending.
17 "4.2: Mr Davies said that it was clear that
18 a mechanism other than normal contract funding would be
19 required for an interim period."
20 This is dealing with the shift, was it, from the
21 old arrangements to the purchaser/provider arrangements?
22 A. As I understand it, yes.
23 Q. "This would help to dispel funding uncertainties as the
24 rest of the NHS moved towards the new arrangements
25 proposed in the white paper. The options covered in the
0015
1 paper proposed a reliance either on accreditation or on
2 continued Central Funding, which would meet the majority
3 of the costs of the service, with marginal costs being
4 met by the purchasers.
5 "4.3: The Secretary pointed out that he had tabled
6 a letter from Mr English...", presumably now Sir Terence
7 English?
8 A. It was indeed.
9 Q. "... who felt that an accreditation system was
10 impracticable and favoured option 2", which is Central
11 Funding. "Mr English thought that the proportion of
12 costs borne centrally should be at least 80 to 90 per
13 cent."
14 Just pausing there, the question was how to adapt
15 the supra-regional funding system for the new
16 arrangements?
17 A. Yes.
18 Q. And what was under consideration was a choice between
19 one of two options, either on the one hand some form of
20 accreditation, secondly, on the other hand, the Central
21 Funding, and it was Central Funding which I think won
22 the day, was it?
23 A. Central Funding won the day. It was not quite the
24 Central Funding I understand is being talked about
25 there, but yes.
0016
1 Q. So far as accreditation is concerned, I appreciate you
2 were not there for this discussion. Had you picked up,
3 during your time as Secretary, how it was proposed that
4 that might work?
5 A. Thank you for accepting that I was not there. I think,
6 and this really is a reasonable distant memory, that as
7 I understand it accreditation would have involved
8 identifying units, in a sense almost designating units
9 to provide particular services, but not funding them
10 from the centre. So in effect you will say to the
11 Health Service at large, "If you want to purchase heart
12 transplantations [let us say], you can only purchase
13 them from one of these units; you must purchase it from
14 one of these units". The accreditation of the units
15 again, as I understand, would have been done broadly in
16 the same way, I think, as the supra-regional service
17 units were designated.
18 So it was an attempt, I believe, to square the
19 circle of trying to keep control on the numbers and the
20 nature of the units providing particular services, where
21 that was felt centrally to be sensible, whilst at the
22 same time allowing funding issues to go the way of the
23 general health reforms under way at that time, and to
24 devolve purchasing to the lowest level.
25 That is my understanding of how the accreditation
0017
1 system would work.
2 Q. So the essence of accreditation was a form of central
3 control, central designation, of those units that would
4 provide a particular service?
5 A. As I understand the term, yes.
6 Q. And that would necessarily imply that someone had to
7 make the choice?
8 A. Yes. I think it would have to operate in broadly the
9 same way as supra-regional service units were
10 designated, as I have just said. It would have to be as
11 a result of a dialogue between the Department, the
12 Colleges and the regions.
13 Q. The reason why I ask you about this, appreciating that
14 you may not have been au fait with the particular
15 discussions at the time, is that later on, as we shall
16 see, an issue arose as to the proliferation of services
17 in the neonatal and infant cardiac surgical field.
18 A. Yes.
19 Q. And there was some discussion as to what might be done
20 about it. Did accreditation, in one form or another,
21 raise its head at that later stage?
22 A. To the best of my recollection, no.
23 Q. The next reference that I want to take you to is DOH
24 2/200. This is a paper, SRS(90)6, and it is clearly for
25 consideration at the July meeting. I can tell you it
0018
1 was considered at the July meeting in 1990, and it deals
2 with the specific service of neonatal and infant cardiac
3 surgery.
4 One sees from the first three paragraphs that
5 officials were invited to visit a number of units that
6 have been identified by the RCS, and in paragraph 3:
7 "Of the designated centres, three were singled out
8 in the recent reports as requiring review. The centres
9 in question were Bristol, Newcastle and the Harefield
10 part of the joint Harefield/Brompton centre."
11 It goes on to say that the question of the number
12 of centres required for the London area has been raised
13 on a number of occasions, particularly by the London
14 Health Planning Consortium. Officials therefore set out
15 to visit ..."
16 And it sets out the names of the five centres:
17 Bristol, Newcastle, Harefield, Brompton and Guy's.
18 Dealing with Bristol, one can see what is said.
19 Again, this was history, of course, by the time you
20 became concerned. But presumably you were familiar with
21 the essence, the broad thrust, of the information which
22 had been obtained by your predecessors, both
23 administrative and clinical, in respect of Bristol when
24 it fell for consideration under your Secretaryship in
25 1992 and thereafter?
0019
1 A. I was certainly aware that there had been problems, or
2 the Bristol unit had had problems in the past in its
3 levels of activity, yes.
4 Q. Just reading down:
5 "Officials visited the Bristol unit and met with
6 the cardiologists, cardiac surgeons, nursing staff and
7 management. The centre had had considerable difficulty
8 in getting the service started. Although the service
9 remains split between two sites there has been
10 considerable capital development in the wards of the BRI
11 and in the diagnostic facilities in the cardiology
12 department of the Children's Hospital. The referral of
13 patients has increased and the centre appeared to be on
14 a much stronger base. There is however a threat to
15 Bristol in the future which arises from the decision by
16 the Welsh Office to establish a neonatal and infant
17 cardiac surgical service in Cardiff. When such unit is
18 established, it will reduce the number of patients
19 referred to Bristol from Wales."
20 This is an example, is it?
21 A. I am sorry, the paper had not quite gone up at that
22 point.
23 Q. I am sorry, my apologies. I am reading from hard copy
24 and I should have been following the screen.
25 This is an example: "When such unit is
0020
1 established, it will reduce the number of patients
2 referred to Bristol from Wales". That is an example of
3 the geographical cross-border considerations that we
4 were talking about a moment ago?
5 A. Indeed, yes.
6 Q. "Further, a proportion of the patients who could be
7 referred to Bristol in fact go to the Brompton Hospital,
8 and it is likely that this referral will continue.
9 Therefore, although officials found the Bristol centre
10 to be soundly based and giving every sign that the
11 centre would be a viable designated unit and despite the
12 fact that the geographical spread of the designated
13 centres is desirable, there remains a question mark over
14 the centre's long-term viability in supra-regional
15 terms."
16 A. Yes.
17 Q. Was that effectively the position so far as Bristol was
18 concerned, which you inherited in January 1992?
19 A. In essence, yes, that is right.
20 Q. If I can trace through what happened thereafter, if we
21 can go, please, to the third meeting of 1990, we find it
22 at DOH 2/167. That is the cover sheet, so you can see
23 when the meeting was and who was present, 3rd October
24 1990. The relevant page is the next page, 168.
25 Designation issues:
0021
1 "Neonatal and infant cardiac surgery: Dr Halliday
2 reported on the outcome of his visit to Harefield
3 Hospital and his meeting with Professor Tynan at Guy's
4 Hospital. He had been impressed with the service
5 provided at Harefield ..."
6 Then about four or five lines down:
7 "Professor Tynan argued the whole service should
8 be de-designated."
9 We looked at some of what he was saying yesterday
10 with Mr Angilley.
11 A. Yes.
12 Q. "Members then discussed whether the overall service or
13 just some units should be de-designated. If the latter
14 option was being considered, the argument in favour of
15 allowing the unit at Bristol to continue to operate
16 would be its geographical location."
17 "Members agreed that the service should ideally be
18 concentrated in no more than six or seven centres and
19 that proliferation occurred to the detriment of
20 patients."
21 Pausing there, the problem was proliferation, was
22 it?
23 A. Yes, it was.
24 Q. If there had not been proliferation, ultimately, do
25 I take it there probably would not have been
0022
1 de-designation of the service?
2 A. It would have been considerably less likely. The reason
3 I slightly qualified that question is that the service
4 was still in effect -- and I think -- I know it was
5 formally recognised later on, being provided in 10
6 designated units. That itself got very close, if not
7 beyond, the criteria for the supra-regional service
8 designation, and therefore I think the Advisory Group
9 would really have had to consider, and indeed would have
10 considered, whether they were content to leave the
11 service with 10 designated units, or to go through the
12 loop that they went through with this particular issue
13 to see whether there were any individual units that
14 needed to be taken, to use your words, "out of the
15 club."
16 But certainly, the whole issue around the neonatal
17 and infant cardiac surgery service during my time was in
18 the fact that the arrangements for the funding stream
19 had failed, basically, to achieve their policy
20 objective, of restricting service provision.
21 Q. Which comes back, I think, to the point I was putting to
22 you for comment, that it was ultimately proliferation
23 that led to the de-designation of the service?
24 A. Yes, it was.
25 Q. And does it not follow that if there had not been
0023
1 proliferation, the service would probably have remained
2 designated?
3 A. I am sorry, I clearly did not explain myself. It was
4 the proliferation of the service which led to this
5 particular service being de-designated. If
6 proliferation was not an issue, if the service was still
7 being provided in 10 designated units and in no other
8 unit in the country, to any appreciable degree, the
9 Advisory Group would have had to consider whether they
10 were content to leave that arrangement in situ, or to
11 consider whether 10 designated units was beyond the pale
12 in terms of supra-regional service criteria.
13 I judge that they would have accepted the status
14 quo.
15 Q. If I were to change the word "proliferation" to
16 "numbers" of centres providing the service, one sees
17 six or seven recommended by the clinicians to the
18 meeting in 1990. If the numbers had been restricted to
19 six or seven units, is it, in your view, likely that
20 this service would probably have remained designated?
21 A. I think it is more than likely. I think it is pretty
22 close to certainty.
23 Q. So if one were to change in my question, the word
24 "proliferation", that is going beyond the 10 that there
25 were in the service, to the "overall numbers", the
0024
1 de-designation, if you like, was the consequence of too
2 many centres doing the work?
3 A. Absolutely, yes.
4 Q. The question, I suppose, arises as to whether or not the
5 purpose of restricting neonatal and infant cardiac
6 services to a few centres was a good one or a bad one,
7 on clinical grounds, and on that you would take clinical
8 advice?
9 A. Indeed.
10 Q. If the clinical advice were to the effect that
11 restriction to a few, six or seven centres, as we see
12 advised in 1990, was advisable because it provided
13 a better service for the public, then de-designation on
14 the grounds of the numbers of units conducting the
15 service was something which inevitably was going to
16 operate against the public interest?
17 A. Yes.
18 Q. Ultimately we will get to that stage in the history and
19 I will take you through the documents. But it may be
20 useful to have, at this stage, your comment, if you can
21 comment, as to why it should be, what other policy
22 considerations applied, to taking a decision which was
23 going to operate against the public interest, because of
24 the exercise, it would seem, of clinical freedom. This
25 is a case of clinical freedom operating against the
0025
1 public interest?
2 A. I am sorry, I think I have kind of lost the thread you
3 were trying to get to. I do apologise.
4 Q. It is my fault. It is the way the question was put.
5 You and I have agreed that if the clinical advice
6 was, "This service is best provided for the public
7 benefit in a few centres", there is it is best funded
8 supra-regionally?
9 A. Yes.
10 Q. De-designation takes place because there are too many
11 centres doing the work?
12 A. Right.
13 Q. The advice is that more centres are doing the work than
14 should be, and "should" I am using in the sense of
15 clinically desirable?
16 A. Yes.
17 Q. The number of centres that do the work do it,
18 presumably, because clinicians, wherever they do the
19 work, have chosen to do so?
20 A. Yes.
21 Q. And there was, am I right, no method of stopping them
22 from doing so?
23 A. That is right, yes.
24 Q. So their exercise of that freedom in this case would, on
25 the assumptions I have made in the question, operate
0026
1 against the public interest?
2 A. Yes.
3 Q. Broken down, that was the question I was putting. It is
4 my fault for having put in it a portmanteau way.
5 A. It is early in the morning. That is right. It is
6 a constant balancing act, inevitably. There was no
7 doubt that the professional advice that the Advisory
8 Group got was that in terms of quality of service, and
9 not to mention economies of scale, there was clear
10 advantage in restricting provision of this service to
11 a low number of units, and there have been various
12 numbers bandied around of six, to seven, to eight,
13 broadly.
14 The fact that we and the profession had failed to
15 prevent proliferation of the service to more than that
16 band of units brought into focus the issue of
17 de-designation as we have seen, and ultimately, led to
18 the service being de-designated.
19 You can very clearly, therefore, argue that that
20 worked against the perceived advantages of designation.
21 I think I will stop at that point.
22 Q. I may take it further in the questions as we go down the
23 story. What I would like to do is to pick up the
24 history. It is actually the same document but I am
25 going to use a different reference for it, RCSE 2/35,
0027
1 the same paper, and under paragraph 10, at the bottom of
2 the page, please, the options. "To continue to
3 designate" -- the first is in bold. It may not come up
4 clearly on the screen --
5 A. I am sorry, nothing is coming up.
6 MR LANGSTAFF: We have an override system which is designed
7 for documents other than these, where there are possible
8 issues of confidentiality. For that purpose, most
9 documents which could potentially give rise to any
10 breach of confidence are checked twice before they are
11 released on to the screen.
12 A. I understand.
13 Q. Paragraph 10:
14 "To continue to designate the service but to
15 reduce the number of centres within the designated
16 service."
17 I will come to the text in a moment. The second
18 option is overleaf, paragraph 14, "To de-designate the
19 service."
20 So the two options -- back to 10, please -- are to
21 reduce the numbers doing it, or de-designate the
22 service?
23 A. Yes.
24 Q. It is not put forward as an option at this stage that
25 the service can remain as it is?
0028
1 A. No.
2 Q. The reasons for that presumably would be that it would
3 not fit within the criteria for supra-regional funding?
4 A. Yes.
5 Q. And no doubt the view would have been taken that because
6 of the numbers already doing the service, any public
7 benefit by restricting the numbers was being diluted?
8 A. Yes.
9 Q. The profession's advice, it says, is that about seven
10 centres are required to cover the caseload of England
11 and Wales. "The case for designation of the service in
12 the interest of patients has been strongly made and
13 still holds good."
14 So the advice given to the Advisory Group at this
15 stage was that there remain good clinical reasons for
16 having the service?
17 A. That is right. And as far as I understand it, that
18 advice was consistent to the end.
19 Q. So the proposition that I was putting to you a moment or
20 two ago, one of the assumptions was that there was
21 clinical advice to the effect of the benefit to the
22 public and your evidence is that so far as you know,
23 this was the strong and consistent advice throughout?
24 A. Indeed, yes.
25 Q. "Designation provides special funding of the service and
0029
1 there is good evidence as to the benefit of that
2 support. The recent National Confidential Enquiry of
3 peri-operative deaths being one such example."
4 That may not be something you can speak about?
5 A. I could not, no.
6 Q. One sees the point that is being made there is that this
7 is not simply an impressionistic benefit; it appears to
8 be supported by such evidence as there is?
9 A. Yes.
10 Q. "Designation also allows for concentration of the
11 service in a few centres, so that patients benefit from
12 the expertise which is derived from a high throughput."
13 That really is the whole clinical rationale for
14 supra-regional funding is it not?
15 A. Precisely so, yes.
16 Q. "New funding arrangements will put non-designated
17 centres at a financial disadvantage and should thereby
18 support the policy on concentration in a few centres."
19 Could I ask you about that? The new funding
20 arrangements will put non-designated centres at
21 a financial disadvantage. What was the "financial
22 disadvantage"?
23 A. Essentially, that they would have to find alternative
24 funding for providing that service. They could only
25 find that funding, it seems to me, through two
0030
1 mechanisms. One is by contracts with their alternative
2 purchasers, or secondly, through charitable donations.
3 Certainly in the case of charitable donations, that may
4 not be a continuous stream; it may not be reliable in
5 terms of finding funding through contracting with
6 alternative purchasers.
7 That should -- the idea was that it would -- prove
8 difficult because the alternative purchasers would say
9 "Why should I pay for this service, since there are 10
10 units in the country, or X numbers of units in the
11 country who are being funded centrally for this
12 service?" So it is all about squeezing off the money to
13 non-designated units.
14 Q. Taking that one stage further, the purchaser would say
15 "I have limited cake here. If I am going to spend it,
16 I will spend it on other things, because the money is
17 already there for this service"?
18 A. Yes, in a sense, "I have already paid for that
19 designated service, because the cost of that designated
20 service funded centrally had been top-sliced from my
21 allocation".
22 Q. That was the theory. One can well understand why -- in
23 1990/91 -- it might work. Anticipating what is to come,
24 why, in your view, did it not work?
25 A. I genuinely think that is actually quite a difficult
0031
1 question to answer. I think the answer is inevitably
2 reasonably complex.
3 There were a number of factors. One
4 unquestionably was that knowledge of the supra-regional
5 service arrangements on the ground in other purchasing
6 organisations -- I am talking here about District Health
7 Authorities -- was not necessarily of the highest order
8 at this period of time we are talking about.
9 For that reason, as soon as I joined as Secretary,
10 I was instructed to write an annual report for the first
11 time on the supra-regional service arrangements and
12 ensure it went out to every District Health Authority.
13 So that was clearly one problem.
14 A second issue is that then, as now -- and
15 I certainly do not want to be disrespectful but, in my
16 experience, many things motivate clinicians -- the cost
17 of their decisions was not necessarily high up on their
18 totem pole of drivers, therefore I certainly came across
19 instances where clinicians were providing services
20 because it was something they were particularly
21 interested in doing, for no doubt completely proper
22 reasons. I am casting no aspersions here, but the
23 financial consequences of their decisions were not
24 something they were particularly interested in or were
25 going to be guided by. They were two factors that
0032
1 I would highlight.
2 Q. In essence, I think, if I can summarise, I hope not
3 unfairly, you are perhaps suggesting that clinicians
4 wanted, for perfectly proper reasons, to do the work,
5 would put "pressure" may be the wrong word, but would
6 emphasise to the district which might fund them, the
7 advantages that they are doing the work, and the
8 districts would not necessarily have the broader
9 perspective because they do not have the information to
10 say "No"?
11 A. Yes, or alternatively, the clinicians would simply go
12 ahead and do the work.
13 Q. And present it as a fait accompli?
14 A. Yes.
15 Q. And that implies that there was no withholding system in
16 the financial arrangements which might have prevented
17 them doing that?
18 A. There was no hard and fast holding arrangement, that is
19 absolutely right. I have already described the
20 intention behind the supra-regional service funding
21 mechanism, and there was also an agreement with the
22 professions. I mean, the supra-regional service
23 arrangements themselves involved the professions in
24 agreeing to restrict provision of designated services to
25 designated units and they did, in all fairness to them,
0033
1 apply persuasion wherever they could, but there were
2 instances, clearly, where that persuasion did not work
3 and where the restrictive effect of SRS funding did not
4 work, and the neonatal infant cardiac surgery service is
5 one such example.
6 Q. The lay member of the public may be forgiven for drawing
7 parallels between the National Health Service and other
8 walks of life. If, for instance, one took the academic
9 sphere, my understanding is, imperfect as it may be,
10 that in that sphere, if a Fellow wishes to run
11 a particular course -- or a university tutor wishes to
12 run a particular course -- he would be able to do so,
13 save out of his own pocket, without there being some
14 funding available. It all depends on the availability
15 of funding in the first place and to run the course and
16 say "I have done it, now pay for it", would meet
17 a pretty frosty answer from the Treasurer, or the
18 University Council responsible for the provision of
19 money.
20 I have put that very crudely, but the point,
21 I think, is an obvious one.
22 A. Yes.
23 Q. What you are saying is that there may well have been
24 cases where people did work which was outside the scope
25 of their funded job description, putting it in lay
0034
1 terms, and then claimed the money for it from the funder
2 locally thereafter?
3 A. I suspect it did not work in quite that way, although
4 the basis of what you are saying, I agree with. I think
5 it is perfectly true to say that, more at the beginning
6 than now, contracting generally throughout the NHS was
7 a relatively crude mechanism. We were all basically
8 trying to learn an entirely new tranche of skills, an
9 entirely new trade. Therefore contracts between units
10 and their purchasers were, in the main, drafted in
11 really very broad terms: "I will provide cardiology
12 services", almost. Therefore, it was entirely possible
13 to provide a service within the terms of that
14 generality, if you like, that was nevertheless
15 a designated service.
16 Q. What one would perhaps need to do, if there was going to
17 be a financial disincentive to providing the service,
18 would be to make sure that in each of the contracts
19 there was a clause to the effect of saying, "Although
20 you are doing this service, you will not get funding for
21 neonatal and infant cardiac services, full stop", so
22 that if the work was done, the funds could then
23 legitimately be denied, unless, presumably, there was
24 some exceptional case made and it came out of some
25 reserve fund somewhere?
0035
1 A. Yes.
2 Q. That would be the way it would have to work?
3 A. That would have done it. I think it would perhaps have
4 got quite close to infringing on clinical judgments and
5 clinical freedoms and therefore you would need some sort
6 of exception mechanism as you have just described. But,
7 yes, you could certainly do it that way. But that would
8 not address the situation which has arisen of services
9 being funded through charitable donations, for example.
10 Q. No, but I think your answer, a little while ago now, to
11 the prospects of a service so funded, would be that one
12 could not necessarily depend upon the income flow from
13 charitable donations being maintained?
14 A. Yes.
15 Q. And for very good reason. If the service was actually
16 being provided on a national basis elsewhere, it might
17 be thought that charitable donations would serve better
18 purposes directed otherwise; but that is a comment,
19 really.
20 I suppose, if the clause were to go into the
21 contract, as you and I have discussed, the only way that
22 it could have got there would have been by discussion,
23 encouragement from the centre, to the purchasers of
24 services, to insert some such clause in the contracts
25 they made for services?
0036
1 A. Yes.
2 Q. That, I take it, was not done because everyone was
3 grappling with the -- I am suggesting the reason: that
4 first of all, the first stage in the questioning, is
5 that it was not done?
6 A. No.
7 Q. And the second question, really, is, why not?
8 A. Because we were all grappling.
9 Q. So I was right?
10 A. Yes.
11 Q. Has that or anything like that happened since?
12 A. Genuinely, I do not know. I do not know. I do have
13 a very vague memory that I discussed it internally with
14 my administrative colleagues at some point in time,
15 whether there was some mechanism for putting things into
16 general contracts. I think it was almost an academic
17 discussion in that context. Certainly I do not remember
18 pursuing it actively.
19 Q. If I can come back: I have taken you, really, on an
20 excursus from what we have on the screen, which is
21 paragraph 10. The last sentence on that page we have
22 not yet dealt with.
23 "The de-designation of two centres and the
24 rejection of the Leicester bid would be necessary to
25 achieve this option."
0037
1 One goes over to the top of the next page:
2 "The centres to be considered for de-designation
3 on the basis of the profession's advice are: Harefield,
4 Guy's (based on surgical activity), Bristol and
5 Newcastle."
6 "12: In general terms, all other factors being
7 equal, there is a strong case for Bristol and Newcastle
8 in terms of geographical spread."
9 So it is coming down to the question of geography
10 really favouring Bristol and Newcastle, and eliminating
11 Harefield and Guy's, on that criteria?
12 A. Given that there appeared at that time to be no other
13 distinguishing factors, yes.
14 Q. "13: It may be difficult, if not invidious, to attempt
15 to de-designate the centres in question on the basis of
16 surgical expertise. Whether it is entirely fair to do
17 so on the basis of referral pattern is a matter for
18 debate."
19 The reference to "referral pattern" may well be
20 a reference back, if we just look at it for a moment, to
21 RCSE 2/33. Paragraph 4, the bottom of the page -- we
22 looked at it a moment or two ago.
23 "Further, a proportion of the patients that could
24 be referred to Bristol in fact go to the Brompton
25 Hospital and it is likely that this referral will
0038
1 continue."
2 A. Yes.
3 Q. Having looked at that, let us go back to RCSE 2/36.
4 I appreciate this is a little before you came in as
5 Secretary. One can understand why it would be difficult
6 to de-designate centres on the basis of surgical
7 expertise. Why would it necessarily be invidious? Are
8 you in a position to comment?
9 A. I am not, to be frank, no.
10 Q. Whether it was difficult or not would depend on there
11 being the available information, to evaluate surgical
12 expertise?
13 A. Yes.
14 Q. Reading this as a text, one might be forgiven for
15 thinking that the next sentence links surgical expertise
16 with referral patterns. The crude point, I think, lying
17 behind it may well be that if referring clinicians are
18 referring to other centres and avoiding, bypassing the
19 centre in question, in this case Bristol, that might be
20 a comment on the perception of their surgical expertise
21 at that centre. That may be a crude point. Again, I do
22 not know whether you can comment as to whether that is
23 a fair reading of the implications from this, or whether
24 that is something I should take up with Dr Halliday?
25 A. I suspect I would actually advise you to take that one
0039
1 up with Dr Halliday.
2 Q. On the point you raise about the second sentence, you
3 said that clinicians may refer to unit A rather than B
4 because of their perception, or whatever?
5 A. Yes. Clearly, the logic of that must be right, but
6 there are other reasons. I will simply make the point
7 that there are other reasons why clinicians may choose
8 their referral patterns in whatever way they do.
9 One of the things I do remember from my time there
10 was discussing with a number of people just how elastic
11 referral patterns were, and in practice, I was
12 constantly being told that clinicians had their
13 favourite units, they established working relationships
14 with the people, and in practice, if they referred to
15 unit A, whatever other units were or were not doing,
16 they would in all probability continue to refer to
17 unit A.
18 I think I would read that second sentence in that
19 way: that Bristol had clearly a problem with its
20 referral patterns, which we discussed before, and it was
21 unlikely, difficult to see, how those referral patterns
22 could be reversed, for whatever reason.
23 Q. I think what you say has strong support from that which
24 Mr Gregory was telling us on Monday in relation to the
25 Welsh position, and the upshot would be, presumably,
0040
1 that referral patterns played havoc with any attempt to
2 get a firm view of a catchment area?
3 A. They did not help, yes.
4 Q. Going down to paragraph 14 on the page -- you are not
5 the Secretary responsible for that?
6 A. I have done it myself.
7 Q. "To de-designate the service, this option recognises the
8 reality of the situation in that there are now 11
9 centres active in this specialised area of surgery that
10 are working under the umbrella of designation. As noted
11 above, there are other units active in the area that are
12 not so covered. There is also a need to consider the
13 broader issue of advances in the method of treating
14 congenital heart disease. This SRS has grown up in the
15 light of cardiac surgery and this now has to be seen in
16 the light of minimally invasive techniques that avoid
17 surgery. The arrangements to be introduced on 1st April
18 1991 would ensure the financial support for the units
19 would be forthcoming, and there is no reason to believe
20 the referral pattern will be altered by these
21 arrangements."
22 That is a reference back to the referral pattern,
23 in the same light as you have just said.
24 If that option were taken, the recommendation we
25 can see in 16:
0041
1 "To recommend that ministers give notice that they
2 intend to remove designation from the service in April
3 1992" and here is the sting: "unless the provider units,
4 in consultation with the medical profession, produce by
5 June 1991 agreed proposals for reducing the number of
6 designated units by at least two."
7 So this option, at this stage, was throwing the
8 problem back to the profession, or appears to be?
9 A. Yes, I think that is right.
10 Q. By the time you inherited the problem, was that still an
11 option?
12 A. Yes. I think by the time I came on the scene, the
13 problem was still there, the discussions were still
14 continuing, the three options which had always been
15 there were still there.
16 Q. Again, anticipating forward in time, was the support of
17 the profession forthcoming on that?
18 A. On what, I am sorry?
19 Q. On the medical profession producing agreed proposals for
20 reducing the number of designated units?
21 A. The medical profession were quite clearly of the view
22 that the advantage lay in de-designation. They
23 accepted, indeed, they told us, that the advantage lay
24 in restricting to this limited number -- seven, I think,
25 we ultimately settled on -- and they undertook
0042
1 a review -- I do not know if I am jumping ahead --
2 during 1992 to again look at this issue, to see whether
3 or not they could come up with recommendations to the
4 group which would have achieved the objectives of
5 (a) keeping the service within the arrangement overall,
6 excepting that the number of units providing that
7 service had to be reduced.
8 Q. We will come and look at those in a moment or two, but
9 broadly, I think we may find the result was that for one
10 reason or another, they could not or did not do it, but
11 we will come to it.
12 If we can move on to page 2/39, please, this is
13 paper 90(12)7, and it is dealing with revenue bids for
14 1991/92. Just looking in the middle of the page,
15 please, RCSE 2/39, please, the middle of the page, under
16 "South Western RHA":
17 "An additional œ621,000 is requested. Further
18 cases cared for in another unit and, not previously
19 identified, have been included in the workload and
20 expenditure return. Even with this, the activity
21 figures do not show an increase."
22 We drop down the next paragraph:
23 "There is no case on grounds of workload increase
24 for additional funds."
25 The position, I think, with Bristol is, as with
0043
1 other units, that it would put in a bid for allocation
2 based on the anticipated workload in a particular
3 service?
4 A. Yes, that is right.
5 Q. As always, it would do its best to make a fair estimate
6 of workload. I think historically, if one looks at
7 estimates, they probably tend to be a shade on the high
8 side, but broadly accurate?
9 A. Yes.
10 Q. What this in effect is saying is that it is not
11 anticipated that there is going to be any development of
12 the service in Bristol in terms of numbers dealt with?
13 A. Yes. I -- yes.
14 Q. At RCSE 2/42, this is paper (90)15, again a 1990 paper,
15 and this was considered at the last meeting in 1990:
16 "At its last meeting, the Advisory Group reviewed
17 the provision of neonatal and infant cardiac surgery,
18 and considered whether, in view of the number of units
19 undertaking this work, the service could continue to be
20 designated ... Members were in favour of continued
21 designation and asked whether there were any units which
22 might be de-designated."
23 So we can see that the options put forward in
24 a previous paper were considered and a decision reached
25 that they would rather like to go on with the service,
0044
1 but reduce the number of units?
2 A. Yes.
3 Q. "Those which have been identified by the Society of
4 Cardiothoracic Surgeons and the Royal College of
5 Surgeons as being most at risk were Bristol, Newcastle,
6 Guy's and Harefield, the latter will been designated
7 jointly with the Brompton, but ... the joint arrangement
8 was not working in practice.
9 "Members asked that more information be obtained
10 about the units at risk. Bristol and Newcastle were
11 considered to be essential on geographical grounds, but
12 officials were asked to discuss with both units ways in
13 which the activity might be increased."
14 So the response was, as one understands it, to see
15 if you could get more cases going through Bristol and
16 Newcastle in order to increase their viability as units?
17 A. Yes.
18 Q. The implication behind that is that although, taking
19 a national perspective, six or seven units would deal
20 with the work, although it follows from what you said
21 nine or ten units was really too many for
22 a supra-regional service, that if Newcastle and Bristol
23 had more cases, more throughput, that the Advisory Group
24 might find its way to recommending to ministers that
25 they remain designated.
0045
1 That is, I think, the implication behind that
2 paragraph; am I right?
3 A. Yes. I would understand this to say there were two
4 issues floating around here. One was the fact that
5 Bristol, Harefield and Newcastle were designated units
6 and operating at levels which people felt were too low,
7 and therefore there was a requirement, a wish, to find
8 ways of increasing that activity, which would also
9 inevitably have squeezed off work from non-designated
10 units. And of course, that was a completely normal
11 function of supra-regional service arrangements, which
12 were all about funding and developing units. So it was
13 accepted, I think, pragmatically and realistically, that
14 in the early days of designation, a unit may well
15 operate at lower levels than the ideal, but over time
16 would achieve them. So that is one dynamic at work
17 there.
18 The second dynamic is really the one which you
19 identified, which is that, given that you have 10 units,
20 which I personally feel went beyond the criteria, and
21 I think people were generally uncomfortable with, you
22 had to seek ways of reducing those numbers. The way
23 most people address that issue was in terms of
24 activity.
25 Q. The paper trail, so far as we can see, I think moves
0046
1 forward into the latter part of 1991, shortly before you
2 came on board. I would like to take you to RCSE 2/69.
3 This is a letter to Dr Halliday, the Medical
4 Secretary of the group, and it is from Sir Terence
5 English, who was President of the Royal College of
6 Surgeons of England. It is about neonatal and infant
7 cardiac surgery, and Sir Terence was a member of the
8 Advisory Group, was he?
9 A. Indeed, he was.
10 Q. It is plain that a Working Party was going to be
11 convened, from the second paragraph of that letter. The
12 third paragraph I want to ask you about in a little bit
13 more detail:
14 "My view at this stage is that it would be very
15 difficult to try and relate designation to specific
16 categories of operative procedures."
17 Pausing there, this was a third proposal, was it,
18 a third option, that if one were not going to
19 de-designate the service as a whole, if one could not
20 de-designate particular units, for this particular
21 service you might identify particularly rare and
22 difficult operations --
23 A. Yes. That is precisely the case. I think we looked
24 yesterday, for example, that the epidemiological
25 evidence indicated that the incidence of conditions
0047
1 covered here were in the 15 or 16 hundreds. That of
2 itself breached the SRS criteria of round about
3 a thousand. It was not a huge breach, but it was
4 nevertheless a breach. Therefore, if you are looking at
5 ways of pulling back, of controlling and getting more
6 firmly fixed within the criteria, a number of options
7 crop up, reducing the number of units we have talked
8 about already. But if that was not perhaps an option,
9 then to look at the specific procedures that were
10 designated to see if by designating procedure A as
11 opposed to procedure B you could achieve control of that
12 service that way. That is the idea there.
13 Q. The next paragraph:
14 "I would also want to see the annual audit data
15 from each designated centre that presumably you have
16 received over the last few years and which you allude to
17 in your letter."
18 Was it the case that the group as such received
19 any audit data in respect of anything other than the
20 numbers of operations performed?
21 A. This, again, is before my time, so I find that a very
22 difficult question to answer. Certainly, in my time the
23 primary data delivered was on activity. The RCS Working
24 Party report, I think we will come on to, contained
25 mortality data, and I remember mortality data for this
0048
1 particular service being tabled or issued. But I mean,
2 there is a great danger of simply looking at mortality
3 data which of itself, as I understand it -- I am not,
4 obviously, a clinician -- is limited in what it can tell
5 you, unless you have the means to analyse it properly on
6 restratification, and I am now getting into an area
7 I know next to nothing about, so I will run away from
8 that straightaway.
9 Q. I think what you are saying is that, well, you cannot
10 really comment on what there may have been then?
11 A. No.
12 Q. But certainly, in your own time, there was no formalised
13 system of having outcome data, although some outcome
14 data was, in the manner you have described, tabled?
15 A. To an extent, but also, to an extent, the entire
16 arrangements were the mechanism. You had, for example,
17 as Mr Angilley was explaining yesterday, the Medical
18 Secretary with the responsibility in this area. You had
19 the units themselves with responsibilities in this
20 area. The members of the Advisory Groups themselves
21 were selected because of their positions, and because
22 they would have access to a range of data and knowledge
23 about the performance of individual units. It was their
24 role, equally, to bring to the Advisory Group anything
25 of particular note one way or another.
0049
1 Q. Before we leave this letter, just a couple of other
2 points. It is the second last full paragraph:
3 "It is my view that if supra-regional designation
4 is to continue, as I firmly believe it should, it should
5 be related to the annual workload of open and closed
6 operations performed", and here he underlines the words
7 'neonates' and 'infants'.
8 And then this: "So that the misuse of
9 supra-regional funds for treating older children is
10 stopped".
11 This is something Mr Angilley touched on yesterday
12 coming from another source, which I think was the Guy's
13 letter from Professor Tynan. It is two or three months
14 before your time, but was this something that you were
15 aware of? Did it happen? Do you accept the
16 suggestion? Is it misconceived? What is your comment
17 on it?
18 A. I am not sure I actually read that paragraph in quite
19 the same way as you do. I read that almost as if it is
20 saying that the supra-regional service funding was being
21 syphoned off or cross-subsidising the treatment of older
22 children.
23 Q. Yes.
24 A. Then I do beg your pardon. There were certainly --
25 I had suspicions that supra-regional service money,
0050
1 certainly in the early days of the internal market, were
2 being used unintentionally and largely unknowingly to
3 pay for other services just as funds provided for other
4 services could well have been subsidising the cost of
5 supra-regional services. That is a statement largely
6 upon the lack of precision, the lack of knowledge, about
7 costing, the recording systems in operation in the NHS
8 at the time, the level of awareness, the skills of
9 contracting. It was the whole gamut. It was very, very
10 early days. So inevitably, that lack of precision was
11 going to occur. It did not surprise me that we had
12 situations like that.
13 I thought the point that you were making --
14 I apologise if I got this wrong -- was by reference to
15 Professor Tynan, the proposition he put forward in
16 a report, that in fact the supra-regional service
17 funding screen worked against clinical freedom.
18 Q. No, that was not the point I was there addressing.
19 A. Then I apologise.
20 Q. The suggestion was raised I think by him that there was
21 an element, it may well be, of cross-subsidy?
22 A. I think it is inevitable. I accept that too.
23 Q. The second last paragraph, the last full
24 paragraph finally:
25 "I believe that any such endeavour would have to
0051
1 accept the possibility of some of the smaller or less
2 effective units (or indeed units that fail to produce
3 regular audit data) being de-designated in order that
4 the good and responsible units could continue to provide
5 a valuable service."
6 Although that is couched in terms of a clinician's
7 view and one supposes that "less effective" means less
8 successful in terms of outcome, essentially that
9 reflects back to one of the two options that we were
10 considering in evidence a few minutes ago?
11 A. Yes. Sir Terence in his letter effectively rules out of
12 court the mini option, if you like, of looking again at
13 the particular procedures, and therefore you are back to
14 the two basic options.
15 Q. It is a convenient moment, perhaps, to take a break
16 there, sir, for 10 minutes or a quarter of an hour?
17 Then we will return after that to crack through what
18 happened coming up to your own period of office.
19 THE CHAIRMAN: Shall we take a quarter of an hour and
20 reconvene at 11.15?
21 (11.00 am)
22 (A short break)
23 (11.15 am)
24 MR LANGSTAFF: The next document which I want to ask you
25 about, Mr Owen, we find at RCSE 2/76, and I have asked
0052
1 that the screen be split between that and RCSE 2/91,
2 because the one at 76 on the right-hand side of the
3 screen is a draft which is plainly the 1991 draft,
4 before you became the Secretary. The one on the left
5 is, it would appear, the final version of the same
6 paper. There are additions and alterations to it.
7 It might not be easy to read some of the screen.
8 I will ask you to do your best, if you can, and if you
9 need it to be blown up, just ask and we will get that
10 done.
11 The background to it is set out in paragraph 1 of
12 both notes:
13 "At its last meeting the Advisory Group reviewed
14 the provision of neonatal and infant cardiac surgery and
15 considered whether, in view of the number of units
16 undertaking this work, the service could continue to be
17 designated.
18 "Members were in favour of continued designation
19 and asked whether there were any prospects of
20 identifying specific operations which might be
21 designated, rather than units, or whether any units
22 might be de-designated."
23 The first of those we have seen Sir Terence
24 English responding to in his letter to Dr Norman
25 Halliday.
0053
1 It identifies ones most at risk, and paragraph 2:
2 "Members had considered a paper which had provided
3 more information on the units at risk. Bristol and
4 Newcastle were considered to be essential on
5 geographical grounds."
6 The word "essential" there appears.
7 "But officials were asked to discuss with both
8 units ways in which the activity might be increased.
9 "3. Members accepted the conclusions", we have
10 seen these conclusions before and I need not, I think,
11 read them through.
12 The final version at the bottom of RCSE 2/91,
13 paragraph 4, has in it a table which sets out activity,
14 "Copy attached at flag C". We see that at paragraph 4,
15 page 91?
16 A. Yes.
17 Q. It tells us that mortality data from each of the
18 designated units will be tabled at the meeting.
19 If we take the split screen off and go to 2/120,
20 better take it back a page to 2/119, this was annex C to
21 the previous paper, SRS(90)15, dealing with the number
22 of operations performed during 1989; and if we turn over
23 to 120, we have the beginning of data which my
24 understanding is, and you should be able, I think, to
25 confirm this possibly from your own recollection, was
0054
1 the data which was added at flag C to the final version
2 of the paper that went before the Advisory Group in
3 1992?
4 A. I think that is right, yes.
5 Q. We see there the total number of operations. What is
6 interesting, perhaps, is that there is, I think, an
7 exact correspondence in terms of numbers between the
8 numbers which were reported to the cardiac surgical
9 register and those reported to the supra-regional
10 Advisory Group, presumably because other units were
11 doing the work which they were reporting to the cardiac
12 surgical register?
13 A. That would certainly be part of the reason for the
14 difference, yes.
15 Q. And it is noted at the bottom, the supra-regional
16 figures exclude Brompton, and it gives us a "health
17 warning", if you excuse the expression in the current
18 context, as to the interpretation to be placed on those
19 figures.
20 If we go over to page 121, the numbers of
21 operations performed, one can see the different units
22 which then were doing the service. As reported to you,
23 whether this is right or whether it is wrong, it is
24 information that the Group had, on which it based its
25 discussions?
0055
1 A. Yes.
2 Q. One sees the units doing more of the work and those
3 doing less of the work, and certainly Bristol, second
4 from bottom of the page, and Freeman which is Newcastle,
5 is it not?
6 A. Yes, it is.
7 Q. One can see how few operations, comparatively speaking,
8 Bristol were actually performing.
9 If we turn over the page we can flick through the
10 sort of information that was before the group. Page 122
11 shows us the figures in respect of -- can we go back to
12 the top of the page, please -- this is Killingbeck,
13 dealing with the operations, and recording here the
14 mortality data which Killingbeck themselves were
15 reporting to the group. We can go through to 125:
16 Southampton. 128: Harefield, in the same way.
17 131: Great Ormond Street. 134: Bristol.
18 This information would have been provided, would
19 it, by Bristol itself?
20 A. I think so, yes. I am honestly not sure, but I think
21 that is right.
22 Q. If we go to page 136, the bottom of the page, there is
23 a summary. The first three figures I can tell you,
24 because I have the whole page open in front of me in
25 hard copy, deals with the over 1 year. The immediate
0056
1 left-hand column, 35, that is the number of closed heart
2 operations over 1 year, the number of deaths, 1. Open,
3 95, 16 deaths. Under 1 year, the fifth column in from
4 the left, the number of closed operations under 1 year,
5 45 and 4 deaths; and the number of open operations, 39,
6 with 5 deaths.
7 Similar information we will see at 137, please,
8 for Birmingham. 140: the Freeman hospital.
9 So that information, as we understand it, was
10 available to the Supra Regional Services Advisory Group,
11 in each case showing what had been done during that
12 particular year, and recording the hospital's own
13 records as to the mortality in those various procedures?
14 A. Yes.
15 Q. The purpose, I take it, of adding in those figures was
16 to better inform the discussion of the Advisory Group as
17 to the numbers, the throughput, and, for that matter,
18 the quality in terms of outcome of the services from the
19 various centres which might be de-designated?
20 A. It was certainly the intention to give the Advisory
21 Group all the information we could to enable them to
22 make their decision, yes.
23 Q. Can we go back to 76 on the one side, and 91 on the
24 other, please?
25 Can we have the top of page 92, on the left-hand
0057
1 side? The text, beginning "The present position",
2 appears obviously in one at paragraph 4 and in the other
3 at paragraph 5, because the later draft has the activity
4 data included.
5 "The present position [reading from the right-hand
6 side] is that there are 10 designated units. The
7 Advisory Group has also received bids from two units
8 wishing to be designated for these services, namely
9 Leicester and Oxford [so that would make 12]. In
10 addition, it is likely that the Welsh Affairs Committee
11 meeting on 18th December will agree to the rapid
12 development..." and we can see paragraph 5.
13 A. The way you read that did not accord with --
14 Q. I was reading from the right-hand side, paragraph 4.
15 I was going to point out, you are quite right, because
16 there is a change between the original draft.
17 "The Welsh Office has now agreed to the rapid
18 development of services at the University Hospital in
19 Wales."
20 So in both, the Welsh unit will significantly
21 impact on the referral to the -- I think it is the
22 Bristol unit, it should be, there is a typo in the
23 right-hand version -- and perhaps also to the Liverpool
24 unit.
25 "A situation now exists where three non-designated
0058
1 units will be" and these words have been added in the
2 second version, "more or less secure in their funding
3 arrangements and the total number of units providing
4 these services in England and Wales will now be 13."
5 Again, it says "England and Wales" there. That is
6 obviously right as a matter of arithmetic. Your earlier
7 answer, I think, in relation to the funding
8 arrangements: was that to imply that the funding through
9 the supra-regional services designation was just for
10 England?
11 A. Yes, that is right.
12 Q. Why was it more or less secure for the three
13 non-designated units -- that phrase "secure" or changed
14 to "more or less secure" would suggest that
15 a consideration of the impact of the National Health
16 Service reforms was such that funding was being obtained
17 for work done outside designation; that purchasers were
18 purchasing the services from providers, even though
19 there was funding available elsewhere for the service,
20 and that designation was not working in terms of
21 limiting the number of centres actually doing the
22 operations.
23 Have I read the implications correctly?
24 A. Forgive me a moment. (Pause). I think what is being
25 said there is that one of the 13 units is clearly the
0059
1 Welsh unit and that that funding was likely to be
2 secure, whatever the decision here. We were largely
3 irrelevant in that context. In respect to the other two
4 non-designated services which were providing those
5 services and clearly getting funded for it, or funds for
6 it in some measure from somewhere, I think it is raising
7 the prospect that that funding had been secured possibly
8 on the basis that those units would eventually enter the
9 supra-regional service arrangements. Whether that would
10 persist should a firm decision be taken on the
11 de-designation issue was questionable, or whether,
12 indeed, a positive decision was taken not to designate
13 those non-designated units, which was also clearly an
14 option, whether that funding string would then persist.
15 I think it is saying no more than that.
16 Q. I was going to ask you a little bit more about that,
17 because again there is a change that may be, I do not
18 know, significant as between the draft and the polished
19 version.
20 If you look at the bottom of page 76, on the
21 right-hand side, paragraph 4 simply finishes with "The
22 number of units providing these services in England and
23 Wales will now be 13"?
24 A. Yes.
25 Q. The left-hand side, the finished version, after the
0060
1 "13", this sentence is added:
2 "Whether the non-designated English units",
3 obviously drawing a distinction between the Welsh units
4 of Oxford and Leicester, "will continue to be funded if
5 designation is not forthcoming is unclear."
6 So somebody has put in the interim between the
7 first paper and the second paper as to what would
8 actually happen if designation was refused.
9 Were there any discussions that you know of which
10 took place with the units at Oxford and Leicester to
11 explore what was likely to happen if supra-regional
12 funding was not available?
13 A. Not to the best of my knowledge, and I have to say, I do
14 not actually think I have ever seen this draft paper,
15 although I clearly saw the finished paper.
16 Q. So you do not know what discussions may have taken
17 place?
18 A. I do not, no.
19 Q. It certainly looks as though someone has queried, in
20 their own mind and hence on paper, the reason why the
21 funding for the two units, Oxford and Leicester, was, in
22 quotes, "secure", in the first paper, becoming "more or
23 less secure", an element of uncertainty about it in the
24 second?
25 A. Yes, I think that is right.
0061
1 Q. You can tell me from other services, was it at all
2 a common situation that clinicians wanted to develop
3 a service, got support from their Health Authority, from
4 the purchaser, with a view to establishing the service,
5 saying, "Look how many cases we are doing, look what
6 need we are serving, look how well we are doing it, now
7 give us designation, even if it means somebody else may
8 lose designation elsewhere in the country"?
9 A. It happened. I certainly would not categorise it as
10 "common", but yes, there were clearly instances where
11 units wanted to be designated for the particular
12 services, for particular reasons. They were prepared,
13 if you like, to put it crudely, to make the up-front
14 investment to try and gain designation.
15 There was therefore always the logical question of
16 what would happen if that attempt failed. Our objective
17 clearly would be to strangle that funding string.
18 Q. A layman's description of the process might be "empire
19 building". I do not know how far that accords with
20 reality?
21 A. I think, yes, I would prefer to say, if they wanted to
22 gain designation for any reason. I think there are
23 a variety of reasons why a unit would want to be
24 designated as the supra-regional service.
25 Q. If we can go to single screen, because there is no other
0062
1 significant difference, and look at the final paper, we
2 can see that the point which arose from Guy's, the
3 expansion of interventional cardiology, is addressed in
4 paragraph 6. So it was considered.
5 We move down to "Options", paragraph 7, the first
6 option:
7 "To de-designate the smaller units."
8 That is at paragraph 8. There is some comment.
9 The staffing problems identified in Newcastle have been
10 resolved, their activity has increased such that
11 Newcastle no longer appears to be a non-viable small
12 unit. The position of Bristol is still uncertain. The
13 decision to expand the service in Cardiff to include
14 neonatal and infant cardiac surgical work will put this
15 unit at risk.
16 Harefield Hospital came out of the exercise very
17 respectably in terms of having comparable mortality
18 rates to those other units performing a similar case mix
19 of similar operations. The Harefield position was made
20 more complex by the fact that Harefield received
21 referrals from other supra-regionally designated
22 neonatal and infant cardiac surgical units.
23 So Harefield was unique because it had
24 a particular expertise for complicated operations of
25 a particular type?
0063
1 A. Yes, I think that is right.
2 Q. So presumably anyone looking at the crude results in
3 terms of mortality outcome for Harefield, would have to
4 read that in that light?
5 A. Yes.
6 Q. It talks about Guy's presenting the most difficult of
7 cases.
8 Paragraph (iii):
9 "It would be possible to decide not to designate
10 Leicester and Oxford, and indeed, to attempt to reduce
11 the numbers of existing units. To this end, discussions
12 are taking place between the units in London with the
13 objective of amalgamating at least two of the units
14 together, thus reducing the number of units within
15 London. Difficulties with this approach would follow
16 from the fact that Leicester, and, we understand,
17 Oxford, are obtaining funding for their activities, so
18 that they may not be financially disadvantaged and will,
19 therefore, continue to function without designation."
20 That really is going over the ground we have just
21 looked at.
22 A. Indeed.
23 Q. "The establishment of a unit in Cardiff would in effect
24 mean that there were 13 units in England and Wales
25 providing this service. Given that many applications
0064
1 for other services have been rejected in the past on the
2 grounds that there were too many units providing that
3 service, it is doubtful whether the Advisory Group could
4 ignore the fact that there are non-designated units
5 providing a neonatal and infant cardiac surgical
6 service."
7 Can you help me with what is meant by that last
8 sentence?
9 A. It is really the basic point that we discussed this
10 morning, that in designating a service, the Advisory
11 Group were mindful of a range of factors, one of which
12 was the patient base for that service and the consequent
13 number of units required to treat that patient base.
14 Having established that optimum number of units,
15 as it were, there was no requirement, and indeed, no
16 desire on the part of the Advisory Group to designate
17 other units over and above that optimum level and
18 therefore, over the years, and it happened frequently
19 during my time in the Group, we would receive bids for
20 designation of a unit for an already established
21 service, which were rejected on the grounds primarily
22 that we had enough units providing that service anyway,
23 and therefore on the basis of consistency if nothing
24 else, that argument equally applied here.
25 Q. So that was an argument purely addressed to the bids at
0065
1 Leicester and Oxford?
2 A. I am sorry, I have just read it again. What I said is
3 perfectly true when considering designation of
4 individual units. What this is actually talking about
5 is, given that many applications for other services --
6 I do I beg your pardon. The Advisory Group clearly
7 rejected bids for designation of the service on the
8 grounds that there were far too many units providing
9 that service to fit the supra-regional service
10 criteria. That is fact 1.
11 Fact 2 is under the neonatal and infant cardiac
12 surgery service, all the expert advice the Advisory
13 Group was getting was that we needed round about 7 or
14 8 units. We had 10, there were 13 in operation. There
15 were too many units. Therefore, on that basis, it was
16 difficult to see who how the Advisory Group could ignore
17 that and in fact continue with the designation of the
18 service at the current level.
19 Q. So it is in fact not addressing Leicester and Oxford, it
20 is addressing the whole service?
21 A. Yes, that is right. I am sorry, it was my
22 misunderstanding.
23 Q. Do not apologise. Paragraph 9, the bottom of the page:
24 "Having considered the options available, there
25 appears to be little prospect of any of the options
0066
1 being accepted by the field."
2 That is a reference to the clinicians, is it?
3 A. I think primarily the clinicians, but I would also read
4 into that the NHS itself, the NHS management structure,
5 the regional structure.
6 Q. "... except, perhaps, a reduction in numbers."
7 We go over the page, and we see the impact of
8 interventional cardiology is added at the top. And the
9 query there was whether that should or should not be
10 part of the service, I think?
11 A. Yes.
12 Q. Move down to 11:
13 "It is, therefore, increasingly difficult to
14 hold the line of supra-regional designation given ...
15 13 units ...
16 "(b) complex relationship with cardiologists
17 associated with these units, and indeed, in other units
18 performing interventional cardiology."
19 So clinical developments in the treatment of the
20 condition were obviously playing their part as well?
21 A. Yes, certainly.
22 Q. 12:
23 "Epidemiological evidence suggests that the number
24 of units required to provide this service is no more
25 than 7, and probably nearer 5."
0067
1 Do you know what the epidemiological evidence
2 was?
3 A. Not in detail. This would have been the views of the
4 medical colleges filtered in through the Medical
5 Secretary.
6 Q. The way in which it is expressed, if you turn over to
7 page 95, the top of the page, "strong case on
8 epidemiological, clinical and economic grounds". So
9 three reasons are given in favour of continuing
10 designation; one quite distinct from the clinical is the
11 epidemiological.
12 The epidemiological evidence was something which
13 the clinicians put forward, was it, so we are to
14 understand it in that light, are we?
15 A. I understand that that references information given to
16 the group by the medical colleges.
17 Q. And it then goes on, as we can see, just reading through
18 it for a moment, to envisage the prospect of possible
19 reduction in numbers?
20 A. Yes, it does.
21 Q. It envisages the establishment of the Working Party
22 about which you anticipated evidence would be given when
23 we spoke earlier this morning?
24 A. Yes, that is right.
25 Q. If we go to page 153, there is a table which may or may
0068
1 not have been circulated by Professor Hamilton, who was
2 one of the Working Party, as part of the Working Party's
3 report as to the activity in terms of open and closed
4 operations in neonatal and infant cardiac surgery
5 between 1989 and 1992.
6 I do not know if you can help as to whether that
7 league table in terms of numbers of operations was
8 something which the group saw or not? Can you help on
9 that?
10 A. I hope so. The way this is presented is that it is
11 almost a self-standing piece of paper, and I am not sure
12 that that, as such, was circulated to the Advisory
13 Group.
14 What was distributed to the Advisory Group, quite
15 clearly, was the actual report of the Working Group,
16 which included this table. I seem to remember it was
17 table 7, or something.
18 Q. We may have to come back to that table in that light.
19 If we go to the report itself, which is June 1992,
20 having moved forward from the beginning of 1992, the
21 paper we have just looked at and the decision made to go
22 ahead with asking the Working Party to report, and we
23 have the Working Party report at RCSE 2/165.
24 "The value of supra-regional designation of
25 funding". Halfway down the page, it says this, first of
0069
1 all:
2 "Supra-regional funding has brought benefits,
3 particularly in staffing levels, in some of the
4 designated units."
5 Pausing there: this, I think, is talking about
6 supra-regional designation in the context of neonatal
7 and infant cardiac services. It may be talking more
8 generally, but I think it is in the context of the
9 cardiac services.
10 Had it, so far as you know, brought benefits in
11 staffing levels, meaning the ability to employ more
12 staff in the particular units?
13 A. I cannot answer directly, but thinking back to some of
14 the papers you brought up on the screen earlier on, and
15 again, this is before my time, but I think there was
16 a problem in Newcastle, the unit we looked at, where
17 I think one of the papers referenced that additional
18 staff or new staff had been taken on.
19 Q. The second reason he gives, the second benefit:
20 "Centralisation of cases, particularly in the
21 rarer diagnostic groups, has occurred. During this time
22 surgical results have improved in the age range.
23 Generally, the greater the experience of the unit and
24 numbers of cases operated, the lower has been the
25 hospital and 30-day mortality in the young children."
0070
1 A. Yes.
2 Q. "Secondly, it was recommended that where staffing levels
3 were below those required to run a 24-hour service
4 remedial action should be taken by local health
5 authorities and new appointments should be made."
6 So presumably, the funding, given
7 supra-regionally, was sufficient to run a 24-hour
8 service, or should have been?
9 A. I think that is a huge leap of faith, with great
10 respect. Can I simply make the point here that the aim
11 in the funding mechanism, our objective, as it were, was
12 to fund 100 per cent of the service being offered by the
13 unit. It was for the unit to organise and structure
14 that service, and to put the funding consequences to the
15 Group. That is what we looked at. I frankly could not
16 answer the question in the way that you put it. I do
17 not know.
18 Q. Okay. We see that the Group proceeded by sending out
19 questionnaires as to the figures, and the mortality for
20 1988 to 1991 for all neonates and infants. They are
21 looking for information about departmental workloads and
22 staffing.
23 If we go through to 168, there is a summary:
24 "This review has reaffirmed our view that
25 supra-regional funding for neonatal and infant cardiac
0071
1 surgery continues to play a vital role in the high
2 standards of practice that is evident in this field in
3 this country. The attempt to establish similar systems
4 is apparent in other countries."
5 Just pausing there, that is something which I do
6 not think is otherwise addressed in the text. Was this
7 something which was generally appreciated by the Supra
8 Regional Services Advisory Group, or is this a bit of
9 polemic by those wanting to keep the service as it was?
10 A. There were certainly discussions in the Group about the
11 fact that the supra-regional service arrangements
12 established in England were widely envied throughout the
13 rest of the world. Dr Halliday, I am sure, tomorrow
14 will be able to point you to specific studies
15 conducted. But I do know, for example, that the French
16 were particularly envious of the arrangements and the
17 way we concentrated services in particular units, and
18 I think -- again this is trying to remember
19 conversations seven years ago -- but I think the French
20 had attempted something similar and had in fact failed.
21 There were several studies, one of which I personally
22 read, in America in the area, for example, of heart
23 transplantation, which indicated that the more you did,
24 basically, the better the results were going to be, and
25 recognising that this was the way the Health Service was
0072
1 structured in America, actual provision of that service
2 was extremely diverse and widespread, and that clearly
3 had an effect upon the outcomes for the patient. And
4 they looked at the British model, I would say,
5 enviously; but perhaps "I would say that". That is all
6 it is trying to say. We had a good system here for the
7 objectives it was designed to achieve. It had been
8 looked at by other countries who had attempted something
9 similar in particular areas, but without the success
10 that we had.
11 Q. It goes on:
12 "We endorse that the system should be continued
13 for 9 centres and that a three-yearly review should be
14 carried out so that adjustments can be made as to which
15 centres are 'recognised' according to workload and
16 results obtained at the time of each review and that
17 funding be allocated based on the findings of the
18 three-yearly review."
19 So the suggestion is, or appears to be, that the
20 9 centres which do the most work and get the best
21 results should continue?
22 A. Yes.
23 Q. It would follow that any other centre should not be
24 recognised for Central Funding?
25 A. Yes.
0073
1 Q. The next page, page 169, gives us, as table 1, the
2 information that was before the Group, as to the numbers
3 and the success -- I am sorry, the percentages; we will
4 come to the success in a moment -- of the various
5 units.
6 The percentages, I hasten to add, are the
7 percentages of the total workload and refer to nothing
8 else; they must not be misunderstood. We can see,
9 running across from 1988 through to 1991, the -- I am
10 sorry, I may be wrong on that. Let me just find it in
11 the text. I am sorry, table 1, we are told, is simply
12 a summary of the details.
13 So going back to table 1, one can look across the
14 neonatal and infants done in Bristol, and one can see
15 the numbers.
16 Table 2, which is page 170, again, the totals and
17 the sequence, as it were the league table, showing which
18 unit was doing most operations. For the total open and
19 closed cases in 1989, under 1 year of age, Bristol, we
20 see, was seventh; for children over 1 year, Bristol
21 fourth; at 171, corresponding for the next year, 1990,
22 Bristol eighth in terms of the total open and closed
23 cases in 1990, and for the older children, sixth. 1991,
24 at 172, Bristol ninth for the under 1s, seventh for the
25 over 1s. So thus far, one would see a trend that
0074
1 Bristol is dropping down the league table in terms of
2 numbers of cases performed?
3 A. We do indeed, yes.
4 Q. The overall sequence is given at 173, table 5. In
5 sequence order, 1989, 1990, 1991. One can see the
6 comparison, Bristol dropping down in total from seventh
7 to ninth, out of the 12 there reviewed.
8 Page 174: that is the older children, from fourth
9 to seventh. Page 175: there is a summary of the final
10 league positions in each of the four areas.
11 Again, this is purely, I think, in terms of total
12 numbers performed. We see Bristol eighth, equal for
13 neonates and infants; for older children, Bristol
14 fifth. Neonates and infants and older children
15 together, Bristol -- I am not sure that one can
16 understand what is meant there. I think it is just the
17 total of the placings. And finally Bristol sixth equal
18 for all.
19 Can I return to table 1? It is page 169.
20 I think, contrary to what I said earlier, my first
21 instincts were right that the percentages are indeed
22 percentages of mortality. You are nodding?
23 A. That is right.
24 Q. I am sorry for being completely misleading on that. If
25 we look at that, there is no legal table in terms of
0075
1 mortality?
2 A. No, I think that is right.
3 Q. The information one would glean from this is that in
4 1988, in 1989 and in 1991, if one looked at the neonates
5 and infants, that Bristol was, if not the worst, because
6 the worst was Harefield, in 1988, it was overall a poor
7 performer in terms of mortality?
8 A. In terms of those bald figures, with all the
9 reservations which we discussed earlier, yes, that is
10 obviously right.
11 Q. But I suppose it might be said that if one looks at
12 1990, and the percentages which are there set out, for
13 neonates and infants, 13 per cent, and older children,
14 17 per cent mortality, in that year for neonates and
15 infants the Bristol performance is well within the range
16 of any of the centres and better than many. That may
17 emphasise the point you are making about the crude
18 nature of the figures?
19 A. Yes, I think that is right.
20 Q. What this table might suggest to some is that there will
21 be a need to explore further the reason for the figures,
22 so that one understood what they actually showed. Would
23 you care to comment on that?
24 A. My comment on that frankly would be that this is
25 a report produced by the Working Group of the Royal
0076
1 College of Surgeons in response to a specific remit from
2 the Advisory Group. They had themselves -- it clearly
3 is not for me to try and get into their minds and
4 understand their thought processes, but it appeared to
5 me, reading the report and looking at the conclusions,
6 that they had accepted that the most realistic or
7 defensible base upon which to do the job they had been
8 tasked by the Advisory Group was to analyse the activity
9 of the units. I think part of the logic of that must
10 be, as we have seen earlier on, that the higher the
11 throughput in general terms, the better the other
12 results, plus the fact that they, infinitely more than
13 I, would understand that simply looking at the bald
14 mortality figures and trying to draw meaningful
15 conclusions is, perhaps, a tricky occupation.
16 Q. The reason I ask is that you were actually there when
17 the discussions took place?
18 A. I was indeed, yes.
19 Q. So you will have heard the reaction of those who had not
20 been on the Working Party to the evidence which the
21 Working Party produced?
22 A. Yes.
23 Q. And I do not know, was there any reaction along the
24 lines of, "Well, this demonstrates how small numbers
25 suggest bad results"?
0077
1 A. It may have been mentioned. If it was, it was almost in
2 as broad terms as you have just put that. I think that
3 the point is that the Advisory Group -- it is almost an
4 inherent belief of the supra-regional service
5 arrangements that smaller units concentrating on the
6 work get better results. What the Advisory Group had to
7 face at that particular meeting, and it had prevaricated
8 or it had taken a period of time to get to this
9 position, but I think there was an absolute realisation
10 that they now had to take a final decision on the
11 designation or de-designation of the service. They had
12 before it a report from the Royal College which made
13 a series of recommendations and therefore, to the best
14 of my recollection, at that meeting the majority of the
15 discussion centered on the precise recommendations that
16 the RCS Working Group had come up with, and a discussion
17 about how realistic acceptance of those recommendations
18 were going to be in terms of constraining the service.
19 I do not remember a specific part of the meeting
20 where, for example, members went through systematically
21 that mortality data.
22 Q. So, so far as the comment that you do recall is
23 concerned, something to the effect of, "Well, small
24 units have poor results", and that being confirmatory of
25 the rationale behind supra-regional services, do you
0078
1 recollect whether anyone took it further and said "We
2 did not understand how bad they might be"?
3 A. No, I do not.
4 Q. And you do not recollect, or do you, anyone saying,
5 "Well, there could be all sorts of reasons for this,
6 but we really ought to find out a bit more about it,
7 because if this service is to remain a service to the
8 public, something needs to be done about understanding
9 why the figures are, apparently, on a crude basis, so
10 poor"?
11 A. Genuinely, no, I do not. The discussion so far as
12 I recall it centered on the specific recommendations
13 that the Working Group had come up with.
14 Q. When the Advisory Group looked at the possibility of
15 de-designating one or more centres -- that was the whole
16 purpose of the report?
17 A. Yes.
18 Q. -- they were focusing on Guy's, Newcastle, Bristol,
19 because those were the three most at risk, as we have
20 seen from previous papers. They were possible services
21 to be de-designated, were they not?
22 A. Yes, indeed, they were certainly possible. I simply
23 hesitate to say what the RCS Working Group were
24 concentrating on. They had been given the remit --
25 Q. I am sorry, you misunderstood. The Supra Regional
0079
1 Services Advisory Group were concentrating upon the
2 options available?
3 A. Yes.
4 Q. One option was de-designating one or two or three
5 centres?
6 A. Yes.
7 Q. Advice was taken. The advice came back, "You ought to
8 keep on designating 9 centres", but that advice did not
9 have to be accepted?
10 A. No.
11 Q. We know from history that it was not accepted?
12 A. Indeed.
13 Q. So if the Group had wished to pursue the second option,
14 de-designating some centres, the question would have
15 been, which one gets the chop?
16 A. Yes.
17 Q. That is, to an extent, a comparative analysis of the
18 position of Guy's, Newcastle and Bristol?
19 A. They were the obvious candidates, yes.
20 Q. So that would involve a comparative analysis of their
21 position?
22 A. Yes.
23 Q. As part of that comparative analysis, the Group would
24 wish to look at the numbers that they were performing
25 and were likely to perform?
0080
1 A. Yes.
2 Q. And we have seen that in so far as Bristol was
3 concerned, as far as numbers went, the impact of Wales
4 was only going to have a downward effect?
5 A. Yes.
6 Q. Do you recollect any comparative discussion in terms of
7 the results, the performance in terms of outcomes, as
8 opposed to in terms of throughput, of the three centres
9 at risk?
10 A. No, I do not. During my entire time on servicing the
11 Advisory Group, I do not recall any concerns or worries
12 or anything else being expressed that the smaller units
13 were, in some way, not performing adequately or
14 properly.
15 Q. The outsider might be forgiven, presented with this
16 material, for thinking that the question was obvious, as
17 to why the rates or the performance of the smaller units
18 was bad and as bad as it appeared to be.
19 I appreciate it begs the question whether the
20 statistics were right, but it was the information
21 available.
22 Can you help us as to any reason why that issue
23 was not actually explored by the Supra Regional Services
24 Advisory Group?
25 A. Frankly, I am not sure I can help you.
0081
1 Q. If we go on to page 2/193, this is a letter you may
2 not have seen -- I suspect you have not seen -- from
3 Sir Terence English to Professor Norman Browse. It is
4 not dated on the face of it, but I think it must have
5 been, obviously, July 1992, because it is in reply to
6 a letter dated 21st July of that year.
7 The second paragraph:
8 "Although I was aware that Bristol was not one of
9 the best paediatric cardiac surgical centres, I had not
10 appreciated the situation was as serious as
11 described ..."
12 I need not trouble you with who described that
13 particularly.
14 The third paragraph:
15 "I have discussed the matter with Professor David
16 Hamilton from Edinburgh, who was Chairman of the recent
17 RCS report to the Supra Regional Services Advisory Group
18 on the future policy with regard to the designation of
19 neonatal and infant cardiac surgery. In this report,
20 which is to be considered by the Supra Regional Services
21 Advisory Group on 28th July, Bristol was included as one
22 of the centres for designation. However, it is clear
23 from the review of table 1 in the report that their
24 mortality statistics, both for the infant age group and
25 the older age group, is worse than any other centre.
0082
1 David Hamilton agrees that sufficient attention was not
2 paid to this by his Working Party.
3 "We agreed, therefore, that to allow Bristol to go
4 forward with support from the College might jeopardise
5 designation of the whole service and, with David's
6 agreement, I have spoken to Norman Halliday who will
7 inform the Supra Regional Services Group on Tuesday 28th
8 that the College does not support the inclusion of
9 Bristol. I am sure this is the right action."
10 That letter, written from a past President to the
11 then President of the Royal College of Surgeons, was
12 written by a member of the Advisory Group at the time,
13 Sir Terence English.
14 It plainly raises the issue as to what those
15 statistics showed, and suggests that the Working Party
16 should not have accepted at face value by the Advisory
17 Group their report saying that essentially Bristol
18 should remain as one of the designated centres.
19 What I ask you is this: did any part of those
20 views, this discussion, find its way through into the
21 discussion of the Advisory Group which then took place
22 in July of that year?
23 A. I recall -- can I say, I have never seen this letter
24 before.
25 Q. I did not think you would have done, but it is the views
0083
1 which they indicate which I am asking you about.
2 A. At the meeting in July, 28th July apparently, where the
3 Advisory Group considered the report of the RCS which
4 had been submitted with the endorsement of Sir Terence
5 at that time, I do recall that Dr Halliday reported to
6 the Group that I think Sir Terence had telephoned him,
7 I do not know when, but I imagine shortly before the
8 meeting, to say that he had doubts, or he did not
9 necessarily agree with the recommendation of the report
10 which he had previously endorsed in regard to the
11 Bristol unit.
12 In all honesty and frankness, I had virtually
13 forgotten about that telephone call until I reviewed the
14 minutes of that meeting for this Inquiry. My memory of
15 precisely the way it was presented is fuzzy, but I am
16 clear, to the best of my memory, that Sir Terence's
17 views as reported to the meeting were not in these
18 terms.
19 Q. There may be an explanation for that. If we move on to
20 2/197, and again, this is a letter you will not have
21 seen, so it is really what happened at the time that
22 I can ask you about, it is dated 3rd August 1992, so it
23 is after the July meeting but before the September
24 meeting of the Advisory Group.
25 The second paragraph:
0084
1 "Following our telephone conversations of Thursday
2 evening, July 23rd, and Friday afternoon the 24th, I was
3 not entirely happy about our agreement to take
4 Presidential and Chairman's action over the Working
5 Party's report."
6 That, I think, must be a reference to changing the
7 recommendation so that Bristol was excluded.
8 "On reflection, I realised that a possible
9 specific source of breach in confidentiality could arise
10 and a further feeling that the de-designation of one of
11 the units would probably leak out in the course of
12 time. Also the members of the Working Party were
13 unanimous in their findings and gave considerable
14 thought to their recommendations ..."
15 Perhaps the material part is the last five lines
16 of that paragraph:
17 "The report is an advisory document to be
18 considered along with other letters and reports, both in
19 [something] and hearsay evidence no doubt, and as such,
20 the Working Party could be requested by the Advisory
21 Committee on supra-regional funding to reconsider the
22 mortality figures of specific units or unit and possibly
23 to amend its findings.
24 "This appealed to me as a far safer course of
25 action. Keith rang Halliday and put this suggestion to
0085
1 him. Halliday then phoned me on Monday morning and
2 appeared much relieved, as he was unhappy that rapport
3 and trust between the DOH and College could have been
4 compromised by the previous suggestion."
5 We could take up that letter with those who
6 corresponded, but there is here telephone conversations
7 going to and fro about whether or not to recommend
8 de-designation of Bristol, whether to invite the
9 Advisory Group to ask the Working Party to reconsider
10 its recommendations.
11 How far did the matters which are central to that
12 letter find their reflection in the discussions that you
13 recall as having taken place in the Advisory Group,
14 between its members at that time?
15 A. The discussion at the Advisory Group that I recall was
16 specifically on the recommendations of the Working Group
17 report: "de-designate some, designate Leicester, end up
18 with 9 units; we believe the service should continue to
19 be designated". The recommendation reached, as we have
20 seen, on the basis of activity data. The mortality data
21 was available to the College. Clearly they presented
22 it. They did not base a recommendation on that.
23 So the first part of the discussion that I recall
24 was on the basis of that report.
25 The Group then looked somewhat briefly, perhaps,
0086
1 at the paper by Professor Tynan. The majority of the
2 discussion was on: if we accept the RCS Working Group's
3 recommendations, does that solve the problem? Does that
4 prevent the proliferation which caused us to get to this
5 position?
6 To the best of my recollection, that was the
7 structure of the discussion.
8 Q. Can we go to page 2/203? At 4, this is supra-regional
9 services (92)9, it deals with the Working Group report
10 which recommended "The service should continue to be
11 designated, the number of units reduced from 10 to 9,
12 and all the existing designated units except Harefield
13 and Guy's should remain designated centres and that the
14 unit at Leicester should be designated."
15 A. Yes.
16 Q. 4.1.2: Dr Halliday reported that he had been approached
17 by Sir Terence who indicated he had reservations about
18 the designation of the Bristol unit.
19 From what you are saying, you do not recollect any
20 wider discussion of the nature of the reservations?
21 A. No. As I say, I think the way my mind was going, and
22 the way my memory throws it up, was that the Group had
23 been asked to reduce to 7 specifically in its terms of
24 reference. It had come up with a recommendation which
25 basically left us with 9. It was unlikely, frankly,
0087
1 that 9 was going to be enough of a retrenchment. The
2 RCS, like everyone, I think, was very committed to try
3 and keep this service a designated service, if possible
4 and therefore the next unit for the "chop", to use your
5 words, I think, would be Bristol, on the basis of the
6 RCS report analysis presented to the Group.
7 Q. 4.1.3 deals with the discussions; the expression
8 "unrealistic" was one you recalled a moment ago. It
9 says this:
10 "To ignore the delivery of the service in
11 non-designated units would be quite contrary to the
12 previously stated views and policy of the Advisory
13 Group."
14 That is saying, is it, really, "If circumstances
15 arise when too many places are doing the work, we cannot
16 justify special funding"?
17 A. Yes. "We cannot ignore the fact that there are
18 non-designated units", yes.
19 Q. That really is a financial view?
20 A. I do not think so. It is the fact that the designation
21 criteria called for services to be constrained to
22 a small number of units, which typically would be round
23 about 8 or 9, I think.
24 Q. It is the next paragraph I would like to focus on,
25 because I would like your help with exploring what the
0088
1 members of the Advisory Group meant and how the
2 discussion went:
3 "The Group concluded the service as a whole should
4 be de-designated."
5 The justification for it is:
6 "This will be a fairer decision in terms of
7 medical and surgical rights of patients than to restrict
8 designation to a few surgical units."
9 May I try and unpick that? What the papers thus
10 far have indicated is that there was continuing and, to
11 use your word, "consistent" agreement clinically that
12 limiting neonatal and infant cardiac surgery to a few
13 units was to the benefit of patients generally.
14 A. Yes.
15 Q. So that, if designation either achieved or helped to
16 achieve, or influenced, a restriction to fewer units, it
17 would in general terms assist the welfare of patients?
18 A. Yes.
19 Q. How, then, did it appear to the Advisory Group that
20 removing the influence for there to be fewer units and
21 accepting the position, "Well, there are so many, let
22 there be more", as it were, as it may seem, was going to
23 be fairer in terms of the medical and surgical rights of
24 patients?
25 A. I find it difficult to answer that question after this
0089
1 period of time, frankly, but I think it is simply
2 a recognition that the nature of the service had
3 changed, proliferation was widespread, and it was simply
4 accepting reality. I think the de-designation decision
5 itself was an acceptance of reality.
6 Q. I follow. I understand. What I am looking at is the
7 wording, really, in the document, because what you are
8 saying, as your understanding of what motivated the
9 Group, was that it really was having to bow to the
10 inevitable rather than something which was actually
11 going to benefit patients in terms of their medical and
12 surgical rights, as your answers would suggest it would
13 not.
14 I just wonder, really, why it was that it was
15 explained in terms of advancing medical and surgical
16 rights, rather than, "Well, it does not but there is
17 nothing else we can do"?
18 A. I am terribly sorry. There was a reason at the time.
19 I just cannot remember now.
20 Q. This is a hypothetical question, but I would very much
21 like your input on it: suppose the Group had decided
22 then, or for that matter earlier, that Bristol should be
23 de-designated. What, in practical terms, would be
24 likely to have been the consequence of that?
25 A. In respect of what, I am sorry?
0090
1 Q. In respect of the delivery of any neonatal and infant
2 cardiac service in Bristol? I appreciate you cannot
3 necessarily be right, but you were in a position to have
4 an overall perspective, and doubtless there were one or
5 two other cases where services, or units, were
6 de-designated?
7 A. Yes.
8 Q. In the case of units which were de-designated, what
9 generally speaking happened to the service which they
10 provided?
11 A. From the perspective of the Advisory Group and the SRS
12 arrangements, what would inevitably follow the
13 de-designation of the unit was that the funding stream
14 would be stopped. Therefore, those services would not
15 be funded centrally through the SRS arrangements.
16 However, the patients that that unit had been
17 treating or could be expected to treat in the future,
18 had it continued to be a designated service, would be an
19 issue the Advisory Group would carefully consider in
20 terms of, where else do they go? Are there the existing
21 designated units after Unit A was de-designated? Could
22 they absorb that workload? Did they have the capacity
23 to absorb that workload? If not, was additional
24 funding, development funding, necessary to ensure that
25 they could? Failing that, was there another unit,
0091
1 perhaps a unit which up until this point had not been
2 designated, which could be set up to absorb that
3 workload?
4 They would be the sort of thought processes from
5 the Advisory Group's perspective.
6 From the perspective of the units themselves,
7 I really cannot comment, I think, on what would happen
8 to the delivery of the service from their perspective.
9 Clearly, everything that the Advisory Group would do
10 would be designed to ensure that that service was no
11 longer delivered from that unit, but for reasons that we
12 have already discussed, there were limits to how far
13 that could be ensured. That would ultimately be a local
14 matter.
15 Q. From what you are saying, the expectation of the Supra
16 Regional Services Advisory Group would be that if they
17 de-designated the service, the patients would go
18 elsewhere?
19 A. Yes, certainly, yes.
20 Q. So the expectation, and an expectation no doubt borne of
21 experience of other units and other services, would be
22 that the likely consequence of de-designation -- by no
23 means certain -- would be that that particular unit
24 would cease to provide that particular service?
25 A. Indeed, yes.
0092
1 Q. And it would follow that so far as one can say, and it
2 is a very hypothetical question, I fully accept, if the
3 Supra Regional Services Advisory Group had, at any
4 stage, taken a decision on whatever basis, to
5 de-designate Bristol, the best one can say is that it is
6 likely that the patients would have gone elsewhere for
7 the same service?
8 A. Hypothetically, yes.
9 Q. And the "elsewhere" may either have been an existing
10 unit, Birmingham, Southampton, whatever, or a new unit,
11 Cardiff or wherever?
12 A. Yes. I think they would have been a bit reluctant to
13 set up a new unit. But hypothetically, yes.
14 Q. If we already had too many, it would seem completely
15 undesirable to do so?
16 A. Quite.
17 Q. And one would lose the benefit of throughput of numbers?
18 A. Yes.
19 Q. I am not going to ask you anything more about the
20 process of continued designation or de-designation. We
21 have been through the history, and it has given rise to
22 quite a number of questions and explorations, we have
23 gone along one or two of the size issues which arose.
24 One aspect I would just like to explore a little
25 bit further is that plainly the development of Oxford
0093
1 and Leicester, for that matter Cardiff, was the
2 expression in practical terms of the principle of
3 clinical freedom. Here were surgeons, clinicians,
4 carrying out the service as a matter of fact?
5 A. Yes.
6 Q. And we were discussing a while ago possible mechanisms
7 for controlling the proliferation of units providing
8 service in that way. You were, I think, saying --
9 Mr Angilley yesterday said that there was peer pressure
10 one could exercise, pressure through the Royal College
11 of Surgeons, there was the denial of the advantage of
12 supra-regional funding, but beyond that, there was
13 nothing which was in fact done?
14 A. Yes.
15 Q. We have explored earlier the question of what might have
16 been or might not have been added to the contract and
17 the reasons you conceded frankly why it was not at the
18 time, because people's minds were on other things.
19 Can I come back to the question of accreditation
20 as a possibility?
21 You may be able to tell us whether, within the
22 debates and discussions on the Group, that was ever
23 taken up further as a means of controlling the
24 proliferation, not necessarily in relation to cardiac
25 services, but any service?
0094
1 A. The only instance that I can bring to mind was in the
2 specific context of what to do about a particular
3 service which the Advisory Group were being invited to
4 consider, the question whether or not it should remain
5 designated or not.
6 It was an unpopular and unpalatable question that
7 amongst the options, almost as a side issue, to be
8 truthful, was "Look, if we de-designate this, or indeed
9 any service, we are losing this ability to control
10 provision and the benefits that we believe accrue to
11 that. Is there, therefore, any other mechanism that we
12 can maintain that sort of central control over the
13 provision of the service, without getting involved in
14 funding issues and associated matters like that?"
15 I think accreditation reared its head again as one
16 possible option, but I do not believe that it was ever
17 seriously -- well, I mean, it was seriously considered,
18 but I do not think it was a "runner" in the eyes of the
19 Advisory Group.
20 Q. Some of the other issues may well be policy issues,
21 which I suspect are outside of the remit of the Supra
22 Regional Services Group?
23 A. Indeed.
24 Q. So any attempt to influence the delivery of a service by
25 considering questions of training status of a hospital
0095
1 would be outside the remit of your Group?
2 A. Yes, it would.
3 Q. And that would be a policy issue one would have to
4 discuss with either the Royal Colleges, or with policy
5 makers?
6 A. Yes.
7 Q. I told you when we started that one of the areas
8 I wanted to ask you some questions about was that of the
9 monitoring of the service and the quality of the
10 service.
11 One of the matters you mentioned in your statement
12 is that there were, on a quarterly basis, review
13 statements or review returns put in by those performing
14 supra-regional services to the Supra Regional Services
15 Advisory Group?
16 A. No, to the Secretariat.
17 Q. Can we have a look at one of those review statements?
18 It is at UBHT 64/270.
19 If we just scroll down and look at the items which
20 it covers, can we go back to paragraph 3, please? This
21 is all to do with numbers?
22 A. Yes, activity numbers.
23 Q. So the quarterly review statement, at any rate so far as
24 cardiac surgery was concerned, had nothing to do with
25 the quality of outcomes, however one might determine it?
0096
1 A. No.
2 Q. Can I pick up a little point. You say in an effort to
3 be helpful that a "finished consultant episode" was
4 basically every time a consultant sees a patient,
5 I think if you were going to give a more considered
6 definition of FCEs, you would not use that expression.
7 Does that cover every time somebody came on a ward
8 round, and you would mean every time somebody was
9 admitted as being under the care of a consultant until
10 that particular admission changed, so it would be either
11 admission to hospital or into the ward under
12 Mr So-and-so, until that particular period of time in
13 hospital under operative treatment or otherwise would
14 finish?
15 A. Yes, that is right. I think there is a degree of both
16 imprecision about the terms, not only the way that I use
17 it, but in the way interpreted in the field generally.
18 It was not a measure which frankly I placed a great deal
19 of reliance on.
20 Q. But it was the measure which was used by the hospital
21 statistics?
22 A. Yes, it was.
23 Q. So the national data were collected, as I understand it,
24 upon the basis of FCEs, at least from 1988 onwards?
25 A. Yes.
0097
1 Q. Again, you may be able to help with this: am I right in
2 thinking that the data, the "hospital episode statistic"
3 data, the HES data, was essentially numerative and not
4 qualitative?
5 A. I believe that is right, yes.
6 Q. Was there any formalised system throughout the time you
7 were Secretary of the Advisory Group for considering
8 data as to outcomes?
9 A. We have already touched on this, this morning, I think.
10 Trying to measure quality was at the time and is indeed
11 still now, extremely difficult. It is extraordinarily
12 easy, all things being considered, and all things being
13 equal, to count the number of open heart operations. It
14 is desperately difficult to interpret the results of
15 that. I think there was an absence of precise
16 meaningful data around.
17 This is not my area of expertise by any means so
18 I am reluctant to get too far down this road, but in the
19 absence of data that you could, in sense, pick up and
20 put down in the way that this is, it meant that the
21 Medical Secretary of the group had to monitor the
22 overall performance in a variety of different ways. So,
23 for example, he would work, as I think Mr Angilley was
24 describing yesterday, through the medical colleges and
25 professional organisations and subcommittees of working
0098
1 groups. He would also clearly liaise with professional
2 colleagues within the Department of Health. All
3 designed to find out what was going on in particular
4 services, particular units, and so on.
5 He would also, for example, discuss with the units
6 themselves their own internal monitoring arrangements,
7 to discuss whether or not they were robustly looking at
8 the right things or whatever. I know he was very keen
9 to encourage units to set up inter-unit peer reviews,
10 which was particularly pertinent in the context of
11 supra-regional services, because by definition you are
12 dealing with very small numbers of patients, as indeed
13 units, so he did all that. He worked, I know, with, for
14 example, the Audit Department at the Royal College of
15 Surgeons to set up audits of, I think it was the
16 transplantation services; I could be wrong, but I seem
17 to think that is right.
18 As I said this morning, the whole structure of the
19 Advisory Group itself in a sense was a mechanism for
20 monitoring what was going on. You had people like the
21 President of the RCS with the access to the data that he
22 had obtained through the clinical networks which I know
23 very little about, his contacts and all the rest of it,
24 and clearly he was there to input that, plus or minus,
25 good or bad, within the deliberations of the Advisory
0099
1 Group when appropriate.
2 So all of that was going on continuously. It was
3 not the situation, however, and I to want to try and be
4 clear on this, it was not the situation, at any time,
5 I think, during my tenure there, that the Medical
6 Secretary, or indeed anybody else, would present the
7 Advisory Group with a paper specifically on the clinical
8 quality issues of the unit on a regular formalised
9 basis.
10 That is a terribly long answer and I apologise for
11 that, but I felt it important to try and get that
12 flavour across to you.
13 Q. I would be grateful to go outside the answer which
14 I have given and just explore one or two matters of
15 principle.
16 When it comes to accountancy, the costs of the
17 service, there are certain targets which are set and one
18 can monitor the outcome financially by seeing whether
19 that target has been met, exceeded or whether the
20 service has fallen below it.
21 It is a useful tool which is used regularly in
22 terms of financial management of a service, is it not?
23 A. Broadly speaking, yes.
24 Q. Essentially what one has to have is standards set in
25 advance against which one can monitor performance?
0100
1 A. Yes, in the context of the SRS contracts, the outcomes
2 were the activity.
3 Q. And one does not need to be an expert in the field of
4 accountancy, or costs or whatever, to recognise whether
5 or not a particular service has met the target, because
6 that is a product of, if you like, hard data?
7 A. Yes, indeed.
8 Q. Once the target has been set, you can know whether the
9 performance has exceeded or fallen below it?
10 A. Yes.
11 Q. If one were looking at clinical performance, then if one
12 were able to -- this is a hypothesis -- set targets,
13 then it would again simply be an administrative matter
14 to see whether or not, from the available data, that
15 target had been met, fallen below, or exceeded?
16 A. Conceptually, that must be right.
17 Q. So the difficulty in it, or the input one needs from the
18 expert, is not in the analysis of the data, it is the
19 setting of the target?
20 A. Yes.
21 Q. Does it follow that if someone had thought of -- one
22 appreciates here that we are now looking at this in
23 1999, and we are dealing with matters which, so far as
24 the Inquiry is concerned, begin in 1984 when it may be
25 said, and it may be said in justification, that the
0101
1 circumstances were very different: what it would need,
2 as I have indicated, would be someone to set standards
3 and if that had been done, then could, within the
4 supra-regional services system, that have led to
5 a monitoring of performance against those standards in
6 the way that I have suggested?
7 A. On the various assumptions and premises that you built
8 into that statement, yes.
9 Q. Can we look at your statement, WIT 57/6, paragraph 15?
10 I think we may very well have covered this, but in case
11 we have not, let me ask you about it. It is the second
12 sentence:
13 "Ad hoc items might include, for example,
14 suggestions to de-designate a service, funding issues,
15 proliferation of service provision in non-designated
16 units or to consider where a service was falling short
17 of expectations clinically or financially."
18 So far as the "clinically" was concerned, did it
19 happen that some services or units -- look at units
20 first -- some units were de-designated on the basis of
21 their poor clinical performance?
22 A. I can remember, or recall, one unit only, which was, as
23 I understand, many years before I actually came on the
24 scene, so I do not particularly want to be drawn into
25 that, but I do understand that there was a unit which
0102
1 was removed from the arrangements on the grounds of
2 clinical failings, and I am sure Dr Halliday was around
3 and can tell you that.
4 During my time, there was an issue which crossed,
5 if you like, a number of clinical services, one of which
6 was a supra-regional service element, in one of our
7 units, if I can put it that way, going to your "club"
8 metaphor, where a problem had been identified, as
9 I remember, locally, and consequently been reported to
10 the Advisory Group, that caused the Advisory Group to
11 undertake a range of actions and de-designation was very
12 much an option for that unit. In the event, it was not
13 an option that was adopted.
14 Q. If one goes to paragraph 22 of your statement, you talk
15 there about the Medical Secretary monitoring the quality
16 of service and matters concerning the provision of
17 medical staff/facilities ...."
18 It is obviously a matter for him to speak to
19 directly, but your understanding of the monitoring was
20 along the lines that you explored a moment or two ago in
21 what you described as the "long and comprehensive
22 answer"?
23 A. Indeed, yes.
24 Q. I need not, therefore, take the question of quality, the
25 monitoring of quality, any further.
0103
1 Two further matters that I want to deal with very
2 briefly with you, and then I shall be finished at any
3 rate, in reasonable time for lunch.
4 The first is a separate issue, really, a discrete
5 issue. Can we have a look at DOH 2/141, please?
6 This is part of a funding bid. It starts at page
7 136. Let us have a look at that, so you can place it.
8 "Supra-regional services: bids for capital funding
9 in 1993-94".
10 We know that the service was going to be
11 de-designated from 1st April 1994 nationally, but that
12 left 1993 to 1994.
13 If we go to page 2/141, item 19, a bid was put in
14 from the Bristol Royal Hospital for Sick Children,
15 looking to locate all paediatric cardiac surgery on one
16 site, that is theatre and ITU, and the capital cost is
17 set out.
18 The "none given" is a reference to what? The
19 revenue consequences?
20 A. Capital charge and revenue consequences, I would
21 imagine.
22 Q. "Defer: bid incomplete", that is a recommendation made
23 by the Secretariat, is it?
24 A. Yes. Just to try and put in it context very briefly,
25 I would look at revenue bids from the regions, but
0104
1 because of the way capital bids were then structured and
2 organised in the NHS generally, because you actually
3 need slightly different expertises, a member of the
4 Advisory Group who was, as I recall, a regional
5 financial officer in one of the regions at that time,
6 always assessed the capital bids and advised the Group
7 accordingly. So this is his paper, not mine, but it is
8 still a recommendation to the Group, yes.
9 Q. Can we look at page 2/148? We will see further details
10 of what was proposed.
11 "The unit plans to provide a 'unified paediatric
12 cardiology/cardiac surgical service' on one site. At
13 present, open heart surgery is provided at the BRI (an
14 adult institution) and the cardiological service and
15 closed heart surgery at the Bristol Royal Children's
16 Hospital. The plan is to construct a third operating
17 theatre and extend the ICU. The total preliminary cost
18 is 550,000, made up of 430,000 for the theatre, 120,000
19 for the ICU. The Supra Regional Services Advisory Group
20 is requested to fund 300,000 in respect of the infant
21 and neonatal work. The remainder will be met by the
22 United Bristol Healthcare Trust. The proposal submitted
23 was only a draft outline requiring further discussion
24 and planning. Until a firm proposal and justified
25 business case is received, members are invited to defer
0105
1 this request."
2 Once a service was funded supra-regionally, would
3 it in any respect have operated as a dead hand on
4 capital developments such as this?
5 A. I am sorry, I do not understand the term "dead hand".
6 Q. Would it prevent or have hindered a development which
7 the local Trust wanted to perform?
8 A. Absolutely not. If anything, the opposite.
9 Q. So does it come to this: that if this need had been
10 identified earlier and put forward in greater detail,
11 that it would have received active consideration instead
12 of being deferred?
13 A. I do not want to be trite, but the Advisory Group gave
14 all bids active consideration. Clearly the fact that
15 this bid, from the words, was a marker bid really
16 precluded the Advisory Group from reaching any firm
17 decisions one way or another. Given the decision to
18 de-designate, that kind of prejudiced any further
19 actions. If what you are saying is, had this bid with
20 sufficient supporting detail and a properly worked-out
21 case come to the Advisory Group three years in the past
22 or four years in the past or whatever, clearly I cannot
23 say that the Advisory Group would have approved it or
24 not. I can assure you that they would have seriously
25 considered it, as they always considered capital bids.
0106
1 Q. Looking at the nature of the bid, you cannot say it was
2 your decision to approve it or otherwise, but was it the
3 sort of bid which stood a reasonable prospect of
4 success?
5 A. It really, I think, would depend -- this is very
6 hypothetical, can I just make that clear.
7 Q. Absolutely. It is put on that basis and I am asking for
8 your best judgment.
9 A. Thank you. The problem with the Bristol unit, for
10 a long time, had been under-achievement of numbers. If
11 the unit could present a convincing argument that one of
12 the reasons for that perhaps was the lack of these
13 facilities, or even that if they had these facilities,
14 it would increase their attractiveness to the referring
15 clinicians, then that, I think, would be the way, if
16 I worked at Bristol, that I would try and present that
17 bid, because I think that would be a positive way of
18 presenting it.
19 The Advisory Group were clearly concerned about
20 the throughput of the unit, that had been expressed to
21 the unit many times. I had expressed it to them
22 myself. This would be perhaps a way of addressing
23 that. This is the sort of bid that the Advisory Group
24 received and approved in the context of other units.
25 There is nothing here which sort of screams out, "this
0107
1 would never be approved under any circumstances".
2 Q. I am very much obliged for your help on that.
3 The second question which arises out of the issue
4 of numbers to which you have just adverted, we have seen
5 throughout the documents we have just looked at a number
6 of occasions which it was suggested that contact would
7 be made with Bristol to see if they could increase their
8 numbers.
9 In the context of something like congenital heart
10 disease, do you know how it was proposed that they might
11 do that?
12 A. Very sketchy. I visited the units, in February of 1992,
13 I think, to discuss the contract. We talked about
14 activity there, I recall, and I think I was asking how
15 they could improve things. I think one of the things
16 that was said to me -- and this is memory stuff again,
17 with respect -- was that they felt that the provision of
18 the service at Bristol was not particularly widely known
19 and they were looking always at ways of publicising it
20 through the professional structure, or whatever.
21 The reason I remember that is, I suspect, with my
22 usual lack of tact, I may have referenced a video as
23 a means of doing that, because I was aware that another
24 unit providing an entirely different service had gone
25 down this route, and that, I think, is the only reason
0108
1 it actually sticks in my brain, but they did not seem to
2 me to have a particularly well-worked plan for the
3 future in terms of increasing referral rates.
4 Q. I think, as you say, that is a matter for them and the
5 suggestion you would make would be a PR type?
6 A. No, I think the PR suggestion was one they had put to me
7 as something they were looking at, and trying to be
8 helpful, which clearly is not something I do.
9 I suggested they might want to have a look at the idea
10 of a video.
11 Q. The last possibly discrete matter which I want to ask
12 you about arises from the DOH 4/45.
13 Can we scroll down, please?
14 "The unit had not submitted any quarterly activity
15 data during 1991/92."
16 It follows that you had not had any of the
17 activity data at the Supra Regional Services Advisory
18 Group?
19 A. That is right, yes. More particularly, the Secretariat
20 did not have the activity data with which it conducted
21 its ongoing monitoring against the contract.
22 Q. We see, looking down the page , "Mr Wishard", as he is
23 termed, in the second paragraph, presented the surgical
24 results to date, but open and closed open heart
25 operations have increased from 1990 to 1991, and he sets
0109
1 out that the mortality for open heart operations at
2 30 per cent, compared to a UK average of 20 per cent,
3 "may be due to a number of particularly difficult
4 cases."
5 Let us go down a little bit further.
6 "Overall, the unit was on target for 1991-92.
7 Mr Owen asked what threat the new Welsh unit posed to
8 the unit's business."
9 So this was a meeting in which you were taxing
10 them with failing to send in their returns, was it?
11 A. I am sorry, can I just ask you to scroll to the top?
12 Thank you. The purpose of the meeting was really to
13 agree the contract for the next financial year and part
14 of that was to assess just how well or badly in terms of
15 activity, so far as I was concerned, in the financial
16 year. So yes, I certainly had a whinge about the fact
17 that he had failed to submit any activity data. In all
18 fairness to the unit, that was not a problem that was
19 particular to Bristol in the early days of contracting.
20 That sort of sense of discipline was not altogether
21 there, and it took me some time to try and instal that.
22 So we talked about that and the impact it would
23 have for the future. I recall that they put together
24 a presentation using overhead slides, where they
25 demonstrated their activity and various other data.
0110
1 I remember specifically asking, in fact, about their
2 30 day mortality data, because I think it was presented
3 in the way that their data was, say the UK average was
4 20 per cent and those were the figures there, and it
5 seemed to me -- I simply asked why that was so.
6 I think you have to understand, also, that this
7 meeting had occurred sort of three weeks after I arrived
8 in the Advisory Group, so I was kind of winging it.
9 I remember quite clearly that Mr Wisheart or -- I think
10 it was Mr Wisheart -- was saying that tragically, he had
11 had a number of difficult cases where the patient had
12 died and as a consequence of that, where you were
13 dealing with terribly small numbers anyway, you only
14 needed one or two to go wrong -- I apologise for the
15 callousness of this -- to have a disproportionate effect
16 on the mortality figure.
17 That seemed to me a reasonable explanation at the
18 time, but what I did following that, and it is not
19 recorded here, but it was a standard procedure,
20 basically, was that when I got back to London, I would
21 give Dr Halliday a copy of any of the slides that had
22 been used, and I did -- I actually remember pointing out
23 that I had raised this issue about the 30 day mortality
24 figure, and basically, Dr Halliday confirmed the impact
25 of what Mr Wisheart had said. Basically, he said "Okay,
0111
1 I have the slides now, I will go away and think about
2 that and see if there is anything for me, thank you very
3 much", and that was that sort of area.
4 Q. Thank you. Would you give me one moment, Mr Owen?
5 (Pause). You will be happy to know, possibly, that that
6 is the end of the questions that I shall ask you, save
7 one, which is this: I have taken you through a number of
8 discrete areas, and at the end, finished off with one or
9 two fairly isolated points.
10 Is there anything which you would wish to add
11 about which I have not asked you, or add further to the
12 answers you have already given, so that this Inquiry can
13 have a proper and full view of anything that you might
14 know which is helpful?
15 A. Just one point which occurred to me last night, and it
16 really relates to a question you and I think the
17 Chairman also addressed to Mr Angilley, which flowed, as
18 I recall, from Professor Tynan's report.
19 I think the basic premise that Professor Tynan was
20 making was that supra-regional service funding would
21 have the effect of distorting clinical judgment. In
22 a nutshell, that was what it was.
23 Mr Angilley's response was: no evidence, and he
24 found it an outrageous suggestion, that professional
25 clinicians could be geared in this way. I entirely
0112
1 agree with both of these.
2 But the point I wanted to add, if I could, is one
3 I made earlier in response to another question you made,
4 which is that simply because a procedure was not being
5 funded through the supra-regional service mechanism
6 route does not mean that it was not being funded
7 elsewhere. It was a basic premise of contracting that
8 all activity was going to be funded and subject to
9 contracting. Therefore, the argument that the absence
10 or presence of supra-regional service funding was of
11 itself going to encourage a responsible clinician to
12 choose operation A over operation B when his clinical
13 judgment was that you needed operation A, I still find
14 facile and unconvincing.
15 MR LANGSTAFF: For my part, Mr Owen, may I thank you very
16 much for coming and giving your evidence?
17 EXAMINED by the PANEL
18 THE CHAIRMAN: There may be some questions from the Panel.
19 MRS MACLEAN: Earlier on today you talked to us about the
20 criteria for designation as a supra-regional service
21 unit. When we asked about the criteria, you mentioned
22 clinical outcome measures and told us that these were
23 difficult to obtain, or unobtainable, for the service
24 that we have been discussing today.
25 To help me put this in context, could you give me
0113
1 your views on whether such outcome measures were
2 available for any of the other services which were being
3 considered for designation? Was it a subject specific
4 problem, or was it a general problem?
5 A. I really think it was a general problem, not only
6 throughout the SRS, the supra-regional services, but
7 throughout the NHS, and it is a problem which, in all
8 honesty, I do not think we have actually cracked yet.
9 I think it was a general problem.
10 Q. Thank you. Perhaps I might take the opportunity to
11 pursue my enquiries about the impact of the SRS funding
12 mechanism for Wales. I know that Mr Angilley is dealing
13 with this and you may prefer to leave it to him, but to
14 deal with my impatience, can you enlighten me as to the
15 impact of SRS funding for the Welsh Office?
16 A. There was no impact at all. SRS funding was for the
17 English units, but because of a quirk in the financing
18 system, which will be the subject of a paper Mr Angilley
19 is providing, it was allowed that Welsh residents could
20 be treated in English units without a bill, if you like,
21 going back to the patient's district of residence in
22 Wales.
23 Q. So this was a 'freebie', in effect?
24 A. In effect, yes, that is right.
25 THE CHAIRMAN: Mrs Howard has a question, but can I just
0114
1 ask -- it is purely for the stenographer -- that you
2 lean back a little and then the microphone will pick up
3 your response? Thank you.
4 MRS HOWARD: Can I take you back to probably the very
5 beginning of this morning, when you were talking about
6 assessing bids for new units to be designated, and in
7 fact, in your statement you talk about looking at the
8 existing level of provision from already designated
9 units.
10 When you were building up criteria which those
11 units would then have to meet, did you consider the way
12 in which those units would be collecting data that you
13 would want to use in the future? Was there any
14 consideration of the formality of that, or the
15 methodology?
16 A. No.
17 MRS HOWARD: Thank you.
18 THE CHAIRMAN: Professor Jarman?
19 PROFESSOR JARMAN: Mr Owen, on page 6 of your statement,
20 paragraph 15, you say that the Advisory Group discussed
21 where a unit was falling short of expectations
22 clinically.
23 I just wonder whether, in, say, the first three
24 years of your job, you did, as the administrator,
25 consider looking into this, other than the work that the
0115
1 Medical Secretary did, because there was a lot of
2 disquiet which had been raised about the Bristol unit on
3 various occasions. Was any of it your job at all?
4 A. Taking the final point first, if I may, in all honesty,
5 I can say that during my tenure as Secretary of the
6 Supra Regional Services Advisory Group I was never made
7 aware that there were problem with the designated
8 service at Bristol.
9 Q. But there was a letter from Dr Doyle to Professor Angeli
10 in July 1994 about problems, so he had been warned. It
11 had been commented on by Dr Bolsin, Professor Angeli,
12 Dr Black, Mr Bryan, Dr Davies, Professor Farndon,
13 Dr Monk, Dr Pryn, Professor Pryce-Roberts, Professor
14 Wyn-Jones and various others had actually discussed the
15 situation, so it was not that there was no concern.
16 A. I am sorry ...
17 Q. It had not reached you, you mean?
18 A. No, no, I expressed myself badly. During my time as
19 Secretary of the Advisory Group and the time that the
20 designated service was a designated service, i.e. before
21 the service had been de-designated, I was never made
22 aware of any disquiet about the unit.
23 When Dr Doyle wrote -- I do not know that letter,
24 I have never seen it, as far as I know, but 21st July --
25 Q. 21st July 1994.
0116
1 A. That was after the unit had been de-designated and
2 therefore left the arrangement, and I would have had no
3 involvement at all with it.
4 Q. The other people that I mentioned were considering it in
5 the 1990 to 1992 period. There were questions from some
6 of them about it.
7 A. They did not get to me.
8 Q. On page 7, paragraph 22, you said you received regular
9 reports which would discuss monitoring and the quality
10 of service. You pointed out how difficult it is to
11 monitor it in terms of clinical quality but the Medical
12 Secretary would do this in conjunction with the Royal
13 Colleges.
14 We have not seen the Royal College of Surgeons but
15 we have seen the Royal College of Physicians. When they
16 came on Day 9, what they said was, "If we are not
17 informed that there are problems, we would not have any
18 ability to interfere."
19 So the Royal Colleges were limited, and I think
20 actually, in terms of acting proactively, they had to do
21 it really mainly via the inspection of training posts.
22 Professor Alberti has written to us saying that
23 when they inspected the training posts in 1992 for the
24 Bristol Royal Infirmary they came back with the report,
25 and I will read it:
0117
1 "There are major problems due to great increase in
2 workload in emergency medicine without commensurate
3 increase in resources. When a full complement of staff
4 is present, the system is able to cope, but if anyone is
5 on leave, those remaining can be stretched to the limit
6 and the level of cover is inadequate to ensure proper
7 training. It seems probable that at times the quality
8 of patient care may fall below safe levels. In my
9 discussions with managers, it was clear that they were
10 aware of these difficulties and some improvements have
11 already been implemented."
12 Would you consider that this was to a certain
13 degree not a medical problem but a managerial or
14 administrative problem, the lack of resources in terms
15 of beds, et cetera, which they referred to, or would you
16 think that is also a medical problem?
17 A. One derives from the other. If the Bristol unit, or
18 indeed any designated unit, felt that the quality of the
19 service it was providing was being jeopardised or
20 hindered because of a lack of resources, or a lack of
21 money, to put it crudely, I would have expected that
22 unit to submit development bids to the Advisory Group,
23 as was normal -- it happened every year -- highlighting
24 the problems. That is one way into that particular
25 problem.
0118
1 The other way is to come in through the quality
2 route -- perhaps it was possible, I do not know, because
3 this is not my area, as I have already said, but it may
4 be possible to identify that there were particular
5 clinical problems through statistical analysis, or
6 whatever. I would have expected that data to certainly
7 come to or be made available to the Medical Secretary of
8 the Group, in so far as it related to the designated
9 service.
10 Q. The point I am trying to highlight is the fact that you
11 said it is very difficult, looking at the statistics,
12 and I accept that point, and therefore you depended very
13 much on the Royal Colleges?
14 A. Yes.
15 Q. I have quoted you that the Royal Colleges have
16 difficulties and really the main way of taking action
17 was really in being proactive in inspecting training
18 posts. I was reading you the report of the inspection
19 which has been sent to us. I was therefore saying that
20 it appeared that there was a lack of resources in terms
21 of beds, et cetera, which was being highlighted in that
22 report.
23 Was there an administrative element, or was that
24 also something entirely for the Medical Secretary?
25 A. I am frankly not aware of that report. I am not aware
0119
1 that the Advisory Group was told that in the view of
2 this gentleman --
3 Q. This is 1992. It is the Royal College of Physicians,
4 I must say, but it is referring to the problems in
5 hospitals.
6 A. I am not aware that that came before the Advisory Group
7 as an issue, but I do actually emphasise that if the
8 unit believed that the quality of its service was
9 suffering because of a lack of money, then that is
10 something that -- I would genuinely have accepted them
11 to have submitted a development bid, as the majority of
12 units did each year, on an annual basis, putting forward
13 their arguments and cases.
14 Q. The next question is, when it was decided -- it is
15 page 88, line 1 of today's transcript -- to override the
16 Royal College of Surgeon's recommendations to limit the
17 designations, and in fact the clearly expressed view of
18 Sir Terence English as the President of the RCS in
19 England was that Bristol should not be designated, who
20 was it who took the decision to override it and who had
21 the ultimate responsibility -- it is two questions,
22 really -- because you were, after all, an Advisory
23 Group?
24 A. What the Advisory Group were overriding was the RCS
25 Working Party's recommendation that the service
0120
1 continues to be designated and changes be made to the
2 composition of that.
3 You then have the element with Sir Terence English
4 adding Bristol, if you like to that list.
5 Q. Yes; his very clearly expressed view.
6 A. Who overrode that recommendation was the Advisory Group,
7 and all of the Advisory Group. I am aware that at the
8 July meeting where that particular issue was discussed,
9 that Sir Terence, I think, was not present at that
10 meeting. However, the way the Supra Regional Services
11 Advisory Group operated was that it was, if you like,
12 refining and reaching its recommendations for the next
13 year throughout that year.
14 At the September meeting, which I think
15 Sir Terence was at, the decision to de-designate the
16 neonatal and infant cardiac surgery service was
17 referenced and discussed, and accepted formally by the
18 Group.
19 The process then was that the recommendations of
20 the Group, in their entirety -- and they covered a range
21 of matters, as you know -- were presented to Regional
22 Chairmen by the Chairman of the SRSAG to get the
23 Regional Chairmen's endorsement, if you like, of those
24 recommendations before the recommendations were formally
25 submitted by the Chairman of the SRSAG to the Secretary
0121
1 of State. It is convoluted, but that was the process.
2 Q. It is, because I have been trying to chase in this
3 Inquiry the responsibilities. So what you are saying is
4 that as an Advisory Group you took the decision
5 together, and you first of all took it to a group of
6 Regional Chairmen?
7 A. Yes. It was in the terms of reference of the Supra
8 Regional Services Advisory Group, basically, to advise
9 the Secretary of State through the Regional Chairmen.
10 The reason for that, Alan Angilley was referring to it
11 yesterday, was that basically we are spending their
12 money, if I can put it in a very crude way, and
13 therefore it is important to make sure they are on board
14 with the recommendations that the SRSAG were taking.
15 So the process is: during the course of the year,
16 reach your decisions; refine your decisions; confirm
17 your decisions at September.
18 Q. Then the final decision is taken by the Secretary of
19 State?
20 A. At September you then go to the Regional Chairmen. That
21 tended to happen in about November, for reasons which
22 I do not know, or think important. On the understanding
23 that Regional Chairmen then endorse those
24 recommendations, the Chairman of the Supra Regional
25 Services Advisory Group would formally submit the
0122
1 proposals, the recommendations, to the Secretary of
2 State. That used to occur at about Christmas of each
3 year.
4 Q. Then ultimately the Secretary of State has
5 responsibility?
6 A. That is right.
7 Q. That is really what I am trying to pin down.
8 A. The Secretary of State could accept or not the
9 recommendations.
10 Q. Finally, would you agree that when this decision was
11 taken that you would use the system of designated
12 services rather than accreditation, this put a lot of
13 responsibility on monitoring quality to the Advisory
14 Group, particularly considering we are not looking at
15 morbidity here, illness, but we are looking at
16 mortality: the deaths of infants?
17 A. The responsibility for monitoring the service was -- the
18 Advisory Group clearly had a role in that. There is no
19 fudging of that. But other people had responsibility as
20 well, primarily, I would argue, as indeed the contract
21 argues, that the unit themselves had a responsibility to
22 monitor that service.
23 Q. To monitor themselves?
24 A. Yes.
25 PROFESSOR JARMAN: I have no further questions.
0123
1 THE CHAIRMAN: It may not be helpful to pursue the question
2 I asked yesterday; it may be that I had not made myself
3 as clear as I should.
4 I was merely asking about the existence of another
5 stream of money. I accept, as you say, that it would
6 not persuade a clinician in a particular case to make
7 a particular decision: that was not my point at all.
8 My point was whether it could persuade a manager to
9 direct his or her attention in one way rather than in
10 another, make a particular appointment, promote
11 a particular development, because of the existence of
12 that stream of money.
13 That was a speculation I just advanced, and
14 I heard Mr Angilley's view. Putting it as clearly as
15 I can, I would value your view.
16 A. I would agree with that as a proposition. I was not
17 trying to criticise your question, I was simply
18 referencing the fact that you were asking the question
19 within the context of Professor Jarman's paper.
20 Q. Professor Tynan?
21 A. Professor Tynan, I beg your pardon.
22 THE CHAIRMAN: Thank you. We have no more questions.
23 Is there any re-examination?
24 MR PIRANI: There is no re-examination, sir.
25 THE CHAIRMAN: I am very grateful to you. Let me repeat --
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1 I think Mr Langstaff will have said it, but I cannot now
2 remember, but I repeat it or say it for the first time:
3 there may be other things that you would wish to put to
4 us, having contemplated what has been said today or
5 having come across other matters. We would be more than
6 happy to receive them, and would be grateful if you are
7 able to do that, either yourself or through your
8 advisers.
9 We thank you for coming today. It has been an
10 extremely helpful meeting for all of us, and we are much
11 in your debt for having given your time. Thank you very
12 much.
13 Mr Langstaff?
14 MR LANGSTAFF: Sir, we have no further witness for today, as
15 you know. Tomorrow we will hear from Dr Norman
16 Halliday, whose evidence has perhaps been anticipated to
17 an extent by that of Mr Angilley and Mr Owen.
18 THE CHAIRMAN: So we adjourn until 9.30 tomorrow morning.
19 (1.30 pm)
20 (Adjourned until 9.30 am on Thursday, 29th April 1999)
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001