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Daily transcripts
Hearing summary
18th May 1999
Today the Inquiry heard evidence from Mr Hugh Ross, Chief Executive of the United
Bristol Healthcare NHSTrust (UBHT). Mr Ross took up this post in October 1995. Mr Ross
described the management structure of the Bristol Royal Infirmary and Trust prior to his
appointment and outlined various changes he has implemented since 1995. He said key
changes to management roles have included: additional sessions for the Medical Director to
spend time on management issues rather than clinical work; redefined responsibilities for
the Director of Nursing, enabling her to concentrate on Nursing strategy and development
rather than day-to-day operational issues; a more formal role for the Director of Finance
as Deputy Chief Executive and a clearer role for the Director of Personnel in relation to
clinicians disciplinary matters. He said that another area which has undergone change is
the responsibility for undertaking and reporting clinical audit. Mr Ross was asked how he
would react if issues of concern were raised with him about the quality of clinical
services at UBHT today. He said he would respond quickly and investigate the concerns and
take advice on how best to remedy any problem, avoiding causing any unnecessary risk to
patients. He was asked how he might have reacted had he been in a similar position in the
80s and early 90s. He said he hoped he would have reacted in the same way, but that the
culture of NHS management had changed during the period and managers were more open to
criticism and willing to seek external advice today. He commented on the culture of the
hospital during the period of the Inquiry’s Terms of Reference and described the
differences between his management style and that of Dr John Roylance’s, the former
Chief Executive, management style. Mr Ross concluded by describing the relationship
between the Trust, the medical Royal Colleges and the Department of Health.
|
FULL TRANSCRIPT
1 Day 19, 18th May 1999
2 (9.30 am)
3 THE CHAIRMAN: Mr Langstaff, we are beginning slightly later
4 again but I understand this was because of the need to
5 look at a document prior to coming in. Is that not the
6 case?
7 MR LANGSTAFF: Yes, it is.
8 THE CHAIRMAN: Thank you. So shall we begin?
9 MR LANGSTAFF: It is not a consequence of my unpredictable
10 time-keeping this morning.
11 This morning, as I indicated yesterday evening, we
12 have Mr Ross, the Chief Executive of the United Bristol
13 Healthcare Trust. It is important to emphasize at the
14 start of today, just as I did yesterday evening, that to
15 which his evidence is directed. We are beginning today
16 part of Block 3 of our evidence, which is the local
17 scene. We have been scene setting, setting the context
18 within which we will proceed to a more detailed
19 investigation of what happened at Bristol between 1984
20 and 1995, and we began in Block 1 with the parents
21 telling the story from their own various points of
22 view. Then Block 2: setting the national picture, and
23 we heard from both the Royal Colleges. We have not
24 finished hearing from the Royal Colleges, so there is
25 a degree of overlap between the end of Block 2 and the
0001
1 start of Block 3, so that Block 3 will be picked up
2 again following today on Monday, when Mr Nix will be
3 with us, and we anticipate that he will still be with us
4 on Tuesday of next week.
5 But his evidence, and that of Mr Ross today,
6 beginning Block 3 as it does, will not address, and he
7 will not be asked to address, the very contentious issue
8 of the retention of tissue. We have earmarked that for
9 a time in July when he will return with others and will
10 give his evidence on that at that stage, or at a later
11 stage. He will not be answering today any question
12 which directly concerns the expression of concern during
13 the 1990s about what had happened with paediatric
14 cardiac surgery in Bristol.
15 With that introduction, which I hope is helpful,
16 may I say one other thing to those who are part of the
17 wider audience. Yesterday evening the transcript of the
18 day was not released on to the Internet, as has been our
19 custom. This was because we finished late in the day.
20 The transcript is checked against the tape to ensure as
21 far as possible accuracy, and that meant that by the
22 time that was done, there was no time to put it on the
23 Internet yesterday evening. The Inquiry put a notice to
24 that effect, to summarise the evidence on the Internet.
25 It promised that by 8.30 this morning there would be
0002
1 a transcript available on the Internet. That promise,
2 I am happy to say, was honoured.
3 Mr Ross, you have, I think, seen some of the
4 evidence before in the Inquiry. Will you stand to take
5 the oath?
MR HUGH ROBERT ROSS (Sworn):
7 Examined by MR LANGSTAFF:
8 Q. Mr Ross, you are Hugh Robert Ross?
9 A. Yes.
10 Q. And your professional address is the United Bristol
11 Healthcare Trust, Marlborough Street, Bristol?
12 A. Yes.
13 Q. You are the Chief Executive of the United Bristol
14 Healthcare NHS Trust?
15 A. Yes.
16 Q. "UBHT" for short?
17 A. Yes.
18 Q. In connection with this part of this Inquiry, did you
19 make a statement which we see on the screen as WIT 128,
20 beginning at page 1? It starts there and goes through
21 to 128/6. That is your signature at the bottom, is it?
22 A. That is correct.
23 Q. And in that you describe your appointment to the post of
24 Chief Executive of the UBHT in succession to
25 Dr Roylance?
0003
1 A. That is right.
2 Q. And you took over in 1995?
3 A. That is correct. October 1995.
4 Q. You were appointed earlier that year, I think?
5 A. That is right.
6 Q. You deal in that statement with a number of management
7 issues about which I am going to ask you. Can I pick up
8 a point which we have been looking at over the last few
9 days in this Inquiry and ask you this: suppose that the
10 Royal College of Surgeons or Physicians, or a senior
11 official in the Department of Health comes to you as
12 Chief Executive, and says, "I have here an indication of
13 serious concern from a respectable and responsible
14 source about the performance of one of your
15 specialties".
16 What would you, as Chief Executive, nowadays
17 consider to be your duty in respect of that?
18 A. I think to respond as promptly and as thoroughly as you
19 could, by trying to find out as much information as
20 quickly as possible about the situation that was alleged
21 to be occurring, and then taking whatever appropriate
22 advice was needed to make sure the situation was
23 corrected, if indeed it needed to be corrected, and that
24 no patients were unduly put at any risk.
25 Q. So the overall object would be to avoid risk to
0004
1 patients?
2 A. Absolutely.
3 Q. And you say, whatever enquiries were necessary, those
4 would be internal, and for that matter, if necessary
5 external, would they?
6 A. Yes. I think Chief Executives in the NHS generally, and
7 certainly myself personally, will be far less reticent
8 nowadays about seeking advice from whatever source they
9 thought was appropriate, and not necessarily limiting
10 themselves to seeking internal advice.
11 Q. The next question may be more difficult. You were not
12 of course in post before October 1995. Would there be
13 any reason that you know of to have given a different
14 answer had you been asked this question 5 years ago,
15 10 years ago, 15 years ago?
16 A. Yes. I think my answer probably would have been
17 different. Views about risk management,
18 responsibilities to patients to provide safe services
19 above all else, views about managerial responsibilities
20 and roles, standards, expectations, public expectations,
21 have all continued to change through those years, and
22 I think the managerial response to the sort of situation
23 you initially described would have changed over time as
24 well.
25 Q. You for your part have been a manager of one form or
0005
1 another in the NHS at senior level since 1986, at least,
2 because in 1986 you tell us you were Unit General
3 Manager of the Coventry Health Authority, with City
4 unit, and in 1990, unit manager of the Leicester General
5 Hospital and subsequently Chief Executive of that Trust.
6 If, in 1986, when you were Unit General Manager in
7 Coventry -- so this is now taking you back 12 years --
8 someone in the Royal Colleges or the Department of
9 Health had come to you with the sort of concerns that
10 I have been describing, what action do you think you
11 then would have taken?
12 A. It is a hypothetical question, of course, but I would
13 like to think I would have responded appropriately and
14 swiftly and would have taken advice to make sure
15 I understood what was being told me and whether indeed
16 there were any problems. Sometimes expressions of
17 concern are raised which when investigated are found not
18 to be supported by the evidence, so I would like to
19 think that I would have taken a similar approach. If
20 I am entirely honest, I am not sure the climate at the
21 time would have led to me being quite so proactive as
22 I would be nowadays.
23 Q. Again, being completely frank about it and acknowledging
24 it is a hypothetical question, in what respects do you
25 think things might have changed specifically?
0006
1 A. I think the most fundamental change has been that there
2 was a time when the provision and quality of medical
3 services was seen to be doctors' business and nobody
4 else's. That has fundamentally changed in recent
5 years. There is an understanding now that the quality
6 of medical services is a matter of interest to many
7 people, both those providing and those receiving the
8 services, and the managerial role in that of someone
9 like myself is far more clearly understood and spelled
10 out than it has been in the past.
11 Q. So even after general management came in, in, what,
12 1985, in the National Health Service, there was still
13 the view, was there, that the hospital business was
14 doctors' business?
15 A. I simplify to make the point, and I was fortunate enough
16 to work for a number of very capable Managers in the
17 1980s in various places who had a very good
18 understanding of what was going on in clinical services,
19 but that was the changing culture of the times. It was
20 not until general management became established that
21 the whole performance of the organisation became the
22 true concern of the Managers in the service as opposed
23 to some more tightly defined areas that had
24 traditionally been their responsibility.
25 Q. Dr Roylance, we know, became a General Manager in
0007
1 Bristol, I think it was in 1985. Personalities aside,
2 is it the case that the older generation of general
3 managers may have taken longer to adapt to the idea that
4 the hospital business was more than just doctors'
5 business?
6 A. I could not say, really.
7 Q. I have taken you away from the local scene to ask for
8 comments, because of your particular expertise, on the
9 national and also your reaction as it might have been.
10 Can I focus now upon the structures that operated at the
11 Bristol Trust?
12 You tell us -- it is 128/3 -- of the structure
13 that you inherited when you became Chief Executive.
14 Have you at any stage described the organisation
15 that you inherited as Chief Executive as "unusual"?
16 A. Yes, I have.
17 Q. Looking at that as a template of the organisation,
18 a chart for the organisation, what was unusual about it?
19 A. I do not think that a simple diagram such as that really
20 gives the flavour. You could look at that particular
21 structure and find it replicated in many places. What
22 was unusual about the UBHT, in my experience, based on
23 four or five previous senior posts, was the way it was
24 actually run on a day-to-day basis as opposed to the
25 structure. The Clinical Director structure is a common
0008
1 one still in use in most large NHS hospitals.
2 Q. So broadly speaking, on paper the structure is
3 a familiar one, clinical directorates?
4 A. Yes.
5 Q. What was unusual about the way it actually worked as you
6 inherited it?
7 A. I think the fact that there was -- clearly, the
8 personalities and the structure intertwine, but trying
9 to stick to your suggestion to the structure issues,
10 I think the fact that the Chief Executive was a doctor
11 of long-standing and worked in Bristol and the
12 surrounding area for virtually all of his career: that
13 was unusual. I think the fact that in the early days of
14 the Trust the Medical Director had a relatively small
15 role to play in terms of time, was also quite unusual
16 for a Trust of this size and I think the way the roles
17 of the team were played out, the way the roles of the
18 team were described and carried out by the team members
19 were unusual as well.
20 Q. Again, I want to put some flesh on the bare bones of
21 that answer. The way in which the roles were described
22 and played out by the individuals: are the roles which
23 you have in mind those which we see on the template?
24 A. Yes.
25 Q. So if we take the Director of Personnel, the role as
0009
1 described and played out by Mr Stone: what was unusual
2 about that?
3 A. My assumption on coming to the Trust was that the
4 Director of Personnel would have clear responsibilities
5 across all of the staff of the Trust, but I came to
6 understand that Mr Stone's responsibilities did not
7 really extend into the area of medical staffing and
8 indeed, at the time, I think the Senior Medical Staffing
9 Officer worked through to the Medical Director and on
10 occasions directly to the Chief Executive, and the
11 Director of Personnel was not as involved as I would
12 have expected with a whole range of medical staffing
13 type issues.
14 Q. So let us look at this now, since we were talking about
15 personnel, talking about what might have been unusual
16 about the other roles.
17 Personnel would include medical and non-medical
18 personnel, and presumably non-clinical personnel?
19 A. Yes.
20 Q. So far as clinical as opposed to medical personnel were
21 concerned, who looked after the personnel issues for
22 them?
23 A. They fell within the remit of the Director of Personnel,
24 as far as I am aware.
25 Q. But the doctors fell within the remit of the Medical
0010
1 Director?
2 A. And the Chief Executive.
3 Q. In the Trusts that you have been involved in before, and
4 no doubt you understood that to be the general pattern,
5 the Director of Personnel would also concern himself not
6 only with clinical staff generally, but with medical
7 staff?
8 A. That is correct.
9 Q. So that if there was a particular issue involving the
10 competence or conduct of a doctor, that would go to the
11 Director of Personnel?
12 A. Certainly he or she would be involved, heavily involved,
13 although no doubt with, you know, senior advice as
14 appropriate.
15 Q. In the system which you inherited, the pattern you
16 inherited, if there was a problem with a doctor in
17 respect of either competence or conduct, would the
18 Director of Personnel be involved other than entirely
19 peripherally in that?
20 A. I certainly got the impression that he would not be
21 centrally involved in such a situation, although it was
22 not an issue with which I unduly concerned myself,
23 because I made it clear that from now on I did expect
24 him to be involved in such issues.
25 Q. Does it follow that in those Trusts that you have been
0011
1 concerned with before, the Medical Director had not been
2 involved, other than peripherally, in issues of conduct
3 and capability for a doctor?
4 A. No, I am sorry if I misled you. I think that the
5 Medical Director would be involved in such issues, also,
6 but would work closely with the Director of Personnel,
7 both bringing their specific expertise and knowledge to
8 the situation.
9 Q. So what was different about this structure is that the
10 Director of Personnel was, as it were, taken out of the
11 loop?
12 A. Yes, that is right.
13 Q. And the Director of Personnel had a management,
14 personnel, background, did he?
15 A. Yes.
16 Q. As you would expect. You are nodding and you will
17 know -- do not worry about it --
18 A. Yes, you would expect that.
19 Q. You will forgive me I hope for saying from time to time
20 you are nodding or you agree, simply so it goes down on
21 the transcript.
22 The Director of Operations: what was unusual about
23 her role and the way that it operated?
24 A. Not quite so unusual, this: quite common to have
25 a Director of Operations, often carrying a brief for
0012
1 other areas as well, in the case of UBHT, Margaret
2 Maisey carried the brief as the Senior Nurse of the
3 Trust also so a Director of Operations post was not that
4 unusual. What was a little unusual to my experience
5 was, as I understood it, the relative separation of the
6 Chief Executive from operational matters. This is
7 a reflection of personal style to some extent, but
8 I felt that almost all of the day-to-day operational
9 management of the Trust in terms of the business of the
10 Trust had been devolved to the Director of Operations,
11 which was a model, as I say, it is not unusual, but not
12 one that I had previously worked with myself.
13 Q. Again, so that I understand, the day-to-day business of
14 the Trust, the business of the Trust might be thought to
15 take many different forms?
16 A. Indeed.
17 Q. Amongst them the operations in the theatre, the care for
18 patients?
19 A. The day-to-day running of patient services would be
20 perhaps the best way to describe it, and all of the
21 supporting facilities and arrangements.
22 Q. So if the Chief Executive had devolved that to the
23 Director of Operations, that would have had two
24 repercussions, would it: first of all upon the time that
25 the Director of Operations had available for her nursing
0013
1 role?
2 A. Yes.
3 Q. And secondly, it would have affected the degree to which
4 the Chief Executive himself was concerned with the
5 day-to-day management of patient services?
6 A. Yes. I think it would.
7 Q. Is that part of what you have described as "somewhat
8 unusual" in the way in which Mr Roylance approached the
9 job, he being a medical man?
10 A. That is really difficult to say. Some Chief Executives
11 do view their role as very strategic and deliberately
12 keep themselves apart from the day-to-day issues.
13 Particularly being new in the job, I wanted to
14 understand those issues as well as I reasonably could,
15 so I was keener to be closer to the operational side of
16 the issues than perhaps would have been the case if
17 I had been in the job several years. But, yes, what you
18 say could well be the case.
19 Q. So far as his strategic role was concerned, you thought
20 it necessary to appoint a further director to have
21 responsibility for development?
22 A. That is correct.
23 Q. Because your view was, you tell us in your statement,
24 that strategic planning, forward planning, really had
25 been somewhat undervalued?
0014
1 A. My view was that it was not being handled in as thorough
2 or far-seeing a way as it needed to, and that was
3 a definite gap from the structure that I inherited, so
4 far as I was concerned.
5 Q. So although there might have been more time for the
6 previous Chief Executive to devote himself to strategic
7 considerations, you felt it nonetheless necessary to
8 strengthen that aspect of the Trust's work?
9 A. I did.
10 Q. It follows that the additional time that it had did not,
11 in your view, appear to demonstrate itself in the
12 results?
13 A. That is quite a broad statement. I am not quite sure
14 what you are referring to.
15 Q. It is. To what extent would that be true?
16 A. What results are we talking about? I am sorry, I do not
17 quite understand.
18 Q. In terms of producing the strategic's planning?
19 A. Yes. I did not think that the Trust strategic plans
20 were as robust and as well owned within the organisation
21 as they needed to be. Nor did I think that they had
22 been in such a way as would guarantee support from the
23 NHS community for all the changes that lay ahead.
24 Q. The Director of Operations, Margaret Maisey, had, you
25 tell us, a nursing role as well?
0015
1 A. Yes.
2 Q. To whom did the nurses in the Trust report?
3 A. They reported to the general managers.
4 Q. And the General Manager, we see from the template,
5 reported through to the Director of Operations?
6 A. Yes, although I have to say, this is my interpretation
7 of the structure as it was when I arrived, and I did not
8 copy it from any document in existence when I arrived.
9 I am not sure how clearly that role was laid down in any
10 organisational structure. This is my impression of the
11 way it worked when I came.
12 Q. Does it follow that there were no organisation charts?
13 A. I do not recall seeing one. That is not to say there
14 was not one, but I do not recall seeing one that
15 actually laid it out like this. I think it may have
16 been laid out slightly differently. This is my
17 impression of what actually happened on a day-to-day
18 basis. I think if it was laid out formally, it would
19 show probably the General Managers formally accountable
20 to the Clinical Directors rather than the Director of
21 Operations. In practice, they worked closely with
22 Margaret Maisey. That is my recollection of the
23 situation at the time.
24 Q. Did you actually look through the files to see what the
25 job descriptions were and how they inter-related?
0016
1 A. There were no job descriptions in place for a number of
2 these posts when I came to the Trust.
3 Q. So there were people appointed to a job and the job was
4 what they thought it was?
5 A. That is certainly the case. I do not know, but I can
6 say that there were no job descriptions for some of
7 these posts when I came to the Trust.
8 Q. There are now, I take it?
9 A. There are, yes.
10 Q. And that is one of the changes you made?
11 A. Yes.
12 Q. That is necessary in the modern world to run a properly
13 organised business, is it not?
14 A. I would think so, yes.
15 Q. So far as the Clinical Directors are concerned, what, if
16 anything, was unusual about their role and the way they
17 operated that?
18 A. That was a fairly standard Clinical Director role; there
19 was no job description for the post that I could find
20 and I set out to create one, but the role had been
21 spelled out, I think, quite carefully by my predecessor,
22 because of his feelings about the importance of
23 involving the senior doctors in the Trust fully in the
24 management of the Trust. So I think I am aware of
25 a number of references to the role that they should
0017
1 play, although there was no job description as such.
2 But it was a Clinical Director role, not unlike that
3 I was familiar with elsewhere.
4 Q. In that connection, I wonder if you would have in front
5 of you, please, a statement that we have had from
6 a Mr Boardman, WIT 79/1 is where it begins. Can we go
7 back to 79/1, so we can see who Mr Boardman is, because
8 we have not met him before.
9 THE CHAIRMAN: Mr Langstaff, there is an address there. Can
10 we take it above the address?
11 MR LANGSTAFF: It has just been done. I am grateful, sir.
12 His background from paragraph 2, 1987 until April 1991,
13 employed as Manager of the District Planning Department
14 for Bristol and Weston Health Authority, subsequently as
15 the acting Director of Planning and Estates and a member
16 of the planning team responsible for the application of
17 a Trust status for the UBHT.
18 Paragraph 3, please: Director of Corporate
19 Development from April 1991 to July 1992 for UBHT.
20 Practically regarded as a full non-voting member of the
21 Board.
22 Can we turn over, please? In 1992 he joined the
23 NHS Management Executive as Business Planning Director
24 for the South and West Region. He looked at business
25 plans and strategic directions produced by all the
0018
1 Trusts in the South West region.
2 In paragraph 5 he tells us he left that to join
3 a specialist management consultancy which works almost
4 exclusively for the NHS.
5 That is his background and input.
6 Page 7 of his statement, paragraph 22: national
7 policy for Trusts to be managed by a Clinical
8 Directorate structure. Dr Roylance decided how many and
9 which directorates were formed. There were 13 separate
10 ones.
11 Then paragraph 23:
12 "Through my subsequent experience with the NHS
13 Management Executive and as a specialist management
14 consultant, it was clear that many Trusts operate with
15 fewer directorates. In my opinion, 13 was too many, and
16 consequently Dr Roylance did not appear to have proper
17 control over them. He almost encouraged directorates to
18 be loosely affiliated to the Trust."
19 How accurate a description is that of the
20 structure that you thought you had inherited?
21 A. There were 13 directorates, that is correct. UBHT is
22 a very large Trust, however, and I think Trusts of
23 similar size would have had a similar number of
24 directorates, broadly speaking, at that time. Certainly
25 the number 13 is correct, from memory, yes.
0019
1 Q. So what do you say about his view that there were too
2 many at 13?
3 A. I hesitate because we have 12 today, and many people may
4 still argue that that span of control was too great for
5 a Chief Executive. There is an issue of balance and how
6 you maintain as much local ownership and genuine
7 responsibility for services provided to patients, and
8 engage all of the clinical staff, not just the doctors,
9 in the running and management of those services, and how
10 much you pay attention to the textbooks which say spans
11 of control should be smaller than that. That is Steve
12 Boardman's opinion.
13 Q. So his opinion is a textbook approach, but it may have
14 to be modified in practice, is that the position?
15 A. The textbooks may say that, but Steve Boardman was
16 giving a view, presumably, on what he felt at the time
17 and that is based on his experience.
18 Q. I think he appears to be relating the number there to
19 the ability of your predecessor in post, to have control
20 over them. The next sentence:
21 "He [Dr Roylance] almost encouraged directorates
22 to be loosely affiliated to the Trust. For example,
23 each directorate formulated its own business plan with
24 little central direction, and essentially, all 13 plans
25 were then bundled together. There was no real overall
0020
1 corporate strategy/planning."
2 Is it the case, from what you saw, that there was
3 little central direction?
4 A. Certainly I did feel, when I came to the Trust, that the
5 devolution to the directorates had gone too far and that
6 the overall performance of the organisation was not as
7 tightly controlled and managed as it needed to be. As
8 the new Chief Executive, I felt a little nervous about
9 that, if I am frank, and have worked since then to try
10 and get the right balance between the local ownership
11 and responsibility that I talked about and the need to
12 performance manage the whole organisation in a very
13 tight and proactive manner, especially as the
14 expectations placed upon the Trust by government grow
15 greater with each year.
16 Q. So the consequence of less central direction rather than
17 more would be the relative autonomy, would it, of the
18 different clinical directorates?
19 A. That is right.
20 Q. In terms of patient care, what effect would that be
21 likely to have which you would consider a disadvantage?
22 A. The potential disadvantage is that if problems emerge
23 with standards of patient care, the warning signals are
24 not necessarily heard outside the directorate as quickly
25 as might otherwise be the case. That is a potential
0021
1 downside from that kind of structure.
2 Q. So if there is a problem in the directorate, it takes
3 longer for it to become appreciated more generally?
4 A. It may do, depending on the accountability mechanisms
5 that are in place across the Trust as a whole.
6 Q. Because there is obviously a divide between
7 responsibility which the Clinical Director may have, and
8 the accountability of the Clinical Director and the
9 Clinical Directors, we saw from your tree, would have
10 been accountable to the Chief Executive?
11 A. Yes.
12 Q. And the problem, presumably, with greater autonomy is
13 that that degree of accountability is lessened and
14 attenuated?
15 A. I think in the culture of the UBHT at the time,
16 I think -- it is hard to say, really, because when
17 I came, I immediately took steps to try and tighten up
18 the relationships, but I think it is fair -- I have
19 heard the directorates described as being
20 'semi-detached' in the past, and I think that is a fair
21 description.
22 Q. I expect that expression "semi-detached" means that you
23 probably would echo the view, would you, of Mr Boardman
24 as expressed in the last sentence of paragraph 23.
25 A. I am sorry, which bit are you referring me to?
0022
1 Q. The very last sentence of paragraph 23:
2 "UBHT always delivered financially (Dr Roylance
3 was known to run a tight ship and thus UBHT appeared to
4 be well managed), but in other aspects the plan was not
5 coherent".
6 So he appears to be saying that financial planning
7 was but nothing else: semi-detached?
8 A. The statement is slightly ambiguous, is it not? I am
9 not sure whether he is referring to the strategic plan
10 or the business plan or the whole running of the Trust.
11 Q. What would you think it appropriate to say, from your
12 perspective?
13 A. Really, I suppose, from my perspective as a newcomer,
14 there were not sufficient mechanisms and information
15 systems in place for me to assure myself that all of the
16 directorates were operating in a proper manner,
17 operating in a manner consistent with Trust and
18 Government policy and achieving all of the results that
19 were expected of them, although some systems, such as
20 financial management systems, worked very well. It was
21 clear that other ones were not really in place in a very
22 robust way.
23 THE CHAIRMAN: Mr Langstaff, may I just interrupt for
24 a moment. Maybe the "semi-detached" point relates to
25 a sentence or two before the one you referred to,
0023
1 namely, "There was no real overall corporate
2 strategy/planning". Is that not where it comes from?
3 A. Certainly it is relevant to that point, yes.
4 MR LANGSTAFF: Can I move on to paragraph 24? Before I ask
5 you about this, just picking up on one aspect of your
6 last answer to me about the information systems that
7 were in place, you say the financial systems were good;
8 others were not as good as you had reason to expect.
9 Does that include systems of clinical audit?
10 A. Yes, it does.
11 Q. Paragraph 24:
12 "The role and relationship [says Mr Boardman]
13 between Clinical Directors and General Managers" -- he
14 is obviously, I think, suggesting that the General
15 Manager reported to the Clinical Director, even though
16 your understanding of what actually happened was that
17 they reported to the Operations Manager -- "both with
18 each other and with the Chief Executive and Director of
19 Operations was ambiguous. In theory, the Clinical
20 director was meant to provide leadership whilst the
21 General Manager managed the Department on a day-to-day
22 basis for the Clinical Director. In reality, there was
23 enormous pressure on the General Managers to control
24 expenditure and keep the Clinical Directors in line.
25 Clinical Directors generally wanted to develop the
0024
1 services and there was also pressure to spend more money
2 and develop new services where there were no contracts.
3 General Managers who argued the case for their Clinical
4 Director or service over-zealously were described as
5 'going native'."
6 Again, is that a fair reflection, or is it not, of
7 the situation which, as you saw it, you inherited?
8 A. It would be wrong of me to suggest there was no
9 ambiguity nowadays about this role. If you ask any
10 Chief Executive of a large Trust, he or she will say
11 inevitably with Clinical Directors only devoting part of
12 their time to the Clinical Director role and the rest of
13 their time to doing their clinical duties, all General
14 Managers tend to have strong relations with people like
15 Directors of Operations, Directors of Finance, and so on
16 so it is not a simple separate line management
17 relationship. So there is still some ambiguity in the
18 system and that is the nature of the complexity of the
19 organisation, I think.
20 I did not get the impression on arrival, though,
21 that is given by the middle part of that paragraph. Of
22 course, there is pressure on everybody to try and keep
23 expenditure in line, but in my experience, it has been
24 that the Clinical Directors, many of them take that
25 issue very seriously also and are not irresponsible in
0025
1 the way they approach their duties as far as that is
2 concerned.
3 Q. It was part of the idea, was it not, in developing
4 clinical directorates in the first place that the
5 clinicians would then have a greater appreciation of the
6 limited "cake" to be divided up between the various
7 different services?
8 A. That is right, and I think I would paint a less
9 unflattering picture of the Clinical Directors and the
10 way they did their job than seems to be the case there.
11 Q. But the description, General Managers being described as
12 "going native" when they support what one imagines to
13 have been a gross development of the service, is that
14 something that you have heard?
15 A. I am not sure I have ever heard that expression, but
16 I mean, there is no doubt that the General Managers are
17 very committed to the areas in which they work, because
18 they work extremely hard, and I am sure they did in the
19 early days of the Trust as well, to try and do the best
20 they could for the patients and the Directorate. They
21 would be letting the side down if they did not argue as
22 strongly and articulately as they could for the
23 developments they felt necessary for patient care. That
24 is part of their job. Also one part of their job is to
25 be one person in the Directorate who can step back and
0026
1 see the bigger picture in the way individual clinicians
2 cannot. I have had discussions since I have arrived
3 with some of the General Managers and asked them about
4 their perspective on issues and have said "Are you too
5 close to this one or engaged too much" or whatever.
6 I have not heard the expression of "going native", I do
7 not think, too often. It is a difficult matter to do
8 the General Manager's job and I think they have to
9 strike the right balance.
10 Q. What it reflects is, you accept the ambiguity inherent
11 in the role on the one hand they have a loyalty, as it
12 were, to general financial management which means
13 keeping the costs down, on the other hand, they may have
14 a loyalty towards their particular directorate which may
15 involve wanting to spend expenditure to increase the
16 service, develop it and so on?
17 A. That is right. If they were just seen as a hatchet
18 person from HQ, they would have no credibility with
19 their clinical colleagues and they cannot work
20 effectively without that credibility.
21 Q. So in the present Trust, how do you facilitate their
22 job, which is inherently difficult and inherently
23 contradictory?
24 A. We try and make sure that information flows as openly
25 and freely as possible, so everybody understands the
0027
1 complexities and pressures facing the whole Trust and
2 can see their own directorate within the Trust.
3 Equally we still try, I think quite properly, to
4 maintain where we can incentives, so people, if they do
5 want to spend their budgets, can take money forward and
6 use it for developments within their own directorate.
7 So there is some incentive structure at work to
8 try and help them, encourage them to use the resources
9 as well as possible. We do encourage them, of course,
10 to be advocates for the services that they are most
11 closely associated with, but to do it in an objective
12 way and try and see the bigger picture, and particularly
13 importantly, getting them to understand that what they
14 want to do must be seen within the context of the five
15 year plans of the Trust, government policy and all the
16 other issues we have to take into account.
17 Q. So does it follow that -- this is talking about the
18 early 1990s -- if there was much being said along the
19 lines that is reported here by Mr Boardman, it is
20 probably reflective, taking the various points you make,
21 of a lack of proper information systems, information
22 flows, communication; secondly, a lack of incentive,
23 being centrally directed, and I think over-arching it
24 all, from your answer -- correct me if I am wrong -- is
25 perhaps an inadequate central direction?
0028
1 A. It is difficult, because what you say may be the case,
2 but equally, I know for example that the system of
3 financial incentives and trying to encourage people to
4 use their resources and then get the benefit from good
5 use of those resources that has been in place in the
6 Trust from the word go, so clearly some aspects of what
7 I consider to be desirable and the way to do things were
8 there.
9 It is hard for me, not having been there, to offer
10 a comment about the central direction or otherwise.
11 Q. In paragraph 25 we have Mr Boardman commenting in the
12 record in the Board meeting on the main task of the
13 Clinical Director being to deliver health care contracts
14 within budget and participate in negotiations of future
15 contracts.
16 Is that the way that you see the proper role of
17 the Clinical Director?
18 A. No.
19 Q. Is that the proper role of the General Manager?
20 A. I think it is one of the main roles of both the Clinical
21 Director and the General Manager, but there are many
22 other important parts of the role of the Clinical
23 Director and that is just one aspect of it.
24 Q. If you were asked to give a thumbnail description of the
25 main task of the Clinical Director, what would it be?
0029
1 A. I think first and most importantly, it would be to
2 assure the quality of patient services delivered by the
3 Directorate and to have in place all the necessary
4 mechanisms and checks to assure that the quality of that
5 patient care was of the right standard, and of course,
6 to take the necessary action if things were found not to
7 be of the right standard. There would be many other
8 tasks as well, which would involve things like, yes,
9 financial issues, professional issues with colleagues,
10 clinical behaviour, recruitment and retention of staff,
11 contract negotiations, with purchasers and links with
12 general practitioners. A whole host of things, really.
13 Q. Can I come back to the chart at 128/3? I will pause if
14 I may after you have given each answer to enable the
15 stenographer to catch up. You have a natural fast way
16 of speaking.
17 A. I am sorry. I shall try and slow down, if that would be
18 helpful.
19 Q. If you can. If you find it unnatural, please do not
20 force yourself. I will simply give space. So if the
21 question seems to take some time in coming, you will
22 understand why.
23 A. Thank you.
24 Q. The Director of Finance, in brackets, (Deputy Chief
25 Executive): what was unusual as you saw it about his
0030
1 role and the way he performed it, when you inherited the
2 structure?
3 A. Before I took up post, I had assumed that the title of
4 "Deputy Chief" implied exactly that, but when I came to
5 the Trust, it became clear to me the Director of Finance
6 was only the deputy in respect of one part of the
7 organisation's activities and in fact the Medical
8 Director was the designated deputy for the medical
9 aspects of the Trust's activities and that was something
10 I had not appreciated before I came to the Trust, nor
11 had it been made clear in the paperwork associated with
12 the interview, and so on.
13 Q. You, for your part, made sure that the Deputy Chief
14 Executive in name became the Deputy Chief Executive in
15 role?
16 A. Yes.
17 Q. So that you had somebody who could deputise for you if
18 and when necessary?
19 A. That is correct.
20 Q. Previously, what you have described as being the
21 situation is that the medical and the financial aspects
22 were effectively split so that there was, as it were,
23 a Chief Executive with two deputies: Deputy (Finance),
24 and Deputy (Medicine)?
25 A. I think it would be incorrect to say just finance.
0031
1 I think the Director of Finance's responsibilities as
2 a deputy were not just contained to financial issues.
3 They did include general managerial issues, but I think
4 from what people told me, I suspect that he will have
5 worked very closely with the Director of Operations on
6 the general managerial issues, because she was a very
7 experienced manager and had a clinical background
8 herself. So I think, as I say, to restrict his
9 deputising to financial issues would be wrong: it was
10 the general management of the Trust, but excluding
11 issues pertaining to medical standards and medical
12 staff. That is as I understood the situation to be.
13 Q. What is the disadvantage of having the twin route rather
14 than the single route?
15 A. As I think in any organisation, it can lead to lack of
16 clarity about who is responsible for what. It can lead
17 to confusion about who is responsible for what, and --
18 I think that is it, really.
19 Q. Did it take away another layer, as it were, of
20 accountability above the Medical Director?
21 A. How do you mean? I am sorry, I do not quite understand.
22 Q. Under the system as you have it, the Medical Director
23 reports to you through the Assistant Chief Executive,
24 the Deputy Chief Executive, does he?
25 A. No. No.
0032
1 Q. Is he accountable directly to you?
2 A. All of the Executive Directors report directly to me.
3 In my absence, the Director of Finance deputises for me
4 across the whole range of my duties.
5 Q. Then you have answered the question.
6 You set out the changes which you made over the
7 next two pages of your statement. Can we have a look at
8 the changes you made in particular in respect of the
9 Medical Director? We have those set out at 128/4.
10 What you have is a Medical Director who was
11 unusual, was he, in the amount of time that was devoted
12 to the job that he was doing?
13 A. I have not got any factual basis or comparison to
14 support that statement, but certainly, I felt that for
15 a Trust of the very large size of the UBHT, certainly
16 two sessions per week was inadequate to undertake the
17 role.
18 Q. The point has been made elsewhere that some of the
19 clinical directorates were as large as some small
20 trusts?
21 A. That is correct, yes.
22 Q. So that gives an accurate flavour, does it, of the size
23 of the whole operation?
24 A. Indeed.
25 Q. You tell us that the new Medical Director whom the Trust
0033
1 has appointed has seven sessions a week, which is what,
2 three and a half days?
3 A. That is correct.
4 Q. So that director now spends what, two and a half days on
5 medical --
6 A. He has 3 clinical sessions and 7 non-clinical sessions.
7 Q. Mr Wisheart was doing what, one day per week, in effect,
8 as Medical Director, and four days other things?
9 A. That is correct.
10 Q. Given the size of the Medical Director's role, could he
11 cope?
12 A. I think he did remarkably well to devote as much time to
13 it as he did.
14 Q. That is not quite the question.
15 A. I will go on to explain: given the tremendous demands of
16 his clinical work, I certainly was of the view that with
17 the agenda changing and growing very rapidly, the
18 inadequacy of two sessions would only grow greater
19 still. So I did not think that was enough time to
20 devote to the role; it was as simple as that.
21 Q. So if I just go back to the question and seek an answer
22 to it, given the amount of time that he was permitted by
23 the structure, could he cope?
24 A. No. He did not have the time to cope with all the
25 things that I wanted him to do.
0034
1 Q. You referred to the increasing demands of government and
2 pressures of the Trust and so on over time. From your
3 own experience as having occupied a senior post in
4 Trusts and their predecessors since 1986, how usual was
5 it for a Medical Director to have only two sessions per
6 week?
7 A. It is hard to say, really. From the start of Trust
8 status, some Trusts had full-time Medical Directors
9 right from the start; other Trusts, like the one I ran
10 in Leicester, had a Medical Director who only devoted
11 two sessions to the job and I supported that Medical
12 Director with other people to share the load. A whole
13 variety of models were in place right from the word go,
14 really.
15 Q. Obviously one has to have a model which is appropriate
16 to the particular institution?
17 A. Yes.
18 Q. For something of the size of UBHT, plainly, when you
19 came in, you would not expect one man to do the job with
20 two sessions a week without support?
21 A. Yes.
22 Q. As I understand what you are saying in 128/4(iv), in the
23 paragraph we have on the screen, there was no support?
24 A. That is correct.
25 Q. So he was doing it all himself, basically?
0035
1 A. Well, trying to, but he just did not have the time to do
2 it.
3 Q. For how long, probably, would that have been the
4 situation?
5 A. I am not sure but I think that there had only ever been
6 two sessions devoted to the Medical Director role since
7 the Trust started, but I would not be absolutely sure
8 about that.
9 Q. If you had been designing the Trust administration back
10 in 1990/1991, before it began in 1991, what, in your
11 view, would have been the appropriate number of hours
12 without support for a Medical Director to have had,
13 broadly?
14 A. I only hesitate because I am mindful that the view of
15 the Trust Board at the time and a view which I share to
16 this day, was that it is important for Medical Directors
17 to continue with some medical and clinical
18 responsibilities in order to keep their feet on the
19 ground, and were, and make sure they stay in touch with
20 clinical practice, but I think it is fair to say that
21 a Trust the size of UBHT could easily have justified
22 a Medical Director working the majority of their time on
23 Medical Director duties, if not full-time, such was the
24 load.
25 Q. If they were not to do it without support, if they were
0036
1 to have support, then you would be looking at -- you now
2 have 4 associated directors providing a further 8
3 sessions. Plainly, if someone was not to spend their
4 whole time doing the job, they would have needed
5 appropriate Associate Director support?
6 A. They certainly would have needed some Associate Director
7 support. I think the actual associates would have
8 reflected the particular priorities and pressures at the
9 time and there have been many changes which have
10 necessitated additional support since the early 1990s,
11 but I am sure some kind of associate support would have
12 been necessary in somebody was not able to devote
13 a substantial part of their time to the job.
14 Q. The consequences in terms of delivery of a service to
15 patients of having inadequate time devoted to Medical
16 Director at Directorate level is what, generally
17 speaking?
18 A. There may be no consequences at all. It may be that
19 there are no problems requiring resolution, no standards
20 that need to be improved; there is no clinical practice
21 that needs better auditing or better governance, as we
22 now understand it.
23 I think the consequence, though, is likely to be
24 that there will not be enough time for the Medical
25 Director to have assured him or herself that all of the
0037
1 clinical services of the Trust are being properly
2 monitored, properly audited, properly developed, with,
3 you know, standards of patient care at the front of
4 everyone's minds. I do not think it is conceivable that
5 that could happen, given such a low level of input from
6 a Medical Director, as was the case in the UBHT in the
7 past.
8 Q. Given the hypothesis you put forward that nothing needs
9 to be done in terms of monitoring, auditing, improving
10 standards, and developing the service, if that were the
11 position, that would be a very unusual hospital, or
12 a very unusual Trust, would it not?
13 A. Indeed, it would.
14 Q. Because the history in the medical service generally,
15 and Trusts I imagine are no exception, is constantly
16 striving to improve, because there is always improvement
17 to be made, is there not?
18 A. That is quite right.
19 Q. Would it follow that giving so little time to the
20 medical directorate as part of the structure was
21 actually to risk adverse consequences in terms of
22 monitoring, auditing standard development and
23 improvement of patient care?
24 A. That would depend in the particular circumstances of
25 UBHT, I think, as to how much time the Chief Executive
0038
1 himself devoted to those issues. It may be that he
2 devoted a good deal of time himself to those issues, in
3 which case he may well have felt that the problem was
4 not as great as you describe it. But I do not know
5 whether that was the case or not.
6 Q. Because you are visualising a situation here where, if
7 you like, he, the Chief Executive, provides the support
8 and the additional time which the Medical Director
9 himself lacks?
10 A. That may have been the case, I do not know.
11 Q. That is the only way in which one would avoid the risk,
12 is it?
13 A. No. There would be other ways to avoid it. For
14 example, by a much greater involvement from other Board
15 members, perhaps non-executive directors, or by the use
16 of other sources of advice and support to try and
17 achieve the same result. It is not immediately clear to
18 me what those might have been, but there might have been
19 other ways it could have been achieved.
20 Q. We have talked in hypothetical terms. From your
21 knowledge such as it is of the Board minutes of the
22 proceedings before you took over, did that happen at
23 Bristol?
24 A. No. I have not studied all of the minutes and agendas
25 and so on from the past in the same detail as the
0039
1 Inquiry has, I am sure, but to my knowledge, these
2 issues were not regularly or even infrequently discussed
3 by, for example, non-executive directors.
4 Q. Can I leave the issue of management and the particular
5 role of the managers within it, save I think I ought to
6 give you the opportunity, perhaps, of commenting, if you
7 would, on Appendix 1 to your statement. We have that at
8 128/8.
9 This is the present structure which you have in
10 place?
11 A. With the exception that since April of this year,
12 subsequent to preparation of this, the mental health
13 services of the Trust moved to another Trust, the Avon
14 and West Wiltshire Mental Health Trust and are no longer
15 part of our Trust. Apart from that, that is an
16 up-to-date structure of our organisation.
17 Q. So if we were to put a black line through "mental
18 health", the top line of the big wide box, with that
19 alteration, this would be a description of the way
20 things now operate, the lines of accountability and
21 responsibility?
22 A. That is correct.
23 Q. If that is the picture, why is that better, in your
24 view, than that which you inherited?
25 A. For a number of reasons. Firstly, the Director of
0040
1 Nursing has a role entirely devoted to professional
2 clinical developmental issues around patient care and in
3 particular the nursing, midwifery and visiting aspects
4 of patient care. I think that is very important, and as
5 you have seen from my statement, I did feel when
6 I arrived in the Trust that Margaret Maisey just did not
7 have the time to devote to those issues, because the
8 Director of Operations of the Trust was a very large
9 one, and I felt strongly the right standards of patient
10 care could only be achieved with a contribution from
11 a nursing professional. So the Director of Nursing's
12 role now is essentially, as I say, around professional
13 standards, care, development, teaching, training,
14 a whole range of issues around standards of service and
15 so on. So I think that is a very important part of the
16 change that we made.
17 We have already talked about the role of the
18 Director of Finance and the Deputy Chief Executive, who
19 is now the deputy across the whole range of the Trust's
20 activities. I think that is equally important in terms
21 of clarity and accountability.
22 We have re-emphasised the relationship between the
23 General Managers and the Clinical Directors, and the
24 General Managers now are quite clearly accountable to
25 their Clinical Directors. Clearly they still continue
0041
1 to have lots of day-to-day contacts with senior members
2 of the management team at executive level, but we have
3 tried to reinforce the partnership that is at the heart
4 of each of the directorates, really, which is the
5 Clinical Director and the General Manager, to try and
6 make that work as well as possible. So that is another
7 change, I think.
8 The Director of Personnel now has responsibilities
9 across all of the Trust's staffing and personnel matters
10 and works closely with relevant other senior
11 professionals, be it Director of Nursing or Medical
12 Director, as appropriate in those issues.
13 The Medical Director as you have previously
14 mentioned is a 7 session Medical Director, well
15 supported in a range of areas which have been
16 increasingly important in recent years like education,
17 research and development, teaching issues, strategic
18 planning and now clinical governance.
19 Finally, a key post really, the Director of
20 Service Development and Review, a post that carries
21 responsibilities both for the long-term planning of the
22 future activities and development of the Trust in
23 collaboration with all our NHS and other partners
24 locally, but also has an important role in helping our
25 thinking about the performance management of the
0042
1 organisation, I think it is probably the best way to
2 describe it.
3 By that I mean he has a specific responsibility
4 for monitoring and reporting to the Board a whole range
5 of indicators about performance of the organisation, but
6 also, he is charged with helping us develop our
7 thinking, and works closely with the Director of Nursing
8 and the Medical Director on aspects of monitoring the
9 clinical performance of the organisation, so although
10 the clinical governance of the organisation is primarily
11 my responsibility, helped by the Medical Director and
12 the Director of Nursing, that Director of Service
13 Development and Review plays a role in gingering up the
14 thinking, if you like, and bringing in performance
15 measurement techniques and ideas from other aspects of
16 our work and see if they can apply to our clinical work
17 as well. So it is an important part of the overall
18 performance management efforts of the Trust.
19 That is the way it now works. I think that is
20 relevant to the demands and the expectations on the
21 Trust in 1999.
22 Q. So if I were to ask, had you institutionalised audit,
23 formalised the lines of reporting and accountability in
24 respect of clinical audit, the answer would be "Yes"?
25 A. It would, yes.
0043
1 Q. That was a development you specifically made, and you
2 tell us about in your statement, because that is a new
3 appointment. There had not been a Director of Service
4 Development and Review before, had there?
5 A. Well, part of the role was that undertaken by Steven
6 Boardman when he was employed by the Trust during the
7 period he outlined in his statement, but I would not --
8 I am sorry if there is certain confusion about the role
9 of the Director of Development. He does not have
10 a specific remit about the standard of clinical
11 services; he is part of the team that helps develop our
12 ideas. The specific remit about the monitoring of
13 clinical services is through the Clinical Governance
14 Committee, co-chaired by the Director of Nursing and the
15 Medical Director.
16 Q. Can I pass from the present to ask you what you say
17 about the style of management, the culture of the
18 organisation. It is 128/5. It is paragraph 9.
19 You say in the second sentence there that your
20 management is as much about personal beliefs and style
21 as it is about management structures and organisation.
22 You say you recognise that Dr John Roylance's management
23 style differed from yours, just as you would anticipate
24 that your eventual successor may have a different
25 approach again?
0044
1 A. Yes.
2 Q. With that in mind, can I ask you to take a look at
3 a report or analysis which was prepared for an executive
4 group workshop on June 3rd 1992 by a Miss Thorn. We
5 have it at UBHT 296/1.
6 This is a document which I think you came across
7 and forwarded to the Inquiry as perhaps providing some
8 interesting insights into what she saw as the position
9 and nature of the Trust back in 1992, before you came
10 in?
11 A. Actually, it was brought to my attention by Steven
12 Boardman who found it in his papers when he was
13 preparing his statement and sent me a copy, and
14 I thought the appropriate thing to do was to send a copy
15 to the Secretary to the Inquiry, which I did.
16 Q. If I can deal with what she says about the general
17 culture in the introduction, she says this:
18 "Rather than writing a full paper for the group,
19 I have decided to present some skeleton ideas. This is
20 a conscious decision and is based upon my experience and
21 understanding of the culture."
22 She goes on at a later stage to say she worked at
23 the UBHT for a couple of years, and had come to know the
24 culture.
25 "Firstly, the organisation at Executive Director
0045
1 level is primarily an oral culture - consequently to
2 produce great reams of written material at this stage is
3 counter-cultural."
4 Was that a reflection of the culture that you
5 think you inherited?
6 A. I am not sure how an "oral culture" is defined. That is
7 why I am struggling with the question.
8 Q. I think it is people talking to each other rather than
9 writing memos.
10 A. If that is the case, that is still the culture. The
11 pace and the complexity with which we work demands that
12 many things are said once and done, and I think if we
13 put everything in writing, the whole organisation would
14 grind to a halt. So there is still an oral culture at
15 director level to a large extent and I think it is fair
16 to say that is what I inherited.
17 Q. The sting in it from her point of view may be the last
18 sentence:
19 "At UBHT, if it is written down, it is either very
20 important or ignored."
21 Does that happen today?
22 A. I would be very disappointed if the second thing
23 happened.
24 Q. But is it then still the case that if it is very
25 important it gets written down?
0046
1 A. Yes, I think if things get put in writing, it means they
2 are important, and they need to be put into writing
3 because they are important.
4 Q. At page 2 she talks about "cultural change" and appears
5 to focus on three areas: the coming into being, which is
6 just down at the bottom of the screen, and then
7 September 1989 to 1990, the development of the Trust
8 idea, redefining the district, setting up the project
9 group to produce a Trust application.
10 "Here the focus on the creation of a new style
11 organisation from the corpse of the old, senior managers
12 in three roles, district, provider and project, and a
13 terrible confusion about what was happening. This was
14 reinforced by the Department of Health's 'continual
15 changing of the rules' [in quotes], a major period of
16 unfreezing in the organisation and a time of many moves,
17 considerable anxiety and stress."
18 Would such a description have been peculiar to
19 Bristol?
20 A. I do not think so, no.
21 Q. Was it something, so far as you are aware, that was
22 general across the country?
23 A. I think certainly for the first-wave Trusts, there would
24 be first-wave Trusts, yes, I think it was a very
25 difficult, complex time.
0047
1 Q. "April 1990 to September 1990, a full provider role and
2 shadow contracting with the purchasers was overshadowed
3 by the appointment of the new Chairman of the DHA."
4 She goes on to describe political conflicts,
5 "insecurity and anxiety increased. The solidarity of
6 the Trust group was reinforced by identifying a common
7 enemy, workloads increased through managing the conflict
8 and attention was deflected from the primary aim."
9 Again, did you see any trace of that or its legacy
10 at the time that you took over?
11 A. There was, I think, a feeling when I took over of "us"
12 and "the rest". There was still evidence of "us" in the
13 Trust. But I think that might have been as much about
14 the history and culture of the BRI particularly, as
15 about the issues particularly around an application for
16 Trust status.
17 Q. I am not sure, it may relate back to a comment which you
18 made and I had noted, in your statement, if we just go
19 back to it for a moment, at 128/6. You are talking at
20 the top of the page about medical audit which had always
21 been a particular interest of yours. You say, in the
22 second line down:
23 "I had always been keenly aware of the potential
24 benefits of having details across the board of how
25 clinical services were performing, or alternatively,
0048
1 whether there are problems which need to be addressed.
2 I am not sure whether these benefits were universally
3 perceived at the outset on the medical side."
4 That is a reflection of a certain reluctance,
5 perhaps, on the part of doctors, to see benefits as
6 opposed to threats from audit.
7 A. That is correct.
8 Q. Is that part of the "them and us" approach to which you
9 are referring, or not?
10 A. No. I was specifically referring to the Trust versus
11 the rest, "us" being the Trust, the UBHT, and the
12 feeling I encountered when I arrived that it was really
13 down for the Trust to manage itself, and it really was
14 not anybody else's business by and large how it did it.
15 That is what the culture of the Trust was.
16 Q. So did this make the Bristol Royal Infirmary a more
17 difficult place to run?
18 A. Not necessarily, in that that culture had developed
19 a strong bond between the senior staff in the Trust, and
20 I think there was a lot of initial difficulties having
21 been got over, there was a loyalty to the Trust.
22 I think it made the relationships with bodies like the
23 Regional Health Authority perhaps more difficult,
24 because the culture of the first-wave Trusts, as you may
25 have heard already, was very much that it really was not
0049
1 anybody's business, perhaps, other than the Department
2 of Health's, how they ran themselves. They were as
3 close to independent as could be the case within
4 a centrally managed state health system.
5 Q. What had created this feeling in the first place?
6 A. The exhortations from the government at the time that
7 Trust status was about new opportunities, new freedoms,
8 and a removal of the monitoring mechanisms that had
9 traditionally been in place.
10 Q. If you go back to Ms Thorn's paper at 296/4, she is
11 talking in the middle of the page here, "UBHT sees
12 itself as a family or club."
13 The "us and them" approach, perhaps, it may be
14 reflected in what she says in the paragraph. I welcome
15 your comments on it:
16 "UBHT sees itself as a family or club. You are
17 either a UBHT type of person or you are not."
18 She goes on, but in particular, one comes to the
19 bottom last seven lines:
20 "Being counter-cultural and challenging the
21 cultural message is viewed in the Executive Group as
22 disloyal. The senior group are deemed to be those with
23 most responsibility for making it work, implementing the
24 culture. It is not appropriate to challenge the message
25 and strategy publicly because it is translated as
0050
1 questioning loyalty. Loyalty to the Chief Executive is
2 a critical cultural attribute, hence disloyalty is
3 viewed with severe disapprobation."
4 Does that reflect the "them and us" approach that
5 you have been talking about?
6 A. It could do, yes. It is a difficult one for me to
7 comment on, because, you know, the period of time that
8 this looked at was not a period of time I was associated
9 with the Trust, but I can see what I perceive to be the
10 "them and us" attitude, UBHT versus the rest, might
11 play internally as well, and I can see how a situation
12 might arise where people are deemed to be not
13 sufficiently on board, but I have never heard it
14 expressed in the terms, you know, that are in this
15 report.
16 MR LANGSTAFF: That perhaps is a convenient moment, sir, for
17 a break? We would normally take a break of a quarter of
18 an hour, at this stage.
19 THE CHAIRMAN: Yes, thank you. Shall we reconvene,
20 therefore, at 11.15?
21 (11.00 am)
22 (A short break)
23 (11.15 am)
24 MR LANGSTAFF: Mr Ross, we have seen what Ms Thorn said
25 about the question of culture. Shall we have a look,
0051
1 please, at what Mr Boardman had to say? It is
2 WIT 79/14. It is paragraph 48.
3 In his view, Dr Roylance actively tried to create
4 a club culture for both the immediate Executive team and
5 the wider cadre of General Managers. This was done
6 explicitly, often using one of the models cited in
7 Charles Handy's management textbooks.
8 He sets out the four features as he saw it of the
9 culture, you were either a UBHT type or not, which
10 actually echoes the very words that Ms Thorn had used,
11 I think. Progress appeared to depend on your fit within
12 the club rather than performance;
13 "(iii) to challenge policy or strategy was
14 perceived as disloyalty; and
15 "(iv) people who transgressed the unwritten rules
16 were required to be 'put back in their box' until they
17 conformed once more".
18 You tell us that it was actually Mr Boardman who
19 sent Ms Thorn's paper through to you?
20 A. That is correct.
21 Q. We may take it, perhaps, from this paragraph, that not
22 only did he send it through, but he appears to endorse
23 it. It may be that he has lifted parts of what he says
24 there from her paper?
25 A. Possibly.
0052
1 Q. But you will have heard, I am quite sure, views
2 expressed to you over time as to how things used to be
3 done. Does this picture correspond with that which you
4 have had expressed to you?
5 A. Some of it I do not have any sort of evidence to offer
6 on, really, but certainly, (ii) there, it certainly was
7 a strong feeling when I arrived from General Managers
8 that issues like promotion within the Trust and so on
9 were not decided necessarily on objective grounds, based
10 on individual reviews and performance reviews and so on,
11 but on some less easily measurable factors and things
12 like fit or, you know, whether you were in, those were
13 the sorts of things they said to me they thought were
14 more influential in deciding issues of promotion and so
15 on than perhaps objective measurements of their success
16 in doing their job.
17 So that would be one aspect that I did hear about.
18 I do not recall hearing particular statements that
19 reflect the other things mentioned there.
20 Q. In terms of fit and performance, was that at all
21 associated either to your knowledge, or for that matter
22 by rumour, with Freemasonry?
23 A. Certainly not to my knowledge. I have heard the
24 Freemasonry issue mentioned a number of times since
25 I came to the Trust. I have never seen any evidence at
0053
1 all to suggest that it played a part in the management
2 of the Trust.
3 Q. Do you know who was or was not a Freemason?
4 A. I asked a couple of people and they said they were not,
5 and that is all I know, really.
6 Q. In terms of employment and promotion, and the progress
7 appeared to depend on "fit", are we talking about all
8 employees generally, by which I include clinicians, or
9 are we talking about clinicians or other employees as
10 distinct from one another?
11 A. My sense of it is what Steven Boardman says here: the
12 club culture was around the wider Executive team and the
13 General Managers rather than more widely spread. That
14 is my sense of what happened.
15 Q. To what extent do you get the feeling that the
16 challenging of policy or strategy might be perceived as
17 disloyalty?
18 A. I am not sure that I did get that perception, actually.
19 It is difficult to say. The Chief Executive goes, a new
20 Chief Executive comes and the culture starts to change
21 straightaway, for good or for bad, that is just the way
22 it happens. I got the impression certainly that there
23 was a good deal of openness in discussing policy issues
24 and so on within the organisation, and I did not find
25 any barriers to that when I came, nor did I find people
0054
1 too inhibited or over-inhibited in saying what they
2 thought.
3 Q. Can I take you back from Mr Boardman's statement to what
4 Ms Thorn said: UBHT 296/6. Under the heading "The
5 Executive Team", she talks about the role and style of
6 the leader, the Chief Executive. You, for your part, in
7 your statement -- this is where we began going into
8 these documents -- said that your management style was
9 different from Dr Roylance's. There is a description of
10 his style here. She says:
11 "All the views can best be summed up by the
12 following quote: 'He is central to everything. He is
13 different. We wouldn't be where we are now without
14 him. He can influence and predict the medical lobby.
15 His considerable intellect opens up wider
16 possibilities. He has the vision'."
17 She goes on to talk about the club culture being
18 critical in the next paragraph:
19 "The Chief Executive surrounds himself with people
20 who can adapt to this style of working in a very
21 personal way. 'I have found my own ideas are permeated
22 with his. He wants people round him basically who have
23 a similar approach. People who cannot cope with that
24 go."
25 I am not sure how far that might reflect the views
0055
1 of your predecessor which have been expressed to you by
2 various people through the grapevine since you have
3 come. Perhaps you can tell us?
4 A. I think there is no doubt that Dr Roylance was a very
5 dominant figure in the organisation, and it would be
6 hard for me to think, thinking about other Chief
7 Executives I have known over the years, hard to think of
8 a more dominant Chief Executive in any other Trust that
9 I have known. His very long service in Bristol, his
10 considerable experience, the fact that he led the
11 district and then the Trust through a very difficult
12 period and established one of the very biggest of the
13 first-wave Trusts, meant really that he was quite
14 unquestioned as the sort of leader and central figure of
15 the organisation.
16 Whether it is correct, as it says here, that he
17 surrounded himself with people who adapted to his style
18 of working, I am not really sure. I think all of us who
19 have positions of responsibility seek to have people
20 working with us who have the same values and the same
21 approach and style, to a certain extent, as we do.
22 Clearly a degree of difference adds value, in my book at
23 least, but equally, people who are at very different
24 ends of the spectrum sometimes find it very difficult to
25 work together, so I am not sure I could comment so
0056
1 easily on the second part of the that statement.
2 Certainly the first bit about the centrality of
3 Dr Roylance is undoubtedly the case.
4 Q. If we can turn over the page, it is the third
5 paragraph down:
6 "All of the executives expressed loyalty as an
7 important construct and felt that there was
8 a paternalistic approach in their relationship. The
9 CE would take care of them if they had problems, would
10 'bail them out'."
11 There is an echo there of perhaps what you were
12 telling us earlier about the feeling of being together
13 in the "them and us" approach, "us" here at the BRI,
14 "them" at region or elsewhere?
15 A. Yes. I think that is fair and I think paternalistic
16 approach, I often heard John Roylance described as
17 a "father figure" in the Trust, and I think that was
18 very much his style.
19 Q. The feeling that he would take care of individuals if
20 they had problems and bail them out, as an expression of
21 feeling, is it probably accurate or probably not?
22 A. I do not know.
23 Q. You cannot say?
24 A. No.
25 Q. So far as you were concerned, I think you addressed the
0057
1 culture in one respect, at any rate, if we have a look,
2 please, at UBHT 9/68.
3 This comes from a minute when you were stressing
4 the value of the Executive Director taking time to lead
5 public relations. Just read it through for a moment:
6 "The Trust would need to spend a little more on
7 public relations than it had done before, and a cultural
8 change was needed to highlight the value of public
9 relations.
10 "The draft action plan ..."
11 A. Can you tell me what document this comes from?
12 Q. Yes, certainly. Can we go back a couple of pages,
13 please, and see if we can find the beginning of it? It
14 is the marketing development committee of 7th March
15 1996.
16 A. Thank you.
17 Q. The view is recorded as being -- I imagine it was your
18 view, but tell me if it was not -- that the Trust would
19 need to spend a little more on public relations than it
20 had done before, cultural change was needed to highlight
21 the value of public relations.
22 First of all, is that an accurate reflection of
23 your view?
24 A. Yes.
25 Q. It follows that before the change was made, having an
0058
1 Executive Director with time to lead public relations,
2 that those in the Trust on the whole were not perhaps
3 sufficiently concerned with PR?
4 A. I think it is -- yes, as a subset of my earlier answer
5 about the Trust being perhaps not unduly concerned about
6 a whole range of external bodies, I think that would be
7 a subset of that answer.
8 Q. The cultural change to which the minute refers and which
9 you refer to by adoption, what sort of change had you in
10 mind?
11 A. To set it in the context of the time, this meeting took
12 place about five weeks after we released the first
13 public report on the paediatric cardiac surgery results
14 in the Trust, in the early 1990s. I am sure that having
15 been through that particularly difficult and sensitive
16 exercise, my thoughts and the Chairman's were turning to
17 no doubt how we could be proactive in the local
18 community, with patients, with relatives and really
19 try, now that we had embarked on a path of openness
20 about our dealings and the results in the past and so
21 on, I think we felt it was very important we try to move
22 that along as quickly as we could.
23 The Trust had traditionally done a lot of good
24 work inside the Trust with patients and their views and
25 so on, but I do not think that had necessarily extended
0059
1 to the wider arena as well as I thought it might have
2 done.
3 Hence the comments there about how you handle bad
4 news, how you try and get out the good news, how you
5 increase the profile and the readiness of people in the
6 organisation to cope with dealing with the media, with
7 issues of interest to the public and how you set that in
8 a management context that ensures sufficient management
9 time is given to it.
10 That was the context of the time and that indeed
11 became part of the role of the Director we appointed
12 within a couple of months of this meeting, the Director
13 of Service Development and Review.
14 I am sorry, have I answered the question or not?
15 Q. I think you have. The public relations, you have
16 indicated in that answer, is about giving information to
17 the public?
18 A. It is about many things. That is one aspect of it.
19 Q. And so far as you can comment, was sufficient done prior
20 to your Executiveship to give information to the public
21 about that which the Trust was doing and how it was
22 performing?
23 A. I have no concrete knowledge about that which was done
24 prior to my arrival in terms of a concerted effort, an
25 ongoing effort in terms of public relations, but the
0060
1 evidence that I saw when I arrived about the way the
2 Trust was responding to issues of public concern I think
3 suggested to me that not sufficient had been done in the
4 past.
5 Q. You mentioned the problems which hit the media over the
6 paediatric cardiac service. Can we have a look, please,
7 at UBHT 52/137? Could I make it plain, I am using this
8 document as a means to ask you questions about the
9 structure and nature of the service.
10 If we can scroll down, please --
11 A. Can I know a date of this to give me some context,
12 please?
13 Q. It is after the de Leval report. It is January 1996 on
14 the next page, your initials at the end.
15 A. Thank you.
16 Q. Can we go back to the lessons the Trust has learned?
17 Can I make it clear, what I want to ask you about is in
18 relation to the subject of today's evidence, so no-one
19 should think that questions are not being asked by, as
20 it were, mistake or by being overlooked.
21 What is said there is that the Trust has learned
22 a number of important lessons from the episode. The
23 first point:
24 "There was no multidisciplinary audit in place
25 that was contributed to and accepted by all. This was
0061
1 a major obstacle."
2 Multidisciplinary audit would be something which
3 management would have to decide upon, would it?
4 A. It would be something that management needed to insist
5 was in place, but it would be for the various
6 professional groups themselves to organise themselves
7 and ensure it was done to an adequate standard. Of
8 course, that would be monitored as well.
9 Q. So the present system is that it is in place?
10 A. Yes.
11 Q. Management insists upon it. It is done by the
12 clinicians but it is monitored?
13 A. That is correct.
14 Q. And you described earlier to us how that is monitored by
15 a particular committee?
16 A. That is right, through a series of reports culminating
17 in an annual report to the Trust Board.
18 Q. "(2) The audit performed by [Steve Bolsin] was done on
19 a personal basis, unknown to (some) colleagues. The
20 methodology was not shared and some of the data and
21 conclusions were subsequently shown to be wrong. The
22 difficulty this caused in [his] (overall) conclusions
23 being accepted should not be under-estimated."
24 What you are reporting there are lessons of the
25 mixture of the culture and the absence of proper
0062
1 institutionalised system of audit?
2 A. Yes, I think that is fair.
3 Q. So far as the culture is concerned, there was, it was
4 understood by you, difficulty in his conclusions being
5 accepted?
6 A. I am sorry, could you repeat that?
7 Q. There was, was there, personal difficulty for a number
8 of people in his overall conclusions being accepted?
9 A. That certainly seems to be the case from all the records
10 that I have seen, yes.
11 Q. To what extent was that a reflection, would you say, of
12 the absence of an institutionalised system of audit
13 properly monitored, and to what extent did you consider
14 that was part of a club culture where someone who rocked
15 the boat, in whatever capacity, might be, as it were,
16 going against the "club"?
17 A. They could both be contributory factors. Clearly, if
18 there was no thorough-going structure in place along the
19 lines we have discussed, then that is not going to lead
20 to a climate whereby individuals doing audit and then
21 presenting it is necessarily going to be received
22 positively. Also, of course, if data is produced that
23 appears to be critical of certain individuals and has
24 not been collected with their knowledge and they do not
25 subscribe to the methodology, then it would be
0063
1 surprising if they did not feel a degree of resentment
2 and rejection of what was put in front of them. And it
3 is possible that if this was undertaken by someone
4 relatively new to the organisation who was challenging
5 senior figures in the organisation, that, yes, indeed,
6 it may have cut across some of the cultural boundaries
7 within the Trust.
8 Q. If we look at the position of the whistle-blower, the
9 man you have just been describing, how, in today's
10 environment, would the Trust protect the
11 whistle-blower?
12 A. I would like to think the whistle-blower would not need
13 protection and that they would be encouraged in coming
14 forward with their concerns. Those concerns would be
15 very thoroughly and properly discussed. If, for any
16 reason, the colleagues themselves were not able to
17 resolve the issues, put the problems right, move
18 forward, then the Clinical Director, and if necessary
19 the Medical Director, if necessary myself, would get
20 involved in making sure that any concerns that were
21 raised were properly understood and properly worked
22 through.
23 So I think "encouragement" of whistle-blowers is
24 the order of the day, rather than "protection".
25 Q. Suppose the whistle-blower wants to complain about the
0064
1 Clinical Director, him or herself?
2 A. The Trust's policies on this are very clear: they are in
3 writing to all the members of staff, and that makes it
4 clear, if the concern is about the Clinical Director,
5 then the concerns must be shared with the Medical
6 Director. If they are about the Medical Director, then
7 they must be shared with the Chief Executive. If they
8 are about the Chief Executive, they must be shared with
9 the Chairman.
10 Q. If the whistle-blowing allegations are ultimately
11 rejected, is there any comeback these days on he or she
12 who makes the allegations if they are made in good
13 faith?
14 A. Certainly the organisation, there would be no comeback
15 from the organisation, but obviously colleagues -- one
16 would do one's best to try and make sure locally things
17 were worked through as locally as possible, but we
18 cannot legislate for individual feelings in certain
19 circumstances, lingering resentment or whatever it might
20 be. It is something we might have to learn to handle as
21 we go.
22 Q. It was that I was going to ask you about next, because
23 obviously there is a question of culture here and how
24 the individual is regarded in the small circle he or she
25 has to work with.
0065
1 How do you handle that? You say you have to learn
2 to handle it. How do you do it now?
3 A. Firstly, we have, as I mentioned, a series of policies
4 and procedures in place that are very clear about
5 people's responsibilities, indeed "obligations" is the
6 word we actually use, if they have concerns about
7 clinical standards in any area.
8 Through all our risk management efforts we do our
9 utmost to encourage all members of staff to come
10 forward, to do so anonymously if they wish, because we
11 feel it is very important to get the information out in
12 the open, even if it is preferable that somebody
13 associates themselves with concerns, better to have it
14 expressed openly and honestly than not have it expressed
15 at all. We encourage a very full and regular discussion
16 of the problems that are raised and through the
17 mechanisms already described, make sure there is a cycle
18 of learning, changing things, auditing practice, taking
19 on board new standards and new ideas from elsewhere, and
20 the aim of course is to achieve a continually improving
21 standard of performance in clinical care.
22 Q. The two aspects of that that I want to press you on
23 a little, so I understand what the present situation is
24 in order to compare it with what may have been, the
25 cultural aspect in the sense of how someone relates to
0066
1 their fellows may depend on that which their fellows
2 expect of the group?
3 A. Yes.
4 Q. If one has a club culture, then necessarily the culture
5 looks adversely on someone who wants to rock the boat.
6 I think that may be a general understanding. Part of
7 making whistle-blowing easier, if it is justified, is
8 presumably attempting to change the culture of those
9 around so that they see it as, you put it well, the
10 "obligation" of the individual.
11 How do you actually go about the encouragement of
12 that? How do people get the message that somebody who
13 is whistle-blowing is not rocking the boat, is not
14 showing disloyalty to the Chief Executive but is in fact
15 doing the opposite and may be promoting everyone's
16 object, which is the better health and care of patients?
17 A. The answer is that it is a long haul, really. It is
18 a long-term cultural change, not just in UBHT but in any
19 large healthcare organisation in this country and
20 probably a much wider field. It takes I think people
21 a long time to leave behind the habits of the past,
22 where it was perhaps easier to sort of turn the other
23 way and say it is somebody else's responsibility, than
24 to actually take the responsibility themselves. People
25 who do really are still quite brave in some
0067
1 circumstances, and it is very hard for, for example,
2 a theatre nurse, however experienced and capable he or
3 she may be, to question the practice of a senior surgeon
4 who has been in place for 30 years and to create
5 a culture where everybody can give and take criticism in
6 a constructive spirit and where everyone can really
7 contribute to a completely objective review of
8 performance.
9 That is a long journey, really, and the Trust is
10 on the way on that journey and lots of other
11 organisations are as well, I guess, but I am not sure
12 where the end point will be; I just know it is a long
13 journey.
14 Q. How far down the road had it got by the time you had
15 taken over?
16 A. I think that is difficult to say. I think that aspect
17 of the organisation's work was almost frozen in time
18 because of what had happened, and I think a great many
19 staff were not sure how things would turn out, and
20 perhaps, I suspect, at that time were even more
21 reluctant, perhaps, to raise criticisms and concerns
22 because they perceived that they might still be punished
23 in some way for that and to this day in the Trust, there
24 will be staff who, in spite all my entreaties and those
25 of the Medical Director and the Director of Nursing and
0068
1 everybody else, will still be wary about raising
2 concerns because they feel those concerns, not wanted,
3 will not be heard, there will be some kind of comeback
4 in some way, and I do think it takes a very long time to
5 change that culture in a health service organisation.
6 I honestly do not think, notwithstanding its unique
7 circumstances, that UBHT is necessarily that different
8 from other larger NHS Trusts. It is a long-term
9 cultural issue.
10 Q. Can I just take something which may touch on this, which
11 has happened within recent years? Can we have a look
12 for a moment at UBHT 52/65? This is to Roger Baird as
13 Chairman of the Hospital Management Committee. It is
14 "private and confidential", and it is 17th May 1996.
15 It is from Dr Coates, Consultant Anaesthetist and
16 Clinical Director of Anaesthesia.
17 It begins:
18 "You should be aware of the views of the majority
19 of consultant anaesthetists regarding the continuation
20 of Mr James Wisheart as Medical Director. In the last
21 6 weeks this has been considered at 3 directorate
22 meetings, each attended by 15 consultants. There is
23 widely-held concern about his position; the belief is
24 that he should step down. The Trust needs clear medical
25 direction by an individual who commands the confidence
0069
1 and respect of all its consultants. It has proved
2 difficult to formulate a letter that encompasses the
3 views of all the members of the Doctorate
4 of Anaesthesia. It is important to stress that these
5 concerns are based on managerial rather than clinical
6 credibility. I have informed James directly of the
7 concerns this morning."
8 He goes on, in the next sentence:
9 "I believe that it is appropriate that I should
10 append my own views. I have suggested that my
11 colleagues may wish to write in a similar vein, but it
12 is my impression that most would prefer to minimise any
13 personal responsibility for criticism."
14 Just pausing there, this is not whistle-blowing in
15 the sense of clinical complaint, because obviously it is
16 dealing with a managerial complaint?
17 A. Yes.
18 Q. But does the same apply in general: that if there are
19 legitimate complaints, they should be properly voiced?
20 A. Oh, yes.
21 Q. And this presumably was a proper way of dealing with the
22 matter?
23 A. That is correct.
24 Q. The second sentence:
25 "Colleagues may wish to write in a similar vein
0070
1 but it is my impression that most would prefer to
2 minimise any personal responsibility for criticism", may
3 perhaps appear to some to be a reflection of the "do not
4 put your head above the parapet, do not rock the boat,
5 be a member of the club" approach.
6 It is, is it not, a reflection of it?
7 A. It could be a reflection of that, yes. It could be
8 a reflection of a number of other things as well. Maybe
9 some of the anaesthetic staff had worked very closely
10 with James Wisheart over the years and therefore found
11 themselves perhaps less willing or less able to
12 criticise him than anaesthetic colleagues who had not
13 worked so closely with him, so it would reflect,
14 probably, a range of views, but there could be a range
15 of reasons why people would not want to personally take
16 responsibility for criticism. It may be somebody feels
17 it was David Coates's job as Clinical Director to speak
18 on their behalf and it may mean no more than that in
19 some cases.
20 Q. What then followed, UBHT 33/138, and the top of the
21 page: "Mr Ross stated that some clinicians had
22 registered their concern and lack of confidence", so you
23 brought it to the attention of others. Plainly, it had
24 been raised with you by Mr Baird?
25 A. I am sure that was the case, yes.
0071
1 Q. The matter was subsequently raised at a special meeting
2 of Clinical Directors held on 3rd June and at the
3 Steering Committee of the Hospital Medical Committee of
4 14th June. All meetings had included input from
5 Mr Wisheart.
6 "Mr Ross and Mr Baird reported to the Trust Board
7 that, based on the comments made at these meetings,
8 there was overwhelming support from medical colleagues
9 for Mr Wisheart to continue as Medical Director of the
10 Trust."
11 I do not want to go at this stage into the details
12 of the lack of confidence or the confidence, but perhaps
13 you can tell me: is this to some extent at any rate
14 a reflection of people coming together behind someone
15 because he was "of the club"? Is it, alternatively,
16 a question of a sectional concern simply not shared by
17 others? What was the position?
18 A. As I recall, the anaesthetic group were somewhat in
19 a minority in the discussions that were held. The
20 discussions concerned, as I recall, not James Wisheart's
21 clinical competence but the way he was doing the
22 managerial aspects of his job as Medical Director. And
23 support was voiced for him on the way that he was doing
24 the managerial aspects of his job at the time, as
25 Medical Director.
0072
1 The foundation of that support, I am sure some of
2 it must have been based on support for a long-standing
3 colleague in the Trust, who I am sure some people felt
4 was being unfairly pilloried by the media and other
5 external forces, and that may in turn have strengthened
6 their wish to support him.
7 Q. So the complaints about his clinical performance may,
8 you suspect, have influenced some, at any rate, in
9 supporting him in his managerial role?
10 A. The external complaints about his clinical competence.
11 By this time, of course, he had ceased operating as
12 a paediatric cardiac surgeon, ceased for quite some
13 time. Yes, and I think that may have reinforced
14 people's views that he could still play a useful role in
15 the Trust, even if not the role that he traditionally
16 played in clinical terms.
17 Q. Is it part and parcel to an extent of the defensive
18 "them and us" approach that you spoke of earlier?
19 A. I think it could be a reflection of, yes, perhaps the
20 medical profession's tendency to be mutually supporting
21 in times of difficulty. I do not think that is unique
22 to UBHT.
23 Q. If I can go back, then, to where we were, and the one
24 before that, if you please, if we go, then, to (3):
25 "Although the Trust moved to appoint a new
0073
1 paediatric cardiac surgeon and established new dedicated
2 facilities and decided to do so in advance of the
3 publicity of ... 1995".
4 Just pausing there, I have said in opening this
5 Inquiry that the paediatric cardiac services at Bristol
6 face no criticism, indeed, perform, it is generally
7 thought, well. Is it right that Private Eye itself now
8 agrees with that?
9 A. Yes. Slightly ironically, after all that has happened,
10 yes, Private Eye did recently enforce the opinion that
11 Bristol was now the safest place in the UK to undertake
12 cardiac surgery of any sort. We think that is a fair
13 reflection of the excellence of our current services.
14 Q. Just going on:
15 "It must be a matter of regret within the Trust
16 that there was not an (earlier) in depth management
17 investigation to resolve the concerns of the personnel
18 whose opinions needed to be respected."
19 That is obviously a record both of view and of
20 fact?
21 A. Yes. This document was a first draft of the public
22 statement that we made on January 31st 1995 [sic,
23 corrected to 1996 later in transcript], from memory, and
24 these were the sorts of points that we were deciding to
25 put in that public statement. So this was very much
0074
1 a statement designed to be made in public, but clearly
2 the Trust had not handled the issue as well as they
3 should have done.
4 Q. It is plain from what you are saying there, although it
5 is in respect of a time when you were not involved as
6 Chief Executive, that even judged by the standards of
7 the time, it should have done better.
8 A. Yes.
9 Q. If we just go down to the bottom of the page, it notes
10 the need for agreed multidisciplinary clinical audit.
11 Over the page, please, the need to ensure staff
12 concerns were listened to objectively and thoroughly,
13 and a commending of the whistle-blower in this case, and
14 then a statement about the standard of care.
15 I have asked you about the question of culture and
16 the question of what might have changed, what might have
17 been done in terms of procedures and so on.
18 You introduced, I think -- it may be part and
19 parcel of this -- a new complaints procedure, or you
20 recognised a new complaints procedure was introduced in
21 the NHS?
22 A. Yes.
23 Q. We can see that at UBHT 33/207. Can we go down,
24 please?
25 You deal with the costs of the NHS complaints
0075
1 procedure?
2 A. Yes.
3 Q. This is for patients complaining, is it?
4 A. That is correct.
5 Q. So this is not for internal complaints?
6 A. No.
7 Q. Internal complaints are dealt with, are they, through
8 the employer/employee relationship?
9 A. That is right.
10 Q. Do they fall under the Director of Personnel?
11 A. Yes. There are policies regarding, for example, raising
12 of internal complaints, grievances, those sorts of
13 things. There would be one series of policies, clearly
14 in the day-to-day general management of the Trust, if
15 that is done well, there should be every opportunity to
16 raise questions and concerns with one's immediate
17 manager.
18 Q. So one is cultural, the other is formalised?
19 A. Yes.
20 Q. So far as the formalised structures are concerned, do
21 you know whether they existed in individual contracts of
22 employment prior to your becoming a Chief Executive?
23 A. Yes. Those policies would have been standard in NHS
24 Trusts.
25 Q. So the question, then, would be the culture of whether
0076
1 they were made to work or not?
2 A. I think that is fair, yes.
3 Q. So far as you know, again, prior to your becoming Chief
4 Executive, did they tend to be used at all for concerns
5 such as those which surfaced in this particular context?
6 A. I do not really know, to be honest.
7 Q. Can I just for the sake of the record, I am grateful to
8 Miss Grey, note that when the transcript comes at the
9 end of the day to be tidied up, I think you said the
10 statement that was made was on 31st January 1995. The
11 draft document is dated January 1996.
12 A. I am sorry, 1996.
13 Q. You probably got the date wrong.
14 A. I did, thank you. 31st January 1996.
15 Q. It was a member of the public who noticed that, to whom
16 I pay thanks.
17 THE CHAIRMAN: In fact it was the lawyers behind you.
18 MR LANGSTAFF: The wider public!
19 Q. Can I turn to a completely separate issue? It is the
20 relationship which there was between the Trust and other
21 professional bodies: is and was.
22 Do you find, as Chief Executive, the relationship
23 between the Trust and bodies such as the Royal Colleges
24 helpful?
25 A. Generally speaking, yes.
0077
1 Q. And the BMA?
2 A. I have very few dealings with the BMA.
3 Q. How do the Royal Colleges and the Trusts interact?
4 Presumably they have to check the training and accredit
5 the training?
6 A. That is right. There is a whole range of, if you like,
7 under-the-surface activity that goes on all the time in
8 terms of rotations and approving rotations,
9 appointments, training programmes, all those sorts of
10 things. The most visible sign of our relationship with
11 the Colleges comes in two areas: one is the appointment
12 of consultant Medical staff, where a College adviser will always be
13 present, and the other is the regular visits that are
14 made by the various Colleges to examine our services and
15 to ensure that we are providing an environment and
16 facilities that are suitable for the training of medical
17 staff. Those are the two main areas.
18 Q. When what used to be the SAC came along to report, or
19 the Hospital Recognition Committee came along to report,
20 would you get a copy of that report?
21 A. When I first came to the Trust, I did not, as a matter
22 of routine, receive those reports, which concerned me
23 slightly. I do now.
24 Q. So the pattern used to be that they stopped where, at
25 the Clinical Directorate?
0078
1 A. I do not know, to be honest. I suspect they went as far
2 as the Chair of the local division, or may be the
3 Clinical Director.
4 Q. But you simply do not know?
5 A. No, I do not know.
6 Q. Because obviously lessons are to be learned from those
7 reports. They are in a sense an objective view of how
8 you are doing, in terms of training, at any rate, and
9 that may affect patient care?
10 A. Indeed, I think they offer a valuable external check on
11 quite what is going on. There is a degree of
12 frustration associated with them sometimes as well of
13 course because the expectations seem to grow with each
14 visit and it is quite difficult sometimes to keep pace
15 with the expectations of the Colleges in these matters,
16 but it is all for the greater good and the improvement
17 of the service, so I think we try and generally respond
18 as constructively as we possibly can.
19 Q. Is there anyone with particular responsibility within
20 the Trust at present for maintaining liaison with the
21 Royal Colleges to get such feedback?
22 A. Each specialist area will have their own strong links
23 with the Colleges, and the Medical Director will take an
24 overview of all of those visits and as he is new in
25 post, I will be expecting him to pick up on all the
0079
1 reports and visits and pick up with local clinicians
2 whether there are issues that need to be addressed and
3 how those issues can be addressed. It may be
4 working hours or something like that.
5 Q. I have dealt thus far with the clinicians, the medical
6 staff. Going back again to what you inherited, Margaret
7 Maisey was the Senior Nursing Officer and Director of
8 Operations, and Mr Wisheart was the Medical Director.
9 To what extent did they work together on clinical
10 issues?
11 A. I am trying to recall some specific instances that would
12 help me respond. I have no doubt that there would have
13 been issues, clinical issues that needed their joint
14 involvement, their joint advice, their joint work.
15 I have no doubt they would have worked together on those
16 issues, but I cannot recall any specifics at this
17 precise moment.
18 Q. So far as the Clinical Director, senior nurses were
19 concerned, what if any view do you have of whether or
20 not either the nurses or the doctors may have felt to an
21 extent disenfranchised, that "here we have a medical
22 hospital; we are nurses with a clinical input, but the
23 doctors are running the show"?
24 A. I think, I am sure, that feeling would have been there
25 to some extent. Again, I do not think it would have
0080
1 been unique to the UBHT.
2 Q. Was that a consequence of having a medical man as the
3 Chief Executive?
4 A. No, I think it more reflects the traditional
5 relationships between the doctors and other clinical
6 staff.
7 Q. You used the example a moment or two ago, the theatre
8 sister finding it difficult to complain about the senior
9 surgeon. Is that a reflection of the way in which
10 doctors were regarded or regarded themselves on the one
11 hand, and nurses were regarded or for that matter
12 regarded themselves, on the other?
13 A. Yes, it would be a reflection of that.
14 Q. That would run right through not the only theatre but
15 presumably the intensive care ward, would it?
16 A. Yes. I think that would be, as I say, a common
17 situation in many places. I think it is only now that
18 the other clinical professions are being seen to take
19 their proper role in the delivery of care as a full
20 member of the clinical team. I do not think that has
21 necessarily been the case in the past.
22 Q. I appreciate you may be talking more from your
23 experience elsewhere than with Bristol, but in so far as
24 you can, if a nurse had had a particular complaint of
25 the whistle-blowing type in respect of the conduct of
0081
1 a doctor in the operating theatre or on the intensive
2 care ward, whatever, before the time that you took over,
3 would there be particular cultural difficulty in her, or
4 for that matter him, pursuing such a complaint?
5 A. Yes. I think there would, although theatre sisters by
6 tradition are a fairly hardy breed and I suspect they
7 may have less reticence than some in expressing the
8 concerns that they have.
9 Q. I used the theatre sister because it was the example you
10 gave. So the hardier the breed, you think
11 nonetheless --
12 A. Have some reticence, yes.
13 Q. Can we have a look, please, turning to something rather
14 different here, at UBHT 29/77?
15 This is a report of the Regional Audit Team which
16 visited in 1994.
17 If I can ask you to turn over the page, it is the
18 very last sentence on the page. This is a visit by
19 Dr Shaw and Nicola Cowie to the UBHT in 1994. What is
20 said in the report is:
21 "The organisation and direction/development of
22 audit within the UBHT has been significantly different
23 to that of all other Trusts within the region. There
24 has been a devolvement of the budget and all audit staff
25 to a Directorate level. This is in line with the
0082
1 decentralised philosophy of the Trust as a whole and
2 operates successfully in the main by virtue of the
3 immense size of the Trust. The control of audit,
4 therefore, lies ultimately with the Clinical Directors.
5 The Audit Committee is not, however, constituted of
6 Clinical Directors, which means its role has been
7 relatively powerless."
8 There are two issues there to explore. One is,
9 what is described up until the words "Clinical
10 Directors" is what you told us earlier: this was
11 a particular feature of UBHT?
12 A. Yes.
13 Q. Is the report right in saying this is different, this is
14 unusual?
15 A. It certainly was not something I had come across before,
16 but then I have never been responsible for a Trust of
17 UBHT's size and a proper comparator would be other very
18 large Trusts and I do not have information about how
19 other very large Trusts would have handled that issue.
20 Q. It goes on to deal, then, with what one might describe
21 as the "cultural" aspects:
22 "The Audit Committee is not, however, constituted
23 of Clinical Directors, which means its role has been
24 relatively powerless."
25 Is that something which you would accept as true,
0083
1 even in retrospect, of that period of time?
2 A. I suspect it is, yes. I think that statement suggests,
3 seems to make clear, it was detached from the management
4 structure of the Trust, in which case, yes, it would be
5 relatively free-floating and perhaps not influential.
6 Q. So if one goes down to the next paragraph, it perhaps
7 says it all, so far as the author of the report is
8 concerned:
9 "There was direct admission from a representative
10 of the management team that issues for audit which the
11 managers feel need to be addressed or are asked to
12 address by purchasers, tend to be implemented by the
13 Clinical Directors rather than by any central overview
14 from the Audit Committee."
15 What is described there is an Audit Committee
16 which basically does not fulfil its role because of the
17 way in which things are structured?
18 A. I do not know what role it was asked to fulfil. If it
19 was asked to be a talking shop, I suspect it achieved
20 that. Clearly, what it was not, though, was locked into
21 the management structure, for example, the Chair of the
22 Audit Committee as far as I am aware was not responsible
23 to the Medical Director, as is the case now, so it would
24 be possible for things to go through the Audit Committee
25 route and then to go no further. There was not the key
0084
1 link on to the Trust Board from that point. That is as
2 I understand what happened in the past.
3 Q. The second aspect of this report, which I would
4 welcome your comments on, is at page 80. It is
5 under "approach":
6 "Recognition [and I think this must be relate to
7 what was said to the visitors] that different clinical
8 professions may be approaching audit differently, using
9 differing methodologies and from different histories and
10 understandings."
11 Is that a fair reflection or not of the way in
12 which audit was conducted until you got to grips with
13 it?
14 A. I think it is still a true statement to say that the
15 different clinical professions do come to audit from
16 different backgrounds. Some clinical work is very
17 easily auditable in terms of some of its outcomes and
18 some clinical work is very difficult to audit in terms
19 of outcomes. I think that situation still pertains
20 today.
21 Q. I think it says more than that: it is describing an
22 inconsistent approach, perhaps?
23 A. A non-standard approach, yes.
24 Q. Is the approach now standardised?
25 A. The process is standardised in that we are quite clear
0085
1 what is in place in each directorate, how reports are
2 expected, how they link into the management structure of
3 the Trust, how issues of concern are dealt with.
4 Q. And the process had not been standardised before?
5 A. I do not think it was, no. The methodologies in use may
6 still be different in the different clinical professions
7 because that is the right way to approach it.
8 Q. So methodologies are necessarily different, but the
9 process is now standardised?
10 A. I think it has to be certainly consistent to a fairly
11 high level to ensure that we do have adequate coverage
12 across the Trust.
13 Q. Whereas what you inherited was a system where not only
14 were the methodologies different, but the process was
15 not consistent?
16 A. That is my understanding, yes.
17 THE CHAIRMAN: May I interrupt to add, Mr Langstaff, to the
18 question? Can we go back to page 80? If you say that
19 the first paragraph under "Approach" would still
20 pertained today, you would not say, would you, that the
21 third paragraph would still pertain today?
22 A. I am trying to get my head around your double negative,
23 Chairman, if indeed it was a double negative. What
24 I would say today is that all audit staff must be
25 trained to support, in a variety of arena, the clinical
0086
1 staff that they work with.
2 Q. I ask only because the implication of that third
3 paragraph to me is that they were not acquainted, so as
4 not to be able to carry out their job?
5 A. It does imply that, yes.
6 MR LANGSTAFF: Page 81 to which we were going may perhaps
7 shed some light on that. If we look at what is said
8 under "resources" under three headings: time, audit
9 support staff and information technology in 1994. Time:
10 "There is general agreement from purchasers and
11 the Trust Board to a half day per month for all medical
12 staff to undertake audit. This does not, however,
13 extend to encompass time allowance for nursing and
14 therapy staff."
15 It goes on to urge that recognition must be given
16 to the reality of the time involved in undertaking
17 audit. It will still be involved by such staff in their
18 own uniprofessional audit and for multi-professional
19 clinical audit, and it needs to be resolved.
20 So it appears to be saying that the medics get
21 time; the nurses and therapy staff do not, for audit?
22 A. Yes.
23 Q. An unsatisfactory position?
24 A. Yes.
25 Q. And it would have been, then?
0087
1 A. Yes, it would have been then an unsatisfactory
2 position. It would have been, again, not uncommon.
3 Q. Audit support staff:
4 "One issue which does require attention is whether
5 there is sufficient audit support time to cope with the
6 undoubted increase in demand on their time emerging from
7 the expanse into clinical audit."
8 This is plainly reactive to developments
9 elsewhere, talking about expansion into clinical audit,
10 but it is urging I think clinical audit support staff.
11 Do you know whether there were such staff in post in
12 1994?
13 A. I am sure there were some staff in post. I do not know
14 the details, though.
15 Q. Information technology: it compliments UBHT on the
16 information technology that it had, so the position
17 reflected appears to be that there was no consistency of
18 process, that there was insufficient time for nursing
19 and therapy staff to conduct audit, and there is a query
20 over the provision of audit support staff, in 1994?
21 A. Yes. I would actually say in addition, I suspect there
22 was insufficient time for the medical staff to undertake
23 audit as well, because of all the other pressures upon
24 them. That remains a difficult balance to this day.
25 Q. Can we have a look at UBHT 16/4? This is a meeting of
0088
1 the Patient Care Standards Committee, and if we can
2 scroll down, please, you can see that it will have
3 a report to it, amongst other things, in relation to
4 audit.
5 Can we go overleaf? It describes there how
6 a multidisciplinary audit for GPs had just commenced.
7 And the next page, please. Paragraph 7:
8 "Dr Bullimore introduced the report [this is the
9 Trust's annual clinical audit report] and made a number
10 of comments. There was a problem in getting information
11 for the report as there was no central co-ordination of
12 audit."
13 I think I see from your expression that you
14 recognise this as having been a problem which you, at
15 this stage -- 24th November -- had just inherited.
16 A. Yes.
17 Q. Is it accurate to say that there was no central
18 co-ordination?
19 A. It is accurate to say that, yes. I think, on paper, it
20 may be that it could be argued that there was, but not
21 central co-ordination in terms of actually managing and
22 gripping it in the way that I felt was necessary.
23 Q. If we scroll down:
24 "She [Dr Bullimore] was concerned that
25 a significant amount of audit work was undertaken with
0089
1 little or no financial/staff support as in community
2 services."
3 It goes on in something of the same vein. So
4 really, there was here expressed concerns from the staff
5 themselves involved as to the way in which audit was
6 managed and the amount of support available for it?
7 A. Yes. I remember the then Chairman being very concerned
8 about this issue, and making it a high priority that we
9 resolve it and move towards a new style of audit
10 committee for the Trust that would truly keep an
11 overview of what was going on, and start to put in place
12 the process improvements I talked about.
13 Q. The Chairman was relatively new, was he?
14 A. Mr McKinley had been the Chairman for a little over
15 a year, 15/16 months, at that stage.
16 Q. When you were appointed, do you remember who it was who
17 actually interviewed you for the post?
18 A. Yes, Mr McKinley was the Chairman then.
19 Q. He, it was, who interviewed you?
20 A. Yes.
21 Q. With the panel?
22 A. Yes, a panel of about 6 or 7.
23 Q. I am just interested to know, was Mr Wisheart one of
24 them?
25 A. He was a candidate for the job.
0090
1 Q. If I can turn away from audit, the only other areas
2 which I want to ask you about, Mr Ross, at this stage,
3 is focusing now on Mr Wisheart himself and the job that
4 he did to the extent that we have not dealt with it
5 earlier.
6 As a Medical Director, in general terms, we dealt
7 with the time he did or did not have to do the job
8 properly, was the use of a working surgeon as Medical
9 Director at all unusual?
10 A. I am trying to think about the sort of balance of
11 clinical backgrounds of the Medical Directors who did
12 emerge in the early days in Trust status, and I think it
13 is fair to say there was quite a cross-representation.
14 There was a view held, I know, by both managers and
15 doctors, that certain clinical backgrounds would lend
16 themselves better to having the time available than
17 others, perhaps because the work could more easily be
18 kept in manageable time proportions. For example,
19 I think pathologists, radiologists and anaesthetists
20 were over represented, if I can put it like that, in the
21 early Medical Director ranks, and perhaps still are to
22 these days.
23 I think the role being undertaken by a surgeon
24 with heavy surgical responsibilities and on-call
25 responsibilities was probably less usual than some other
0091
1 roles.
2 Q. Because it was bound to flow out of the traditional
3 difficulties of doing the job?
4 A. Indeed.
5 Q. And probably doing both jobs?
6 A. Indeed, quite possibly.
7 Q. Because no doubt surgery demands being at one's best
8 while one is operating?
9 A. Yes.
10 Q. And with the other demands on time, that must be
11 difficult?
12 A. I think it must be, yes.
13 Q. Having a surgeon, or for that matter any other medic as
14 Medical Director, does that create, in your view, any
15 conflict of interest when they may be having to deal
16 with other doctors?
17 A. Potentially it could, yes.
18 Q. Has it in practice?
19 A. Not in my time in the Trust, no.
20 Q. If there were a conflict of interest which involved the
21 Medical Director himself, as it were, being responsible
22 to himself for himself, that is something which you have
23 resolved by the means you have described,
24 institutionally?
25 A. Yes.
0092
1 Q. But plainly a problem which existed in the structure you
2 inherited -- I say "plainly"; was it?
3 A. I do not know enough about the guidance that was in
4 place before my time in the Trust about raising
5 expressions of concern and so on to know whether it was
6 actually spelled out that the Medical Director must
7 bring to the attention of the Chief Executive any
8 concerns about his or her own performance, his or her
9 own clinical performance. I do not know whether that
10 was actually spelled out. I think common sense would
11 say that is what must apply, but whether it was spelled
12 out in the way it is now, I do not actually know.
13 Q. I am grateful for your answer, anyway, as to common
14 sense, and I do not want to take that any further. If
15 you just give me one moment, if you please, Mr Ross ...
16 (Pause)
17 Mr Ross, I have asked you a lot of questions
18 covering the administration and structure of the UBHT.
19 You appreciate that there will be other questions which
20 will come on different areas at a later stage in the
21 course of this Inquiry.
22 A. Yes.
23 Q. And you will have an opportunity, then, to say whatever
24 you wish about those areas. But is there anything which
25 you wish to volunteer yourself so that the Inquiry knows
0093
1 what you have to say as will best help them in respect
2 of those matters I have been asking you about?
3 A. No, I do not think there is anything else particularly
4 relating to these matters that I want to add, thank
5 you.
6 THE CHAIRMAN: Mr Ross, the Panel may have some questions
7 for you.
8 EXAMINED BY THE PANEL
9 MRS MACLEAN: Thank you, Mr Ross. Earlier this morning you
10 were describing to us how, on your appointment, you
11 thought it wise to increase the number of sessions which
12 Mr Wisheart could devote to his managerial duties.
13 I wonder if you could expand on the dynamics of
14 that change? Is it your recollection that Mr Wisheart
15 was seeking further time to spend on managerial duties,
16 or was the idea coming from you and if so, was it
17 welcome to him?
18 If you could fill in that change a little, thank
19 you.
20 A. The idea came from me. I think Mr Wisheart was always,
21 at bottom, a clinician rather than a managerial
22 clinician, and his first love was his clinical work.
23 I do not think there is any doubt about that.
24 I found myself in a position where, even if I had
25 been in the Trust for some time, I felt that his two
0094
1 sessions would not be adequate to cope with all the
2 issues, either that I needed him to lead directly or to
3 advise me on. But of course being new to the Trust,
4 employing even then something over 200 consultant
5 medical staff, I was in need of a good deal of advice
6 about the personalities, the issues, the history, the
7 plans and so on, things that would have been second
8 nature, really, to Dr Roylance, that he would have known
9 about. I had none of that knowledge when I came to the
10 Trust, so it was my instigation to ask Mr Wisheart to go
11 to the four sessions, based on the rationale I have just
12 described to you, and he expressed himself very willing
13 to do that. I do not recall exactly where we made the
14 change, but it was certainly within a fairly short time
15 of my arrival.
16 MRS MACLEAN: Thank you.
17 THE CHAIRMAN: Mrs Howard?
18 MRS HOWARD: Mr Ross, two questions. Firstly, you have
19 talked about the review of Mrs Maisey's role and
20 particularly emphasising your need to have a greater
21 understanding of the operational and day-to-day
22 management issues.
23 When you were considering a review of her role,
24 had you developed a feeling for or gained any evidence
25 on whether there had been a build-up of a nursing
0095
1 strategy or a focus on nursing and professional issues
2 previous to your review?
3 A. I got the impression, which was what led to the change
4 of job plan, if you like, that there had not been
5 sufficient attention devoted in the Trust to a whole
6 range of professional and developmental issues
7 surrounding nursing and midwifery and health visiting.
8 I have explained before that there was no way that
9 Mrs Maisey had the time to do those things. Given the
10 very significant operational role she carried, she was
11 I think very well aware of those issues and had invited
12 a number of capable senior nurses within the Trust to
13 help contribute to those developmental and professional
14 issues, and that in itself was valuable, but I felt that
15 the top nurse had to be seen to undertake that, because
16 I felt it was so important. That is why, after
17 discussion with her, we started to change the focus of
18 her role.
19 Q. May I just ask a supplementary to that. Was there an
20 issue of visibility for the Executive Nurse?
21 A. I smile, because some of the General Managers may say
22 she was extremely visible, and was indeed very well
23 known throughout the organisation, but I think that was
24 in her role as Director of Operations more than her role
25 of the most senior nurse in the Trust.
0096
1 Q. Thank you. My second question is part comment and part
2 question. You talked about perhaps a continued emphasis
3 on "oral culture" since you have taken up the post of
4 Chief Executive. How does one develop common goals,
5 organisational ownership and effective communication if
6 the emphasis is on oral culture?
7 A. I am talking about within the executive team when I say
8 that, let us be clear about that. I could not do my
9 role as Chief Executive of UBHT if I relied on an oral
10 culture throughout the organisation.
11 Q. My question is strengthened by that comment and I would
12 still perhaps push you for a comment with respect to
13 common goals within the Trust and on organisational
14 ownership of what the Trust executive team would be
15 seeking and effective communication without and within
16 the Trust?
17 A. I think we are probably approaching the issue from
18 a slightly different perspective. That is where maybe
19 I have slightly misled you, and I apologise if that is
20 the case.
21 The Trust has very clear policies, plans,
22 procedures, strategies, strategic plans, all of which
23 have been widely debated in the organisation,
24 particularly the clinical staff, are well owned and well
25 understood and we are working hard to make sure people
0097
1 understand the overall direction of the organisation and
2 the standards and values we are trying to espouse and in
3 particular the standards of clinical service we are
4 trying to achieve. All that has been in writing and is
5 widely discussed and I think has been well owned.
6 When I was referring to "oral culture", I was
7 referring to just within the management team. I do not
8 write lots of memos to my executive directors. I work
9 on trust and I work on making sure I get the right
10 people and they do the work. That is the way it works.
11 THE CHAIRMAN: Professor Jarman?
12 PROFESSOR JARMAN: Mr Ross, we have heard of the management
13 structure in UBHT in the past, where the Medical
14 Director whose first love was his clinical work had only
15 two sessions in very large trusts. There was a club
16 culture, and the Chief Executive who was described as
17 "dominant."
18 Would you care to comment on how effective this
19 arrangement would have been in dealing with allegations
20 of abnormally high mortality rates in infant cardiac
21 surgery, particularly when the Medical Director himself
22 was involved in those allegations? A general comment?
23 A. I think the organisation and the culture of the Trust
24 added to the difficulties that would have been in place
25 in any organisation if you are confronting such
0098
1 a traumatic situation.
2 Q. Would it have been an effective arrangement?
3 A. I think if you were trying to design an organisation
4 that could respond as rapidly as possible to expressions
5 of concern and make sure they were resolved, then you
6 probably would not have designed it to look like UBHT
7 did several years ago, can I put it that way.
8 Q. Could you comment on how this setup was allowed to
9 exist?
10 A. Only in saying that the internal organisation and
11 management of NHS Trusts was almost entirely a matter
12 for the Trusts themselves in the early days of Trust
13 status and to this day, to be fair, quite properly,
14 Trusts are judged on their outputs and outcomes rather
15 than the processes by which they achieve those.
16 Q. So you are suggesting that the Department of Health has
17 no responsibility at all and it could continue like that
18 even now?
19 A. I would suggest very strongly, if the regional
20 Department of Health told me how we should run the Trust
21 on a day-to-day basis, that that was my responsibility
22 rather than theirs and I would say they should judge the
23 Trust on what it achieved.
24 Q. I am talking about the general arrangement, not the
25 specific day-to-day running. That is the point I am
0099
1 trying to make. The setup they had put in place.
2 A. I do not think anyone would suggest that that would be
3 a matter for the Department of Health or the regional
4 office. At the time, certainly, "that was not of their
5 concern" would have been the dominant view.
6 PROFESSOR JARMAN: Thank you.
7 THE CHAIRMAN: I have no questions. Mr Miller, is there any
8 re-examination? Please come forward.
9 RE-EXAMINED BY MR MILLER
10 MR MILLER: Sir, within house rules, I only wanted to
11 clarify one point. As well as the Medical Director
12 there was the Chairman of the Hospital Management
13 Committee?
14 A. The Hospital Medical Committee.
15 Q. Who was a senior consultant appointed or elected by the
16 consultant body?
17 A. Correct.
18 Q. What, if anything, was to be interfaced between those
19 two roles: the Medical Director and the Chairman of the
20 Hospital Medical Committee? What were their separate
21 roles? Or are their roles?
22 A. Generally the Chairman of the Hospital Medical Committee
23 is generally characterised as the senior shop steward
24 who takes it upon him or herself to represent the views
25 of the wider medical community and the Trust to the
0100
1 Trust Board, whereas the Medical Director's role is
2 clearly as an Executive Director of the Trust with the
3 responsibilities that that entails. In the early days
4 of the Trusts, the roles were undertaken by one and the
5 same person, firstly by Mr Dean Hart and then by
6 Mr Wisheart, and then I think in recognition of the
7 growing weight of the Medical Director role, it was felt
8 appropriate that they be split. At that point,
9 Mr Wisheart became Medical Director only and another
10 senior doctor took on the role of Chairman of the
11 Hospital Medical Committee.
12 Q. Because you were asked about conflict for the Medical
13 Director in dealing with senior consultant staff; but
14 there has been a distancing of the two roles in recent
15 years?
16 A. That is correct.
17 Q. The only other thing is that I think Mr Dean Hart was
18 a surgeon, was he not?
19 A. He was.
20 Q. And Mr Wisheart's successor, a Mr Baird, was a vascular
21 surgeon?
22 A. Yes.
23 Q. I think the latest incumbent is a non-surgeon?
24 A. He is a radiologist.
25 MR MILLER: That is all I wish to ask, sir.
0101
1 THE CHAIRMAN: That is very helpful, thank you. Mr Ross, we
2 are to meet again in due course, but for the moment,
3 thank you very much for coming. We have been greatly
4 assisted by what you have been able to tell us today.
5 I know to a degree you were talking about things which
6 you were, as it were, receiving by report, having taken
7 position, but we are much helped by what you have been
8 able to tell us today. Thank you, and we will see each
9 other again shortly.
10 MR LANGSTAFF: Thank you, Mr Ross.
11 THE CHAIRMAN: Mr Langstaff?
12 MR LANGSTAFF: Sir, tomorrow we will hear from Dr Armstrong
13 of the British Medical Association. I understand from
14 recollection, I hope I am correct, that we begin at 10,
15 rather than at 9.30?
16 THE CHAIRMAN: Yes, that is right. I think there are travel
17 arrangements which have to be accommodated as such, so
18 we begin at 10.
19 MR LANGSTAFF: For those who may be interested in the rest
20 of this week, on Thursday of this week we have
21 Dr Crompton of the Welsh Office. I apologise that his
22 statement is not yet available. We expect to follow his
23 evidence with that of Miss Mandie Lavin of the UKCC.
24 THE CHAIRMAN: Thank you. We adjourn now, then, and
25 reconvene tomorrow morning at 10 o'clock.
0102
1 (12.41 pm)
2 (Adjourned until Wednesday, 19th May 1999 at 10.00 am)
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5 I N D E X
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8 MR HUGH ROBERT ROSS (Sworn)
9
10 Examined by MR LANGSTAFF ..................... 3
11 Examined by the PANEL ........................ 94
12 Re-examined by MR MILLER ..................... 100
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001