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Daily transcripts
Hearing summary
24th May 1999
Today the Inquiry heard evidence from Mr Graham Nix, current Deputy Chief Executive and
Director of Finance at the United Bristol Healthcare NHS Trust (UBHT) and an executive
director during the span of the Inquiry’s terms of reference. Mr Nix has been called
to assist the Inquiry with Block Three evidence looking at the Bristol services, focussing
on management issues relating to the Bristol Royal Infirmary (BRI), including how the
paediatric cardiac services were set up and how they were organised. Today he described
the evolution of the NHS structure in the Bristol area in the late 1980s, including the
make up of district health authorities, regional health authorities and the establishment
of Trusts in the early 1990s. Mr Nix went on to outline the plans to develop cardiac
surgery, particularly through an increase in the number of open cardiac surgical cases in
Bristol. He confirmed that increases in neonatal cardiac cases were marginal over the
period. He described budgeting allocations, and commented on new diagnostic equipment
bought by the Regional Health Authority for the Bristol Children’s Hospital. He went
on to discuss matters surrounding increasing bed numbers and medical and nursing staffing
levels. Mr Nix then told the Inquiry about contracting agreements for referrals to Bristol
from outside the district, known as cross boundary flow. He then answered questions about
the responsibilities of the Medical Director during the period and confirmed that
additional senior management personnel have now been employed in the past few years to
assist the current Medical Director with workload pressures. He concluded today by
outlining the details of obtaining Trust status.
Mr Nix will conclude his evidence tomorrow, beginning at 9.30 a.m.
|
FULL TRANSCRIPT
1 Day 22, 24th May 1999
2 (10.30 am)
3 THE CHAIRMAN: Mr Langstaff, good morning.
4 MR LANGSTAFF: Good morning, sir. Today we will hear from
5 Mr Graham Nix, and I anticipate that his evidence will
6 go over until tomorrow.
7 May I though, before Mr Nix comes to give his
8 evidence -- Mr Maclean will be asking him the
9 questions -- deal with one matter which has arisen over
10 the end of last week and the weekend, which perhaps
11 requires some clarification, or at least reiteration of
12 our procedures.
13 ADDRESS TO THE PANEL BY MR LANGSTAFF:
14 Unhappiness has been expressed by the
15 representatives of Dr Roylance about the questions which
16 were addressed to Mr Ross. In part, the concern relates
17 to the use of a statement which was critical of
18 Dr Roylance, which Mr Ross was asked to comment on.
19 Dr Roylance had not himself had the opportunity to
20 comment before parts of it were referred to.
21 Secondly, a concern was expressed that the
22 questioning argued a point of view which was critical of
23 Dr Roylance's management style.
24 As to the statement, may I accept, on behalf of
25 the Inquiry, that the statement was not seen beforehand
0001
1 by Dr Roylance and accept that ideally it should have
2 been. For my part, I regret that it had not been and
3 that that fact had been overlooked before the matter was
4 put to Mr Ross in the course of his examination.
5 Efforts will be made to ensure that similar
6 statements will not be put without warning where that is
7 practicable; that has been the procedure; it needs to be
8 reiterated and somewhat of a lapse from it is regretted.
9 As to the questioning, it is not accepted that
10 this amounted to an argumentative case; the questioning
11 was designed merely to explore the differences of
12 approach and evaluation of those differences as between
13 Mr Ross and Dr Roylance, from a witness who will, after
14 all, be the first of a number of witnesses dealing with
15 evidence of the local scene.
16 In particular, I must be quite clear that in
17 general some questions may be put to elicit a response
18 which may be informative to the Inquiry, and indeed,
19 which may highlight areas which a later witness will,
20 him or herself, be asked to deal with, so that they are
21 forewarned that they may be asked to do so. But it
22 should not be read into any such question that I, still
23 less the Panel, have formed a view. That would be
24 entirely wrong and it would be entirely misleading to
25 think so. If any such impression has been formed, it is
0002
1 misguided and may I say, for my part, if I have had any
2 part in creating that impression I am sorry; it may
3 simply be a misunderstanding about the nature of the
4 procedure in which we are engaged. It cannot be
5 restated often enough that we, as Counsel to the
6 Inquiry, have no case to put. We have simply to explore
7 the evidence to the full and to do so neutrally.
8 I had indicated to Mr Francis, who appears to
9 represent Mr Roylance -- it is Ms Powell today, and
10 indeed, he will acknowledge -- the broad scope of
11 questions to be put to Mr Ross.
12 We, again it should be reiterated, rely in part on
13 representatives telling us in advance of any points they
14 think may be helpfully put to or drawn from a witness.
15 The fullest use of this procedure should in future avoid
16 representatives feeling we have not explored matters
17 which go to the credit of their client.
18 May I, in saying that, pay tribute to the way in
19 which all representatives have contributed, not least to
20 the forthcoming questioning of which Mr Maclean will
21 address to Mr Nix today.
22 In any event, we are at an early stage in this
23 part of the evidence, as you know, sir, we are just
24 starting the local scene, and at all times, if there is
25 any shortcoming in the evidence that is perceived, then
0003
1 any individual is free to put in a statement of rebuttal
2 and any such statement will be published. It is open to
3 any interested participant to put in a commentary upon
4 evidence which others have given, and any such
5 commentary will be published; and it is open to any
6 participant to pass questions or matters of interest to
7 Counsel to the Inquiry, and finally, in the case of
8 Dr Roylance, of course, we look forward to hearing his
9 evidence, which is coming very shortly. It is within
10 a fortnight.
11 Sir, that said, it is I think unnecessary to go on
12 at any greater length. May I leave you in the capable
13 hands of Mr Maclean and Mr Nix?
14 THE CHAIRMAN: Thank you, Mr Langstaff. I just interject
15 that we have heard your expression of regret and I hope
16 it has been heard by all, and we should try to put that
17 behind us. As regards your reiteration of the
18 procedure, I am grateful to you. It will have been
19 heard by everybody and we will seek to make it work in
20 the future, as we have tried to make it work in the
21 past. Thank you.
22 MR LANGSTAFF: Thank you.
23 THE CHAIRMAN: Mr Maclean?
24 MR MACLEAN: Sir, we are just waiting for Mr Nix to be
25 brought in. (Pause)
0004
1 Mr Nix, I think you are going to give evidence on
2 oaths, are you not? Can I ask you to stand and take the
3 oath, please?
4 MR GRAHAM RICHARD NIX (Affirmed):
5 Examined by MR MACLEAN:
6 Q. You are Graham Richard Nix and you are the Deputy Chief
7 Executive and Director of Finance at the United Bristol
8 Healthcare NHS Trust?
9 A. Yes.
10 Q. I think you are one of the few witnesses that the
11 Inquiry is going to hear from who has worked in and
12 about the Bristol Royal Infirmary for the entirety of
13 the period with which this Inquiry is concerned?
14 A. Yes. I joined Bristol & Weston Health Authority in July
15 1983.
16 Q. You are, I think, an accountant by training?
17 A. Yes.
18 Q. You were a trainee with the South West Regional Health
19 Authority as long ago as 1974?
20 A. Yes.
21 Q. You joined, as you said, the Bristol & Weston Health
22 Authority in July 1983?
23 A. Yes.
24 Q. By 1990 you were Deputy Treasurer of that Health
25 Authority?
0005
1 A. I was the Principal Assistant Treasurer and took over
2 the role of deputising for the Treasurer, yes.
3 Q. Towards the end of 1990 you were the Treasurer of the
4 Bristol & Weston Health Authority and the Shadow Finance
5 Director of the Shadow Trust?
6 A. Yes.
7 Q. And the Trust went live, as it were, on 1st April 1991?
8 A. Yes.
9 Q. It was the first-wave NHS Trust?
10 A. Yes.
11 Q. You became Director of Finance from the outset?
12 A. Yes.
13 Q. And I think you are now the sole deputy to Mr Ross from
14 whom we heard last week?
15 A. Yes, that is correct.
16 Q. We will explore in due course the situation that existed
17 before that, when there were two deputies: Mr Wisheart
18 was Deputy Chief Executive dealing with clinical matters
19 and you were Deputy Chief Executive dealing with other
20 matters when Dr Roylance was the Chief Executive?
21 A. Yes.
22 Q. Can I take you, please, to document WIT 0106/0001?
23 Is that the first page of the formal written
24 statement that you have made to this Inquiry?
25 A. Yes, it is.
0006
1 Q. If we go to page 49, please, that is your signature, is
2 it not?
3 A. Yes.
4 Q. Have you read that statement recently?
5 A. Very recently, yes.
6 Q. Is there anything in that that is inaccurate or wrong
7 and you wish now to add to or subtract from, or change
8 in any way?
9 A. There is only one point, that I did actually say
10 Mrs Maisey was the Director of Nursing and Operations
11 but actually she was the Director of Operations and
12 Chief Nursing Adviser.
13 Q. I think we will hear from Mrs Maisey in a couple of
14 weeks.
15 Can I just set out one or two ground rules,
16 Mr Nix, for the questions I am going to ask today? You
17 gave evidence to the General Medical Council on
18 30th April 1998. I am sure you remember doing that?
19 A. I certainly do.
20 Q. Much of that evidence, and we have the transcript of
21 what you were saying and what questions you were asked,
22 much of that questioning of you was concerned with the
23 events in the spring of 1995, when you were Acting Chief
24 Executive in the absence of Dr Roylance, when something
25 called the Hunter de Leval report arrived at the Trust?
0007
1 A. Yes.
2 Q. That ground, concerning the Hunter de Leval report in
3 its first form, in its final form, how it got from one
4 to the other, is not a matter dealt with in this formal
5 written statement. I think you understand that the
6 Inquiry will be asking you to make a separate formal
7 written statement dealing with the events of the spring
8 of 1995 and the Hunter de Leval report over the coming
9 months?
10 A. Yes. This statement was based on the request made to
11 me, so it covers the items you have asked me about, not
12 that.
13 Q. So you understand that it is a possibility, to put it no
14 higher at this stage, that you might come back and give
15 us further evidence dealing with the Hunter de Leval
16 report when the Inquiry reaches Block 6 of its
17 deliberations?
18 A. Yes.
19 Q. I hope I do not trespass into the forbidden territory,
20 then. If I do, please stop me and we will consider
21 whether I have or not or whether it is appropriate to
22 deal with the matter later on that.
23 When the Inquiry's period began, NHS Trusts did
24 not exist, we had a system of regional and district
25 health authorities. You have already told us that you
0008
1 started as a trainee in this area in 1974.
2 Can I take you right the way back to 1974,
3 please? Could we have document WIT 38/5?
4 With some trepidation, this is a statement of
5 a witness from whom we have not yet heard, Pamela
6 Charlwood, now Chief Executive of the Avon Health
7 Authority. I do not think there is anything
8 controversial here.
9 Can I take you to paragraph 3:
10 "The NHS Reorganisation Act 1973 with effect from
11 1st April 1974 coincided with the reorganisation of
12 local governments in England and Wales and that is what
13 established the South West Regional Health Authority."
14 That is the organisation that you then went to work for?
15 A. Yes.
16 Q. You see what is said in paragraphs 3(i) and 3(ii):
17 "The Avon Area Health Authority (Teaching) served
18 800,000 people living in the city of Bristol and parts
19 of what had previously been South Gloucestershire and
20 North Somerset...", and that there were a number of
21 Health Districts, one of which was a Bristol Health
22 District (Teaching), and that is the one that included
23 both the Bristol Royal Infirmary and the Bristol
24 Children's Hospital?
25 A. Yes.
0009
1 Q. The Bristol and Weston District Health Authority was
2 formed on 1st April 1982 and that is dealt with in
3 paragraph 4 of that same statement on the same page.
4 What Pamela Charlwood says there is an accurate
5 reflection, is it not, of the coming into being of the
6 Bristol and Weston Health Authority?
7 A. The only point to add is that at some time... Does it
8 say there Bristol and Weston were joined together as
9 health districts?
10 Q. Yes.
11 A. That is correct. 1978, yes.
12 Q. Yes. So Bristol and Weston District Health Authority
13 comes into effect on 1st April 1992, and that Health
14 Authority existed until 1990.
15 If we go, please, to WIT 106/11, this is your own
16 statement. If we just scan down that page, in the
17 bullet point there from the appointment of Dr Roylance,
18 he was appointed as District General Manager on
19 1st April 1985, and at this stage the Bristol and Weston
20 Health Authority was divided into two main units known
21 as Central and South; is that right?
22 A. That is correct.
23 Q. The Bristol Royal Infirmary and the Bristol Children's
24 Hospital were both in the Central unit?
25 A. Yes.
0010
1 Q. If we go over the page to page 12, please, of your
2 statement, we see at paragraph 22 that explanation.
3 Then the flow chart below it. So if we look in the
4 central unit, that is a unit that included the BRI and
5 the BCH?
6 A. Yes.
7 Q. And each of those two hospitals were respectively
8 sub-units, as we see in the box at the bottom of the
9 diagram?
10 A. Yes, that is correct.
11 Q. And each of those units would, for example, prepare
12 their own monthly accounts and so on?
13 A. No, the financial information was provided from
14 a centralised Treasurer's Department. Each of the
15 sub-units had their own financial budgets that they
16 managed, so all the reports and all the accounting was
17 done centrally and information supplied reflected back
18 to the managers about how they were performing against
19 the budget, i.e. the plan.
20 Q. So there is a central Treasury, a finance office?
21 A. Yes.
22 Q. In the District Health Authority?
23 A. Yes.
24 Q. Feeding information to and fro between the central
25 finance organisation and ultimately down to the sub-unit
0011
1 level; is that right?
2 A. Yes. Within the sub-units, each sub-unit had its own
3 allocation. That was subdivided down into individual
4 budget managers, so that would be a ward manager or
5 a department. They would order their goods and employ
6 their staff and the financial consequences of that were
7 recorded and monthly budget statements provided.
8 Q. So just to be clear, a sub-unit sounds like a small
9 organisation, but the whole of the Bristol Royal
10 Infirmary was a sub-unit?
11 A. Yes. There were varying sizes. The sub-units
12 themselves would vary from the Children's Hospital -- in
13 fact at that stage the Children's Hospital and the
14 Maternity Hospital were one sub-unit.
15 Q. The South unit, with which we are not concerned, that
16 embraced Weston-super-mare, community services, mental
17 health and mental handicap?
18 A. Yes.
19 Q. It is the Central unit we are concerned with, embracing
20 the hospitals close to the University, the teaching
21 hospitals.
22 A. Yes.
23 Q. Mr John Watson was the Manager of the Central unit at
24 the beginning of the period with which we are concerned,
25 and Margaret Maisey was the Manager of the South unit?
0012
1 A. Yes, from 1985 onwards.
2 Q. Towards the end of the 1980s, they swapped jobs and
3 Mrs Maisey became concerned with the Central unit?
4 A. Yes.
5 Q. Why did they swap jobs?
6 A. To be honest, I cannot actually recall why they
7 swapped. I know that John Watson eventually took over
8 to be the sort of head of the purchasing arm of
9 Bristol & Weston Health Authority as we were preparing
10 for the new, or the changes to the NHS reforms.
11 But the detail of the reasons why, I am not sure,
12 now. It was not a decision I was involved in making.
13 Q. Mr Watson's career in the end leads him to the purchaser
14 side of the purchaser/provider divide, if I can put it
15 like that.
16 A. Yes.
17 Q. Mrs Maisey's career in Health Authority management in
18 the 1980s led her eventually, like you, to be one of the
19 Executive Directors of the UBHT?
20 A. Yes.
21 Q. I think she is now fairly recently retired from that
22 post at the Trust?
23 A. Yes.
24 Q. In 1985 the Bristol & Weston Health Authority management
25 structure -- this is at the time that Dr Roylance was
0013
1 assuming his role as district General Manager -- was set
2 out in a document called DGM 3. If we go to WIT 3862,
3 please, are you familiar with this document, do you
4 remember, DGM 3?
5 A. I would not have been involved at the time in any way
6 with this document, no.
7 Q. Let us just have a --
8 A. Would you scroll on down through it?
9 Q. If we have a look at the whole of that page, please, and
10 then perhaps more materially, over the page at 63,
11 paragraph 4, "units and sub-units", units by definition
12 are managed by Unit General Managers. The Unit General
13 Managers are directly accountable to the District
14 General Manager."
15 So we can put names to roles, that is Watson and
16 Maisey accountable to Roylance?
17 A. Yes.
18 Q. "The large size of the district inevitably means that
19 units will be too large or too numerous.
20 "Units which are too large would necessitate
21 sub-unit structures which would not benefit from the
22 ethos of general management if they were to be
23 accountable to units through multidisciplinary
24 functional hierarchies ...", and so on.
25 Then we see 4.6:
0014
1 "The District General Manager will need the
2 assistance of two Unit General Managers to cope with the
3 resulting span of control. The present Unit Management
4 Groups will remain as Subunit Management Groups each
5 with a Subunit General Manager."
6 So there is a General Manager at the subunit
7 level, a General Manager of the South unit and Central
8 unit and the District General Manager at the top of the
9 organisation.
10 A. Yes. You have to realise that Bristol & Weston Health
11 Authority was a very large Health Authority and I do
12 know that the structures such as this would have been
13 passed to the Regional Health Authority.
14 Q. If we go, please, over the page to 65, paragraph 7, the
15 District Health Authority had four main areas of
16 responsibility: strategic planning, operational
17 planning, the quality and cost-effectiveness of the
18 service and monitoring the District General Manager.
19 There were three Standing Committees. You make
20 reference to these in your statement, in particular at
21 this stage, the Policy, Planning and Resources
22 Committee, because that is the one, obviously, that
23 included finance. That is the one you were most
24 directly concerned with?
25 A. That is interesting, because of course after that, I do
0015
1 not know when, a fourth committee was created which was
2 the FPCC, Finance Property and Computing Committee, so
3 I would have had a lot of involvement with the Policy
4 and Planning Committee, but resources were taken out to
5 a separate committee.
6 Q. If we go over to page 67, this might be the most useful
7 summary of this structure. That, in tabular form, is
8 the structure of the District Health Authority in 1985,
9 is it not: the District General Manager, the two units,
10 South and Central, known as UGM 1 and UGM 2, and then,
11 below that, we see the sub-units. Towards the
12 right-hand side, we have BCH/BMH which as you have
13 already said, were managed together at that stage?
14 A. Yes.
15 Q. They are in the same little box, and then four boxes
16 along to the right, BRI. So they are the sub-units?
17 A. Yes.
18 Q. So this structure of management emerged in the wake of
19 something called the Griffiths Report in 1983, which was
20 the genesis of the concept of General Management in the
21 National Health Service?
22 A. Yes.
23 Q. To what extent, then, did Griffiths and its influence
24 leading to this structure represent a departure from
25 what had gone before?
0016
1 A. Prior to this, you would have actually had a district
2 management team with a District Administrator, District
3 Treasurer, public health doctor, and the Chairman of HMC
4 would have actually managed the organisation as a team,
5 working to the Health Authority, rather than in this
6 situation, when Griffiths was making one person
7 responsible for the organisation and its delivery.
8 Q. So it is making the top of the pyramid sharper; is that
9 right?
10 A. Yes.
11 Q. What would the position be in terms of finance going to
12 a part of the Bristol Royal Infirmary operation? Let us
13 take cardiac surgery, for example. How would it get its
14 money? If I was one of the surgeons in the Cardiac
15 Surgery Department at the Bristol Royal Infirmary in
16 1985, from which source would my money appear to allow
17 me to carry out my job?
18 A. The funding comes from government and will have gone to
19 the Regional Health Authority for the South West
20 region. That money was allocated out to each of the
21 districts of which Bristol & Weston Health Authority was
22 one.
23 Q. Just pausing there, some of that money from the Regional
24 Health Authority was top-sliced off. We see that,
25 I think, later; is that right?
0017
1 A. Different periods have different levels of top-slicing.
2 Top-slicing is just for other people, it is just the
3 removal of an amount of money when it comes down through
4 the system, but the allocations would have been made to
5 each of the health authorities, taking into account
6 population, and they were historically-based
7 allocations, so what you get next year is what you had
8 last year, plus inflation, plus your share of growth.
9 Within the Health Authority, the budgets for
10 cardiac and all the other areas would have been
11 historically-based as well.
12 The Health Authority would have looked at what
13 money it was getting in. It would have made an
14 assessment about the amount of inflation that needed to
15 go out to every directorate, and then it would have had
16 an amount of growth left if it was a good year, that it
17 could decide actually how it would invest that, and that
18 would have been about making choices by the Health
19 Authority as to what services it might expand or
20 develop.
21 So that was the basic way, so if it was one of the
22 sub-units, they would be making a case, really, through
23 to the Health Authority about expanding and developing
24 a service; the Health Authority would also have to take
25 into account any national directives that there were
0018
1 about expanding services.
2 That is at district level.
3 Separate to that, the Regional Health Authority,
4 from its top-slice money, would push ahead developments
5 of certain services, and cardiac surgery is one of
6 those.
7 Q. We will come to look at that in a minute. So, in order
8 to get a substantial injection of money for a new
9 service or a significant development of an existing
10 service, the District Health Authority had to make sure
11 that it got that priority on to the Regional Health
12 Authority's radar screen; is that right?
13 A. No, it had a quite substantial amount of money itself,
14 and, out of the growth money that it received, it could
15 make its own decisions about what services would
16 develop, and that is one of the major roles of the
17 Policy and Planning Committee, the PPRC.
18 Q. There is a complication if the service that you provide
19 is a service that is provided not merely for the
20 residents of your own district but to attract
21 substantial what is called "cross-boundary flows" when
22 patients arrive from outside the district?
23 A. Yes, and that is where the Regional Health Authority
24 would have been involved. There are a number of
25 examples of that, as well as cardiac.
0019
1 Q. So if you were developing a service either from scratch
2 or developing the existing service, which was a service
3 which was a regional specialty, not available in every
4 district hospital, then the Regional Health Authority
5 would be of greater importance, obviously, than if you
6 were simply developing a service for the internal
7 consumption of a particular district?
8 A. Yes, it would be.
9 Q. And in particular, the Regional Health Authority could,
10 on occasion, be persuaded to confine the funding of
11 a significant development for a period of I think up to
12 three years?
13 A. Yes. You have put a limit on it. For some services it
14 funded it in perpetuity.
15 Q. Just to tidy up the alphabets of the various health
16 authorities, the Bristol & Weston Health Authority was
17 abolished -- I think I may have said earlier 1990 -- in
18 fact on 1st October 1991 and was replaced by a new
19 Health Authority known as the Bristol and District
20 Health Authority?
21 A. That is correct.
22 Q. If we look, please, at document HA(A) 16/6, there is
23 a proposal that from 1992 there should be a single
24 Health Authority. This is a report that was compiled
25 jointly by three district health authorities. If we
0020
1 look back at 16/4, please, briefly, this document sets
2 out the broad intentions of the Bristol & Weston Health
3 Authority, Frenchay and Southmead Health Authorities for
4 the purchase of health care services for their
5 populations over the next three years, so this is
6 a three-year plan for these health authorities after
7 Trusts have become a reality?
8 A. Yes.
9 Q. So if we go back, then, to 16/6, paragraph 1.1, the
10 first paragraph there simply explains the
11 purchaser/provider distinction in very simple terms.
12 "As from 1st April 1991, the Bristol & Weston
13 Health Authority no longer has responsibility for any
14 directly managed services, with one exception.
15 Following the creation of the Trust and the Weston Area
16 Health Trust, which was the other Trust in this area.
17 "Southmead and Frenchay Health Authorities
18 currently have both purchasing and providing
19 responsibilities as NHS services continue to be directly
20 managed in both districts."
21 Then there is a reference to some second-wave
22 trust applications that were in the pipeline.
23 "If these four applications are successful,
24 Bristol and Weston, Frenchay and Southmead district
25 health authorities will have no responsibility for
0021
1 direct service provision from 1st April 1992 and
2 the proposal has been made by the Regional Health
3 Authority that they [that is the three district health
4 authorities] should form a single NHS purchasing
5 authority for the Bristol and district populations."
6 That is what happened when the Bristol and
7 District Health Authority came into being in 1992?
8 A. Yes.
9 Q. I think that in turn was later abolished, and the Avon
10 Health Authority was established in April 1996, although
11 for some time previously the Bristol and District Health
12 Authority and the Avon Family Health Services Authority
13 had been acting as a body known as the Avon Health
14 Commission?
15 A. Yes.
16 Q. So now the structure, so far as we are concerned, is
17 that the Trust, the United Bristol Healthcare Trust, is
18 the provider, and the Avon Health Authority is the
19 single Health Authority with the National Health Service
20 Executive regional outpost, the third element in the
21 picture?
22 A. Yes.
23 Q. I think I followed that, because I have been reading the
24 documents. I am not sure if everyone else does.
25 May I then turn to look at the development of
0022
1 cardiac services at the Bristol Royal Infirmary and the
2 Bristol Children's Hospital during the period with which
3 the Inquiry is concerned?
4 If we go back to October 1983, the South West
5 Regional Health Authority and the Bristol and Weston
6 District Health Authority formed something known as
7 a "joint project team" which was looking at the
8 expansion of cardiac surgery.
9 You, I think, were a member of that project team?
10 A. I expect so, yes. I would have thought something
11 actually occurred before that.
12 Q. There was something before that. Can we look, please,
13 at document UBHT 266/415, this is a report of something
14 called the Strategic Planning Working Party of
15 14th February 1983.
16 If we just look at paragraph 1.1, please:
17 "At its meeting on 8th March 1982, the Regional
18 Health Authority had received a detailed recommendation
19 from the Strategic Planning Working Party relating to
20 the open cardiac surgery" and the report of a Working
21 Party chaired by Dr Mather during 1981. "The resolution
22 of the Regional Health Authority was as follows ..."
23 So this is the position in 1982.
24 "The merits of the case of expansion of the open
25 cardiac surgery service in the South Western region to
0023
1 600 cases per year be accepted in principle."
2 That 600 would include adult and paediatric open
3 heart operations?
4 A. Yes. There was no differentiation.
5 Q. "In view of the anticipated nil growth in revenue, no
6 commitments should be made to implementing the
7 recommendations of the report at present."
8 So it is accepted in principle, but no action in
9 1982.
10 "Steps should be taken to ensure that should
11 revenue become available, the authority was in
12 a position readily to develop this service by
13 establishing the capital, staffing and equipment
14 consequences of the proposed development.
15 "Further consideration was to be given to looking
16 at a range of investment by which this service could be
17 developed, including the possibility of better
18 utilisation of present facilities. Once a profile of
19 costs for different levels of open heart surgery
20 operations had been prepared, further consultations
21 would take place ..."
22 If we go to 419, just at the very end, if we
23 scroll down to the end of the document, we see the whole
24 of that page. There is the initial at the bottom,
25 "JSM/CMT". That is Mr McClelland, is it not?
0024
1 A. Yes, it is.
2 Q. If we go back to 412, and scroll down, we see at the top
3 it is sent to district administrators, and "If you
4 telephone, please ask for JS McClelland".
5 He was the person responsible for drawing up the
6 Working Party report?
7 A. Yes. He was a senior planning officer at the Regional
8 Health Authority.
9 Q. If we go to the body of the report, please, at 416, if
10 we just look at that page, please, there was at this
11 time, and indeed, there was generally, a waiting list
12 problem for cardiac surgery at the Bristol Royal
13 Infirmary?
14 A. Yes. The report demonstrated that the region required
15 a bigger capacity for cardiac surgery.
16 Q. We see that at 4.1:
17 "The case before the Working Party demonstrates
18 the practicality of increasing by 100 cases the number
19 of open cardiac surgery operations carried out at
20 Bristol on behalf of this region. The existing waiting
21 lists of patients is currently such that the additional
22 surgical capacity could already be committed without any
23 expectation of an increased referral rate of patients to
24 the physicians in Bristol. On the other hand, it has to
25 be borne in mind that having once increased by 100 cases
0025
1 per year, this would be a continuing increase in
2 capacity and that the new referrals of patients which
3 have in any case been increasing over recent years would
4 still not meet the overall demand."
5 So there is an excess of demand over supply. That
6 is the key motivating factor behind this Working Party
7 report?
8 A. Yes, it is. I think it is important to look at what is
9 in 4.2 as well, because that refers to the fact that the
10 South West region should continue to send patients to
11 London as well.
12 Q. Yes, and at this time it was -- first of all, it was
13 known that patients were sent to London; secondly, it
14 was anticipated that if the cardiac surgery capacity in
15 Bristol was expanded, there would still be a significant
16 need to refer patients to London in order to meet the
17 demand for this surgery in the Bristol and Weston and
18 wider South Western area?
19 A. Yes.
20 Q. If we look at the bottom of the page, 4.3:
21 "It is suggested that in order to ensure that the
22 enhancement of service is real, that a regular review
23 should be undertaken not only of the patients being
24 operated upon in Bristol who are residents of the South
25 Western region, but also of those who are being referred
0026
1 outside the region to other centres".
2 That is the point we have just touched on.
3 "At the present time it is not easy to identify
4 these on a regular basis since some of the hospitals in
5 London are outside the normal hospital activity analysis
6 data systems. It is therefore proposed that the
7 Regional Medical Officer in discussion with the
8 clinicians in the region should establish a regular
9 method of obtaining statistics for referrals outside the
10 region."
11 Why should it be that London was different?
12 A. Within the South West region, we, all the health
13 authorities had worked together to use the same computer
14 systems, so it was possible to access data about patient
15 flows, so we were in the infancy around that time as
16 well, but at least we could access information.
17 There was not the sophistication that exists now
18 where we know where every patient comes from using their
19 postcode. So it is much more difficult to establish, at
20 that time, and there was no real need to do it either.
21 When you asked me about allocations earlier on,
22 when we had the funding into the Health Authority, there
23 was no question about how many patients did you actually
24 have to care for? We were provided an allocation to run
25 the hospitals. The system now is completely different.
0027
1 Q. But it was a reference to the London hospitals not being
2 part of the hospital activity analysis. Why should that
3 be?
4 A. They are in a completely different region, so you would
5 actually have had to have gone to those hospitals and
6 said "Did you care for any of the patients from the
7 South West?" and with a lot of the hospitals in this
8 country, they would not have had any idea where their
9 patients were coming from. It would have been a manual
10 exercise, probably, to have gone through every set of
11 notes to find out where those patients' residential
12 address was.
13 Q. So it would have been an unrewarding task for the South
14 Weston Regional Health Authority to go off and, as it
15 were, knock on the door of the London hospitals and ask
16 for that information?
17 A. Yes, and the London hospitals might not actually agree
18 that it was an issue that they could put resource into
19 identifying. It was a completely different sort of
20 environment then.
21 Q. If we look on 417 where we are, if we scroll down to
22 paragraph 6, we had reached the point where the thesis
23 is that more operations ought to be done at the Bristol
24 Royal Infirmary to try and do something about the
25 waiting lists. This paragraph deals with the funding.
0028
1 "The problem which arises in funding the
2 development of regional specialties is that the current
3 RAWP formula --
4 A. Resource Allocation Working Party.
5 Q. -- does not adequately cater for the funding of such
6 specialties on a regional basis. The way in which the
7 formula operates is as follows ... Districts providing
8 regional specialties are deemed to have", a phrase which
9 is designed to make lawyers look more carefully, "the
10 financial resources for providing these specialties
11 contained within their existing allocation."
12 So there is no separate express pot of money to
13 deal with cross-boundary flows; it is dealt with in as
14 it were the block of money that is passed to the
15 District Health Authority?
16 A. Yes.
17 Q. "In calculating district target positions, the
18 cross-boundary flow of patients between districts is
19 taken into account, including the cross-boundary flow
20 for regional specialties."
21 I understand what that means in theory. In theory
22 it means that there will be enough money to meet the
23 needs not only of as it were the home population, but
24 also the people coming from outside the district, but
25 how was it, how was the level of cross-boundary flow
0029
1 estimated? How was it taken into account? What was the
2 mechanism?
3 A. There is an hour's lecture in this. The allocation for
4 each Health Authority was adjusted, as it says here, but
5 the cross-boundary flow data was probably two years old,
6 if not older than that.
7 Q. If you look at 6.2, I think that might help you.
8 A. It is okay to take into account for the work that has
9 already been done, but when you want to expand the
10 service, then it is a long time before any funding will
11 ever get to you, because of the vagaries of the formula.
12 Q. So the RAWP formula is not a very reactive beast?
13 A. No. The RAWP formula was really set up to try and
14 equalise access to health care through making sure that
15 the spending per head of population in each Health
16 Authority across the country was the same. What it did
17 not do, and it was never aimed at, was creating
18 a mechanism to fund such issues as regional specialties,
19 so it was basically incapable of doing that.
20 Q. That is essentially what paragraph 6.2 says, I think.
21 6.3:
22 "Taking these factors into account, it is clear
23 that the expansion of regional specialties can only be
24 funded in the short to medium term either by the
25 district providing the service or by a special addition
0030
1 to the district allocation."
2 Were the district providing the service on its
3 own, it would be providing a "free lunch" to the other
4 districts?
5 A. Yes.
6 Q. "Whilst individual districts may be prepared to fund
7 minor developments in regional specialties, they are
8 unlikely to divert the resources needed to fund a major
9 expansion when much of the benefit will accrue to other
10 districts." So "free lunches" are not on the menu?
11 A. And most district authorities would not have the level
12 of resource in growth terms to allow that to happen,
13 given all the other choices or demands on those funds.
14 Q. So in order to fund the regional specialties, therefore,
15 the region has to agree to give some special help to the
16 district which happens to host the regional specialty?
17 A. Yes.
18 Q. By giving a top-slice of money before the region's money
19 is divided among the various districts in its region?
20 A. Yes.
21 Q. Which is why, going back to something I said earlier,
22 for the development of regional specialties, in order
23 actually to bring a planned project to fruition, you
24 have to get high on the region's agenda in order to, as
25 it were, get your hands on the top-slice of money?
0031
1 A. Yes. You either have to get it high on their agenda or
2 you had to have central initiative from central
3 government saying, "This is an area of priority. You
4 need to have this looked at within your own region".
5 Q. We will see that in due course, when the government
6 produced the Health of the Nation document, one of those
7 specialties was cardiac surgery, heart disease in
8 adults?
9 A. Yes.
10 Q. So now and again, government will put something on the
11 agenda, but if you have an area which is not on the top
12 of the government's agenda, the district has to persuade
13 the region that it ought to be on the region's agenda.
14 Is that a fair way of putting it?
15 A. Yes.
16 Q. In 1984 this project of increasing the amount of cardiac
17 surgery at Bristol was taken a little further forward.
18 If we look, please, at document HA(A) 95/28:
19 "Dear Colleague,
20 "Further to the project team meeting on
21 13th February 1984 ..." scan down to the bottom:
22 "All members of the Project Team/Working Party",
23 and there you are at the bottom of the second column.
24 A. Yes.
25 Q. Some of these names are familiar to us and others are
0032
1 not. I know it is a long time ago, but can you help us
2 with who the runners and riders are?
3 First of all, for the Regional Health Authority?
4 A. Crofts was a planning person. Fearon was a finance
5 person for the Regional Health Authority. Fleming was
6 an architect. Hoffman was a nurse. Kent, I cannot
7 remember. McClelland was the Senior Planning Officer.
8 Q. He is the man we have just seen?
9 A. Yes. Dr Pearce was Public Health Medicine. Rex
10 Saunders was a specialist in purchase of major X-ray and
11 scientific equipment. Reynolds, I recognise the name as
12 being, I would imagine, the Regional Medical Officer,
13 but I am not sure. On the right-hand side, Dr Ian
14 Baker, at that time is a public health medicine doctor
15 and District Medical Officer. Thelma Burt was a senior
16 nurse at Health Authority level. Chris Fewtrell was the
17 Deputy District Administrator. Dr Hyam Joffe is
18 a paediatric cardiologist. Dr Steve Jordan is an adult
19 and paediatric cardiologist, I believe, at that time.
20 Gerald Keen was a cardiac surgeon. I was the planning
21 accountant. Donald Short was an anaesthetist. Peter
22 Wilde is a radiologist. James Wisheart, a surgeon.
23 Vincent Harral, District Administrator. David
24 Hucklesby, District Treasurer. I should remember that
25 one ... Mr AJ Webb ... I do not know.
0033
1 Q. Was Mr Hucklesby at that stage your boss?
2 A. Yes, he was. He was the District Treasurer.
3 Q. And was it he whom you replaced as Treasurer of the
4 Bristol & Weston Health Authority in due course?
5 A. No. Mr Tony Parr, Anthony Parr, replaced Mr Hucklesby
6 until late 1990 when he got a post elsewhere, and I took
7 over from him.
8 Q. Do you remember when Mr Hucklesby left as Treasurer?
9 A. No. 1986? 1987?
10 Q. Do you know where he went?
11 A. He retired.
12 Q. So he was replaced by Mr Parr and you replaced Mr Parr?
13 A. Yes.
14 Q. Okay --
15 A. I am sorry, can I say, we ought to check when
16 Mr Hucklesby left. I cannot recall that exactly.
17 Q. I am sure I should know, it is my fault, I am sure
18 I have written it down 10 times already. If I cannot
19 find it, I will ask.
20 Can I go next, please, to the report known as the
21 third report, I think, of the Open Cardiac Surgery
22 Working Party? UBHT 295/265.
23 A. May I just make a comment? This is in 1984 and work
24 actually did go on in 1983 to expand the service from
25 275 to 375 cases, because it was one of the first jobs
0034
1 I was involved with. That is not included in the
2 report.
3 Q. I am going to mention that in just a minute.
4 This one is dated June 1984. We see at the top of
5 265 -- this is your copy -- you were the Assistant
6 Treasurer?
7 A. Yes.
8 Q. You have a helpful habit of writing your name on your
9 copies of documents.
10 If we go over to 266, we see at the bottom "June,
11 1984". I think this is your writing, is it not?
12 A. Yes, it is.
13 Q. "Strategic Planning Working Party - 11th June 1984" and
14 it is going to go to the region on 11th July 1984?
15 A. Yes.
16 Q. Consultation over the summer and sign it off by
17 September 1984?
18 A. Yes.
19 Q. Over the page, 267. If we just scan down, please, at 4:
20 "The existing service." This is the Bristol unit
21 since the Mather report, 1991, so this is the background
22 against which this is to be seen.
23 If we go to 270, that is the same recitation of
24 the events of 1982 that we looked at already. In the
25 middle of the page, please:
0035
1 "As a consequence of these decisions, a Working
2 Party was set up on 13th September 1982, with the
3 following brief ..."
4 That was essentially to look at expanding open
5 cardiac surgery from 275 up to 600 cases per annum.
6 We will look at that in a minute.
7 If we go to 309, please, these are the members of
8 this Working Party. I have not done the exercise of
9 marrying them up with the long list we saw a moment ago,
10 but we see it is substantially the same people.
11 From the Bristol & Weston Health Authority point
12 of view, there is Dr Baker, Mr Hucklesby is there, the
13 two cardiologists, the two surgeons, and Mr Wilde along
14 with yourself.
15 You rightly indicated to me that there had been
16 some activity before 1984.
17 If we go, please, to UBHT 295/270, paragraph 2.2,
18 just below where we were a moment ago:
19 "Arising from consideration of the Working Party's
20 first report dated January 1983 ... it was unanimously
21 agreed that there should be a scheme for the immediate
22 expansion from 275 to 375 operations per annum to be
23 implemented" in 1983/84.
24 So when the Inquiry period begins in 1984, it
25 begins against a background of open cardiac surgery at
0036
1 the Bristol Royal Infirmary having just been increased
2 from 275 operations per year to 375?
3 A. Yes.
4 Q. So that is where the Inquiry comes in?
5 A. Yes.
6 Q. Then there is a second Working Party report. If we
7 scroll down to the bottom of the page at 2.3:
8 "The Working Party's second report dated March
9 1984", following hot on the heels of the first,
10 "concentrated on the investigational service for both
11 adults and children to meet the needs of the regional
12 cardiac service in Bristol, in keeping with the proposed
13 surgical expansion to 600 operations per annum."
14 So although there had been this initial expansion
15 of 100 in 1983/84, the long-term objective had been set
16 as long ago as the Mather report of moving to 600 per
17 year in the medium term?
18 A. Yes.
19 Q. So the second report was concerned with the
20 catheterisation facilities, essentially?
21 A. Yes.
22 Q. And at that time, there were, I think, two cath' labs in
23 the BRI and none in the BCH?
24 A. That is correct.
25 Q. The proposal was to have a particular catheterisation
0037
1 machine suitable for children at the BCH and to upgrade
2 the two existing rooms at the BRI to give a total of
3 three catheterisation labs between the hospitals?
4 A. Yes.
5 Q. That was done and completed, I think, by about April
6 1987, or thereabouts; is that right?
7 A. Yes.
8 Q. So if we go to 273, please, just to pick up on that:
9 "Following consideration of", this is the second
10 Working Party report, the March 1984 one, "the Regional
11 Health Authority on 9th April 1984 made those
12 resolutions. There was to be a new cath' room at the
13 BCH with a biplane cineangiograph unit, and then the
14 existing service at the BRI was to be upgraded as well.
15 Proposals were to be submitted to improve the service
16 for the adult population to be incorporated into the
17 proposals to increase open heart operations which were
18 due for submission shortly."
19 Then we come to the third report. 2.4, the aim
20 now was to examine the implications of achieving the
21 proposed longer term need to increase up from 375 to
22 600?
23 A. Yes.
24 Q. If we go to 274, this flow chart shows where the
25 patients were going at this time:
0038
1 "The following flow chart indicates the referral
2 pattern for cardiological investigation and cardiac
3 surgery within the region and outside to London
4 hospitals. The volume of flow is depicted by the
5 thickness of the line. 200 patients were operated in
6 London but were followed up within the region."
7 So we see there with general practitioners'
8 initial cardiological diagnosis, some GPs will refer
9 patients to the district general hospital, some will
10 refer straight to the regional specialty unit. The
11 district general hospital will refer on to the regional
12 specialty unit, or to the London specialty unit, and on
13 occasion, the regional specialty unit, in other words
14 the BRI, usually, will refer patients on to Hammersmith,
15 Brompton, or the National Heart Hospital, or others?
16 A. Yes. That depends on what the relationships were
17 between individual clinicians within the region, and how
18 close you were, obviously, to places like the Children's
19 Hospital. If you lived in Bristol, then you would go
20 straight to the Children's Hospital.
21 Q. So at this time when there were 375 open cardiac
22 operations in Bristol in a year, that is only a little
23 under two-thirds of the total number of operations
24 carried out in South Western Regional Health Authority
25 residents, because roughly 400 had been done in Bristol
0039
1 and half of that, 200, are going to London?
2 A. Yes.
3 Q. So the Bristol service at this time was only able to
4 cope with two-thirds of its own demand -- I say "its
5 own", I mean the South West region's demand?
6 A. I think if you go back to the Mather report, I think it
7 is inferring that there is a higher demand than that.
8 That is two-thirds of the actual number of cases being
9 operated on, not the demand.
10 Q. Yes, there was a pent up demand behind that.
11 A. Yes.
12 Q. If we go to 275, the Working Party says ... and it
13 refers to the Mather report, and then, in the last
14 sentence, actually, of the first paragraph, makes the
15 point you have just made: it was not expected that the
16 800 operations, that is 600 in Bristol and 200 in
17 London, would fulfil the total demand from the region.
18 Further review of clinical needs would be carried out
19 when it got to the 600 stage.
20 Then there is this paragraph:
21 "The reasons for settling for 600 operations
22 annually as the minimum viable size for a unit in
23 Bristol were that not only did it provide an economic
24 size for which to provide staff and facilities, but it
25 is internationally recognised that the overall mortality
0040
1 rate drops in direct relationship to the number of
2 operations carried out."
3 Then it explains how the 600-odd operations were
4 going to break down, and we see that 100 of them are
5 going to be bypass. I am sorry, when it reached 375,
6 just over 100 with the coronary artery bypass surgery,
7 but at 600 almost 300 would be bypass operations,
8 thereby securing the best survival rate. So what is
9 being said is, "We will have a large number of coronary
10 artery bypass operations by that stage, so if this
11 direct relationship works, we should be getting top
12 results".
13 I know that is not something --
14 A. That is not really something for me to respond to.
15 Clearly public health medicine people have had an input
16 into creating those paragraphs.
17 Q. But that is the logic of the reasoning there?
18 A. I can only say that is what is written down.
19 Q. Yes, that is what is written down.
20 "In increasing the size of the unit it would be
21 anticipated that there would be a gradual increase in
22 coronary artery bypass operations and that valve
23 replacements and operations on children with congenital
24 defects would increase marginally."
25 So this report, which is March 1984, comes out
0041
1 almost to the day at the time when Bristol was
2 designated first of all as a supra-regional centre for
3 infant and neonatal cardiac surgery?
4 A. Yes.
5 Q. Again, it is not a matter obviously for you to comment
6 on in any detail, but the Inquiry has already seen that
7 there is a small number, I think either three or four,
8 of neonatal and infant open heart operations being
9 carried out at that time. It would seem from this
10 Working Party report, would it not, that the focus of
11 the Working Party was very much on adult as opposed to
12 paediatric surgery, and within adult surgery, on
13 coronary artery bypass operations, to get those up to
14 such a level as ought to secure the best survival rate?
15 A. Yes. I cannot actually remember much discussion about
16 children at all, when we were in the Working Party. It
17 was, as you say, directed at -- I think I would say it
18 was directed at increasing the number of cardiac surgery
19 operations that were undertaken rather than splitting it
20 between adult and children the way you have.
21 Q. I am just picking up on the use of the word "marginally"
22 there.
23 A. Yes.
24 Q. If we go to 284, perhaps this deals with the point we
25 are just discussing.
0042
1 This is Appendix A, as I read it, to the Working
2 Party report. It follows immediately afterwards.
3 A. Yes.
4 Q. We see the definitions there. If we scan down to
5 paragraph 2, the actual caseload for 1982 and 83, there
6 were 200 open heart adult operations in Bristol, the
7 same number in London, a total of 400. Children, open
8 heart operations in '82/83 was a total of 75, so the
9 total number of operations was 525.
10 If we go over the page to 286, please, projected
11 caseload for Bristol, the idea was that once Bristol was
12 performing 600 open heart operations a year, 420 of
13 those would be on adults and 180 on children.
14 I think to be fair, actually the proposed increase
15 from 75 to 180 may be thought to be slightly more than
16 marginal, but anyway, "marginal" is the word that is
17 used in the report, but the actual figures are 420
18 adults and 180 children.
19 If we go, please, back to 276, this takes us to
20 the physical buildings and so on. The second paragraph:
21 "The agreed scheme to enlarge the cardiac surgery
22 facilities (Ward 5) on level 6 ... by 4 beds ...
23 commenced on 17th October 1983 and was completed ... on
24 2nd March 1984. It was anticipated that the enlarged
25 facilities will be fully operational as from June 1984,
0043
1 when the two additional anaesthetists will be in post."
2 Can you help us with that: the cardiac surgery
3 ward in the BRI was known as Ward 5?
4 A. Yes.
5 Q. That was on level 6 of the building?
6 A. Yes.
7 Q. The theatres were on a different level, they were on
8 level 4, and what had happened was that the initial
9 expansion from 275 to 375 involved four additional beds,
10 two intensive care beds and 2 low dependency beds;
11 is that right?
12 A. Yes.
13 Q. There was now to be a further expansion in the number of
14 beds to cope with the expansion to 600?
15 A. Yes, there was.
16 Q. If we just scroll down, please, that is the proposal: in
17 1984, doing 375 operations, 6 intensive care beds, three
18 children's beds, four high dependency and 6 low, a total
19 of 19. There is now a proposal to increase that to 32,
20 8 ITU, 6 children, 8 high dependency, 10 low dependency
21 and to increase the number of operating theatre sessions
22 by 50 per cent from 12 to 18?
23 A. Yes.
24 Q. It sounds like a large increase, 50 per cent, how was
25 that possible in terms of capacity without building
0044
1 a new theatre?
2 A. I am sorry, I cannot recall -- I mean, in detail. But
3 I am sure there were manoeuvres about maintenance
4 sessions, but somebody else would probably have to
5 handle that. If you look back in the past you will find
6 that maintenance sessions in the working week were
7 mechanisms to, if you could move those out then you
8 could create more theatre capacity, but the detail I am
9 afraid I cannot remember.
10 Q. But there was no new theatre at this stage?
11 A. No.
12 Q. So this is boxing and coxing with the existing
13 facilities?
14 A. Yes.
15 Q. Then the revenue funding arrangements at 4.2, what was
16 happening, if I have understood it correctly, is that
17 a one-off three-year injection of money would be made
18 available by the Regional Health Authority for 84/85,
19 85/86, and 86/87?
20 A. Yes.
21 Q. After that, the districts would have to, as it were,
22 sort it out between themselves through the RAWP -- it
23 would be sorted out through the RAWP formula, which
24 might by then have had a chance to catch up with the new
25 reality?
0045
1 A. Well, sort of. The Regional Health Authority would have
2 funded it and then it gave each of the other health
3 authorities three years notice about how much money they
4 would actually have to pass over to Bristol & Weston
5 Health Authority to cope with it. It did not actually
6 go through the RAWP formula as such. So out of
7 Somerset's allocation, they would know that in a certain
8 year they would have to have found whatever the money
9 was, 50,000, to pay across to Bristol & Weston Health
10 Authority for their share of this development.
11 Q. So at the end of the three-year period, each of the
12 districts having established what size of the cake they
13 were eating, would then have to pay their way?
14 A. Yes.
15 MR MACLEAN: Sir, I have no idea what the time is, but I am
16 told by Mr Langstaff it is probably teatime. Is this
17 a convenient moment?
18 THE CHAIRMAN: Yes. We normally take a break for a quarter
19 of an hour around now. Just one matter which I would
20 like to raise, in one of your answers, Mr Nix, and for
21 the purposes of the transcript, at 45/1, you actually
22 adopted Mr Maclean's term of "boxing and coxing". Are
23 you content that should be a description allocated to
24 you?
25 A. Could I ask what it was in relation to?
0046
1 MR MACLEAN: It was in relation to the use of the theatres,
2 I think. I was suggesting that what looks like a large
3 increase of 50 per cent from 12 to 18 sessions was
4 contemplated. We agreed there was no new theatre to be
5 built?
6 A. There were no new theatres. I am not sure it gives --
7 it gives an inference it was not planned. These
8 additional sessions would have been planned by moving
9 other sessions around for other clinicians and
10 allocating moving, for example, maintenance sessions out
11 of the working week.
12 THE CHAIRMAN: I just wanted to give you an opportunity to
13 explain that more fully. Thank you. So we will adjourn
14 now for 15 minutes and reconvene just after noon. Thank
15 you.
16 (11.46 am)
17 (A short break)
18 (12.03 pm)
19 MR MACLEAN: Mr Nix, we were dealing before the short break
20 with the report in 1984, the June 1984 report.
21 Can I go now, please, to UBHT 295/417? We are
22 still dealing here with the aim at this stage of
23 increasing the number of open heart operations to 600.
24 Can we see that whole page, please? We see from
25 the top that it is the "Full Working Party version,
0047
1 South Western Regional Health Authority proposed
2 expansion of adult paediatric cardiology provision to
3 facilitate an increase in open heart surgery."
4 If we go to 418, and go to paragraph 2, at that
5 stage 880 cardiac catheter investigations per annum were
6 sufficient to satisfy the throughput of 275 open heart
7 cases in Bristol, 200 in London and 50 closed heart
8 cases in Bristol, which is in rough terms a little less
9 than 2 to 1?
10 A. Yes.
11 Q. "With the considerable success that has been achieved in
12 recent years using coronary surgery in particular, the
13 demands for increased cardiac investigation in adults
14 can only increase".
15 Then at 2.3:
16 "Risks of ferrying paediatric cases", this is
17 referring to the split site that we will come back to in
18 due course.
19 "The present investigational facilities at the
20 Bristol Royal Infirmary consists of two adjacent
21 catheterisation rooms ... the newest equipment was
22 installed some eight years ago", which would be in 1976,
23 "and both rooms are nearing the end of their useful
24 predicted life, i.e. within two years. There is no
25 accommodation at the Bristol Children's Hospital.
0048
1 "Therefore, at the present time, patients' lives
2 are frequently being put at risk by the need to transfer
3 very young children between the BCH and BRI every time
4 a catheter investigation was needed. 50 per cent of
5 these patients are critically ill neonates and infants,
6 many of whom require urgent surgery. This type of
7 emergency surgery is predominantly of the closed heart
8 type which is currently performed at the Bristol
9 Children's Hospital, 50 closed heart cases. The open
10 heart cases, although with severe disease, are usually
11 admitted electively for surgery in the Bristol Royal
12 Infirmary."
13 Just unpicking that paragraph, a child who needed
14 a catheterisation as part of the investigative process
15 who was born, say, in the Maternity Hospital would have
16 to be taken to the BRI for the catheter investigation,
17 and then, if they needed a closed heart operation, taken
18 back to the BCH for that operation to be performed?
19 A. Yes.
20 Q. That is how it works?
21 A. Yes. In fact, they would come down and go back up
22 again.
23 Q. Yes, and what is being said is that that put their lives
24 at risk?
25 A. Yes.
0049
1 Q. The last sentence is referring to the fact that the
2 problem of moving patients was perhaps less severe for
3 the open heart surgery candidates because they would be
4 generally admitted in the first place into the BRI?
5 A. That is what it says. I am not directly involved, or
6 was not directly involved with that.
7 Q. But that is the importance of the reference to them
8 being admitted electively for surgery, so they would not
9 have to make that trip down the hill?
10 A. Yes.
11 Q. If we go, please, to 420, and I think scan down
12 a little, if we can just stop at 3.1.4, the report says
13 that:
14 "The transportation of critically ill infants must
15 be avoided. This current practice has given
16 considerable concern to the paediatric cardiologists for
17 some time."
18 So that is 1984, this report?
19 A. Yes.
20 Q. So there is no doubt, we see from these reports, that
21 one of the significant, perhaps the most significant
22 fact, in the development of the cath' lab at the BCH was
23 the concern that to take children down the hill from the
24 BCH to the BRI for catheterisation was a risk which
25 should no longer be taken. Is that a fair way of
0050
1 putting it?
2 A. Yes, I think so.
3 Q. Again, if we go to 422, please, setting out various
4 options for the upgrading of the catheterisation
5 facilities, this option, option 2, was simply to replace
6 the old equipment in the two existing rooms at the BRI.
7 If we scan down, please, to 3.4.5, "Unfavourable
8 factors":
9 "(iii) Paediatric cases would continue to be
10 transported from the BCH to the BRI and back for their
11 catheter investigations."
12 Then the conclusion, if you scan down a little
13 more:
14 "This option does not provide a full
15 investigational level to service the projected surgical
16 workload. Also, it would still leave the problem of
17 transporting critically ill infants between the BCH and
18 BRI unresolved. The option has, therefore, been
19 rejected on clinical grounds."
20 So that one was a non-starter for those reasons?
21 A. Yes.
22 Q. If we go then to 425, please, we will get to your status
23 in finance in a moment. This is option 4, the one
24 proceeded with:
25 "To re-equip the two rooms at the BRI and provide
0051
1 a new room at the BCH".
2 Then you see the proposal set out at 3.6.1.
3 If we scan down to 3.6.4, at that level we are
4 allowing for the anticipated demand post-1988.
5 "Favourable factors: (i) avoids the high risk of
6 transporting critically ill infants between the BCH and
7 the BRI. (ii) maintains ready access to expert
8 paediatric support, neonatal, anaesthetic, intensive
9 care and nursing", et cetera and "unfavourable factors"
10 are concerned with the cost of equipment and cost of
11 staff.
12 If we go to 426, some of the other factors,
13 "(ii) the proposed BCH provision is not dependent on
14 the main cardiac surgery scheme, i.e. the increase to
15 600 operations in Bristol, so the ferrying of children
16 could be eliminated as soon as the necessary funds are
17 available."
18 I think in fact the catheterisation room at the
19 BCH was developed first, was it not, so that the process
20 of ferrying children to and fro stopped before the end
21 of this development was complete?
22 A. Yes, and it also gave backup, then, if there were
23 problems in replacement in one of the Royal Infirmary
24 rooms.
25 Q. It would be possible in the extreme to take an adult up
0052
1 and down the hills?
2 A. Yes.
3 Q. "Although the proposed catheterisation room at the BCH
4 is not expected to carry out catheterisations
5 continuously", it was going to be fully staffed?
6 A. Yes.
7 Q. If we just look at the cost of all this, at 429 -- if we
8 see the whole page, please -- are those, as you recall,
9 the order of costs that was talked about here?
10 A. Yes.
11 Q. œ1.175 million in capital, that is the cost of doing the
12 work and professional fees of those involved and buying
13 the equipment, and œ300,000 a year on ongoing revenue
14 costs?
15 A. Yes. In today's prices it would be about œ1m each, so
16 that would be 3 million, the top one.
17 Q. So in today's prices it would be about...?
18 A. About œ1m per catheter machine.
19 Q. So today's prices you would be talking about?
20 A. 3 million.
21 Q. 3 million, only on equipment?
22 A. Yes.
23 Q. That is against a turnover in the Trust of what,
24 nowadays?
25 A. The UBHT has œ200 million turnover.
0053
1 Q. So that would be about one and a half per cent of the
2 annual turnover of the Trust?
3 A. Yes.
4 Q. So would it be right, in sealing it down proportionately
5 to the prices then this would be of that order?
6 A. This was a substantial investment by the Regional Health
7 Authority in this equipment.
8 Q. If we look at 433, please, just to source this document,
9 the bottom of the page, it is written by Dr Joffe, but
10 no doubt with input from others?
11 A. I am sorry, the document itself, the whole document
12 would have been written by the Regional Health
13 Authority. I think you will find that Dr Joffe is
14 probably only that element of it, I would have
15 suggested.
16 Q. We can check that. If we go, please, to UBHT 62/72,
17 this is a meeting of the committee that you refer to in
18 the statement, the Policy, Planning and Resources
19 Committee of 25th May, a report by the District
20 Treasurer, that is Mr Hucklesby at this stage?
21 A. That is correct.
22 Q. If we scroll down and stop it at paragraph 1, there is
23 the same costs set out: cardiac catheterisation,
24 1.175 million capital, 300,000 revenue, and then the
25 cardiac surgery options have been split into 4A and 4B.
0054
1 That was two ways of achieving the increase to 600 open
2 heart operations at the Bristol Royal Infirmary; is that
3 right?
4 A. Yes.
5 Q. One was a bit more leisurely than the other, and not
6 surprisingly, the quicker of the two options involved
7 the larger capital expenditure?
8 A. Yes.
9 Q. We see July 1990 and August 1988?
10 A. Yes.
11 Q. The preferred solution was 4B. We see that with the
12 star beside it and the explanation at the end of
13 paragraph 1.
14 Which option was in the end adopted, do you
15 remember?
16 A. No, I am sorry, I cannot, because the scheme itself
17 actually changed slightly as well as we went along.
18 Q. But I think the expansion to 600 operations per year was
19 in fact in place before July 1990 as matters turned out?
20 A. Yes, it was.
21 Q. It was, I think, substantially closer to the August 1988
22 date?
23 A. 1988/89.
24 Q. Can we go to WIT 38/19, please, paragraph 11? This is
25 Pamela Charlwood's statement. She says:
0055
1 "In May 1985 the Regional Health Authority asked
2 the district to extend cardiac services further. It
3 would fund a new catheterisation room at the BCH out of
4 capital, would upgrade or re-equip 2 catheterisation
5 rooms at the BRI and would appoint a third cardiac
6 surgeon for adult and children's work."
7 As it turns out, that was Mr Dhasmana?
8 A. Yes.
9 Q. "But the South West Regional Health Authority repeated
10 that it would fund the extension for three years only.
11 Thereafter districts to bear the cost according to
12 usage."
13 A. Yes.
14 Q. That is what we discussed before the short break?
15 A. Yes.
16 Q. So the funding of the cath' labs and the refurbishment
17 at the BRI of the cath' labs and the new one at the
18 Children's Hospital and the expansion to 600 cases per
19 year were all funded for three years by the region, and
20 thereafter were to be funded by the districts as to the
21 ongoing revenue cost, according to the usage?
22 A. That is right. It should reiterate the revenue. The
23 districts only picked up the revenue. The Regional
24 Health Authority out of its capital allocation paid for
25 the equipment and the adaptation work.
0056
1 Q. Yes, I think I tried to make that clear, yes.
2 Now, around the same time but a slightly different
3 point, can we go to UBHT 516, please? If we go back to
4 the beginning of this, just to put it in -- UBHT
5 295/516, the Plymouth Health Authority. We see at the
6 top of the page -- is this a document you remember
7 seeing before?
8 A. I must say I have seen it because that is my writing on
9 the top right-hand corner, but I cannot recall it
10 particularly.
11 Q. That is a copy to -- that is Mr Baker, is it?
12 A. Dr Baker.
13 Q. His initials are "IAB"?
14 A. Yes, Ian Baker.
15 Q. And Mr Wisheart?
16 A. That is correct.
17 Q. If we scan down to see the whole of this page, it is
18 a document from the Plymouth Health Authority concerned
19 with the needs of the population of Devon and Cornwall
20 for cardiac surgery, dated 9th September 1985.
21 If we go to 517, please, we see that it is
22 a draft. I confess, I have not found a final version of
23 this report, but this is obviously the one that you
24 received and sent on to those two recipients, Dr Baker
25 and Mr Wisheart.
0057
1 We see then, in paragraph 1, in the second
2 paragraph, a reference to the joint report of the
3 Cardiology Committee of the Royal College of Physicians
4 and the Royal College of Surgeons and the Panel have
5 seen that in the context of the development of
6 supra-regional services in the evidence we have had over
7 the last couple of weeks and they will be familiar with
8 that.
9 If we scan down 517, the paper considers the
10 questions including "Should patients from Devon and
11 Cornwall have to continue to go to Bristol or outside
12 the region for their heart operations: (c) If a second
13 cardiac surgery unit is provided in the South Western
14 region, where should it be? (d) what are the options
15 for providing cardiac surgery in Plymouth."
16 This document is a pitch, in essence, for adult
17 cardiac surgery to be carried out in Plymouth as
18 a second regional centre along with Bristol serving the
19 South West?
20 A. Yes. I think if you go back to the Mather report, it
21 did talk about a second unit which reached 600.
22 Q. Yes. If we go to 520 at the bottom of the page:
23 "The need for a cardiac surgery unit based in
24 Devon and Cornwall.
25 "With a population of 3.2 million the residents of
0058
1 the South Western region could expect to have performed
2 annually 1700 to 1900 total heart operations in a year,
3 including paediatric heart operations".
4 If we go to 521 at 3.1, this paper is suggesting
5 that it would be logical to have two centres in the
6 South Western region, one of which was to provide
7 a service for paediatric cardiac surgery.
8 So there is no suggestion from Plymouth that they
9 are going to set up a paediatric cardiac surgical unit,
10 but they do suggest complementing Bristol's adult one.
11 Then the paper goes on to discuss where patients
12 go in order to get services at that stage.
13 If we go to 523, please, paragraph 5.6: "There is
14 no intention to provide paediatric cardiac surgery in
15 Plymouth and it is expected that all such cases will
16 continue to use Bristol, Southampton and London as at
17 present."
18 So it would seem that there was no change
19 contemplated.
20 If we go to 531 -- this is coming back to your
21 neck of the woods, now -- paragraph 11.1:
22 "Current financial arrangements. Before examining
23 the costs of the options for developing a cardiac
24 surgery service, it is pertinent to consider the current
25 financial arrangements. At present the cost of
0059
1 treatment for patients from the southern part of the
2 region who go either to Bristol or London are recharged
3 to the host district by means of the RAWP cross-boundary
4 flow mechanism", which you explained earlier.
5 "The intra-regional recharge to Bristol is based
6 on an estimated cost per case of œ4,357 at 1984/5
7 prices."
8 That is a price which, so it would seem, applies
9 equally to adult or paediatric open heart operations?
10 A. Yes, certainly at that stage, it would.
11 Q. "There is however an inconsistency in the way the
12 recharge to the London hospitals is calculated. As the
13 statistics do not regard cardiac surgery as a separate
14 specialty, the recharge is based either on the cost per
15 case of thoracic or general surgery. This results in
16 a much lower than expected recharge."
17 If we go to 11.2, please, scanning down -- and
18 I should say, these are not my markings on the
19 right-hand side, I suspect they are yours?
20 A. I suspect so.
21 Q. "In determining the cost of a Plymouth-based development
22 it is relevant to consider offsetting some of the
23 proposed costs by the amount of recharge currently
24 transferred to Bristol and London. This could be of the
25 order of 600,000 for the districts in Devon and
0060
1 Cornwall. There are two important points of principle
2 here, namely, it is likely that the DHSS in the region
3 would require Plymouth to concentrate its efforts on
4 increasing South Western patient throughput in absolute
5 terms and not to transfer patients from London ... and
6 in view of the present recharging arrangements, it is
7 cost-effective to maintain existing London throughput.
8 This situation could, of course, change in the near
9 future."
10 What that is saying, unpicking that, is to the
11 extent Plymouth was having to send its work elsewhere,
12 it was cheaper to send that work to London because, so
13 it would seem, the London hospitals were not in
14 a position to estimate the cost of cases in the same way
15 that Bristol was, so it quoted a lower price. Have
16 I got that right?
17 A. I think, as I said earlier on, the level of or the
18 quality of information in different hospitals varied, so
19 the London hospitals, what they are saying here, were
20 probably counting these cases as either thoracic or
21 general surgery, and they are probably in the thoracic
22 package, I would suggest.
23 Their costs are probably okay, but it has been
24 diluted, the overall cost, by the thoracic work, which
25 is cheaper than cardiac work. So it is not that I would
0061
1 have thought it was cheaper necessarily, but it is just
2 that the data would not have been available at that time
3 to split cardiac out separately.
4 Q. It may not actually have been cheaper, but we have to
5 split the perception from the reality, have we not?
6 A. Yes. I think the link here, I think if you go back to
7 the other document, was about increasing the number of
8 cases or surgery for people from the South West. In the
9 papers we saw earlier, we saw a comment that actually we
10 should not be repatriating people back from London,
11 otherwise we are not increasing the volume available to
12 people resident in the region.
13 Q. I just want to focus on these prices. Rightly or
14 wrongly, Plymouth was being quoted a cost per case of
15 œ4,357 by Bristol?
16 A. Yes.
17 Q. If we assume that was, indeed, the best estimate
18 available at that time of the cost of an open heart
19 operation in Bristol, at that same time this document
20 would suggest that London hospitals were quoting a lower
21 cost per case for the same operation, but that does not
22 mean that it was actually cheaper to carry out the
23 operation in London; it does mean that the average price
24 was extracted from a pool, as it were, which had been
25 diluted by having other types of surgery in, driving
0062
1 down the average cost?
2 A. Yes.
3 Q. But it does have a real impact on Plymouth, because the
4 money that Plymouth pays in the long run through the
5 RAWP formula will be based on the lower cost that the
6 London hospitals are quoting?
7 A. Yes.
8 Q. So there is a real economic sense in Plymouth, if one is
9 sitting as the Treasurer of Plymouth at this time, if
10 you had been the Treasurer at Plymouth, you would have
11 been much happier for people being sent to London rather
12 than to Bristol, because the London hospitals, perhaps
13 because their systems were not sophisticated enough or
14 whatever, were quoting a much lower price than was
15 Bristol?
16 A. Yes, in pure financial terms.
17 Q. And it would be the pure financial terms that would be
18 of interest to the Treasurer?
19 A. Yes.
20 Q. So those marks down the side of that paragraph indicate
21 that those were the kind of thoughts that passed through
22 your mind as you read this report all that time ago. Is
23 this right?
24 A. Probably.
25 Q. Those would be the points that would emerge to somebody
0063
1 in your position reading this report?
2 A. I would have homed into obviously the financial angle to
3 see what the basis of their calculations were.
4 Q. You copied this to Dr Baker and Mr Wisheart and dealing
5 perhaps with each in turn, what did you expect or hope
6 they would do with this report?
7 A. I do not think I expected them particularly to do
8 anything; it would have been just my whole approach to
9 life is to share stuff, so I clearly received the report
10 from somewhere, I do not know where, and copied it out
11 to James Wisheart because he had done a lot of work with
12 him, obviously, in the regional office and to Dr Baker
13 whom I worked with very closely as the District Medical
14 Officer.
15 Q. Do you remember discussing this point? It would seem
16 that one interpretation of this document is that through
17 no fault of Bristol's own, it has been prevented from
18 having referrals sent to it because other hospitals
19 elsewhere in London are quoting a figure which is
20 actually too low for the type of operations being
21 carried out.
22 What would the Bristol & Weston Health Authority
23 be able to do about that in order to correct the
24 position and, to use a modern term, "level the
25 playing-field"?
0064
1 A. I do not think we would have done anything with this
2 report at that time, other than we only -- I think there
3 was an aspiration of Plymouth to create a second unit
4 which we were aware of. We would probably have done
5 nothing with this document at that time, other than
6 noted it. The issue of comparative costs would have
7 been a concern to me at two stages. One is that the
8 Regional Health Authority, in comparing the cost of
9 developing cardiac surgery in Bristol, might well be
10 comparing our prices or the individual unit costs with
11 London, and I think I could handle that in the same way
12 as we could have a discussion here about the
13 watering-down because of thoracic inclusion.
14 The second is that actually the prices was an
15 issue that is a more recent phenomena than it was then,
16 and there is quite a lot of reference in my files to
17 where we did comparisons between our costs, Oxford,
18 Southampton and London, to check them out. As a result
19 of this document, we probably did nothing.
20 Q. If we look at 532, please, if we just scan down the
21 page to 11.8:
22 "In the general absence of specialty costs there
23 is limited data available with which to compare the
24 proposed costs. Information has been received from
25 three Health Authorities, but any comparison without
0065
1 further knowledge should be treated with caution. The
2 information is summarised below ..."
3 We see the Bristol costs and the costs from
4 St George's and Papworth.
5 Whilst in assessing the cost of setting up a unit,
6 these figures were to be treated with caution,
7 I understand that, there was a very real drain of cases
8 and therefore ultimately of money through the RAWP
9 formula from Bristol, because of the type of cost
10 pattern that we have seen on the previous page.
11 It is the sort of thing which nowadays a provider
12 of health services would be very interested to, as it
13 were, put right?
14 A. Yes, and there is probably a better comparison of unit
15 prices now than there was in the 1980s when this was
16 prepared. I should say that there are still
17 considerable problems with price comparisons about
18 inclusion or exclusion of intensive care costs,
19 inclusion or exclusion of paediatric intensive care
20 costs and there are inconsistencies around the country
21 even now, having had pricing since 1990/91.
22 Q. Is that something that can be dealt with by way of
23 an NHS Executive letter, or guidance, or ...
24 A. Well, the basics of how you create a price are, I think,
25 probably pretty consistent; it is how you turn that cost
0066
1 into a price and whether or not you have one package so
2 it is œ5,000 or œ7,000, no matter how long that child or
3 adult stays in your hospital, and other people have
4 decided to do it on the basis that it is so much for the
5 operation and so much per day in the hospital whether
6 you are in intensive care, high dependency or low
7 dependency.
8 So people have structured their prices
9 differently.
10 Q. Can we look at a memo that you prepared on
11 18th September 1985, so that would be nine days after
12 this document was produced: UBHT 295/241.
13 These are the detailed revenue implications.
14 1985/86, an expected throughput of cases in 1985/86 was
15 450, which was a little more than the then funded level
16 of 420?
17 A. Yes.
18 Q. You set out the costs. Then '86/87, to go up to 480
19 cases. That is when the third surgeon is going to be
20 fully in post, Mr Dhasmana, as it turns out. And the
21 maximum then was going to be 500 cases. Then if you
22 break down the additional costs by the various personnel
23 involved, WDA's whole time equivalent, so the marginal
24 cost of 30 cases we see is just over œ50,000, so the
25 total cost of the expansion would be 159,900 per unit?
0067
1 A. Yes.
2 Q. If we scan down again, please, if 500 cases are
3 completed the cost would be increased by a further
4 33,000 to a total of 193, 700. So 400 cases were
5 planned for '96/97. Can we look in the same file at
6 295/575? This is a document which goes to the project
7 team, of which I think you were a member?
8 A. Yes.
9 Q. On 20th January 1986, and it is concerned with the
10 expansion scheme at the BRI to 600 operations.
11 We need not look at this one in any detail,
12 because a later version in March 1986 goes to the
13 project team. So we will come to that in a moment.
14 Keeping on with the chronology, if we go to 507,
15 please, this is a meeting attended by you, amongst
16 others, between officers of the regional and district
17 health authorities. So we can identify who is who here,
18 Dr Reynolds you mentioned earlier was copied into one of
19 the documents we looked at earlier?
20 A. Yes.
21 Q. Who were those people, what were their functions?
22 A. I think Reynolds, as I said at that stage, we should
23 have picked it up on the other lists, but I think he was
24 a regional Medical Officer. Marianne Pitman was
25 a Public Health Medicine doctor. Foreman was finance.
0068
1 Webster, I do not know. Ian Baker and myself. Ian
2 Baker was the District Medical Officer.
3 Q. If we go to paragraph 2.2, please, we see reference made
4 at 2.2 (a) to visits by a consultant cardiologist,
5 I think, from the Brompton Hospital to Cornwall,
6 questions being asked there about whether that impacts
7 upon the referral pattern.
8 Then B:
9 "450 operations a year at that time, probably up
10 to the proposed 600. Little room for manoeuvre since
11 most are urgent cases. If provision is made for more
12 than 600, the situation will become more flexible and
13 the position of under-users and over-users can be
14 examined."
15 That means under-users or over-users in terms of
16 districts?
17 A. Yes.
18 Q. "Even if the increased throughput still consisted of
19 predominantly urgent cases increased facilities may
20 enable fairer distribution of urgent cases. Authorities
21 and clinicians continue to need to be kept informed as
22 to how they are performing in these statistics."
23 If we go over the page, please, to 508 2.3(d):
24 "Because of the existing referral patterns,
25 devising a funding mechanism is difficult as there is no
0069
1 equitable and readily transferable system. Costings may
2 have to be recalculated on a speciality basis as at
3 present costings may not reflect the true mix, although
4 it was felt that the present composition was probably
5 correct."
6 That is the point we have just been discussing
7 about how you arrive at a price for a particular
8 operation at this time?
9 A. Yes, bearing in mind that here you are talking about
10 open heart, closed heart and cardiac catheterisation,
11 all of which have different prices. They certainly do
12 now, anyway.
13 Q. Yes, and the growth area is expected to be coronary
14 artery bypass grafting. We saw that already earlier:
15 the suggestion was that almost 300 of the 600 cases
16 would be bypass grafts?
17 A. Yes.
18 Q. So that is the focus of the attention in going to 600
19 cases.
20 There was some attempt at this stage to piece
21 together the referral pattern. If we go to 510, this is
22 the work in 1984, by district of residence and location
23 of treatment. Can we see that whole table, please?
24 The total number of people treated in Bristol,
25 according to my note, was 384. That is the sum of 159
0070
1 and 215 in the first column.
2 A. Yes.
3 Q. Mr Langstaff tells me it is 374, and his arithmetic is
4 better than mine.
5 A. Yes.
6 Q. The first column there shows people treated in Bristol;
7 the second column shows the people referred elsewhere.
8 The numbers are very similar. For the second 6 months
9 of the year in particular, 215 people treated in Bristol
10 and 217 referred elsewhere.
11 We can see them broken down by the different
12 districts. If we go to 512, these are the London
13 referrals for the same period, so this is breaking down
14 the referred elsewhere into those referred to London.
15 Some are referred, as we saw in that earlier flow chart,
16 direct and some are referred from Bristol.
17 But from this table we can pick out perhaps in
18 particular Plymouth, which was referring 67 in the first
19 6 months of 1984 direct to London, and 54 in the second
20 6 months, and very few, only 2 in the whole of the year
21 by Bristol.
22 Cornwall: again, significant numbers of people
23 referred direct from Cornwall, bypassing Bristol and
24 being referred direct to London.
25 That would be the result, at least in part, of
0071
1 visits by cardiologists and perhaps a result of the
2 pricing position that we have just been exploring.
3 A. It is probably more related to relationships with people
4 coming than it is to price, because clinicians would not
5 have been involved very much at that time with anything
6 to do with costs.
7 Q. If we go over the page to 513, one more table: these
8 show where people were going in 1984, and of course we
9 are dealing here with, by and large, adults, although
10 there may be some children mixed in here, there is no
11 way of telling from these figures.
12 We see there is a very wide range of hospitals in
13 London. Not all of those were designated as
14 supra-regional centres for neonatal and infant work, and
15 the majority were going to the National Heart Hospital,
16 St George's, Brompton and London Chest Hospital, far
17 away from the majority of the total number of referrals.
18 So that is the picture in 1986. Can I go now to
19 UBHT 295/506? Can we see the whole letter first of all,
20 please? It is a letter which is from Dr Pitman to
21 Dr Thorne at Torbay Hospital. Can we have a look at the
22 content of it?
23 "As you know, it is intended that the expansion of
24 cardiac surgery operations at the BRI should increase
25 the number available to 600. In drawing up arrangements
0072
1 for funding, it is becoming apparent that we need to
2 have some idea of whether current referral patterns are
3 likely to be substantially altered. It would be helpful
4 if your committee could comment by the end of February
5 on the likelihood of more patients being referred from
6 districts outside of Avon to Bristol when the extra
7 capacity becomes available. Attached are copies of the
8 minutes of two meetings, the latter of which
9 unfortunately no cardiologists were able to attend from
10 Bristol, which give the background to this question. It
11 is perhaps fair to add that Bristol and Weston, because
12 of their RAWP position, find themselves in considerable
13 difficulties and the district management wish to assess
14 whether it is possible to prevent a disproportionate
15 amount of the new capacity being used by Avon residents
16 to the detriment of residents outside of the district."
17 If we go over the page, I think you will see that
18 that letter was -- that is not very helpful, but I think
19 that letter was copied to you, in any event?
20 A. Oh, was it?
21 Q. Yes. Can you help us with the nature of the group which
22 is referred to there at the Torbay Hospital? Is that
23 something within your knowledge?
24 A. No, I am sorry, I have actually never heard of
25 Dr Thorne.
0073
1 Q. But the letter would be reflecting the concern that you
2 would have in the Health Authority that this expansion
3 was not going to be in the end properly funded because
4 of concerns with the adequacies of the RAWP formula; is
5 that fair?
6 A. The concern shown in that letter is the fact that the
7 Bristol & Weston Health Authority was seen to be
8 spending more per head of population than the average
9 for the country, and therefore only had basic growth,
10 very little growth, and the concern is that as the
11 Regional Health Authority is going to fund the expansion
12 of cardiac for a three-year period, if the Bristol and
13 district residents take up a higher proportion of that
14 capacity, then clearly the amount that Bristol & Weston
15 has to pick up at the end of the three years is much
16 higher, and there were concerns about that, seeing as
17 the unit was created for the region, then the management
18 need to make sure that referrals from elsewhere would
19 come in, otherwise all of the revenue would fall on
20 Bristol and District, or Bristol & Weston.
21 Q. Yes. I am reminded of why I think this was copied to
22 you: the rather grubby mark at the top of the page, if
23 we blow that up --
24 A. You mean that is my writing?
25 Q. No, I was not being unkind at the writing; it is the
0074
1 mark there and we see underneath "G Nix", and then it
2 says "Finance Committee". That is where I got that
3 from, so that letter would be reflecting those concerns?
4 A. Yes.
5 Q. So this is region passing on concerns of district,
6 namely you in the district, Dr Pitman the region, and
7 passing them on to somebody outside the district whom it
8 is hoped, along with others, will use this new regional
9 specialty and also through the RAWP formula, pay for it?
10 A. Yes.
11 Q. Can we then to 295/546? This is the project team
12 meeting of 3rd March 1986. It is right to say that
13 I think you did not attend this one. Yes, we see your
14 apologies in the first paragraph of the minutes. Do you
15 see Messrs Croft, Keen, Lees, Lilley, and you are one of
16 those?
17 A. Yes.
18 Q. If we go to the top of the page you are sent the
19 minutes?
20 A. Yes.
21 Q. If we go into 548, please, just take the first
22 two-thirds of the page:
23 "Agreement was reached that additional revenue
24 consequences from 480 operations per annum on wards
25 should be assessed for the following levels of
0075
1 service ..."
2 This was going to be referred to you, we see your
3 name in the right-hand column?
4 A. Yes.
5 Q. This is your department: 600 operations, and the plan
6 was for 8 additional cardiac beds, 8 additional
7 cardiologist beds and 3 additional theatre sessions, to
8 go up to 17.
9 We see earlier the proposal that the number of
10 theatre sessions might go as high as 18 from 12.
11 Then 675, contemplating that expansion can be
12 achieved without any additional beds, but with an extra
13 one or two theatre sessions.
14 Then a further increase to 750. Were that to be
15 contemplated, there were going to be another 7 cardiac
16 beds, 4 to 7 cardiological beds, and yet more theatre
17 sessions?
18 A. Yes.
19 Q. So you would have taken that away and priced it up?
20 A. Yes. I would have actually contacted an awful lot of
21 people to get information back, so I would have been in
22 discussions with the senior nurses, the perfusionists,
23 cardiac surgeons, anaesthetists, radiology, physio,
24 a whole range of people within the organisation to say
25 "Tell me what the implications are of this expansion",
0076
1 and then I would have compared what they had sent me
2 with what they had actually said previously for some of
3 the expansions, and we would have had a discussion about
4 that and I would have reflected that back to the Working
5 Group.
6 Q. It is important to bear in mind that there was something
7 happening with the district gynaecology service at this
8 time, was there not: it was moving. Was it moving in
9 order to create the space for the cardiac expansion?
10 A. It was outpatients.
11 Q. What was happening there, do you remember?
12 A. We were moving the outpatients to create space for
13 cardiac surgery.
14 Q. Where were they going, the gynaecology?
15 A. They are actually at St Michael's Hospital now, so it
16 was probably linked in with that, but I think the new
17 gynaecology block was after that, so I am not sure
18 whether they went anywhere in the interim.
19 Q. But they were going outside the BRI?
20 A. Moving from where they were currently placed, yes, which
21 is alongside of cardiac in the building.
22 Q. If we go to 555, please, this is a scheme logic for the
23 expansion to 600 plus?
24 A. Yes.
25 Q. The gynaecological clinic was going from level 6 -- that
0077
1 is where Ward 5, the cardiac ward, was?
2 A. Yes.
3 Q. And that was going to the Pratten building?
4 A. Yes, which is a temporary building in the old building
5 courtyard, which is the other side of Upper Maudlin
6 Street.
7 Q. In the last column the purpose-built gynaecological
8 facilities were to be adjacent to the Maternity
9 Hospital?
10 A. Yes.
11 Q. If we go down to paragraph 4, the other stages, it sets
12 out what was happening. The short stay surgery ward was
13 to take over some of the space of the gynaecological
14 clinic. Ward 5 was to be retained and modified, and
15 then, as it were, encroach upon what had previously been
16 the short stay ward. Rationalisation of short stay
17 surgery theatre provision, and we see in the right-hand
18 column that the theatres 2 and 3 in level 4 were to be
19 used only for cardiac surgery?
20 A. Yes.
21 Q. So taking short stay surgery out of those theatres;
22 is that right?
23 A. Yes.
24 Q. That is one of the ways in which you managed to increase
25 the number of theatre sessions from 12 to 17 or 18?
0078
1 A. Yes.
2 Q. Then scanning down to 5, there was to be district, the
3 centralisation of the gynaecological facilities, and
4 that was a district specialty as opposed to a regional
5 specialty?
6 A. Yes. It still would have been a call against the major
7 regional catheter programme.
8 Q. We will see how much in a moment. Then a further
9 expansion -- this is why we looked at the two
10 alternative dates with the expansion to 600. One was
11 1988 and one was 1990?
12 A. Yes.
13 Q. By this stage it has moved on because it was a further
14 expansion to 850 in 1989/90 so that is the long-term
15 plan, but still we see from the right-hand column, with
16 the 2 theatres, but now to be used at maximum
17 utilisation?
18 A. Yes.
19 Q. If we go to 559, can we look at the expansion of Ward 5
20 from 480 to 600, paragraph 2 "Functional content". The
21 8 additional beds were originally going to be
22 1 intensive care, 2 high dependency, 5 low dependency
23 and no new children's beds, but that plan had been
24 modified.
25 A. Yes.
0079
1 Q. So that there was one new child bed, one intensive care
2 bed, four high dependency and two low dependency?
3 A. That is why I said earlier on that there were changes as
4 we went along to this plan.
5 Q. Do you remember whether the setup in the right-hand
6 column was the one that was finally adopted, or is that
7 too much detail?
8 A. No, I cannot. I remember it being on a sheet of paper
9 somewhere where I wrote it down, and it was about that,
10 I thought we ended up with 8 ITU, 8 high dependency and
11 8 low dependency, as a final ...
12 Q. That would be --
13 A. I think there is another change after that, to read
14 8, 8, 8 and 4, making 28.
15 Q. We do end up with 4 children's beds?
16 A. Yes.
17 Q. If we move now to 571, the cost of this, if we just look
18 at the whole page, if we take the top third, capital
19 elements, and just scan down, the total capital cost of
20 the surgery package scheme was 1.25 million at this
21 date, was it not?
22 A. Yes.
23 Q. In round figures?
24 A. Yes.
25 Q. The additional revenue cost per annum was 768,000, or
0080
1 thereabouts?
2 A. Plus, queried. There should be a schedule attached to
3 something that actually shows the final figures.
4 Q. If we look down the page, the BMH enabling scheme, the
5 new provision for gynaecology outpatients department,
6 the capital cost of that was going to be 4.2 million, so
7 against the cardiac surgery expansion, this was a very
8 much more expensive part of the operation, this new
9 build?
10 A. Yes, it was a new build alongside St Michael's, and
11 I think the final figure was 5 million.
12 Q. The 1.25 million, the capital element of the cardiac
13 expansion, all came from the region?
14 A. Yes. Do not forget that was adaptation to current
15 buildings rather than brand new.
16 Q. Of course, and the regional contribution to the
17 gynaecology development we see at the bottom of the page
18 here is 700,000; is that right?
19 A. Yes. I cannot remember exactly. I thought it all came
20 from regional capital programme, but maybe I was wrong.
21 Q. This one would suggest that the District Health
22 Authority was providing 3 and a half million of its own
23 money?
24 A. No, I think what that may well be is that within the
25 regional capital programme there were sub-allocations,
0081
1 if you like, to each Health Authority, and 3 and
2 a half million was coming from that figure. The other
3 was coming from an overall RHA fund.
4 Q. Obviously the District Health Authority would be
5 provided with some capital monies every year?
6 A. Yes.
7 Q. But it was, as it were, choosing to spend that
8 3.5 million on less as opposed to something else?
9 A. That is correct.
10 Q. It had been given an extra 700,000 on top by the region
11 to fund the total project; is that right?
12 A. Yes.
13 Q. And there were no revenue consequences of that because
14 it was an existing service. What was needed was a new
15 building?
16 A. The drive would be when you transfer services to do it
17 with no additional revenue cost, and hopefully less.
18 Q. Just dealing with some of the figures, then, at 295/574,
19 turning that round, we have updated figures for the
20 catheterisation scheme, so we have three major projects
21 going on at once here: the catheterisation project
22 involving both the BCH and the BRI; secondly, the
23 cardiac surgery expansion at the BRI, the 1.25 million
24 scheme and, to make way for that second point, we have
25 the gynaecology scheme?
0082
1 A. Yes. There would have been other major schemes as well
2 happening at that time.
3 Q. I dare say.
4 The updated totals here, if we can just look at
5 the left-hand side. It is 1.519 million in capital and
6 #349,000 per annum revenue costs for the total
7 catheterisation scheme, so we see at the top of the page
8 that is the BCH one, and then the second half of the
9 screen is the re-equipping of rooms 14 and 13, and the
10 bottom of the page are the grand totals, and the price
11 had gone up from December 1984 until now, which is March
12 1986, to 1.5 million, so 1.5 million as near as makes
13 little difference in capital and œ350,000 or thereabouts
14 in revenue?
15 A. Yes, because if you move on years you will add inflation
16 to those figures.
17 Q. It does not look as if there was any significant real
18 increase in cost?
19 A. No.
20 Q. Can we go then to 141, please? This is a progress
21 report on the proposed increase. At the top of the
22 page it says:
23 "Mr G Nix" and does that say, "Graham, silent
24 copy"?
25 A. Yes.
0083
1 Q. What does that mean?
2 A. Probably that I was not supposed to have a copy of that
3 paper, at that time, because it was a Regional Health
4 Authority paper and worked for Bristol & Weston.
5 Q. And that would have been sent to you --
6 A. Privately.
7 Q. On 14th April, and that would be 1986, I think?
8 A. Yes.
9 Q. I do not think we need to pursue this paper in any
10 detail, because it is essentially covering the same
11 ground: that the capital costs of the catheterisation
12 and the cardiac surgery developments were to be a charge
13 on regional resources, and there are further detailed
14 costs; they do not differ significantly from the ones we
15 have just looked at.
16 Can I take you on a bit, then, to June 1986, to
17 a meeting with the Bristol & Weston Health Authority on
18 16th June 1986, at UBHT 76/53?
19 There is a long list of attendees. I can tell
20 you, Mr Nix, it does not include you; you were not at
21 this meeting.
22 Can I take you to page 57? It is the second
23 paragraph, under the heading "Performance Assessment
24 Committee", Mrs Perriam -- she chaired that committee;
25 is that right? She is mentioned in your statement.
0084
1 A. I had her down as chairing the Policy and Planning
2 Resources Committee, because I did not actually recall
3 that there was a Performance Assessment Committee of the
4 Health Authority.
5 Q. There obviously was by this stage?
6 A. There obviously was, yes.
7 Q. The terms of reference were attached, and approved.
8 "Mrs Perriam pointed out that the volume of services
9 currently provided by the district almost exactly
10 matched the total volume of service received by the
11 district's residents when service at Ham Green and Manor
12 Park were returned ... Mr Hucklesby said that
13 reimbursement under RAWP was made on a patient day basis
14 which substantially recognised the higher costs of
15 complex treatments."
16 What does that mean, "the patient day basis"?
17 Does that mean if you were there for 10 days you were
18 paid twice through the RAWP formula than you would have
19 been if it was only 5 days?
20 A. There were big debates in the formula itself as to
21 whether you should use cases or days. Clearly anybody
22 who has long-stay patients with great variability would
23 be pushing to have a patient day basis for that.
24 I should point out Ham Green and Manor Park were not in
25 Bristol & Weston, Ham Green was in Southmead and Manor
0085
1 Park was in Frenchay district, hence the comments about
2 there were hospitals in Bristol and flows obviously from
3 patients resident in Bristol & Weston to go to those two
4 hospitals.
5 Q. Can I go over the page, then, to 58? I appreciate this
6 is a meeting that you were not at, but perhaps you would
7 help us with the background, if you can:
8 "Members received the proposed strategy for
9 neonatal care which Mr Smith had reported had been
10 approved by the PPRC for submission to the Regional
11 Health Authority ..."
12 Then a number of factors and prerequisites are in
13 mind, including:
14 "Specific funding of expanded neonatal cardiac
15 services for three years."
16 That is (vi). That is a reference to the regional
17 funding we have talked about?
18 A. It could be, or it could be related to something to do
19 with supra-regional, seeing as it is neonatal.
20 Q. Could be; and (vii), the maintenance of the quality of
21 the service.
22 If we go to the bottom of the page:
23 "Dr Baker undertook to supply, on an electoral
24 ward basis, the mortality and morbidity rates. It was
25 agreed to accept this strategy bearing in mind the
0086
1 clinicians believe the service to be already
2 under-funded and request the Regional Health Authority
3 to include neonatal care as a priority service."
4 Do you remember ever seei