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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 seeing or being at a meeting
5 where there were presented mortality and morbidity rates
6 on an electoral ward basis?
7 A. No. "Mortality and morbidity rates" here is related to
8 the whole of the neonatal care service, the Special Care
9 Baby Unit, in effect, for St Michael's Hospital, and is,
10 I believe, the reference to the Regional Health
11 Authorities reflecting the fact that ill Mums yet to
12 deliver, whose child will require that sort of service,
13 were difficult cases referred to the Maternity Hospital,
14 so it was a much wider issue than just cardiac. That
15 was saying, "Here is a unit that is providing a regional
16 service, although there are neonatal units elsewhere in
17 the region and we need to look at that". The Regional
18 Health Authority needs to fund it in some specialist
19 way.
20 Q. It is obviously right that (ii) is not referring to
21 cardiac surgery, because by this time neonatal cardiac
22 surgery was a supra-regional service?
23 A. Yes.
24 Q. But what I was seeking to find out from you was, there
25 is a reference there to Dr Baker, who was the District
0087
1 Medical Officer, later the title becomes "Public
2 Health", but he was a District Medical Officer, and he
3 was undertaking to supply mortality and morbidity data
4 on an electoral ward basis.
5 Do you ever remember seeing data presented on that
6 basis, whether for cardiac surgery or for something
7 else?
8 A. No.
9 Q. The document that is referred to there is the strategy
10 for neonatal care. That is at UBHT 238/235. It is
11 pretty long-term, pretty ambitious, 1986 to 1994. It is
12 dated May 1986. If we go to 236, please, we see from
13 the second paragraph:
14 "Professional representation has indicated
15 a desire to increase the quality of services generally
16 and to maintain or improve access to services in Bristol
17 maternity and children's hospitals for obstetric and
18 neonatal referrals from within and outside the South
19 Western region. A key request was an increase in
20 nursing levels to manage the desired workload without
21 undue stress on those concerned."
22 If we scan down again, please, just picking up the
23 penultimate paragraph:
24 "The strategy has been accepted as one which takes
25 into account a regional commitment, 'to provide adequate
0088
1 facilities for the intensive care of infants (in
2 consultation with neighbouring authorities if
3 necessary)', and a pragmatic assessment of the
4 opportunities for implementation throughout the decade.
5 The adequacy of facilities for intensive care
6 contributed by this district will be determined on
7 a year-to-year basis in the light of developments in
8 other districts and agreement on the best balance of all
9 aspects of obstetric, neonatal and children's care
10 within the district's children's and maternity unit."
11 If we can go, please, to the last paragraph there:
12 "Members of the Authority's Policy, Planning and
13 Resource Committee and district managers acknowledge
14 that in interpreting the policy of the Authority and
15 accepting the resource assumption for planning, that
16 there will be a shortfall of attainment for future care
17 of neonates. Members are not unaware of the extra
18 strain which will be placed upon staff in the exercise
19 of their professional judgment and in their relationship
20 with the parents. If the district's resource allocation
21 increases in the future and the policies of the
22 Authority change, the opportunity to respond to future
23 demand ... will be taken."
24 I appreciate that is not essentially concerned
25 with neonatal cardiac surgery, but what it is, so it
0089
1 would seem, is suggesting is that there was a shortfall
2 of attainment, and going to be a shortfall in attainment
3 in the care of neonates the following years, and
4 "shortfall in attainment" means essentially a lack of
5 provision, which comes back in the end to staffing and
6 money; is that right?
7 A. Yes, what was technically going to be achieved for
8 neonates was going to be expanded and is still expanding
9 even now and there are strains on the service.
10 Q. If we go to 238, paragraph 2.3, present services were
11 reviewed in February 1986. One of the observations made
12 was that there is no separate routinely available
13 information recorded for the outcomes of neonatal care
14 in relation to neonatal surgery, both cardiac and
15 non-cardiac.
16 So it would seem as though there was a blank sheet
17 in terms of recording operation data in February 1986.
18 That is probably not a matter within your compass?
19 A. No.
20 Q. If we go to paragraph 2.4:
21 "No routinely available information is recorded
22 for measures of morbidity in relation to survival of the
23 neonate."
24 Paragraph 2.12, over the page at 239:
25 "Neonatal care for neonates with cardiac problems
0090
1 is rendered by staff and facilities in a separate
2 Intensive Care Unit in the Children's Hospital.
3 Neonates undergoing open heart surgery at the BRI return
4 to the BCH for care after 24 to 48 hours."
5 If we can have --
6 A. I must say, I was not aware of that. I think you should
7 ask one of the clinicians about the returns to the
8 Children's Hospital after 24 to 48 hours.
9 Q. Obviously we will update ours to when those returns took
10 place. I was not going to ask you about it, but it may
11 be the fact that it was an optimistic time-scale.
12 Can we go to 240, paragraph 3.3? Evidently
13 Bristol was a designated supra-regional centre for
14 neonates and infants. The estimated number of live
15 births was 40,000 per annum. Services have surgical
16 targets for children of all ages of 180 open procedures
17 at the BRI".
18 That is a figure we saw earlier, the 420 plus 180,
19 coming to 600?
20 A. Yes.
21 Q. "The proportions of these targets which concern neonates
22 are modest by current figures: 5 per cent open, 20 per
23 cent closed, 25 per cent catheterisations. There is
24 a trend towards earlier investigation and surgery, but
25 not into the neonatal period significantly. The number
0091
1 of neonates requiring special and intensive care will
2 increase in relation to the open surgery target at the
3 BRI and associated investigations at the BCH."
4 Then I think finally on this document, at the top
5 of page 244 to give this some context, I think these are
6 the recommendations, "Strategic Proposals".
7 In paragraph 5.7:
8 "Information services: better information on the
9 origins and characteristics of neonates, types of care
10 and outcomes of care is required. Additionally,
11 information must cover cardiac and surgical care. This
12 information should evolve from Korner minimum data
13 requirements and existing information files."
14 Before we have another break, can you help me with
15 those two references, "Korner minimum data" and the
16 "existing information from files". With what would
17 those comprise?
18 A. Edith Korner actually led a review in the National
19 Health Service about the information service
20 requirements of the service. Her view was very much
21 whatever we needed to deliver nationally, i.e. returns
22 about our workload et cetera, had to be based on
23 information that we would need locally to run the
24 service.
25 As for the specific nature related to neonates,
0092
1 I would say have to say, I am not aware of that in
2 detail.
3 Existing information files, I am sorry, the only
4 thing I can imagine must relate, something to do with
5 the patient record itself, but I do not know.
6 Q. There was not any, so far as you are aware, separate
7 computerised system at this stage operating in recording
8 details of cardiac surgery?
9 A. No.
10 Q. "No" you do not know, or "No", there was not?
11 A. No, I do not know. I mean -- no.
12 MR MACLEAN: Sir, is that a convenient moment for another
13 break? I think it might be 45 minutes.
14 THE CHAIRMAN: Yes, shall we take a break now for 45 minutes
15 until 2 o'clock? We will reconvene then, thank you.
16 (13.16)
17 (Adjourned until 2.00 pm)
18 (14.02)
19 MR MACLEAN: Can I have document HA(A) 129/27, please? This
20 is the Bristol & Weston Health Authority annual
21 programme, curiously, covering 1987 to 1989, and it is
22 dated October 1986. This is a final draft.
23 Can we go to the next page, please, 28? We
24 mentioned a little earlier, Mr Nix, in our discussions,
25 the question of particular priorities that might be
0093
1 identified by a Regional Health Authority or a District
2 Health Authority from time to time.
3 We see here the priorities as they were then.
4 Number 9, category 2, priority, was cardiac
5 disease.
6 What would the impact of being a category 1, 2 or
7 3 priority be?
8 A. It would be about funding.
9 Q. So it would be the pecking order for the development of
10 new services?
11 A. Yes.
12 Q. If we go to page 30, please, there is a mention on this
13 page of the development of cardiac surgery, we see in
14 the first paragraph:
15 "The annual programme carries plans for action
16 within the authority for the financial years 1987-89.
17 These plans pursue the agreed strategies ..."
18 We see mentioned that specific attention is given
19 to the expansion of cardiac surgery and cardiology,
20 renal services, joint replacement surgery and bone
21 marrow transplantation for children.
22 This is a very long document that runs to 141
23 pages, I think?
24 A. Yes.
25 Q. If we go, please, to page 84 -- just before we look at
0094
1 this, what kind of role would you have had in the
2 production of this, or your superiors at the time?
3 A. Obviously whatever I did was the responsibility of the
4 Treasurer, I think that would be fair to say, but
5 I worked very closely with Ian Baker doing the financial
6 side of every annual programme, so looking at the cost
7 of the services, when they would actually start, the
8 profile for recruitment of staff in the run-up for the
9 start of a service and actually reflecting that into
10 detailed schedules that would back up each of these
11 sessions that would show you what is actually happening,
12 the anticipated date and the financial implications of
13 that.
14 Q. What would be the forum which would select which were to
15 be category 1, 2 or 3 priorities?
16 A. The information would go to the Policy, Planning and
17 Resources Committee of the Health Authority, and I know
18 that the Health Authority itself would be the final or
19 formal committee that would sign off this document, or
20 adopt it for the Trust -- for the Health Authority.
21 Q. And the Treasurer would sit on that committee, the PPRC?
22 A. Yes, and the Health Authority as well, so he would sit
23 on both committees.
24 Q. This is dealing with the region's key commitments and
25 the district's current position. I want to look at
0095
1 numbers 30 and 31, those particular key commitments.
2 30:
3 "Ensure that children in hospital are cared for in
4 designated wards when highly specialised treatment is
5 required". The current position was that "all children
6 were housed in designated wards but not all were
7 provided at the Children's Hospital".
8 "31: Ensure that paediatricians and nurses with
9 paediatric training are involved in care of all children
10 in the hospital". The current position was that
11 "involvement of paediatricians was indirect in some
12 designated wards, e.g. orthopaedic, eyes and ear, nose
13 and throat. Not all nursing staff are paediatric
14 trained."
15 That would be particularly true, would it not, of
16 the Intensive Care Unit in the Bristol Royal Infirmary,
17 which housed the adult and paediatric cardiac surgery
18 patients after operations?
19 A. Yes. There was a shared intensive care in the BRI.
20 Q. So if we look at what was planned to be done about those
21 key commitments in order to bring the current position
22 up to meet the commitment, if we go to page 87, picking
23 up the same numbers, 30 and 31, what does that page tell
24 us about what was going to be done over 87 to 89 in
25 terms of meeting commitments 30 and 31?
0096
1 A. No funding would have been allocated to achieve that.
2 Q. So would it follow that those commitments were likely to
3 be no nearer being met at the end of the period than at
4 the beginning?
5 A. That is right, they would not be. It is identified as
6 an aspiration but certainly there are no capital revenue
7 or manpower implications. You may well find there are
8 items in here -- I cannot think that ENT would have
9 moved to the Children's Hospital at that time, but you
10 will find there are key commitments down the left-hand
11 side, i.e. equivalent to 30, 31 and 32, that might be
12 able to be achieved without having capital, revenue or
13 manpower implications. But for both of those: "Relocate
14 ENT children from BGH to BCH" is achieved now and
15 certainly was when we closed operating at the General
16 but I am not clear as to when we did that; and "Develop
17 plans for future children's services for Avon" of course
18 may well have occurred in that period.
19 Q. If we look at commitment 31, about paediatric training,
20 that would have certainly revenue and manpower
21 consequences, if anything was ever to be done about
22 that, would it not?
23 A. No, not necessarily. That is about identifying if there
24 is, within ophthalmology, for example, because that was
25 one that was named, it would be saying to ophthalmology,
0097
1 "When you are recruiting nurses, could you make sure
2 that you are recruiting some of the nurses with
3 a paediatric background"; it did not actually
4 necessarily mean you had to have more nurses in that
5 area.
6 Q. I think I may have put it badly. If we think about
7 intensive care nurses in particular, intensive care
8 nurses who are paediatrically trained are going to be
9 more difficult to get and more expensive to keep than
10 non-paediatrically trained intensive care nurses; is
11 that fair?
12 A. No, there would be no cost difference between
13 a paediatrically trained intensive care nurse and an
14 adult care nurse. I do not believe there were any
15 enhancements in any way for that. What could be
16 happening is having paediatric trained nurses in
17 intensive care in cardiac, but I think that is really
18 a question for somebody else, about what the proportions
19 were.
20 Q. So your response to 31 would be that you do not see that
21 there would necessarily be a significant capital revenue
22 or manpower implication for moving towards the meeting
23 of commitment 31; is that what you are saying?
24 A. I think I am, in particular related to nurses. I think
25 with paediatricians, I would agree with you that if we
0098
1 were going to have more paediatricians involved in some
2 of the other areas, then you would have to have more
3 staffing to achieve that. But nurses, it is about what
4 the background is of the nurses we are employing in
5 those areas.
6 Q. But if it is the case that a paediatrically trained
7 intensive care nurse starts his or her career as an
8 ordinary intensive care nurse, but has an additional
9 qualification, might one not expect that they would
10 command a higher salary than nurses without that
11 qualification?
12 A. I would not have thought so, no, because it would depend
13 what grade they are on. You could say they might get
14 to, it is now an F grade quicker, but that is about the
15 responsibilities they hold, not about their training.
16 You might have lots of qualifications, but you do not
17 necessarily get more pay. You will probably get
18 promotion quicker.
19 Q. So that might be a reason why people might be reluctant
20 to obtain those additional qualifications, because there
21 is no immediate financial reward? Maybe that is
22 something you could comment on?
23 A. That may well be, but it is about -- as I understand it,
24 it is where the nurses would wish to work.
25 Q. Let us look at a couple more references in this
0099
1 document. Can we go to 89, please? We have already
2 seen that cardiac diseases are one of the category 2
3 priorities. We have something here in the background,
4 in "Profile":
5 "The district provides a cardiology and cardiac
6 surgery service to the South Western region and to
7 neighbouring regions. They had expanded gradually ...
8 the overall target was 1400 cardiac surgery cases for
9 the region."
10 That does not necessarily mean performed in the
11 region, that would include the references to London?
12 A. Yes.
13 Q. "The district is designated as a supra-regional centre.
14 For cardiac surgery in 1985, waiting time for an
15 out-patient appointment was 3 to 5 weeks; average
16 waiting time for in-patient admission was 4 and a half
17 months for adults, and 6 months for children. Of
18 in-patient cases, 18 per cent were district residents
19 and 74 per cent residents from other districts, but only
20 8 per cent from outside the region as a whole."
21 So if that pattern had been continued, the funding
22 at the end of the three years, the expansion period,
23 would have meant Bristol & Weston picking up 18 per cent
24 of the tab, as it were?
25 A. Yes.
0100
1 Q. Other districts 74 per cent, and districts from outside
2 the region the remaining 8 per cent, if that pattern
3 were to continue?
4 A. Yes.
5 Q. Then we see: "The Authority agreed that subject to the
6 uptake of services for residents of this district being
7 regulated and subject to other districts of the region
8 being liable for their share, the proposed expansion of
9 staff and facilities to achieve 600 operations yearly
10 should proceed."
11 Can you help us with what is meant by "the uptake
12 of services for residents in the district being
13 regulated"?
14 A. I think that refers back to the letter that we discussed
15 before lunch, to Dr Thorne, which is about a concern
16 that if patients from the district came to Bristol, or
17 were cared for in Bristol, then it would be a cost that
18 would use up substantial parts of the growth for the
19 Health Authority. I am not quite sure what the word
20 "actually regulated" meant. I am not sure you can do
21 much when the patient is referred to your hospital and
22 they are in cardiology and they require cardiac surgery.
23 Q. So that strikes you as being an aspiration without an
24 obvious mechanism?
25 A. Yes. I think the concern has always been, and it is
0101
1 that if you do live in Avon, because you have a lot of
2 what I certainly call "regional specialties", then the
3 population of Avon does benefit from that. We do use
4 a higher proportion of those services than other people.
5 Q. Assuming that the take-up of the expanded service was
6 higher than expected among the other districts, other
7 than the home district, how would that impact on the
8 general block grant money given to the Bristol & Weston
9 Health Authority in due course?
10 A. When we were expanding the services, you will note from
11 the papers that the Regional Health Authority actually
12 did allow us to exceed the numbers, because even at the
13 end, when we created a unit for 600, I think we did 675
14 cases. You have already seen when it was 375 I think we
15 achieved 420. The Regional Health Authority funded
16 that. I do not think, at the end of the period, we ever
17 had any problems because the system itself actually
18 changed in the early 1990s, where people were paying on
19 a per case basis, anyway.
20 Q. So we will see that shortly?
21 A. Yes.
22 Q. Can we go, then, to 90, please? Key commitments:
23 "There was an exploration of a target of 1400
24 cardiac surgery operations", and then key commitment 34:
25 "Increased cardiac surgery for children towards
0102
1 the national average" which suggests that cardiac
2 surgery was at that stage below the national average,
3 "and increased catheter investigations on children to
4 400 per annum by 1988."
5 Do you ever remember seeing or hearing about
6 particular encouragement to the Bristol Royal Infirmary
7 coming from elsewhere to increase its throughput to
8 paediatric cardiac surgery?
9 A. No. I have heard it since, more recently, but not at
10 that time. I would say that if it was from a finance
11 person's point of view, if there is source for funding,
12 to allow expansion of service most of the time within
13 the Health Service, it was one thing to find mechanisms
14 to find expansions where it could expand. If I knew
15 there was somewhere that we could go to receive
16 additional funds to allow services to expand, then
17 certainly, I would have been encouraging people to make
18 use of that route.
19 Q. By 1991, you were the Finance Director of the Trust?
20 A. Yes.
21 Q. And the supra-regional service was in operation until
22 1994, so covering the first three years of the operation
23 of the Trust?
24 A. Yes.
25 Q. During that time, when you were Finance Director, were
0103
1 you aware of any encouragement or pressure or cajoling
2 from the Supra Regional Services Advisory Group or from
3 the Royal College of Surgeons or Physicians to increase
4 the throughput of neonatal and infant cardiac surgery?
5 A. No.
6 Q. We will come on later to deal with the supra-regional
7 funding aspect; I want to come back to that.
8 These are the key commitments then, 33, 34 and
9 35. Can we go over the page to 91 and see what was
10 happening in terms of funding? We know about the
11 cardiac surgery target because that is a reference there
12 to the 600 plus cases. That is what we were exploring
13 before lunch, the capital and revenue consequences
14 there. There is no funding entered opposite key
15 commitment number 34.
16 A. No.
17 Q. And 35, again, has the other aspect we were dealing with
18 before lunch, about the new cath' lab at the BCH and the
19 two refurbished cath' labs at the BRI?
20 A. Yes. I would have expected 34 to some extent to have
21 come under 33, as we discussed previously.
22 Q. There is no specific extra step being taken, in respect
23 of --
24 A. No, we did not separate out children and adults in the
25 expansion.
0104
1 Q. If we go, please, to page 130, this is, I hope,
2 a summary of the developments by care group?
3 A. Yes, it is.
4 Q. We see here, do we not, that if we look at capital,
5 major capital first of all, in 1987/1988 we see that
6 cardiac disease capital funding -- that is the expansion
7 to 600 cases and the cath' lab provision -- is by some
8 significant way the biggest single capital investment,
9 because the only other one that is bigger is "other
10 acute services" which presumably includes a range of
11 different specialties.
12 A. It probably includes -- do not forget, we had already
13 completed Weston General and the Bristol Eye Hospital,
14 which I think came on stream in 1986, so that could well
15 be the tail-off of payments for those contracts.
16 Q. And you would expect the revenue consequences to kick in
17 a little after the capital, if you were developing a new
18 service?
19 A. Yes.
20 Q. If we look at '88/89, under the revenue column, again,
21 far and away the biggest revenue cost of development is
22 cardiac diseases at just over a million pounds per
23 annum?
24 A. Yes, and the money beforehand would be related to
25 getting staff in and training them prior to the facility
0105
1 being opened.
2 Q. You, I think, were responsible for producing some nurse
3 staffing figures to go with the development of the
4 cardiac surgery unit, up to and above 600 cases. We
5 will see that I hope, at UBHT 295/207. This is a note
6 from you to Miss Gerrish, General Manager of the BRI
7 sub-unit, and then attached is a handwritten schedule
8 outlining the nurse staffing levels, and you had done
9 a straightforward comparison of the number of cases per
10 annum per nurse.
11 If we go over the page to 208, I do not know if we
12 can turn this round so we can see all of it? Possibly
13 not. Can we see the first half, please, the top half?
14 This sets out the current nursing staff at a 480 case
15 capacity, does it not?
16 A. Yes.
17 Q. 6 whole-time equivalents for sisters and 25.9 SRNs,
18 8.4 SENs and 4 nursing auxiliaries, a total of 44.3.
19 We see the original and then increased extra
20 capacity required to go to 675 cases and the addition is
21 22.45, is it not, so an increase of about 50 per cent;
22 is that right?
23 A. Yes.
24 Q. And the total cost of that is œ193,000 per annum?
25 A. Yes.
0106
1 Q. And then there is a further revised assessment because
2 we have gone up from 66.75 to 79.5 and so your latest
3 estimate date, January 1987, was that the revised
4 increase would be 35.2, so that is getting on for an
5 increase of 75 per cent over where we started?
6 A. Yes.
7 Q. At œ296,000 per annum.
8 That is for the ward. If we look at the bottom of
9 the page, it is the same figures for the theatres and
10 for cardiology. There was no further increase to add,
11 so we have gone up by whatever it is, whatever 5.76 is
12 as a percentage of 8.74, again, about three-quarters?
13 A. Yes.
14 Q. As you recall, is that the order of magnitude of
15 increase in nurse staffing levels that was brought about
16 at that time?
17 A. Yes, I mean, you need to follow that through so the
18 actual revenue sheet that we made the claim against the
19 regional office for, that is the right sort of numbers,
20 the comparison I was making was to make sure the
21 Regional Health Authority could not come back to us and
22 say "You have too many nurses for the increase" and
23 hence the cases per nurse was just an accountant's way
24 of saying "Are we in the right order or not?"
25 Q. So you were reassured that these figures were realistic?
0107
1 A. Yes.
2 Q. If we go to page 209, this is your letter --
3 A. I am sorry, can I add, when you say "realistic", it was
4 that the new figures were similar to the figures that
5 had previously been presented, rather than -- I have no
6 view as to how many nurses you need to nurse a child or
7 an adult in cardiac surgery, it was just me comparing
8 each of the bids, as we have expanded the service, to
9 make sure that we were in line.
10 Q. So you do a comparison of 10.8 cases per nurse at 480,
11 and then you do a check at the end of the 675 and see
12 whether it is within the same region?
13 A. Yes.
14 Q. So this letter here of 15th January, this is you having
15 checked your working, as it were, we have just looked
16 at, sending the figures off to the region?
17 A. Yes.
18 Q. Mr Everest in the planning department?
19 A. Yes.
20 Q. You say a revision is necessary because a revision of
21 the nurse staffing levels had been required.
22 If we go over the page to 210, we see one of the reasons
23 for that was that there was now to be 8 and not 7
24 intensive care beds, and that takes us back, you
25 remember before lunch, to the figures and I think you
0108
1 said it came out as 8 in the end?
2 A. Yes, 8, 8, and 8.
3 Q. If we scroll down, it is the middle paragraph:
4 "(b) The distribution of beds has been changed to
5 intensive care unit 8 beds, and high dependency 7. This
6 therefore requires the reassessment of the staffing
7 need ..."
8 Then the 79.5 full-time equivalents is the figure
9 we have just seen in your handwritten sheet?
10 A. Yes.
11 Q. Can we move, then, to WIT 106/11? This is back to your
12 own witness statement now. You refer there to the
13 Policy, Planning and Resources Committee, paragraph 21.
14 If we go to UBHT 238/41, this is now the
15 4th February 1987. If we go to page 42, this is the
16 committee saying that it has received a progress report
17 on the expansion of cardiac services and it recommends
18 that the District Health Authority publicises widely as
19 indicative of excellent progress made in promoting
20 a DHSS and RHA priority project of considerable public
21 interest. The PPRC asks the DHA to note the importance
22 of the expansion of cardiac service in relation to the
23 future development of both the BRI and the BCH.
24 Is that because cardiac services were always seen
25 as being high profile and an indicator that the hospital
0109
1 was a really serious player? It is one of the things
2 that a major hospital would want to have?
3 A. I think it was a major step forward within the region,
4 actually, to create a significant expansion in capacity
5 at what was then and still would be now a considerable
6 capital revenue investment. I would not say it was
7 something that you picked out like that. If you think
8 about Avon, each of the main hospitals in Avon have
9 different regional specialties, so I would not pick
10 cardiac out any differently than a children's hospital
11 or oncology or ophthalmology, but it was an area where
12 significant investment had been made.
13 Q. If we go to page 43, this is the progress report. This
14 shows that the supply of operations in Bristol and
15 London for adults was still not adequate to meet the
16 supply. That is what we see from paragraph 1, do we
17 not?
18 A. Yes.
19 Q. The total number of adult operations was 620, with
20 a total of 250 child operations, so there was
21 a shortfall of 580 against the estimated demand of 1450.
22 So, you remember at the beginning of this process,
23 in 1983, there was a pent-up demand, an unsatisfied
24 demand. There is still here a very significant
25 unsatisfied demand, if this document is accurate?
0110
1 A. Yes.
2 Q. If we can go to page 44, towards the bottom half of the
3 page, "the following additions are required above the
4 present level of 480 cases by groups of staff to get to
5 675". You see the surgical cardiological full-time
6 equivalent extra provision was needed.
7 "Manpower approval is not available for junior
8 staff posts, 2 surgical and 2 cardiological. As
9 a result, an overseas Registrar may be obtained for
10 cardiac surgery and a consultant cardiologist for
11 children."
12 Can you help us with what that means?
13 A. When I do the revenue consequences, as I said before,
14 I would have approached every area of the organisation,
15 saying "We are expanding to 675, let us go through
16 exactly what the implications are in staffing and
17 non-pay", and out of that would have come the medical
18 figures. Just because you have funding, does not
19 necessarily mean that you can appoint junior medical
20 staff; they have to have training approval, so it is not
21 as straightforward.
22 What this is saying is that we have not got
23 manpower approval from what would be the Post-graduate
24 Dean, now. To be honest, I am not absolutely clear
25 about all of the way this worked at that stage.
0111
1 Certainly, even now, you cannot get -- unless you have
2 manpower approval, you might have the money but it does
3 not mean you can employ these people.
4 Q. So the manpower approval would come from whom?
5 A. Now it would be the Post-graduate Dean. I do not know
6 then. Outside of Bristol & Weston, anyway.
7 Q. We have seen here that we have moved from a 600 open
8 surgical procedures plan to 675. Can we go to UBHT
9 295/187?
10 Just scan down the page. It is a letter to
11 Mr Hucklesby. This is dealing with the region's
12 attitude to the suggestion that the total number of
13 cases should be 675 and not 600?
14 A. Yes.
15 Q. How would you characterise the region's reaction to
16 that?
17 A. May I just read it? (Pause). I mean, we created a unit
18 that I think from previous experience we were
19 over-achieving the number of cases, and if we
20 over-achieved the number of cases, then we had some sort
21 of a tacit agreement with them that we would actually be
22 able to receive additional funding, and this is asking
23 some questions of us, and doing exactly what I was doing
24 with the nursing earlier on, doing some comparisons
25 between the different bids and asking questions about
0112
1 it. This is exactly what I would do if I was there.
2 Q. So are they, as it were, putting the district to proof
3 of its new proposals?
4 A. Yes. You do not get money easily. It is only finite
5 sums that are available, and you have to prove every bit
6 of it, the same as you had to within the Trust. There
7 were letters on file as regards to me questioning
8 a number of people who asked for their -- or sought
9 additional funding for this expansion.
10 Q. You remember before lunch we looked at that Plymouth
11 document? I think from memory that the price that was
12 quoted by Bristol was 4,400-odd in 1987, I think it was,
13 about the same time.
14 Here there is a reference to the cost per case
15 exceeding œ5,000. That would be the cost per case for
16 a cardiac surgery case, would it?
17 A. I would think so.
18 Q. Not discriminating between adults and children?
19 A. No.
20 Q. But including all the costs of the case, including the
21 pre and post-operative care?
22 A. The cost would include pre and post-operative care, yes,
23 but we need to do some comparisons, to be honest,
24 looking at this against all the other papers that there
25 are relating to costs.
0113
1 Q. The œ5,000, that refers to the average marginal cost,
2 does it, of the extra cases, or does that refer to the
3 average cost of the 675 cases which would be achieved?
4 A. Can you point me to the 5,000 you are quoting on that?
5 Q. It is the third paragraph.
6 A. Yes.
7 Q. The marginal increase is either 75 or œ1600 per case?
8 A. I would imagine that is the marginal cost?
9 A. We see in the last part of the second paragraph: "PDRC
10 approval was sought on the understanding that the
11 proposal would be made cost-effective by increasing the
12 total number of cases to 675 per annum, constraining the
13 additional costs of the 75 cases", that is the extra
14 uplift --
15 A. Yes.
16 Q. -- "to a marginal increase of œ1600 per case, so
17 achieving a cost per case for the additional 195 [above
18 the 480] of approximately 4,600."
19 Then what seems to be said is that the new figures
20 as presented were going to have a cost per case of the
21 extra 195, of œ5,000 each?
22 A. That is what it says at the bottom, which is really,
23 "Sorry, we will not accept this bid for additional
24 funding. Go away, Bristol & Weston, and take it out of
25 the cardiac revenue proposals you have made".
0114
1 Q. Do you remember what the reaction was from the Bristol
2 & Weston to this letter? What happened?
3 A. I would have gone away and talked to everybody involved,
4 but the reaction beyond that, I have to say, I cannot
5 recall any major problems with it, or whether or not
6 eventually I did get any more money out of them.
7 Q. Can we have a look at 443 and see if this helps?
8 This is from Mr Everest to Mr McClelland, so this
9 is an internal regional document.
10 A. Yes.
11 Q. I think it sheds some light on what was happening. Can
12 we just scan down, please, you see the penultimate
13 paragraph which says:
14 "I have intimated that the project can proceed on
15 this basis without further authorisations being
16 necessary or changes to the capital programme as long as
17 the approval in principle figure of œ1.25 million is not
18 exceeded?
19 A. This does not relate to revenue, it is capital, I think.
20 Q. That is right, so is any light shed here on the
21 reluctance of the Regional Health Authority or otherwise
22 to proceed?
23 A. No. This was capital approval process, whereas the
24 other was a revenue issue.
25 Q. At all events, the expansion did proceed, did it not, to
0115
1 675 cases?
2 A. Yes.
3 Q. Can we go to UBHT 295/63. Can we just scan down this?
4 It is a letter to Mr Watson from -- just go down to the
5 bottom -- from Mr Keen, one of the surgeons?
6 A. Yes.
7 Q. If we just look at the body of the letter, Mr Keen had
8 some disconcerting information from you:
9 "As you know, the number of cases undergoing
10 cardiac surgery to the year ending 31st March 1988 is
11 under review."
12 This is a letter stamped 7th December 1987, we see
13 that at the top of the page.
14 "It may be that the allocated monies will run out
15 before this time", and someone has written "No"?
16 A. That is me.
17 Q. "Since there is no money in district and none apparently
18 at region, the unthinkable is possible, that is that we
19 would be unfunded for cases during the last 5 or 6 weeks
20 of the financial year. Furthermore, we are overspent on
21 valves and this may have an increasingly serious effect
22 on the surgical workload.
23 "My discussion with Mr Nix was of the contribution
24 made by private patients to the cardiac surgical
25 budget. I innocently assumed that every private cardiac
0116
1 surgical patient who pays œ330 per day for accommodation
2 would in some way contribute to the cardiac surgical
3 budget ... I further assumed that private patients
4 having valve replacement who are required to pay the
5 full cost of their valve would in some way benefit our
6 valve budget."
7 Somebody -- you, I suspect -- has written "Funded
8 in full for workload"?
9 A. Yes.
10 Q. "I am therefore very surprised to learn from Mr Nix that
11 this is not so, but that the charges to private patients
12 for accommodation and valves support the central unit
13 and not the cardiac budget."
14 That was accurate, was it?
15 A. Yes, because the unit itself had funding to provide this
16 level of service, and it was financed in part overall
17 for the Trust from private patient income. So, if you
18 like, they have a spending budget and we also had an
19 income budget. The income budget for the Health
20 Authority came either from the Regional Health Authority
21 plus the money coming on the private patient route.
22 I should say, we did not do an awful lot of private
23 patient work, so this is not part of any private major
24 funding stream. I think at the top you might find some
25 of the notes. Could we go back to what I wrote at the
0117
1 top as well, please?
2 Q. By all means. It says:
3 "18 private patients, first 8 months" it might be,
4 "6 had a valve", and then some figures there?
5 A. Yes, then the cost of the valves.
6 Q. œ80,500 over the 8 months, and the annual value would be
7 œ121,000?
8 A. Yes.
9 Q. Then something on the right-hand side about the cost of
10 valves. On the left-hand side, 50,000 for cardiac at
11 RHA, and then another reference to valves, varying
12 levels of private patients, April/June as January/March?
13 A. I would have responded to the letter, back to Gerald
14 Keen.
15 Q. Okay. We will see if we can find the response. What
16 I wanted to ask you about was the annotation to the
17 first paragraph. Was it possible, as a matter of logic,
18 for money to run out before the end of the year?
19 A. No, because we had an arrangement with regional office,
20 the Regional Health Authority, that we were estimating
21 all the time the volumes of numbers of cases that we
22 were doing, and the idea of that was to actually spread
23 it appropriately throughout the whole 12 months and we
24 never had a situation where you hear sometimes people
25 say, "We have got to the end of January and we have
0118
1 stopped operating", at Bristol & Weston Health Authority
2 and UBHT we have never done that.
3 Q. So if we take, say for this year up to March 1988, the
4 level at which the unit was funded was 480 cases, if it
5 was still there?
6 A. Yes.
7 Q. When it comes to the 480 first and the 480 second
8 operations?
9 A. We would still have carried on and done them.
10 Q. And the money for them came from where?
11 A. As it is now, we would have had a discussion with the
12 Regional Health Authority and that is why there is quite
13 a close tab. You have seen where we have listed how
14 many cases there were in April to June and forecasted
15 them forward, to make sure we were having good estimates
16 with the regional office.
17 If we carried on and did 482 and the unit
18 overspent, that is something the Health Authority would
19 have picked up. Nobody would have said "Stop" and they
20 would not be done.
21 Q. They would have picked it up then or the next time
22 around?
23 A. We would have picked it up then, and if I did not get
24 finance via that route, I would have tried the following
25 year.
0119
1 Q. So when it comes to who is bearing the risk of there
2 being more operations than the estimate, there is no
3 risk, to use the later language, on the provider unit,
4 because it could do as many operations as it could, as
5 it had a capacity for, and the Regional Health Authority
6 would, in the end, pick up the tab?
7 A. Yes. I think, from what I can recall, we were
8 encouraged to do as many cases through the facilities as
9 we could.
10 Q. By whom?
11 A. I do not know. It is just a feeling. Nobody was really
12 putting any restrictions on the number of cases.
13 I think that somehow or other reflected through the
14 whole of all the documentation. It said "There is
15 a demand for 1400 and we are not meeting anything like
16 that", so, a push on the surgeons, I cannot say whether
17 it was Catharine Hawkins or somebody else who said "Do
18 what you like", but I think that was the perception.
19 Q. It is one thing to put no cap on the number of
20 operations, it is another positively to encourage
21 people, "You must do more". Was it a case of the
22 impression being, "You can do as many as you like", or
23 was the impression "You guys are going to do more of
24 these?" I think there is a difference between the two.
25 A. I think it was -- I suppose the way I would have -- yes,
0120
1 it was an encouragement to do whatever we could through
2 the facilities, not of "You must do more", but more of
3 a ...
4 Q. And the encouragement coming from the Regional Health
5 Authority? Is that the feeling you had?
6 A. I think I would say, yes, the way it was actually
7 structured, the arrangements with the Regional Health
8 Authority would tend to encourage that, yes.
9 Q. That letter -- if we just go over the page (64), we know it
10 was copied to you and it was copied to the two surgeons,
11 and it was copied to Miss Gerrish, who was the General
12 Manager for the BRI?
13 A. Yes.
14 Q. We will see if we can find a response from you to that
15 letter.
16 A. It is financial, so John Watson would almost certainly
17 have given it to me to respond to.
18 Q. Were you involved at all in recruitment decisions in
19 respect of cardiologists or cardiac surgeons in the
20 latter part of the 1980s?
21 A. No.
22 Q. You would not have been involved in the selection
23 process or sat on any of the relevant committees?
24 A. No, certainly not.
25 Q. Moving on a little bit, to UBHT 295/75, this is the
0121
1 operational policy for the cardiac surgery unit in June
2 1988. I think the note at the top of the page, the
3 right-hand column, if you have a look at that --
4 A. It is my writing.
5 Q. That says "cardiac file", does it?
6 A. Yes, that is me putting it in my cardiac file.
7 Q. This policy document would have been drawn up by whom?
8 A. The BRI cardiac unit.
9 Q. And presumably there would be similar operational
10 policies for other units in the BRI?
11 A. There may well be. This was a document prepared for the
12 new unit, I think.
13 Q. If we can scroll down to see the whole page, we see that
14 this document was obviously some time in gestation, was
15 it not, because this one is stamped 10th September 1987,
16 but the policy is to be applicable, as I understand it,
17 from June 1988 which is when the end of the expansion is
18 due to be complete?
19 A. Yes. You would do a lot of work in advance for
20 commissioning such a development.
21 Q. Yes. If we go to 79, this document deals first of all
22 with adults and then with children?
23 A. Yes.
24 Q. "Care of the child: the following flow chart depicts the
25 passage and timescale of the average child. Admission,
0122
1 2 days pre-operatively or emergency, operating theatre
2 4 and a half to 12 hours", I think that should be,
3 "intensive care unit, 1 day to three weeks. Average
4 length of stay for a child, 4 to 5 days."
5 Does that sound more realistic than the 24 to
6 48 hours we saw before lunch? You remember, you
7 commented on it at the time.
8 A. Yes, and I commented because from my sort of
9 non-clinical background, I would not have seen us moving
10 children who had just had heart surgery in that very
11 short period of time. This is obviously from the
12 clinical staff who understand these things, so I would
13 have thought that was more of the sort of number, but
14 I am sure there may be other people who can help you
15 with that, rather than me.
16 Q. The average length of stay was said to be two weeks for
17 an infant?
18 A. 14 days, yes, that is improved from an average length of
19 stay which was longer than that, and I was doing work on
20 it in the middle -- before this.
21 Q. Obviously clinicians can help us with some of these, but
22 these are the type of figures that people like you have
23 to be very familiar with?
24 A. Yes. This would have been the basis of the sort of
25 underlying information that nurses would have used or
0123
1 I would certainly have used to work out how many beds
2 I thought were necessary and would have been used to
3 check the bed information linked with the number of
4 patients coming through, and I am sure the nurses would
5 have used this in some way to work out their staffing
6 levels.
7 Q. If we just pick up the staffing levels at page 80, the
8 plan at this stage, if we just see about halfway down
9 that screen, cardiac surgery, nursing, this is still in
10 the context of children, ITU, 8 beds, and that would
11 have been increased from 4?
12 A. Yes.
13 Q. 1 to 1 nurse to patient ratio; so that was the ratio
14 being used at that stage. Now can we move on to 1989?
15 You were a member of something called the Standing
16 Cardiac Surgery Working Party at that time. I do not
17 know whether you remember that you were, but you were.
18 A. Yes.
19 Q. UBHT 295/322: Cardiac Surgery Working Party, 12th May
20 1989.
21 Why was it you were appointed to this Working
22 Party?
23 A. Because, well, I would have provided all the financial
24 input into the expansion of cardiac surgery.
25 Q. You had actually been quite closely involved ever since
0124
1 you started working at Bristol & Weston with this
2 ongoing development of cardiac services?
3 A. Yes. It was, as we have already discussed, a major
4 financial investment; it was complex because we had
5 expanded the cases year on year on year, and had two
6 major developments, the cardiac catheter development and
7 this one running, so all of the meetings to do with
8 cardiac surgery to regionally held ones, then it would
9 be normal for me to be there.
10 Q. And by this time you were the Deputy Treasurer, were
11 you, at this stage?
12 A. Principal Assistant Treasurer, running financial
13 management and -- yes, Deputy Treasurer, really.
14 Q. You were Mr Parr's number 2 by this time?
15 A. Yes.
16 Q. This was chaired by Mr Watson, and he was the General
17 Manager of the Central unit?
18 A. Yes.
19 Q. Shortly to swap over with Mrs Maisey. If we go to 323,
20 "staffing", this is Mr Wisheart's report:
21 "An additional appointment had been made in the
22 summer of 1988 giving three staff at Registrar level.
23 This satisfied the government regulations up until
24 1991/2, but was not considered adequate by the South
25 West Region. The number of senior house officers had
0125
1 remained at 4 and these staff were now under some
2 pressure."
3 Then Mr Wisheart said that there might be funding
4 in the budget for the appointment of an extra junior
5 member of staff, and you said that you thought all the
6 money had been allocated and used. "Dr Baker expressed
7 concern that the Registrar rota would not be tolerated
8 by the region."
9 That suggests that the clinical staff within the
10 unit were working too hard; there were too few of them?
11 A. Yes, they were under pressure.
12 Q. And if we go over the page, 324, just at the top of the
13 page:
14 "Mr Watson said that the problem of finding funds
15 was a short-term one, as by 1992, with planning
16 agreements, it would be possible to employ additional
17 staff and increase the cost per case."
18 What is that all about? That is something to do
19 with Trusts, is it?
20 A. That is to do with charging per case and was extremely
21 optimistic of Mr Watson.
22 Q. What was Mr Watson's optimism, first of all, before we
23 explain why it was misplaced?
24 A. Because an assumption that you can increase the cost per
25 case has not come to fruition at all; I mean, the
0126
1 thought that just because we were moving into
2 a situation where invoices were sent or patients came
3 with money with them meant that you were then able to
4 get more money out of purchasers would not have
5 existed. I do not think we believed that would have
6 happened, even then.
7 Q. So that was not a particularly practical response to
8 Mr Wisheart's concerns?
9 A. No. I would have expected us to have gone back and --
10 I would have reflected, I think, what I would say is
11 that "Actually we have allocated all the funds we have
12 been given by the Regional Health Authority to the BRI
13 sub-unit. Now it is about a decision for you, as
14 managers of that area, to look at the balance between
15 the different areas, review it and see whether you can
16 find money from within your own resources for
17 a phlebotomist, or another --"
18 Q. So you were saying "You have had all the money", to put
19 it crudely, "You have had all the money you are going to
20 get and if you want an extra X, you will have to do
21 without a Y"?
22 A. "You should review it". When you do major developments
23 like this, I personally think there is always room for
24 manoeuvre within that funding, because you are making an
25 estimate into the future and then you need to review it
0127
1 to make sure that your estimate has worked through
2 properly. There may well be this money there.
3 Q. Was this an isolated complaint from Mr Wisheart or
4 people like Mr Wisheart about inadequate medical
5 staffing in his department, or was it something that was
6 repeated --
7 A. I would not pick Mr Wisheart out specifically, but as
8 a finance person and Finance Director for the last 9
9 years or so, the Health Service itself is under pressure
10 and people do come to you and say, "With what we have to
11 do, I do not have enough staffing to do it with".
12 Q. Was it your impression at about this time or
13 subsequently that this unit was under particular
14 pressure compared to other units, or was this just the
15 typical sort of pressure that units like this would be
16 under?
17 A. I think most units like this would be under this sort of
18 review, where they are trying to do more and more cases
19 because people are on the waiting list, and that puts
20 pressure on the system.
21 Q. So this was not a particularly surprising or outstanding
22 type of complaint, if that is the right word, from
23 someone in Mr Wisheart's position?
24 A. No. I mean, the discussions about staffing levels and
25 the non-pay budgets go on all of the time.
0128
1 Q. If we look at nursing, we see what is said in that first
2 paragraph.
3 I should have said, by the way, Mr Watson I think
4 we discussed earlier, he ends up on the purchaser side
5 of the purchaser/provider divide?
6 A. Yes, he does.
7 Q. So he would have ended up as a recipient rather than
8 a sender of the invoice, as it were?
9 A. Yes, he would have received the invoice.
10 Q. So he would not have fallen for his own trick.
11 Moving then to nursing, at the end of that
12 paragraph, the last two sentences:
13 "There was a particularly worrying problem with
14 imbalance between experienced and junior members of
15 nursing staff. This was most pronounced where
16 paediatric experience was concerned."
17 If we scroll down, we see the nursing
18 difficulties. Again, it is really a similar type of
19 question we have just been exploring with the medical
20 staff. Was there, at this time, a particular problem
21 with nursing, especially paediatric nursing, or was this
22 again the run-of-the-mill type pressure within the NHS?
23 A. I am not sure whether at that time there was
24 a difficulty recruiting nurses with paediatric training
25 or not. I can recall phases of that; whether that was
0129
1 in the cardiac unit or not, I would not know. It is
2 obviously not my area. Part of the reflection when
3 I would go back to people would be, as you see, we have
4 created a plan for staffing these areas which was
5 submitted and agreed, and that makes it very difficult,
6 then, to go back at a later date and say, "By the way,
7 we have the staffing levels wrong" and get more money.
8 We did try to go back to the Regional Health Authority
9 and ask for more cash, as you will see.
10 Q. We will see that in a minute. Can we go to 327?
11 You presented figures for '86/87, '87/88, and
12 '88/89, showing the district of residence of patients
13 who had operations in the cardiac surgery unit.
14 Then you mentioned the fact that in 1989/90,
15 "shadow planning agreements would be in effect with
16 other districts based on their historical use of cardiac
17 surgery."
18 At this stage we are preparing for, although we
19 are not yet involved in the purchaser/provider split,
20 and as you explain in your statement, in 1989/90 there
21 was a shadow system operating I think just among the
22 districts in the South Western region?
23 A. That is correct, yes.
24 Q. Then in 1991, a proper contracting system between those
25 districts for cross-boundary flows, a year before the
0130
1 Trust itself was in operation?
2 A. And before our contracting became a national requirement
3 as well.
4 Q. Yes, so as you suggest in your statement, to that
5 extent, this was ahead of the game?
6 A. Yes.
7 Q. "During 1989/90, shadow planning agreements would be in
8 effect with other districts based on their historical
9 use of cardiac surgery. In subsequent years the
10 planning agreements would be the basis for determining
11 the income and workload of the cardiac surgery unit.
12 Dr Baker said it was important that the planning
13 agreements were a provider led initiative rather than
14 a consumer led one", in other words, the hospital
15 keeping control of the process as far as possible?
16 A. Rather than a purchaser led one, I think.
17 Q. "Mr Wisheart said that the clinical staff would wish to
18 have involvement in the shadow planning agreements.
19 This was agreed. It was felt that these issues would
20 appropriately be discussed in the cardiac unit
21 management group."
22 We have some tables at 329:
23 "Open heart surgery by district of residence,
24 amended figures for 1988/89."
25 They have been divided here into adults, children
0131
1 over 1 year and children under 1 year.
2 Why go to the trouble of dividing into the
3 children under 1 year, because they were funded from the
4 Department of Health pot through the Supra Regional
5 Services Advisory Group structure?
6 A. I do not know why it was done, but I would assume it was
7 because it gave the totality for the unit. Did I do
8 that?
9 Q. You were the one who is said to have presented these
10 figures.
11 A. You have the previous two years as well, then?
12 Q. Yes, I think we have.
13 A. Certainly from my point of view, I would always want to
14 show the totality of it. If you separate it out, then
15 people will misunderstand that they actually only have
16 496 cases to do, for example, and say, "Well, that is
17 the size of the unit" and the size of the unit is
18 actually 624. So I would always try, whatever I do, to
19 actually show the total picture. That is what is
20 there.
21 Q. The ratio of children over 1 year to children under
22 1 year is almost exactly 3 to 1. 83, 28, the total of
23 paediatric operations compared to adults is about 5 to
24 1?
25 A. Yes.
0132
1 Q. The original plan of going up to 600 cases, was that
2 there should have been 420 adults and 180 children, so
3 in fact the ratio of adult to child cases is much bigger
4 than that original estimate would have suggested?
5 A. Yes.
6 Q. Which suggests that the percentage of the relative
7 expansion of paediatric work was more marginal, to pick
8 up that word we saw in the earlier report, than was
9 anticipated?
10 A. Yes.
11 Q. If we go to 333, I think this might be the answer to
12 your question. I hope this is the right reference.
13 Those are the figures for the previous two years. You
14 see that in the earliest of the three years, '86/87,
15 there is no separate column for under 1s.
16 A. It is probably because I could not get the information.
17 Q. I was going to ask, is that because the data would not
18 have been collected at that stage?
19 A. It should have been collected, because you are into
20 supra-regional status, at that stage.
21 Q. If we just see the totals and scan down slightly, we see
22 that in 1987/88, the ratio of adults to children is
23 about 4 to 1.
24 A. Yes.
25 Q. But in '86/87, it is again getting on 5 to 1.
0133
1 Mr Langstaff tells me it is exactly 5 to 1, so we can
2 both take his word for it.
3 If we just look at 335. Although you presented
4 these figures to the meeting, it was Mr Joomun who
5 actually produced them?
6 A. That is correct.
7 Q. I think we will see in the supra-regional documents that
8 when it came to filling in the annual returns of work
9 loads and so on, you would often receive these documents
10 from the Regional Health Authority and send them on to
11 Mr Joomun and he would dig out the relative statistics
12 and send them back to you?
13 A. That is because I wanted to make sure that correct
14 comparisons had been made from year to year and had
15 a discussion with Mr Wisheart and Dr Joffe and others
16 about the forecast forward, because supra-regional being
17 three years, you needed the actual current year and
18 a forecast for the next year.
19 Q. Can we go to UBHT 295/340? This is now May 1989. This
20 is, as it were, putting out a feeler now to the Regional
21 Health Authority for yet another expansion in work. If
22 we go to the second and third paragraphs, it is to
23 Mr Wilson by you.
24 "Already apparent that the unit is working at and
25 is capable of achieving a throughput of 725 cases in
0134
1 1989/90. This higher level of throughput is putting
2 pressure on certain areas of the organisation...
3 financial position".
4 You have an indication of the region's willingness
5 to fund the higher level, and the marginal cost would be
6 œ2,000 to œ3,000 per case. That is, I think, a lower
7 marginal cost, as you would expect. The marginal cost
8 would be falling as one increased the total number of
9 operations because your fixed costs are a smaller
10 proportion of the total cost.
11 A. I think also that the length of stay of patients was
12 dropping as well, so that would mean that the unit price
13 for marginal expansion would have been lower because the
14 staffing requirements would have been different.
15 Q. Yes. We will come back to the Working Party report and
16 so on in 1989 and 1990 when we look at how the split
17 site was treated, because the split site of the business
18 of having paediatric open heart operations carried out
19 at the BRI was something that persisted until 1995,
20 I think. We will look at that in a little more detail
21 later.
22 Can I, though, turn now to the preparation for
23 Trust status and to cross-boundary flows?
24 In your witness statement at WIT 106/14,
25 paragraph 29, you say:
0135
1 "There was a substantial flow of patients to
2 Bristol from the rest of the region ... The greater the
3 number of referrals from around the region the greater
4 was the pressure on spending because no money flowed
5 with the increase in patients until several years
6 later". So you had to rely on the RAWP formula we
7 discussed this morning?
8 A. Yes.
9 Q. So it is especially important that the allocation of
10 RAWP money should have accurately reflected
11 cross-boundary flows. As we discussed this morning, it
12 was a rather insensitive instrument when it came to new
13 developments across the region?
14 A. Yes.
15 Q. So what happened was that there were shadow
16 cross-boundary flow contracts. If we go to
17 UBHT 112/180, this is a meeting of the Bristol & Weston
18 Health Authority Policy, Planning and Resources
19 Committee. We see you attended there, the fourth line
20 down.
21 A. Yes.
22 Q. If you go to 182, "Cross-boundary flows" at the bottom
23 of the page:
24 "The committee received a paper from the FPCC
25 outlining the changes being proposed by the Regional
0136
1 Health Authority."
2 Mr Parr summarised the position, which was each
3 DHA would be responsible for its population and
4 therefore each would look to buy the most efficient
5 service which may place the providing authorities at
6 some risk.
7 Of course, it would not apply to a regional
8 specialty, because by definition there would be nowhere
9 else to go within the region for that specialty?
10 A. No, that is correct.
11 Q. Then there was to be a pilot system in 1989/90, and then
12 a full system in 1990/91.
13 Mr Parr said that the degree to which each service
14 provided by the authority was costed was a function for
15 each district.
16 If we look, then, at the paper from the FPCC, that
17 is at 112/353.
18 We see the current systems described at 1.3. Do
19 you agree with those criticisms of the system as it then
20 was?
21 A. Yes. I wrote the paper.
22 Q. If we go to page 354, paragraph 3.5, the effect of these
23 contracts, as you saw it, would be that Bristol & Weston
24 would lose 7.729 million from the allocation which it
25 had to look after people from outside of the district.
0137
1 "In order to budget to continue to provide
2 existing services a budget for income of 23.84 million
3 would be needed."
4 If we go over the page (355), 3.6, one of the effects of
5 this system would be that costing systems would have to
6 be improved to identify costs in different specialties.
7 Monitoring would have to spruce up its act, and billing
8 systems and so on, because now it was going to be
9 important to cost and source patients?
10 A. Yes.
11 Q. So this is the same type of financial discipline being
12 imposed on this shadow basis that Trust status imposed
13 on the whole of the NHS from 1991?
14 A. Yes. Again, there is two years head start within the
15 region.
16 MR MACLEAN: Sir, we are just about to get to Trust status.
17 Would it be appropriate to save that until after we have
18 had another short break?
19 THE CHAIRMAN: Yes, shall we take 15 minutes and reconvene
20 at 3.30?
21 (15.15)
22 (A short break)
23 (15.31)
24 MR MACLEAN: Mr Nix, we were looking at this document about
25 the cross-boundary flow and shadow contracting process
0138
1 for 1989/90.
2 Can we go to the paragraph 4.2(b). If we just
3 pick it up at 4.1:
4 "Some real incentives and a greater degree of
5 control will be real benefits. A very major concern for
6 Bristol & Weston has been to control the inflow of
7 patients to regional specialties and this system will
8 provide funding arrangements which will cover increased
9 workloads from outside the district .... The Regional
10 Health Authority will need to exercise a level of
11 monitoring and control ... (b) In recognition of the
12 fact that the system cannot, in the current context of
13 the NHS, operate in a totally commercial way, i.e. there
14 are bureaucratic and administrative controls within
15 which management must operate, they are effectively
16 monopoly providers of service, the principle of clinical
17 freedom will remain, although we will need to
18 incorporate managerial and financial responsibilities;
19 service standards must be protected; the market is
20 restricted; cash limits will still prevail."
21 There seem to be a lot of concepts in that
22 sentence, but as far as cardiac surgery is concerned, we
23 touched on this before the break, the Bristol Royal
24 Infirmary was the only centre within the region for that
25 service and therefore there was no question of anybody
0139
1 in need of cardiac surgery going to any other district
2 within the region?
3 A. Not within the region, no.
4 Q. If we go, then, to 356, we see that the document was
5 drawn up by, it says "Treasurer", 23rd November 1988.
6 I think you said you actually drew this document
7 up?
8 A. Yes.
9 Q. You and, at that stage, the Treasurer?
10 A. No, all documents prepared within the Finance Department
11 such as this would go out under the name of the
12 Treasurer and that is the same situation now. Other
13 people might write them, but they go out under my name.
14 Q. And 357: this shows that Bristol & Weston was expecting
15 to be a net gainer under this system. I appreciate it
16 was only a shadow system for 1989/90, but if we look at
17 the top in the first row, Bristol & Weston's original
18 allocation, and then you strip out the sum which was
19 previously allocated to cover cross-boundary flows,
20 23.8 million is the amount of money that was to be
21 charged to other districts for people they sent to
22 Bristol & Weston; 16.1 million was people going the
23 other way. So Bristol & Weston was expecting to be
24 a net gainer to the tune of 7.7 million; is that right?
25 A. All of this would have been in balance, so Bristol
0140
1 & Weston would not have had any more cash to spend. It
2 is just a net change in allocations, so by changing the
3 system around this is the impact on the allocations of
4 each of the Health Authorities. You inferred that it
5 was -- I am sorry, I took what you had said as if
6 Bristol & Weston had more money to spend and it has
7 not.
8 Q. What this was suggesting was that if there were to be
9 a system whereby money followed patients from district
10 to district, operating as it were for real across the
11 region, Bristol and Weston would be a gainer rather than
12 a loser?
13 A. Yes.
14 Q. If we go to 358, this is the cross-boundary flow
15 profile. If we go to 360, the cross-boundary flow,
16 regional specialties, Bristol & Weston, cardiac surgery
17 is the first column. We see there the districts who
18 were sending patients into Bristol & Weston. I think
19 this table is for 1988. We see, for example, that
20 Cornwall sent no-one at all in that year to Bristol?
21 A. Yes.
22 Q. Despite there being no other regional specialty between
23 Bristol and Cornwall?
24 A. Yes.
25 Q. So they must all have been going somewhere else?
0141
1 A. Southampton and London.
2 Q. Past Bristol, as it were. Dealing then with the shadow
3 contracts, can we go to UBHT 231/37? This is a paper
4 from Mr AA Wilson.
5 A. Regional Treasurer.
6 Q. He was in the Finance Department at the region. You see
7 what he says at paragraphs 1, 2 and 3.
8 Can we go to paragraph 4? This was the
9 initiative:
10 "To introduce charging for interdistrict
11 cross-boundary flows for a trial year in 1989/90 with
12 the real contracts in 1990/91".
13 He explains the different types of contract. Can
14 you explain in your own words what the different types
15 of contract were at this time for cross-boundary flows?
16 A. Most of our contracts would have been a block type, the
17 first one you have there, which means that you get
18 a fixed cash sum of money. It is based on, obviously,
19 flow from the previous year but it means that you get an
20 amount of money based on that which is fixed. You get
21 a fixed cash sum and it is what I would class as an
22 indicative workload, so it is really the workload from
23 the previous year: if you do more work, you do not get
24 any more money; if you do less work, you do not lose any
25 money. So it is purely block.
0142
1 Q. So 10 operations at œ100 each, to take very simplistic
2 and ludicrous figures, is œ1,000 and if you only do five
3 you get #1,000 and if you do 15 you get #1,000?
4 A. Yes, you will still get #1,000. Obviously, that has an
5 implication. And then you have totally variable.
6 Q. Can we scan down? That is block. Can we go over the
7 page? (38) The cost and volume.
8 A. We would normally put a limit on that somewhere along
9 the lines now.
10 Q. What is the key concept there?
11 A. Really we got a very good idea about how many cases you
12 are going to do and we agree an amount of money for that
13 number of cases, so you are very close. With that one
14 you are talking about 98 to 102 rather than 50 to 150,
15 so you have a cost and volume. What we tend to do now
16 is to actually put an upper and lower limit on it, so
17 that you have a band around that 100 hernias, so nothing
18 would happen if we did 95 to 105 but if we went beyond
19 that in some way then there would be finance given to
20 you or taken away from you.
21 Q. If we had a band of 10, so it was 100 hernias but there
22 was a slack of 95 either way --
23 A. If you went above 105, you might get funding at marginal
24 price only, rather than full price.
25 Q. If you did 92 or 93?
0143
1 A. Then you would lose it at marginal levels. And the
2 price per case is where everything is totally variable,
3 so people talked in the early 1990s of somebody coming
4 with a cheque attached to them, cash with them, so it is
5 a price per case. So every case that comes you charge
6 a figure for. I see with that one they have actually
7 put floors and ceilings in, which we tend not to have
8 now.
9 Q. So the floors and ceilings mean that the purchaser takes
10 the risk within the floor and ceiling. In our hernias
11 example, it is the purchaser who takes the risk of
12 buying 100 hernias and only getting 95?
13 A. Yes.
14 Q. But outside the floor and the ceiling, the risk then
15 reverts to the provider?
16 A. Yes, it is shared.
17 Q. We have the contract between Bristol & Weston and
18 Frenchay Health Authorities for 1989 and 1990,
19 UBHT 69/1.
20 If we go to page 3, and scan down, please, the
21 standard of service:
22 "In addition to any more specific obligations
23 imposed by the terms of this contract, it will be the
24 duty of the supplying authority to provide the service
25 to a standard which is in all respects to the reasonable
0144
1 satisfaction of the authorised officer."
2 The "supplying authority" in Trust language is the
3 provider?
4 A. Yes.
5 Q. And the authorised officer was nominated in this
6 contract by the receiving authority, so it was the
7 purchaser, as it were, who was responsible for
8 nominating the authorised officer, and the authorised
9 officer in turn who was responsible for monitoring the
10 standard of the service.
11 So the onus on standards in this early form of
12 contract was put on the purchaser, not the provider?
13 A. Yes.
14 Q. The quality aspects in monitoring arrangements of this
15 contract were at schedule 5. If we go to page 29, there
16 is Schedule 5. "Quality aspects in monitoring
17 arrangements, 1: waiting times."
18 There was a target for waiting times for
19 outpatient attendance within a month and non-urgent
20 outpatients and inpatients to be seen within the average
21 waiting time of 1987/88.
22 Monitoring arrangements: as you recall, was
23 anything else being monitored other than the waiting
24 time through the annual survey or the PAS system?
25 A. No. I mean, this was the very first year of doing this.
0145
1 Q. I appreciate that?
2 A. Most of the effort was actually in trying to collect the
3 data quickly enough to be able to provide monitoring
4 information between what you could class now as
5 "purchaser and provider", so I do not think any or very
6 little work would have been done in this area at all.
7 Q. The only factor which is referred to in Schedule 5 which
8 is capable of being monitored is waiting times?
9 A. Yes. I do not know whether any information at all was
10 provided from that.
11 Q. What would PAS --
12 A. Patient Administration System.
13 Q. What would that tell us?
14 A. That would tell you about numbers of patients waiting,
15 who had come as outpatients, whether it was a new or
16 follow-up, whether a patient was an in-patient or a day
17 case.
18 Q. It would tell you things like when they were admitted,
19 when they were on the waiting list, what they were
20 referred to, when they were discharged?
21 A. What is difficult for me is to separate out exactly what
22 was available then and what is available now. Obviously
23 the systems we have now are pretty, compared to then,
24 sophisticated. We know all the outpatient waiting
25 times, in-patient waiting times, because those are
0146
1 factors that we now have to report on regularly to the
2 NHS Executive.
3 At that time, PAS would only have picked up
4 inpatients and day cases, according to this schedule.
5 Q. The reference to surveys, that is essentially
6 questionnaires or people standing with clipboards asking
7 patients what they thought of the service?
8 A. No, I think you will find that is looking at a point in
9 time as to how long outpatients are waiting for their
10 appointments, I would expect.
11 Q. That would be taken off PAS as well, would it?
12 A. No, that is probably taken manually. I mean, manual
13 information systems.
14 Q. The Planning, Policy and Resources Committee had been
15 one of the Bristol & Weston Health Authority key
16 committees?
17 A. Yes.
18 Q. In 1989, that work was divided into two groups called
19 the "purchaser group" and the "provider group"?
20 A. Yes.
21 Q. If we look to UBHT 113/100, that is what that document
22 says. This is in preparation for Trust status?
23 A. Yes.
24 Q. If we go over the page to 101, that splits up the work
25 of the PPRC between the purchaser and the provider?
0147
1 A. Yes.
2 Q. And if we scan down, we see that -- if we go back up to
3 the top, please, we have purchasers on the left-hand
4 side, providers on the right-hand side, and then back
5 down to 3, the annual programme, the purchasers'
6 provision?
7 A. Yes. It is about what you use any growth money coming
8 in for.
9 Q. The cost of improvement programmes and provider and so
10 on?
11 A. Yes.
12 Q. If we go to UBHT 103/16, this is a letter from
13 Dr Roylance to Catharine Hawkins. He is writing to the
14 Regional General Manager, Miss Hawkins, to set out the
15 details of the management arrangement.
16 "The former Standing Committees of the authority
17 i.e. Policy, Planning and Resources .... was suspended
18 in the autumn of 1989 and replaced by three new
19 subcommittees ... 3 teams of senior officers support
20 these committees and the two teams supporting the
21 Bristol & Weston provider committees are simultaneously
22 pursuing NHS Trust status."
23 We will see where, if anywhere, you fit into
24 that. If we go to UBHT 113/97, that is a meeting of the
25 Bristol & Weston Health Authority. If you go to the
0148
1 last paragraph of that page --
2 A. I am sorry, it was not a meeting with the Health
3 Authority, I do not think; it was a meeting of the
4 Steering Committee of the Hospital Medical Committee.
5 Q. I am sorry, you are quite right. If we go to the foot
6 of the page -- it does not, I think matter terribly
7 much. It is really the last paragraph:
8 "While studying ways of splitting the roles,
9 Bristol & Weston had been asked by the Secretary of
10 State through the Regional Health Authority to produce
11 two business plans for possible self-governing status
12 for hospital and community services based on Bristol and
13 on Weston respectively."
14 So the pressure for two Trusts, one to be carved
15 out of the Bristol bit and one of the Weston bit, had
16 come from the highest level in the Department of Health?
17 A. I did not think that the Secretary of State had asked
18 individuals; I thought it was an issue where
19 organisations could put their name forward for Trust
20 status. The Secretary of State did issue a general
21 request, I thought, so I do not believe the Secretary
22 said, "Bristol & Weston, you will split into Bristol and
23 Weston"; it was more that it was a call for people to
24 set up Trusts and I thought that Bristol and Weston had
25 responded in the way it did by moving to set up one for
0149
1 Bristol and one for Weston.
2 Q. This minute would suggest that there was some blueprint,
3 if that is the right word, coming from the Secretary of
4 State which had come down to Dr Roylance via the
5 Regional Health Authority?
6 A. I would not be aware of that.
7 Q. That is what this suggests?
8 A. Yes, that is what that suggests, but I was not aware --
9 Q. It is news to you?
10 A. Yes, and I was not operating at that level at that time.
11 Q. Okay. I dare say that is something we can explore with
12 Dr Roylance.
13 If we go to page 98, please, over the page, you
14 were to be a member of the Bristol Provider Team?
15 A. Yes.
16 Q. There were five of you altogether: Dr Roylance ends up
17 as the Chief Executive of the Trust, Mrs Maisey as the
18 Director of Nursing and subsequently of operations as
19 well?
20 A. Yes.
21 Q. You as the Finance Director?
22 A. Yes.
23 Q. Mr Stone as the Personnel Director?
24 A. Yes.
25 Q. And Mr Boardman was responsible for development?
0150
1 A. Corporate Development, I think the term was.
2 Q. And four of those five stayed with the Trust for some
3 considerable time after it was set up?
4 A. Yes.
5 Q. Namely, the first four named?
6 A. Yes.
7 Q. Then, if we go to the last paragraph on this page:
8 "The committee as a whole approved the idea of
9 doctors being appointed to lead the departments with
10 help from the managers and administrators."
11 This is the genesis of the directors, is it not?
12 A. Yes, clinical directors.
13 Q. "Dr Roylance felt that such appointments would have to
14 be made by the Authority on the advice of consultants."
15 Who in fact appointed the Clinical Directors once
16 the choice was up and running?
17 A. The Chief Executive, because they were accountable to
18 the Chief Executive.
19 Q. So it was the Chief Executive, Dr Roylance as it turns
20 out, who chose those people to take up the various
21 directorates?
22 A. I think the way it happened was that in the early days
23 it was the areas themselves were asked to nominate
24 a consultant to be the Clinical Director. That came
25 through a discussion with John Roylance.
0151
1 Q. If we go over the page to 99, the penultimate paragraph:
2 "Regarding the hours of work submission,
3 Dr Johnson said that Region would allow only cardiac
4 surgery to have an illegal junior staff rota. This
5 meant that there were still problems in general surgery
6 and urology at the Senior Registrar level in Bristol and
7 at the SHO and Registrar level at Weston."
8 Can you help us with the junior staffing position
9 in cardiac surgery?
10 A. I am sorry, I have no information about that.
11 Q. It would appear as if the junior staff rota was
12 stretched further than it ought to have been, but that
13 Region was turning a blind eye to that?
14 A. I do not know what the rules were for junior staff
15 appointments then.
16 Q. Who is the appropriate person to deal with that?
17 A. The Medical Director or John Roylance.
18 Q. So it would be Mr Wisheart or Dr Roylance, or Mr Dean
19 Hart, perhaps?
20 A. Or Mr Dean Hart, depending on when it was.
21 Q. Originally. But obviously for cardiac surgery --
22 A. This would have actually been before Trust status. It
23 is 55/89, so that would be John Roylance, and maybe the
24 Chairman of the Hospital Medical Committee.
25 Q. Now can I go to UBHT 249/75? This is a meeting of the
0152
1 Health Authority, 16th July 1990.
2 A. Yes.
3 Q. You attended that. You are at the foot of the first
4 column of attendees. There is a difference between
5 being present and being in attendance, but I do not
6 think we need to get into the finer points of that.
7 A. Yes.
8 Q. If we go to 77, "in attendance" just means you were not
9 actually a member of the authority formally.
10 77, if we can just scroll down:
11 "The purchaser committee had approved for
12 consultation the health care and resources guidelines
13 for 1991/92."
14 There was a new Regional Health Authority set up
15 in July 1990, and a new District Health Authority taking
16 post from September 1990?
17 A. Would you say that again?
18 Q. If we look over the page to 78, Chairman's remarks:
19 "Appointments to the new district health
20 authorities would be made by 17th September and they
21 would come into existence on that day. The new RHA
22 would be designated on 26th July and its first meeting
23 was likely to make some appointments to the DHAs."
24 A. Yes, that must be the reduced numbers on the
25 authorities.
0153
1 Q. If we go to 83 and 84, we come to Dr Roylance's
2 discussion of the Trust application.
3 Just before we look at this document in any more
4 detail, as you understood it, who was going to be
5 responsible for standards and quality of care? Was that
6 to fall on the purchaser side of the line or the
7 provider?
8 A. I would have said that it was a -- well, a shared thing
9 between both, but a lot of it would have lain with the
10 provider.
11 Q. What about numbers, the throughput? Who would be
12 responsible for making sure that adequate numbers of
13 patients passed through the door of the hospital?
14 A. The responsibility for purchasing would be with the
15 Health Authority. The idea was that they would identify
16 the health care needs of their population and decide
17 what volumes of patient care would be necessary to be
18 purchased to meet that need. Clearly, the provider has
19 no direct responsibility, but they are the ones who will
20 have to treat the patients at the door.
21 Q. What would the role of the Regional Health Authority be
22 after the purchaser/provider split came in? How would
23 its role change?
24 A. We had less of an involvement. I comment about it.
25 Before, the regional health authorities had a strategic
0154
1 planning responsibility, so I would see after that --
2 they are probably not the right words, but I would see
3 the Regional Health Authority as having some management
4 responsibility with the purchasers, because Trusts have
5 a direct line through to the Secretary of State through
6 regional office, not through the Regional Health
7 Authority.
8 Q. There is no need for the Trust to have any particular
9 dealing with the Regional Health Authority after Trust
10 status, because the Chief Executive is answerable to the
11 Department of Health?
12 A. Yes.
13 Q. And the Regional Health Authority is not the purchaser,
14 because it is the District Health Authority that is the
15 purchaser?
16 A. Yes.
17 Q. So the role of the Regional Health Authority is --
18 A. It is still, to me, it should be still a strategic view
19 of health care in the whole of the region.
20 Q. But buying nothing and running nothing?
21 A. No, but it has influence.
22 Q. Mr Keefe was at this meeting. Do you remember Mr Keefe?
23 A. Yes.
24 Q. Do you know who he was?
25 A. No, but I remember the name. One of the Health
0155
1 Authority members.
2 Q. We will see in a moment. If we go to this page, if we
3 just scan down, please, if we stop there, do you see in
4 the last paragraph on that page: "Dr Roylance said that
5 much misinformation had been circulating about Trusts.
6 For example, there would be wholesale changes in terms
7 and conditions of staff; they would be independently
8 profit making and the Trust would be free to determine
9 which care to provide."
10 THE CHAIRMAN: Mr Maclean, it needs to be scrolled up, it is
11 not on our screen.
12 MR MACLEAN: It is there but I did not start at the
13 beginning of the paragraph:
14 "It was important to recognise the status quo was
15 not an option. The separation of purchaser from
16 provider had been started but the full implications were
17 difficult to comprehend. The new DHA would be entirely
18 different in composition, function and in its
19 accountability to the new Regional Health Authority.
20 There was no doubt that the new Regional Health
21 Authority role would be much sharper and more
22 prescriptive."
23 What did you understand by those words of
24 Dr Roylance: "much sharper and more prescriptive"?
25 A. I do not know, really. From a Trust point of view,
0156
1 I know you are talking about the Regional Health
2 Authority, we were given what was classed as "more
3 freedoms", so I am not clear as to what the pressure
4 would have been on the RHA role to the purchaser.
5 Q. So you cannot help us there?
6 A. No.
7 Q. If we go to page 84, the first new paragraph:
8 "The NHS was now required to develop a precise
9 definition of what health care could be provided within
10 the available resources. Any shortfall in quality of
11 care would inevitably be placed at the door of the
12 provider."
13 That suggests that it is for the provider, the
14 Trust, to ensure that the quality control systems are in
15 place?
16 A. Yes.
17 Q. "Any shortfall in quantity of care, i.e. the number of
18 patients to be treated, would be placed at the door of
19 the purchaser. There was therefore a commanding need
20 for a debate between two bodies of equal stature to find
21 the right balance of quality and quantity of health
22 care."
23 Then he explained that "the team making the
24 proposal had yet to set out to communicate its
25 intentions to staff but he identified the following
0157
1 advantages of Trust status; Greater member input ..."
2 Now, "member" there means what, clinician?
3 Employee?
4 A. I do not know. I would have thought it was about staff
5 input, but it is not a term -- "member" does not
6 actually link any term whatsoever into Trust status.
7 Q. "... freedom from bureaucratic control", and the
8 bureaucratic control of the provider unit at that time
9 was provided by the Bristol & Weston Health Authority,
10 of which Dr Roylance was the District General Manager?
11 A. I think the bureaucratic control was outside from even
12 that level, in that, certainly towards the end of my
13 involvement with the purchaser, I felt more like
14 a form-filler than an accountant, in that the amount of
15 data I had to complete and return to the centre was just
16 quite phenomenal. The freedom, interestingly, was that
17 we had a new system with guidance and very little direct
18 rules set up at the beginning, so we were able to
19 formulate the way we thought it was best to provide
20 health care.
21 Q. Were those forms you were filling in and sending to the
22 centre about numbers of patients and the amount of money
23 you had been spending?
24 A. Yes.
25 Q. Were they concerned with the quality, the outcomes of
0158
1 treatment?
2 A. You would not ask an accountant to do that. I was not
3 involved and I cannot remember seeing anything at all
4 about quality. It was about volumes of patients, for
5 whom and what the costs were.
6 Q. So there was the kind of bureaucracy that we see in the
7 returns of the Supra Regional Services Advisory Group
8 annually, for example?
9 A. That was very simple compared to what we were doing
10 towards the ends of my involvement with the purchaser.
11 Q. If we go to the bottom of the page, we see that Mr Keefe
12 said that in the resolution the committee was not saying
13 that there should be no Trust whatever for Bristol,
14 "just not this Trust now."
15 If we go over the page (85), Mr Keefe makes the point
16 in the fourth line down:
17 "The vast bulk of services that the Bristol
18 & Weston purchaser DHA would buy would come from only
19 one provider unit ..."
20 That is true, is it not?
21 A. No, the substantial amounts of work provided from
22 Weston, Southmead and Frenchay. The largest is quite
23 rightly UBHT, but significant volumes of care are
24 provided by Southmead and Frenchay to Bristol and
25 Weston, and vice versa, from us to what was then
0159
1 Frenchay and Southmead districts.
2 Q. So what extent is that care which is provided, which is
3 also available within what used to be Bristol and
4 Weston -- to what extent is it that they have some
5 regional specialties?
6 A. The service provided across Avon is actually a balance
7 of what I would class as "local services", so all the
8 four hospitals provide, for example, emergency medical
9 services, but when you come down to regional
10 specialties, then Southmead provide renal and
11 orthopedics, Frenchay do plastics and urology; UBHT do
12 really all the other regional specialties that exist:
13 oncology, cardiac, children's.
14 Q. We see in the middle of that paragraph Mr Keefe also
15 made the point that he believed that the advice given to
16 purchasers would come, plainly, from providers.
17 What is your view of that point? Is it right that
18 in the early days of Trusts in particular, purchasers
19 were substantially reliant on providers for information
20 about the cost and volume?
21 A. No. I think that the expertise and the knowledge about
22 individual specialties does lie with the providers.
23 What you need is a very good communication between
24 purchasers and providers to actually make sure that
25 there is a learning on both sides. But I do not think
0160
1 you would ever end up with a situation where the
2 purchaser has the expertise in cardiac surgery,
3 children's, gynaecology, obstetrics. You have to have
4 a good communication between the two organisations.
5 Q. Is that not just the same point we saw earlier, that the
6 Trust, those in the provider unit, would want to make
7 sure that the process was provider-led rather than
8 consumer-led? Is that not all that Mr Keefe is saying?
9 A. Yes. I think, as the previous paragraph said, there
10 were some misconceptions, there were some concerns; we
11 were moving into a new system in the National Health
12 Service. None of us actually knew how it was going to
13 work. There were concerns on all sides about -- there
14 was one comment made earlier on that the purchasers
15 would only be interested in volume and not interested in
16 quality at all. There were comments that providers were
17 going to have to protect quality. I think that they
18 were comments that were around at that time, as
19 a result, probably, of significant change, and people
20 are always concerned when there is change.
21 Q. Is it fair comment to say that Trusts in general, and
22 the UBHT in particular, was ahead of its purchasers in
23 the early days of Trust status, in being able to look at
24 the services it provided and cost them with a reasonable
25 degree of accuracy?
0161
1 A. Yes, we did have good or better data within the
2 providers, because all of the information had to flow
3 from our patients administration systems through to
4 purchasers. To that extent, we could get at that sort
5 of data first. From a cost point of view, all the cost
6 data would be at provider level. Yes.
7 Q. So it is right, then, is it not, to say that the advice
8 given to purchasers would inevitably come mainly from
9 providers?
10 A. Yes. I think at that stage, I mean, we had already
11 shared, before 1st April 1991, all of the data about the
12 prices, because, within the South West, we had run this
13 for two years.
14 Q. So it would be the case then, would it not, that that
15 point of Mr Keefe's, at least, was a good point, and not
16 a misconception? It must follow, must it not?
17 A. I think that it would be -- yes. I mean, a lot of the
18 data would come from the provider, but I was trying to
19 add to that that I think that is about where you come
20 into this from, not in an adversarial way but in
21 a supportive way, to make this new system work. You had
22 to have both sides wanting to do that. Do not forget,
23 for Bristol & Weston, the people on the purchasing side
24 were colleagues of mine, and other people within the
25 Trust.
0162
1 Q. Let us move on over the page to page 86. Dr Roylance's
2 comment is here, at 122/90:
3 "Dr Roylance said that the NHS Act [the NHS
4 Community Care Act 1990] required the greater
5 involvement of doctors in management and a series of
6 seminars on the matter had been held with senior medical
7 staff in the district. Clinical directorates could be
8 easily matched with contracts, and as his paper ...
9 showed, a named doctor had been nominated [by him] for
10 nearly all directorates."
11 There was an exception with community care.
12 "Mr Keefe again said that he had found the paper
13 unenlightening in terms of the various relationships
14 between and amongst managers and directors and
15 questioned what procedures there were to appoint the
16 Clinical Directors."
17 We have discussed that already.
18 "Dr Roylance said that the system had been extant
19 for some time in the NHS and the basic requirement was
20 to involve doctors in management. Indeed, it would be
21 difficult for anybody other than a clinician to sign
22 a service contract. They would not in fact be managers
23 at all but would perform a medical leadership role, and
24 in this context, the government had agreed with the
25 British Medical Association that doctors who undertook
0163
1 this role could be paid for up to two sessions over and
2 above their clinical role, or to pay for a locum."
3 So we are talking here about the Medical Director
4 role?
5 A. No, you are talking about Clinical Directors in that
6 role, and Medical Directors as well.
7 Q. The Medical Director of the Trust to begin with worked
8 as Medical Director for two sessions per week?
9 A. Yes.
10 Q. I think Mr Ross explored that with Mr Langstaff last
11 week?
12 A. Yes.
13 Q. So is it right that Clinical Directors and the Medical
14 Director were both paid for two sessions a week on that
15 management role?
16 A. Yes, they could be. I think there was an issue within
17 UBHT that many of the Clinical Directors did not take
18 the payment; they used it to buy cover for their
19 sessions. There was a mixture. Some people had locum
20 cover for one session as Clinical Director and got paid
21 another; some of them did not take any payment at all
22 and were able to cope with it; others, two sessions of
23 locum cover. So it is a complete range for Clinical
24 Directors.
25 Q. Is it your view that, looking back on the implementation
0164
1 of the Trust system, that up to two sessions a week for
2 the Medical Director was adequate or inadequate?
3 A. I think the demands on the things that the Medical
4 Director has been asked to do have expanded and
5 expanded. Two sessions, certainly now, would not be
6 able to fulfil those sorts of roles.
7 Q. Was two sessions adequate in April 1991, in your view?
8 A. I think that was really more of an issue between John
9 Roylance and the Medical Director than between me and
10 the Medical Director, because most of my time was spent
11 working with executives other than the Medical Director.
12 Q. You were the Financial Director from the beginning?
13 A. Yes.
14 Q. And you were watching these other two senior colleagues
15 working, as you were, in the new Trust set up. You must
16 have formed a view as to whether or not the Medical
17 Director had too much on his plate or not?
18 A. To be honest, it was not something that I actually
19 thought about at the time. I mean, there was a lot of
20 work to be done. Most of the systems that were changing
21 were financially orientated, and that is where my
22 thought was. I did not really have a view as to the
23 time and commitment of the Medical Directors at that
24 time; that is clearly a different situation now.
25 Q. Did you ever discuss the question of the time that the
0165
1 Medical Director, who I think was Mr Dean Hart to begin
2 with, and then Mr Wisheart, that either of those two men
3 spent as Medical Director, as to whether they were too
4 pushed at two sessions per week?
5 A. No. Never had any discussions at all.
6 Q. Do you think that now seven sessions a week for the
7 Medical Director is appropriate or inappropriate?
8 A. I think that is certainly appropriate now, plus, of
9 course, there is a lot of other support to that post as
10 well now, in clinical governance, research and
11 development, teaching, strategic planning.
12 Q. There was no Associate or Deputy Medical Director in
13 Mr Dean Hart's time, or Mr Wisheart's time as Medical
14 Director?
15 A. No, and at that time there would have been a Medical
16 Director and the Chairman of the Hospital Medical
17 Committee as a combined role.
18 Q. Who in the new set up, would be responsible for medical
19 staffing issues?
20 A. Now?
21 Q. No, in 1991?
22 A. The Chief Executive and Medical Director.
23 Q. But now?
24 A. Director of Personnel, Medical Director and Chief
25 Executive.
0166
1 Q. So the burden of medical staffing is one that the
2 Medical Director no longer carries alone or with the
3 Chief Executive, but in Mr Dean Hart and Mr Wisheart's
4 day in the early part of the Trust, they were solely
5 responsible, save for the Chief Executive, for medical
6 staffing issues?
7 A. As far as I am aware.
8 Q. Has there been any other part of the Medical Director's
9 job that has been either taken from the Medical Director
10 or diluted, with the assistance of others?
11 A. Yes. I mean, we have, within UBHT, appointed a Director
12 of Research and Development; that has been in post for
13 three years. We have appointed an Associate Medical
14 Director on strategic planning. That post has probably
15 been there for about two years. We now have an
16 Associate Clinical Director for teaching, an Associate
17 Medical Director, I apologise, for teaching, in all our
18 liaison with University and teaching across the whole
19 gamut, not just medical but all teaching. About
20 9 months ago, we appointed somebody to assist with the
21 clinical governance responsibilities.
22 Q. You were one of the provider team for the putative
23 Bristol Trust; we have seen that.
24 A. Yes.
25 Q. So you would have been a co-author of the Trust
0167
1 application?
2 A. Yes.
3 Q. You summarise that in your witness statement at
4 WIT 106/16.
5 If we just scan down so we have paragraph 33 at
6 the top of the page, this is a recitation of the
7 benefits of Trust status:
8 "To give Clinical Directors and Managers the
9 freedom to build on the efficiency and innovation of the
10 existing United Bristol Hospitals to improve services.
11 Local autonomy: the expertise of the non-executive
12 directors will be used to direct care more
13 appropriately. They will also take a leading role as
14 laymen and women ensuring that all patients are treated
15 as individuals."
16 What did you see as being the disbenefits of Trust
17 status?
18 A. It was not about Trust status, I do not think; it was
19 about the change in the funding streams to the NHS,
20 which meant that there was more risk being built into
21 it. As a Finance Director, we are fairly risk averse.
22 We had a new system that was requiring tight financial
23 control and we would be able to do that with the new
24 arrangements in the first 12 to 24 months? That is the
25 biggest concern, and, because of that, if you overspent,
0168
1 would it actually have a knock-on through to patient
2 care?
3 Q. There are six identified advantages for benefits here:
4 local autonomy is the first; freedom to manage is the
5 second; the third is improved quality of care:
6 "Standards and monitoring programmes for the
7 future will be agreed with the purchasers and will be
8 published for patients."
9 That is what happened in the contracts which were
10 subsequently drawn up with the schedules dealing with
11 quality that were attached to it; is that right?
12 A. Yes. They were not published for patients. I think
13 improved quality of care, for me, went beyond that, and
14 that was about provision of information to patients,
15 about the services that were provided. But yes, I mean,
16 the actual documentation with the purchasers developed
17 over the following years; you could not do everything on
18 Day 1.
19 Q. "Value for money: competition with nearby units for
20 contracts will sharpen costing and quality of services."
21 Which nearby units are in mind there?
22 A. This was written before we got Trust status, of course.
23 Q. I appreciate that?
24 A. At Southmead -- I would class, as Southmead, Frenchay
25 and Weston -- in that we would need to review how we
0169
1 provided the services, whether or not there were more
2 efficiencies in them, whether it was appropriate to
3 provide -- I was going to say "services"; I do not quite
4 mean that -- whether it was appropriate for services to
5 be provided by us to people from the north of the city,
6 in other words, it was more appropriate that they went
7 to Southmead and Frenchay. It was about looking at how
8 best to provide the services.
9 Q. A Trust, then, will provide those services which have
10 been purchased from it by a purchaser?
11 A. Yes.
12 Q. They do not carry any money as extras to start providing
13 new services on spec' in the hope that somebody will buy
14 them?
15 A. No, you were not allowed to do that.
16 Q. So how does that square with the last part of page 16,
17 if you scroll down:
18 "Financial freedoms: the new freedoms will enable
19 the Trust to respond more quickly when capital
20 investments are needed."
21 A trust can only provide that which somebody else
22 has decided to buy from it?
23 A. Yes.
24 Q. So how can the Trust respond when capital investments
25 are needed?
0170
1 A. Because one of the freedoms that was supposedly given to
2 Trusts was that they would be able to invest in capital
3 with no controls from the centre.
4 Q. You say "supposedly"?
5 A. Because when it came to fruition, the freedom that was
6 seen in all of the documentation prior to Trust status
7 actually did not come through at the end of the day, in
8 that the centre still controlled the amount of capital
9 that any Trust might invest. For example, the
10 depreciation in capital charges that UBHT has is around
11 œ7 million a year. Theoretically, it should be able to
12 reinvest that, but it is actually capped at œ5.5 million
13 as the amount it can actually invest of that money, so
14 there were still central controls on capital investment,
15 which, prior to Trust status, we were not expecting.
16 Q. If we can go over the page and just deal with this
17 point, it may be a convenient moment:
18 "Staffing flexibility. The changed status will
19 allow the Trust to reward excellence and ensure that it
20 retains staff."
21 What was the mechanism for that anticipated to be,
22 when you draw up this document with your colleagues?
23 A. Centrally, Trusts were told that you could change the
24 way you pay staff. Prior to this you had to stick to
25 Whitley Council payments, terms and conditions of
0171
1 service, and under Trust status you could move away from
2 that and pay people locally. In reality, UBHT are stuck
3 to Whitley all the way through, but other trusts did use
4 other mechanisms.
5 Q. The plan at this stage, obviously, for those drawing up
6 this document, of which you were one, was to reward
7 excellence, presumably in financial terms. Was there
8 a corollary of that, of an intention, at least
9 a willingness, to penalise the opposite of excellence,
10 where that was found?
11 A. No, absolutely not. This was really saying that, as
12 Trust status, you had this flexibility to achieve this
13 end. In reality, we have not used it the way other
14 Trusts have done, because we felt that Whitley Council
15 terms and conditions have been created over many years
16 of experience, and we should stick with that.
17 Q. Then we see this: "Clinical Directors and Centres of
18 Excellence for education and research", and then
19 "Dedication to quality of care. Purchasers will need
20 to emphasise value for money. The Trust will balance
21 this by protecting quality and promoting new
22 developments underpinned by its teaching and research."
23 How was the Trust to provide that counterweight,
24 that balance of protecting quality?
25 A. Clearly, I think the thoughts then would be that it
0172
1 would come through in our discussions with the
2 purchasers about the level of funding they were putting
3 into UBHT for patient services, and saying to the
4 purchasers, "Look, if you invest in this, this is what
5 is actually now achievable." That would be, obviously,
6 the teaching and research part which is backing up the
7 services that we could provide.
8 Q. But the protection of quality, then, would depend upon
9 the purchasers asking the appropriate questions in the
10 discussion with the providers?
11 A. This is to some extent reflecting back to the previous
12 discussion, where we were talking about the purchasers
13 wanting to push for volume to meet the demands from
14 their residents for care, and thus having a discussion
15 which is saying, actually, we can only cope with this
16 certain volume in a way that is acceptable.
17 Q. I think we will see, I suspect now tomorrow, that the
18 discussions which purchasers had with providers, with
19 the Trust after 1991, tended to focus on numbers of
20 operations and the costs of X operations?
21 A. Yes, it did.
22 Q. It was throughput and cost that was the focus of
23 attention?
24 A. Yes, it was.
25 MR MACLEAN: Sir, I am I am a little over halfway through
0173
1 Mr Nix's evidence. Plainly, we are not going to finish
2 today. I wonder, is this a convenient moment for me to
3 sit down, with the intention that, all being well,
4 Mr Nix can resume at 9.30 tomorrow morning?
5 I understand there may be one or two other matters which
6 perhaps Mr Langstaff would be better to deal with
7 than I.
8 THE CHAIRMAN: Thank you, Mr Maclean. Shall we allow Mr Nix
9 to leave first, if he should so wish? You may of course
10 stay, Mr Nix, but otherwise we thank you so far and we
11 will see you tomorrow morning at 9.30.
12 MR NIX: Yes, thank you.
13 (The witness withdrew)
14 THE CHAIRMAN: Mr Langstaff?
15 MR LANGSTAFF: Sir, you will recall that I began the day's
16 proceedings by saying a few words about some feelings
17 which had been expressed by Dr Roylance's legal
18 advisers. I understand Miss Powell has something she
19 would wish to say to you
20 APPLICATION BY MISS POWELL
21 MISS POWELL: Thank you sir, Mr Langstaff. I am grateful
22 for the opportunity to address you very briefly on
23 a short application in relation to the Inquiry's
24 procedures.
25 Mr Langstaff, as he said, started the day by
0174
1 referring to some unhappiness and concerns on the part
2 of Dr Roylance's legal representatives, which concerns
3 had arisen out of the questions put to Mr Ross in his
4 evidence.
5 On behalf of Dr Roylance, we welcome
6 Mr Langstaff's expression of regret this morning in
7 relation to the statement of Mr Boardman, which,
8 contrary to what we understand to be the procedure laid
9 down for critical statements, had not been made
10 available to Dr Roylance for his comments before it was
11 introduced in the evidence in questioning of Mr Ross.
12 We welcome also his commitment on behalf of
13 himself and his team to make efforts to ensure that in
14 future such a situation does not arise.
15 However, those representing Dr Roylance consider
16 that a potential weakness in the Inquiry's procedure has
17 been highlighted by the evidence elicited from Mr Ross.
18 The way this has been done, and this potential weakness,
19 will not be solved by the undertaking, welcome though it
20 is, that Mr Langstaff has given in relation to critical
21 witness statements.
22 Mr Langstaff rightly drew attention this morning
23 to the very important procedure by which representatives
24 are expected to make suggestions to Counsel to the
25 Inquiry as to the matters that may helpfully be put to
0175
1 a witness. We were given access to a copy of Mr Ross's
2 six-page witness statement in advance of his giving oral
3 evidence. Like many other witness statements, to this
4 Inquiry, it confined itself largely to factual matters
5 within his own knowledge, relevant to the issues under
6 consideration in this block. There was nothing in that
7 statement which caused those advising Dr Roylance to
8 wish to ask that any particular question be put to him.
9 That is perhaps not a matter of surprise, since Mr Ross
10 was talking about things on which Dr Roylance himself
11 will be giving evidence in relation to the material
12 period of time.
13 We understand that other representatives, quite
14 properly, made suggestions as to matters that they
15 wished to be canvassed in evidence, matters which went
16 far beyond what was contained in Mr Ross's statement.
17 The day before Mr Ross was due to give evidence,
18 Mr Francis, who is leading counsel for Dr Roylance,
19 informally asked Mr Langstaff, broadly, what evidence he
20 would be eliciting from Mr Ross. He was told that
21 Mr Langstaff might well be asking Mr Ross to compare the
22 management structure that he instituted with that
23 applied by Dr Roylance. No details of the nature of the
24 questioning were proffered.
25 It will be apparent from the transcript of the
0176
1 evidence of Mr Ross that, in the event, much of the
2 questioning was critical of the management structures
3 employed by Dr Roylance, and Mr Ross's evidence was
4 sought in relation to such criticisms.
5 We wish to make clear that we appreciate that it
6 is, of course, in the public interest that any
7 criticisms made of organisations and individuals,
8 including Dr Roylance, are thoroughly investigated.
9 To the extent this occurs, we can and of course do make
10 no complaint.
11 However, we are concerned that where only the
12 criticisms are put to a witness who is thought to be
13 able to give relevant and helpful evidence to the
14 Inquiry about them, that there is a danger the
15 investigation will not be sufficiently thorough and the
16 Inquiry may well be denied evidence that would be both
17 relevant and helpful in assessing what the Inquiry has
18 to assess.
19 I should say that had we been given any advance
20 notice of the nature of the questions to be put to
21 Mr Ross, a request would have been made to Mr Langstaff
22 by us to put questions with a view to obtaining
23 Mr Ross's evidence on the responses to the critical
24 questions that were put.
25 This would have avoided the unhappiness that we,
0177
1 as lawyers, felt at the apparently one-sided nature of
2 the questioning of Mr Ross, and the possibly unfair
3 impression that was no doubt unwittingly thereby
4 created, but perhaps more importantly, it would have
5 ensured that the Inquiry had available to it all of the
6 relevant evidence.
7 It is with this experience in mind that we would
8 respectfully ask the Inquiry to consider a modification
9 to its procedure: this is that, wherever Counsel to the
10 Inquiry intends to put questions to a witness which are
11 critical of an interested party, whether at the request
12 of another party or on his own initiative, the party
13 concerned should be informed of that intention and the
14 general intended subject matter of the questions, and of
15 any documentary material on which it is intended the
16 base the questions, where that is practicable and where
17 the documentary evidence has already been identified,
18 et cetera.
19 I do not wish in any way to under-estimate the
20 enormity of the task that we know faces Counsel to the
21 Inquiry, and I hope that this application will be
22 thought to be helpful.
23 We would submit that if this is done, there will
24 then be at least some opportunity on the part of the
25 representatives of the interested parties to respond in
0178
1 the way clearly desired by the Inquiry, by submitting to
2 Mr Langstaff points that the party concerned would wish
3 to have put.
4 Sir, we believe that it is only in this way that
5 the Inquiry will be helped to see and to obtain relevant
6 evidence upon the full picture in relation to the issues
7 before it, and not merely a partial one.
8 Sir, I am grateful.
9 THE CHAIRMAN: I am very grateful, Miss Powell.
10 Mr Langstaff?
11 REPLY BY MR LANGSTAFF
12 MR LANGSTAFF: Sir, yes. It is our view that the intention
13 behind this application is helpful, as indeed
14 Miss Powell has stated it to be.
15 We think that it misses or misunderstands three
16 fundamental points which need to be emphasised: there is
17 criticism, it is suggested, of the nature of the
18 questioning, and the questions were thought to be
19 adverse to the interests of he whom Miss Powell
20 represents.
21 It is of course fundamental that the questions in
22 an Inquiry such as this do not matter but the answers
23 do. It is the answers that form the evidence; the
24 questions form no part of it.
25 I, for my part, have indicated already that we do
0179
1 not accept that the questioning should have given that
2 impression; that it did so is plainly the case, because
3 otherwise Miss Powell would not be saying what she says
4 now, and we understand and appreciate that.
5 May I say simply this: it is unfortunate, if the
6 questioning gave any impression that a view had been
7 taken in any way adverse to Dr Roylance, because that is
8 not the case; we have not heard the evidence. You, the
9 Panel, cannot (and I know have not) drawn any
10 conclusions. Whatever may be the position elsewhere in
11 respect of Dr Roylance, this Inquiry starts, as
12 I emphasised a number of times, with a clean sheet.
13 That applies as much to Dr Roylance as it does to any
14 other person who comes to give evidence before this
15 Inquiry.
16 Secondly, the criticisms that are made, again,
17 there is perhaps a misappreciation in the sense that
18 when a witness gives evidence to the Inquiry, there have
19 been, throughout thus far, a number of occasions when
20 Counsel to the Inquiry, not only me, has raised, through
21 questioning, matters which are, as it were, flagged up
22 well in advance, so that when another comes to give
23 evidence, they will be able to deal with what may be
24 thought to be a matter of concern.
25 That, I would emphasise, is a helpful process.
0180
1 Thirdly, it is impossible, in any practical sense,
2 to give the detailed nature of questioning.
3 Examination, which consists of leaving out the material,
4 consists to an extent of cross-examination, cannot be
5 scripted in advance, and in particular, it may have to
6 be responsive to the answers which are given.
7 I did indicate to Mr Francis, as Miss Powell is
8 kind enough to acknowledge, that the nature of the
9 questioning would be a comparison and contrasting of
10 Mr Ross's tenure with that of Dr Roylance's predecessor,
11 and certainly that formula has conveyed to at least one
12 other representative who spoke to me the thought that
13 there would inevitably be a comparison which might lead
14 to the witness, not the questioner, but the witness
15 suggesting some advantage in the present system.
16 Whether there is or not is not a matter upon which we
17 can draw conclusions. Dr Roylance will, I am sure, put
18 his own side of the case, and I hope will feel in no way
19 constrained to put it just as he would have wished to
20 have put it in the first place had there not been this
21 intervention.
22 However, all that said, we acknowledge that the
23 application made expresses a concern which, in the
24 remarks which I made this morning, I hope we have
25 indicated that we, for our part, take on board. We try
0181
1 to do our best to accommodate, as far as we can, the
2 views from one direction or another of the various legal
3 representatives. We are open, of course, to receive the
4 views of those who were not represented but who wish to
5 pass them to us. That equally is important and needs to
6 be said. We try to do that with the impartiality which
7 we must have and must maintain, and we try to maintain,
8 and as I say, it is a matter of regret if any inference
9 should be taken, however sensitively, from any
10 individual who has listened to or read the questioning
11 which has taken place.
12 Sir, I do not think it is necessary for me to
13 respond any further, save to say that the modification
14 to the procedure as requested has something of the
15 bureaucratic about it, if not the 'albatross', and the
16 good intentions I would hope of us, assisted as we have
17 been by the ready access we have made available to all
18 counsel and continue to offer to make available to all
19 counsel and other representatives, should, we hope, do
20 the trick. I hope, I am sure we both hope, that it will
21 not be necessary for an application like this, on behalf
22 of anyone, to be made again.
23 THE CHAIRMAN: Thank you, Mr Langstaff.
24 Ms Powell, Mr Langstaff, I wonder whether you
25 would be prepared to wait until tomorrow morning for, as
0182
1 it were, a form of words which constitutes the Panel's
2 response when we have had an opportunity to talk about
3 it?
4 I will just say now, I am not sure that we
5 necessarily accept your characterisation of the
6 application as being necessarily an 'albatross'. I am
7 sure it was intended to help --
8 MR LANGSTAFF: Not the application, the consequence of it.
9 The application, I accept, is entirely in good faith and
10 entirely justified.
11 THE CHAIRMAN: Quite right, or even the content of it,
12 although I understand the tenor of what you are saying.
13 I would say this to you, Miss Powell: we are most
14 anxious not only to be fair but to be seen to be fair in
15 all that we do. We have had the benefit of Counsel to
16 the Inquiry, whose impartiality has been evident
17 throughout, and we have had the benefit of the helpful
18 input of legal representatives, and I would hope that
19 that continues.
20 Let me say that tomorrow I will, as it were, give
21 you a form of words. I am not currently minded to
22 accede to the request simply because I will say this:
23 that I rather think that it represents, as it were, an
24 acting out in practice of what has already been declared
25 in principle, but we will consider it overnight and come
0183
1 back tomorrow morning with a form of words which
2 constitutes our view on it. I hope that is satisfactory
3 to you.
4 MISS POWELL: Thank you, sir.
5 THE CHAIRMAN: Reverting, if I may, to Mr Maclean, or
6 Mr Langstaff, should it be you who wishes to stand, we
7 now, I take it, adjourn for today. We will reconvene at
8 9.30 tomorrow morning, when we continue the evidence of
9 Mr Nix. Thank you all very much indeed.
10 (4.45 pm)
11 (Adjourned until 9.30 on Tuesday, 25th May 1999)
12
13
14 I N D E X
15
16
17 ADDRESS TO THE PANEL BY MR LANGSTAFF .............. 1
18
19 MR GRAHAM RICHARD NIX (Affirmed):
20 Examined by MR MACLEAN ...................... 5
21
22 APPLICATION BY MISS POWELL ........................ 174
23 REPLY BY MR LANGSTAFF ............................. 179
24
25
0184
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001