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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

Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001