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FULL TRANSCRIPT

   1                       Day 23, 25th May 1999
   2   (9.30 am).
   3   THE CHAIRMAN: Mr Maclean, good morning. Perhaps I should
   4     first deal with the application which was made last
   5     evening, and then call on you, if I may.
   6   MR MACLEAN: Yes.
   7             CHAIRMAN'S STATEMENT
   8   THE CHAIRMAN: I will just read out what we have agreed.
   9        Let me repeat what was said yesterday morning,
  10     that the Inquiry is only beginning its task of receiving
  11     and hearing evidence on the subject of the local scene
  12     here in Bristol, and specifically, upon the management
  13     of paediatric cardiac surgical services.
  14        We anticipate hearing evidence from a number of
  15     perspectives or points of view, not least that of
  16     Dr Roylance himself.
  17        At this very preliminary stage we have all heard
  18     Mr Langstaff say that nothing in the questioning of
  19     a particular witness should have been thought to suggest
  20     any predetermined view on the part of Inquiry counsel,
  21     still less on the part of the Panel, and I emphasise
  22     that once more.
  23        It follows from this that in the course of this
  24     Inquiry there will be ample opportunities to ensure that
  25     any person is able to answer criticisms made of him or

   1     her.
   2        It does not need to be done instantly. In the
   3     case of Dr Roylance, he may submit comments or rebuttal
   4     at any time, and he himself will, of course, be giving
   5     evidence shortly.
   6        Miss Powell's application was specifically for an
   7     amendment to be made to our procedure whereby advance
   8     notice of any criticisms of another person that may be
   9     put to a witness should be given to the person who may
  10     fall to be criticised, or his or her legal
  11     representatives.
  12        The Panel is not minded to grant that
  13     application. It seems to us to be an excessively
  14     elaborate way of doing what Inquiry counsel have already
  15     sought to do in the spirit of co-operation.
  16        Further, it seems to us that it is important that
  17     the Inquiry should be able to explore potential avenues
  18     of criticism with a witnesses, even in circumstances
  19     when notice has not been given. It might not be
  20     practicable to do so, perhaps because they arise out of
  21     the comments of the witness when giving evidence, or
  22     because questions arise out of the contribution of
  23     another representative at the Inquiry, which may reach
  24     Inquiry counsel at a very late stage.
  25        The answer to any potential problem caused by

   1     that, as we have already indicated, lies in the fact
   2     that we will be here for a considerable length of time,
   3     sufficient to hear any comments or evidence in rebuttal.
   4        Finally, it is open to every representative within
   5     the parameters of the procedure that we have already
   6     announced to ask himself whether any witness called or
   7     from whom a statement has been received may have
   8     evidence that would support the perspectives or view of
   9     his clients, and if so, to ask Inquiry counsel to
  10     explore that possibility.
  11        It seems to us that use of that entitlement,
  12     coupled with what counsel to the Inquiry have already
  13     said about both their practice and their intentions,
  14     should avoid this situation from arising again.
  15        We hope, therefore, that this is satisfactory to
  16     all concerned.
  17        Mr Nix, you will forgive me for having dwelt on
  18     that: it was important and I was grateful to Miss Powell
  19     for raising it.
  20        Mr Maclean?
  21            MR GRAHAM NIX (recalled):
  22          EXAMINED BY MR MACLEAN (continued):
  23   MR MACLEAN: Mr Nix, you affirmed yesterday and we need not
  24     go through that process again, but you are obviously
  25     giving your evidence today on the same basis as you were

   1     yesterday. You understand that?
   2   A. Yes, I do.
   3   Q. Can I turn to the question of the directorates? This
   4     was a key concept of the management structure of the
   5     UBHT, was it not?
   6   A. Yes.
   7   Q. If we look in your witness statement at WIT 106/21, at
   8     the foot of paragraph 43 you say:
   9        "Management responsibility was devolved to the
  10     directorates with the Clinical Director working like
  11     a Chairman ... and the General Manager working as the
  12     Chief Executive for the Directorate?
  13   A. Yes.
  14   Q. Then over the page you set out the various
  15     directorates. Can you just explain which directorates
  16     would be involved in the delivery of paediatric cardiac
  17     surgery as at April 1991?
  18   A. Surgery, because cardiac surgery was part of the
  19     surgical directorate at that time, and children's
  20     services, because at that time we would have had closed
  21     heart surgery at the Children's Hospital and cardiology
  22     at the Children's Hospital.
  23   Q. So children's services would embrace paediatric
  24     cardiology at the Children's Hospital?
  25   A. Yes.

   1   Q. And closed heart operations at the Children's Hospital?
   2   A. Yes.
   3   Q. But open heart operations, adult and paediatric, would
   4     fall within the Directorate of surgery?
   5   A. Yes.
   6   Q. And that had, as an associate directorate, cardiac
   7     surgery?
   8   A. Yes.
   9   Q. But other directorates would be involved as well as, for
  10     example, anaesthesia?
  11   A. Yes, and radiology.
  12   Q. This pattern, I think, has been described as being on
  13     the John Hopkins medical school structure of management
  14     as a directorate system. Were there any other
  15     structures of management that were considered for
  16     potentially being applied to the Trust?
  17   A. Not that I am aware of, no.
  18   Q. Where did the genesis of this particular structure come
  19     from? Whose idea was it to apply it to the Trust?
  20   A. It would have come from John Roylance as the Chief
  21     Executive.
  22   Q. Did you have any discussions with Dr Roylance about the
  23     appropriate management structure which was to be in
  24     force after April 1991?
  25   A. We must have had some discussions. I do not recall

   1     any. I am sure it was not about whether or not we had
   2     directorates or not; it was more probably about how many
   3     directorates we had and what services and how they might
   4     be structured. We must have had those discussions, but
   5     I do not recall them now.
   6   Q. You do not recall the content of them?
   7   A. No.
   8   Q. So would it be fair to say that from a very early stage
   9     it had been decided by Dr Roylance, and I think it is
  10     your evidence, that the management structure would be
  11     based on these directorates, and that that was
  12     thereafter taken essentially as a 'given'?
  13   A. Yes. I think there were two areas of discussion I do
  14     recall. One was about community as a directorate, and
  15     the other was how many directorates would be within the
  16     field of mental health, psychiatry as it is listed here,
  17     because I recall there was some issue over whether we
  18     would have a directorate for the elderly acute or not.
  19   Q. This general pattern of devolving power to directorates
  20     as it were chaired by a Clinical Director and with the
  21     Chief Executive, as it were, of the directorate being
  22     the General Manager, was that a structure that was
  23     replicated in other Trusts in the area, acute Trusts?
  24   A. Within acute Trusts, clinical directorates was
  25     a structure that was being created. I think people had

   1     different arrangements with regard to the status of the
   2     Clinical Director in it, in that within UBHT the General
   3     Manager was accountable to the Clinical Director and the
   4     Clinical Director accountable to the Chief Executive,
   5     and some of the Trusts at that time, the General
   6     Managers would be accountable to Chief Executives.
   7   Q. So to the extent that the reporting line for the General
   8     Manager of the Directorate was to the Clinical Director,
   9     and from Clinical Director to Chief Executive, that
  10     suggested that this structure was an attempt to devolve
  11     more power to the Clinical Director than some other
  12     examples of the same basic structure?
  13   A. Yes. You have to recognise that UBHT was, I think, the
  14     seventh largest Trust in the country at that time and
  15     has been for a number of years. It is only recently
  16     where there have been mergers that there are now
  17     a considerable number of larger Trusts and some of these
  18     directorates were as large as some Trusts, so it was
  19     only right that they should have a significant amount of
  20     delegation and as you can see, the range of services
  21     provided are quite different.
  22   Q. And the Clinical Directors, who I think you told us
  23     yesterday were appointed by Dr Roylance --
  24   A. Yes.
  25   Q. -- they were all at the time of their appointments in

   1     post as clinicians at whatever hospital was appropriate?
   2   A. Yes.
   3   Q. They were not brought in from elsewhere?
   4   A. No.
   5   Q. Was there any discussion as to whether or not people
   6     might be brought in from elsewhere to bring a different
   7     perspective?
   8   A. Not that I can recall, no. It was about having
   9     a clinician who understood the service that was being
  10     provided, and how it was provided.
  11   Q. You have told us about the reporting line from the
  12     General Manager of the Directorate to the Clinical
  13     Director. Take something like cardiac surgery which
  14     involves a team approach. You have already explained
  15     the different directorates that would be involved in
  16     actually carrying out an open heart operation,
  17     particularly on a child who may have come from the
  18     Children's Hospital originally and perhaps goes back to
  19     the Children's Hospital subsequently.
  20   A. Yes.
  21   Q. If something goes wrong, if there is some systemic
  22     failure, let us assume, in the delivery of cardiac
  23     services or some other type of surgery, how would the
  24     different directorates be able to collectively
  25     investigate and put matters right?

   1   A. The staff within each of the directorates are working
   2     together all of the time, so certainly I would expect
   3     them to work together to resolve any issues that are
   4     occurring, and if necessary, for the Clinical Directors
   5     to meet to review the issues and to find the way
   6     forward. Clearly, if that did not work, then I would
   7     expect that to come up to the Chief Executive.
   8   Q. Let us take a purely hypothetical example --
   9     I emphasise, purely hypothetical -- of a junior surgeon,
  10     a trainee surgeon, who thinks that there is something
  11     wrong with the practice of anaesthesia in the theatre.
  12     Would that junior surgeon look to the General Manager of
  13     Surgery or the Clinical Director of Surgery, or would he
  14     or she be in a position to go to the Clinical Director
  15     of Anaesthesia, the General Manager of Anaesthesia? How
  16     would they go about bringing their concerns to the
  17     attention of more senior people?
  18   A. I do not know, is the truth of it. But I know what
  19     I would have expected to have happened, which is for
  20     them to have had a discussion at the level of the team
  21     providing the care, and then, as I have said, to raise
  22     it within, if it is a junior surgeon, I would expect
  23     that person to raise it with their consultant.
  24   Q. The consultant surgeon?
  25   A. Yes.

   1   Q. And the consultant surgeon would take it to the Clinical
   2     Director of Surgery?
   3   A. Or to have a discussion with the anaesthetist. I think
   4     that you have to recognise that clinical directorates
   5     were about managing the organisation, but that flowing
   6     sort of horizontally across this was a lot of contact
   7     between all of these groups, and I would have expected
   8     a conversation to have gone on at that level.
   9   Q. These directorates had their own finance input and their
  10     own personnel input?
  11   A. Yes. They shared finance. There are three senior
  12     finance people supporting all of these directorates so
  13     they have a number of them each.
  14   Q. Personnel would embrace ...
  15   A. For some of the personnel, some of these directorates,
  16     they would have their own personnel support, and for
  17     others, they would have a personnel officer supporting
  18     a number of directorates. There was not enough to give
  19     one each to each one.
  20   Q. Let us change my hypothetical example and assume there
  21     is a problem which is purely confined within
  22     a particular directorate, it is not a question of
  23     a junior surgeon spotting something wrong with
  24     anaesthesia, but a junior surgeon spotting something
  25     wrong with surgery, to change the example. Might there

   1     not be a danger with having separate directorates that
   2     problems would be too easily confined within their own
   3     box rather than brought to general attention?
   4   A. There could be that situation, but the aim was that
   5     people would talk together. All health care is a team
   6     delivered and we certainly would not have wished the
   7     directorates to get involved or to become chimneys of
   8     their own. If there were difficulties, then I would
   9     have expected that to be raised at the monthly meetings
  10     of Clinical Directors with the Chief Executive, or the
  11     Senior Managers meeting.
  12   Q. So if there is a problem in, to use your word, one
  13     "chimney", the way in which that becomes more widely
  14     known across the Trust depends on the relevant Clinical
  15     Director bringing the matter to the attention of the
  16     Chief Executive?
  17   A. Or raising it with the other Clinical Director, yes.
  18   Q. But it would be a rare problem, would it not, which the
  19     Clinical Director would want to share to another
  20     directorate without bringing to the attention of the
  21     Chief Executive?
  22   A. No, I do not think that is the case. I think that they
  23     will make comments, and comments have been made
  24     previously between directorates. I think that some
  25     people might have classed it as the last stage, to have

   1     taken it to the Chief Executive, because they have not
   2     been able to resolve it locally.
   3   Q. Now --
   4   A. By the way, whatever was on my screen has now
   5     disappeared.
   6   Q. Let us have another screen.
   7   THE CHAIRMAN: I will bring it back, I apologise. I took it
   8     off so we could just concentrate on the question.
   9   MR MACLEAN: The system now is that there is a Director of
  10     Cardiac Services?
  11   A. Yes.
  12   Q. So this structure at the page we were looking at has now
  13     been altered?
  14   A. Yes.
  15   Q. How does paediatric cardiac surgery now fit into the
  16     directorate structure?
  17   A. Now, at this date, today?
  18   Q. Yes.
  19   A. Then all open and closed cardiac surgery and paediatric
  20     cardiology is provided through the children's services.
  21     Anaesthesia is still provided from the Directorate of
  22     Anaesthesia and radiology through radiology, and
  23     currently obviously we have a Cardiac Services
  24     Directorate in the Royal Infirmary which includes
  25     cardiology and adult cardiac surgery.

   1   Q. Just looking at your witness statement at paragraph 46,
   2     page 23, in the last sentence there cardiology had
   3     previously been included in the Directorate of
   4     Medicine. Should that be adult cardiology?
   5   A. Yes, it should be.
   6   Q. The original plan was that these directorates would be
   7     given their own budgets and would negotiate their own
   8     contracts with purchasers?
   9   A. They would have their own budgets and they would be
  10     involved in the discussions with purchasers. They would
  11     be involved in the negotiation, but clearly, as a Trust,
  12     I would personally be involved in many of these
  13     discussions to make sure that we balanced financially,
  14     so they could not go off and do their own thing
  15     completely.
  16   Q. If we look at paragraph 48, just turning down, you say
  17     that individual directorates were generally involved
  18     with either attending meetings with purchasers or
  19     responding to requests. Directorates, clinicians and
  20     managers, the General Manager and the Clinical Director,
  21     were involved directly in discussions with Avon Health
  22     Authority, but for the non-Avon purchasers, the only
  23     directorates represented on a regular basis were cardiac
  24     and children's.
  25        Then there is a qualification about the Oncology

   1     Director in Somerset?
   2   A. Yes.
   3   Q. Forget for a moment about cardiac and children. Why was
   4     it that the clinicians and managers would be involved in
   5     discussions with Avon Health but not with other
   6     purchasers?
   7   A. The majority of services provided by UBHT were for the
   8     local population and the purchaser for that was clearly
   9     Avon Health. The only people who would know in detail
  10     how we provided services and our capacity to provide
  11     services were the clinicians and the managers involved
  12     in those relevant areas. So we always had meetings
  13     special for each directorate with Avon Health to discuss
  14     the problems, capacity and ideas from the directorates
  15     to develop their services.
  16        So they had to be involved there.
  17        With the non-Avon purchasers, we could not -- we
  18     would have taken our clinicians and managers away from
  19     doing their job of providing services if we had included
  20     them in all of the discussions with purchasers, because
  21     there were too many. For the majority of them, they
  22     were not major suppliers of services to non-Avon
  23     purchasers, apart from cardiac and children's.
  24   Q. What was special about cardiac and children's services?
  25   A. Children's services provided services really to every

   1     Health Authority in the South West region and beyond, so
   2     it went into as it is now the South Western region, so
   3     it provides services in Dorset, Wiltshire and over into
   4     Wales, and cardiac in a similar way but it did not have
   5     quite the same range as we saw yesterday. Very few
   6     patients came from Cornwall and Plymouth to Bristol, so
   7     cardiac would not have been involved in those
   8     discussions.
   9   Q. So would it follow that the General Managers of cardiac
  10     and children's services and the Clinical Director of
  11     cardiac and children's services were significantly more
  12     heavily involved in discussions with other purchasers,
  13     other than Avon, than were other General Managers or
  14     Clinical Directors?
  15   A. Yes.
  16   Q. So there would be a greater demand on their time in
  17     travelling around the region, talking to purchasers,
  18     than would be the case with others?
  19   A. Yes. You are talking about possibly 4 to 8 other
  20     meetings a year.
  21   Q. If we go over the page to page 24, paragraph 49, you
  22     say:
  23        "In the main contracts were agreed by individual
  24     directorates before they were signed by the Chief
  25     Executive."

   1        Are we to draw a distinction between the phrase
   2     "agreed by" and "negotiated by"? Is what you are
   3     getting at here that the contracts for most directorates
   4     would be drawn up and would then be approved by the
   5     individual directorates before formally being signed by
   6     the Chief Executive?
   7   A. Yes. The reason for the use of the words was that, yes,
   8     they would be involved in the discussions with the
   9     purchasers, and in some context you could call that
  10     negotiating, where they would give a bit of additional
  11     volume in exchange for additional cash. But at the end
  12     of the day, with Avon in particular, you would have to
  13     broker a deal, taking into account the volumes that had
  14     been agreed for the individual directorates, but we
  15     needed to make sure we were picking up such issues as
  16     inflation, funding, changes in National Insurance and
  17     other things, that we needed to bottom out for the whole
  18     of the Trust.
  19        So at the end of the day, we would have had
  20     a high-level discussion between the Chief Executive, the
  21     Finance Director of UBHT, the Director of Operations and
  22     Avon Health's Chief Executive, Financial Director.
  23   Q. So that would be from the Trust point of view yourself
  24     and Mrs Maisey?
  25   A. Yes. We took a lead in the early 1990s on the

   1     contracting.
   2   Q. And on the Health Authority side, it was then the
   3     Bristol and District Health Authority?
   4   A. Yes. It would have been Deborah Evans, Pam Charlwood,
   5     I cannot remember the name of the Chief Executive
   6     preceding Pamela Charlwood, and Bill Healing.
   7   Q. And Deborah Evans I think had the title of Contracts
   8     Monitoring Officer?
   9   A. Director of Contracting.
  10   Q. Mr Ross in his evidence last week described the
  11     directorates as being "semi-detached". He accepted,
  12     I think, that that was a fair expression -- page 21 of
  13     his evidence. Would you agree with that
  14     characterisation of the directorates?
  15   A. It was described sometimes that UBHT was like
  16     a "holding company" with individual directorates
  17     operating as elements beneath that holding company.
  18   Q. Is that another way of saying "semi-detached"?
  19   A. Yes.
  20   Q. Are those directorates more or less semi-detached now
  21     than they were in 1991?
  22   A. They are less semi-detached now. They still have
  23     responsibility for delivering their contracts and their
  24     financial targets, but the requirements on the NHS have
  25     changed over time and there is a lot more central

   1     control.
   2   Q. Central control coming down from the top of the Trust
   3     management structure?
   4   A. Yes.
   5   Q. Is that a change, in your opinion, for the better or for
   6     the worse?
   7   A. I think that we needed to change the way that we managed
   8     the Trusts so that we were able to meet the changing
   9     demands of the NHS. The requirements on us to report
  10     nationally had changed quite significantly. There are
  11     very specific targets placed on the Trust now in terms
  12     such as waiting times and we needed to make sure that
  13     was managed properly.
  14   Q. What type of change, what kind of difference in approach
  15     was it that was coming through the National Health
  16     Service that necessitated these changes?
  17   A. If you look back at 1991/92, there were no rules set up,
  18     really, nationally. We had guidance about the National
  19     Health Service and what we were trying to achieve, but
  20     how we achieved it was very much left to individual
  21     Trusts. As we have moved on through the 1990s, the
  22     prescription from the centre in the issuing of executive
  23     letters, giving us direction on issues, has increased:
  24     we are getting more and more letters of direction.
  25   Q. Is that a pattern that was apparent before the change of

   1     government?
   2   A. Yes.
   3   Q. What, if anything, has been the change since the change
   4     of government?
   5   A. Since the change of government obviously we have a new
   6     system, not quite the same as in 1991, but still quite
   7     radical in its effect. So we are getting more and more
   8     executive letters now than I can ever remember, and
   9     a lot more targeted investment that we have to respond
  10     to.
  11   Q. Is one of the effects of those changes that acute Trusts
  12     across the country now have more similar structures than
  13     they did back in 1991?
  14   A. I am sure there are a lot of similarities between the
  15     structures. I think some of it depends on how your
  16     facilities are structured as well, but, yes, there is
  17     a lot of similarity now. I am not quite sure how much
  18     that has changed now from the early 1990s, because
  19     I believe then that most people had gone down the
  20     clinical directorate route.
  21   Q. Is it still the case that the General Manager of the
  22     Directorate is accountable first and foremost to the
  23     Clinical Director or is there now a more direct line
  24     between General Manager of the Directorate and Chief
  25     Executive of the Trust?

   1   A. General Managers are still accountable to the Clinical
   2     Directors. I think there is a stronger link between the
   3     Chief Executive and the Clinical Directors, as we have
   4     had to, and there is a strong link with General
   5     Managers. There has to be a strong link.
   6   Q. Let us look, then, back at who was who in the UBHT at
   7     the start of Trusts. If we go, please, to UBHT 23/671,
   8     this is the note of a meeting, as opposed I think to
   9     minutes of a meeting, of the prospective members and
  10     officers of the United Bristol Healthcare Trust held on
  11     7th December 1990. We see your name there.
  12        If we go to 672, if we just scan down:
  13        "Mr Graham Nix, the Financial Manager, commented
  14     that the United Bristol Healthcare Trust was one of 14
  15     out of 56 awarded Trust status earlier this week."
  16        So Trust status had just been confirmed and it was
  17     going to go live from April 1991?
  18   A. Yes.
  19   Q. At the foot of the page:
  20        "Mr Christopher Dean Hart, Chairman of the
  21     Hospital Medical Committee, commented that what Mr Nix
  22     had said made it easier for him to commend Trust status
  23     to his colleagues. They were at the forefront with the
  24     public and were the most expensive employees ...(673) Their
  25     first consideration was for the quality of care they

   1     gave and secondly for costs. The medical staff are
   2     considerably influenced by the advice they receive from
   3     the learned Royal Colleges and their Trade Union, the
   4     BMA."
   5        So the Trust having been confirmed, the inaugural
   6     board meeting, I think, took place on 2nd January 1991.
   7     That is UBHT 23/603. We see the non-executive directors
   8     are named on the left-hand side and then the executive
   9     directors of the Trust are the first five names on the
  10     right-hand side, going down to Mr Stone.
  11   A. The Executive Directors with voting rights are the first
  12     five.
  13   Q. Yes, I think there had been a debate as to whether the
  14     final voting member should be Mr Stone as Personnel, or
  15     Mr Boardman as Development. In the end, they both went
  16     to Mr Stone?
  17   A. Yes.
  18   Q. This really reflects paragraphs 34 to 38 of your
  19     statement. We need not, I think, go into it in any
  20     greater detail. If we look at UBHT 296/009, sorry to
  21     inject a little law into proceedings, that is the
  22     statutory instrument, that is the Establishment Order
  23     for the UBHT, and we see that it was made on
  24     4th December 1990. It came into force on
  25     21st December. If we scan down, 2:

   1        "There is hereby established an NHS Trust which
   2     shall be called the United Bristol Healthcare National
   3     Health Service Trust."
   4   A. Yes.
   5   Q. If we look over the page (10), the functions at the top of
   6     the page:
   7        "To own and manage hospital accommodation ...
   8     at the Bristol Royal Infirmary" and associated
   9     hospitals. There was to be a Chairman, paragraph 4(1),
  10     5 non-executive directors and 5 executive directors?
  11   A. Yes.
  12   Q. The operational date was to be 1st April 1991,
  13     paragraph 5(1).
  14        That was the legal green light for the Trust. You
  15     were at this time the acting Treasurer of the Health
  16     Authority following the departure of Mr Parr?
  17   A. Yes.
  18   Q. If we go in your witness statement -- we do not need to
  19     go to it. Your witness statement explains that the main
  20     players in the Trust were the Chief Executive, John
  21     Roylance, the Personnel Director, Ian Stone, you were
  22     the Director of Finance, Mr Wisheart was the Medical
  23     Director replacing Mr Dean Hart who was initially
  24     Medical Director?
  25   A. That was after the first 12 months of Trust status.

   1   Q. Yes. Mrs Maisey was Director of Operations, and
   2     Mr Boardman we have seen was in charge of Development?
   3   A. Yes.
   4   Q. The Health Authority at the same time had obviously
   5     changed its structure in response to the
   6     purchaser/provider split. If we go to WIT 38/79, and
   7     turn it round, that is the structure, is it not? That
   8     is what I think you had in mind a moment or two ago. We
   9     see it is dated on the left-hand side 10.4.91.
  10   A. Yes.
  11   Q. So this would be the structure of the Health Authority
  12     at the inception of the Trust, and the part of this
  13     which is relevant for our purposes, we have the District
  14     General Manager acting, because Dr Roylance has gone off
  15     to be Chief Executive of the Trust?
  16   A. Yes.
  17   Q. The Treasurer was Mr Healing, so he would be your, as it
  18     were, opposite number?
  19   A. Yes. He was the Finance Director of Frenchay and he was
  20     appointed I think in March 1991.
  21   Q. And the other people relevant for our purposes is
  22     probably Miss Evans?
  23   A. Yes.
  24   Q. Whose title was Director of Contracting?
  25   A. Yes.

   1   Q. Can I go back in time a little, UBHT 249/1, this is
   2     a meeting of the Health Authority on 25th February
   3     1991. We see that you attended this because you were
   4     a member of the Health Authority?
   5   A. Yes.
   6   Q. And various other familiar names either as observers or
   7     attenders. If we scan down a little under "Chairman's
   8     remarks", Mr Bill Healing had been appointed to the post
   9     of Director of Finance?
  10   A. So it is February not March, as I said just now.
  11   Q. If we go, please, to page 3, I think the bottom of the
  12     page:
  13        "The Chairman reported that Professor Stirrat..."
  14     Who was he, or is he?
  15   A. The Professor of Obstetrics and Gynaecology at
  16     St Michael's Hospital, a University employee.
  17   Q. "... had written to say that he had been completely
  18     reassured that the quality of the surgery involved in
  19     the waiting list initiative was satisfactory following
  20     his comments in the last meeting. Mr Wisheart reported
  21     that a thorough (4) investigation had taken place and not
  22     a shred of evidence had supported Professor Stirrat's
  23     informant."
  24        Do you remember the context of that discussion?
  25   A. No. Is it possible to go back to the previous minutes?

   1   Q. Not at the moment, I am afraid. You do not recall the
   2     context of that discussion?
   3   A. I am sorry, no.
   4   Q. But it would seem at all events as though Professor
   5     Stirrat had put something in writing and Mr Healing had
   6     responded?
   7   A. It seems it was raised at the previous meeting.
   8   Q. The Trust obviously has standing orders and standing
   9     financial instructions as well?
  10   A. Yes.
  11   Q. I do not want to dwell on those too much, but can I just
  12     go briefly to UBHT 8/730?
  13        These are the standing financial instructions and
  14     if we look at the bottom of the page, this version
  15     actually is the revision from 1994. Perhaps you can
  16     help me as we go along as to the extent to which there
  17     is any material change since 1991?
  18   A. The standing financial instructions, very little. We
  19     used the Health Authority financial instructions for the
  20     first three months, and then I revised them and they
  21     basically stayed as written until 1994. Then they have
  22     been amended each year since, just marginally.
  23   Q. That is very helpful. Can we go to 732, paragraph 1.5?
  24        Paragraphs 1.5 to 1.9 explain your role, do they
  25     not? Perhaps you would just have a look through them.

   1   A. Yes. I do not know them off by heart, but yes.
   2   Q. Can we go to 734? 3.3 to 3.5:
   3        "Service budgets are to be compiled by managers
   4     within guidelines and policies set by the Board." It is
   5     your job to co-ordinate the preparation of the overall
   6     budget within the total income received by the Trust?
   7   A. Yes.
   8   Q. And you are the person who requires officers to provide
   9     the statistic and other information for comparing
  10     budgets and forecasts?
  11   A. Yes.
  12   Q. "The Chief Executive can delegate the management of
  13     budgets for defined services to the officers responsible
  14     for the performance of those services", so that would be
  15     the Clinical Director?
  16   A. Yes.
  17   Q. And obviously they are to exercise control of their
  18     budgets in accordance with the rules.
  19        If we go to 736, 4.2 to 4.4, your job is to
  20     prepare, certify and submit the annual accounts which
  21     statute imposes an obligation on the Trust to send to
  22     the Ministry?
  23   A. Yes.
  24   Q. You submit returns as the Secretary of State demands?
  25   A. Yes.

   1   Q. Then section 21 of these financial instructions deals
   2     with standards of business conduct.
   3        Can we go to 745 and can we go on a bit to 765?
   4     Keep going, please.
   5        Page 8/772, "Standards of Business Conduct". If
   6     we scan down that page and go over a couple of pages,
   7     please, to 774, the foot of the page, and again over the
   8     page (775), please, 21.17 and 21.18, "Commercial
   9     in-confidence":
  10        "Staff should be particularly careful of using or
  11     making public internal information of a commercial
  12     in-confidence nature particularly if its disclosure
  13     would prejudice the principle of a purchasing system
  14     based on fair competition."
  15        Then 21.18, perhaps you would read that to
  16     yourself.
  17        Are those the rules that have applied to
  18     commercial in-confidence matters for employees of the
  19     Trust since April 1991?
  20   A. Yes.
  21   Q. And those are to be read, are they not, alongside the
  22     guidance given by central government about the so-called
  23     "whistle-blowers' charter"?
  24   A. Yes.
  25   Q. Can I turn, then, to supra-regional services, and I hope

   1     fairly briefly. You deal with that in your witness
   2     statement at 106/5. We need not go to that. Can we go
   3     to UBHT 278/579? This is data which I think you
   4     compiled as long ago as 1984, I think it is. If we
   5     could just see the whole page, please, we see the
   6     handwriting at the bottom of the page. Is that yours?
   7   A. Yes.
   8   Q. If we just highlight that, the third asterisk:
   9        "Information supplied by Mr Wisheart's secretary,
  10     21.5.84."
  11        If we scan up the page again, we will see where
  12     that comes from.
  13   A. Yes.
  14   Q. It comes from the figure 3, does it not: number of
  15     operations performed, open heart, actual, 1983 to 1984
  16     was 3?
  17   A. Yes.
  18   Q. That is on open heart surgery, on under 1 year old
  19     children?
  20   A. Yes, at the BRI.
  21   Q. And the estimate for 1984 to 1985, 12 to 20, where would
  22     that come from?
  23   A. Mr Wisheart.
  24   Q. From the same source as footnote 3?
  25   A. Yes. It may well have included the discussion with Hyam

   1     Joffe.
   2   Q. The cardiologist?
   3   A. Yes.
   4   Q. Can you help us with the handwriting, "7 days, LOS"?
   5   A. Length of stay, then to BCH, so I must have asked how
   6     long would these children remain in hospital because
   7     I would have had to have created costs, and that was the
   8     data I was given.
   9   Q. We will see that in just a moment. In your statement
  10     you refer to the first document you had on file as being
  11     one of 17th April 1984 which refers to Bristol having
  12     already been designated a supra-regional centre.
  13        Can you for your part shed any light on why
  14     Bristol was originally designated?
  15   A. I am sorry, no.
  16   Q. You were not involved in that?
  17   A. No. I had a copy of the letter from the Regional Health
  18     Authority asking for information.
  19   Q. Were you aware of any application having been made to
  20     the Department of Health for supra-regional status to be
  21     granted to Bristol?
  22   A. Not for neonatal and infant cardiac surgery. I can
  23     recall working with a number of other groups to make
  24     applications in future years, but not for this one.
  25   Q. When such applications were made, were they the sort of

   1     applications that you had an input into?
   2   A. Yes.
   3   Q. So if there had been an application in about 1983 for
   4     supra-regional status, what type of financial input
   5     would there have been and from whom?
   6   A. Well, I joined Bristol & Weston Health Authority in June
   7     1983. The person I took over from for the expansion of
   8     cardiac surgery for the first 100 cases from 275 to 375
   9     was a gentleman called Mr John Light, so whether he had
  10     an involvement in it, I do not know, but I do not
  11     certainly recall personally being involved.
  12   Q. I know, Mr Nix, that you have kept copious files, for
  13     which we are most grateful, but so far as you are aware,
  14     there is nothing on file relating to an application for
  15     designation as a supra-regional centre?
  16   A. No. There is one file with all the supra-regional
  17     documents in for the Finance Department and there is
  18     nothing prior to that letter, I mentioned in my
  19     statement.
  20   Q. That letter I think is 17th April 1984. Its reference
  21     is UBHT 278/577. Do you suspect or know that there was
  22     an application, a formal application, made to the
  23     Department of Health?
  24   A. I do not know. I think that supra-regional services,
  25     these were probably the first ones that were designated,

   1     I assume, and therefore whether or not people were asked
   2     for an application or not, I am not clear. After that,
   3     there was a proper application system and we would have
   4     had a Working Group working on it.
   5   Q. Certainly those who would be involved in an application
   6     for designation as a supra-regional centre for neonatal
   7     and infant surgery would include at the very least
   8     paediatric cardiologists and the paediatric cardiac
   9     surgeons?
  10   A. Yes.
  11   Q. So perhaps we might more usefully ask them?
  12   A. Yes.
  13   Q. Can I go to UBHT 62/49?
  14        This is your estimate of neonatal and infant
  15     cardiac surgery expenditure for 1983/84. That is your
  16     writing again, is it not?
  17   A. Yes.
  18   Q. If we look down the page, please, to the Bristol Royal
  19     Infirmary, three patients during 1983, length of stay
  20     varied from 3 to 9 days?
  21   A. Yes.
  22   Q. And the operating times were all between three and
  23     four hours?
  24   A. Yes.
  25   Q. So the prices that you calculated would be based upon an

   1     average taken from those three cases and the operating
   2     times from the previous year; that is all you had to
   3     work on?
   4   A. That is all I had, yes. Can I say that the figure in
   5     the bottom right-hand corner of œ705,000 was
   6     over-estimated and it was recalculated on subsequent
   7     pages within the document, because the length of stay
   8     was over-estimated. That is not that length of stay,
   9     which is clearly actual, but some of the others.
  10   Q. I think this estimate was based on 3 and a half hours
  11     operating time?
  12   A. Yes.
  13   Q. So that type of information would have come from the
  14     surgeon's log or from the surgeons themselves, as to
  15     operating time?
  16   A. Yes, or from the theatre register. I cannot remember
  17     which.
  18   Q. The Regional Health Authority every year would send
  19     forms to you to be filled in for onward submission to
  20     the Supra Regional Services Advisory Group?
  21   A. Yes.
  22   Q. And I think we mentioned Mr Joomun yesterday?
  23   A. Yes.
  24   Q. He was the District Statistical Officer and for example
  25     in 1985, you passed the form on to him and asked him to

   1     pull together the data?
   2   A. Yes. Well, various. I would always want the forms to
   3     come back to me so as I could check from year to year
   4     and have a discussion with Mr Wisheart and Dr Joffe
   5     about their estimates for -- the form required actual
   6     for the previous year, estimate for the year you were in
   7     and a forecast for the future year, which clearly
   8     Mr Joomun could not do.
   9   Q. Was there any difficulty in obtaining the necessary
  10     information?
  11   A. Yes.
  12   Q. Why?
  13   A. We had to get people to concentrate on it.
  14   Q. Which people?
  15   A. Both to get the information out from Mr Joomun and to
  16     create time to see Mr Wisheart and Dr Joffe.
  17   Q. Can we can to UBHT 278/473.
  18        This is a memo from Dr Baker, who was the District
  19     Medical Officer, I think, to you?
  20   A. Yes.
  21   Q. If we just scan down and pick it up in the paragraph now
  22     at the top of the page:
  23        "There is an additional central pre-emption of
  24     œ15,000 ... the letter contains advice with regard to
  25     the capital implications of supra-regional services and

   1     allows for applications to be made for such capital
   2     allocations for the financial year 1987/88."
   3        Just pausing there, as you understand it, the
   4     position was that in the early days of supra-regional
   5     services, only revenue funding not capital funding was
   6     available; is that right?
   7   A. No. I cannot recall whether there was capital in the
   8     early days. All of my submissions were related to
   9     revenue. Whether there was any capital, I cannot recall
  10     that, but clearly it has come into play here.
  11   Q. It is certainly available from 1987/88?
  12   A. Yes.
  13   Q. "Dr Baker said it may be we have missed the boat having
  14     committed capital at the Children's Hospital for the
  15     cardiological aspects of neonatal and infant cardiac
  16     surgery."
  17        That is a reference to the cath' lab?
  18   A. Yes.
  19   Q. "But arguably some part of the capital requirement for
  20     the cardiac surgery developments in the BRI could be
  21     made in respect of the neonatal and infant workloads."
  22        He suggests there might be liaison with the
  23     regional treasurers and planners.
  24        Do you remember if that was followed up?
  25   A. I would imagine it would be, but from Bristol & Weston

   1     Health Authority's point of view, the Regional Health
   2     Authority had provided the capital and revenue to us to
   3     allow this development to proceed, so the key here,
   4     really, is can the region get any of its money back that
   5     it has invested from the region's allocation from the
   6     supra-regional system? I am sure we must have had
   7     a discussion about that once the issue had been raised.
   8   Q. Do you remember if any application for capital funding
   9     was ever made by Bristol to the Supra Regional Services
  10     Advisory Group?
  11   A. I did not think we had ever made a submission, but
  12     I have subsequently found out that a discussion and an
  13     outline submission was made in June 1992.
  14   Q. What was the outcome of that?
  15   A. We did not get any capital, so I assume that it was
  16     rejected in some way.
  17   Q. It was rejected, I think, because the bid was
  18     incomplete?
  19   A. Well, up until Friday evening of last week, I was not
  20     aware that we had made a submission. There were no
  21     papers in any of my files related to this yet you had
  22     mentioned something to me and I spoke to Kate Orchard,
  23     the Manager of Cardiac, and she said she was asked about
  24     it at the GMC, and on Friday I spoke to Mr Wisheart and
  25     asked did he know anything about it, and on Friday

   1     evening I saw a copy of a paper that had been submitted
   2     in 1992 -- in fact I saw two papers. The first was one
   3     that I had written which was what work would need to be
   4     undertaken to make a submission, and that was dated
   5     9th June, and then, about a fortnight later, the very
   6     short paper had been submitted. It was sent down under
   7     a compliments slip from Dr Joffe and on that compliments
   8     slip it indicated that Mr Owen had suggested that an
   9     application should be made and that the application that
  10     had been sent in was an interim statement. I do not
  11     recall being involved. I cannot remember anything about
  12     it, and there is nothing on the files, but clearly, the
  13     document is not extensive in its content.
  14   Q. Just unpicking some of that, would it surprise you that
  15     a bid for capital funding had been made to the Supra
  16     Regional Services Advisory Group in 1992 when you were
  17     Finance Director of the Trust without you knowing
  18     anything about it?
  19   A. Yes. Or for me to not recall doing it, or have anything
  20     on file, I find surprising.
  21   Q. Having now learned a little more about the situation,
  22     are you satisfied that you did not in fact have anything
  23     to do with the application that was made?
  24   A. I know that I wrote the paper, because my name is on the
  25     bottom. This is the paper which said what we would need

   1     to do to make a proper application. But I do not recall
   2     anything to do with the submission that was actually
   3     made. It was in effect committing the Trust to putting
   4     capital into a scheme. I would certainly have recorded
   5     it if the Trust Board had agreed to commit capital to
   6     this scheme, and it certainly did not.
   7   Q. You have seen the paper submitted by Dr Joffe and I have
   8     not, and I do not think the Inquiry has.
   9   A. Well, I had not until Friday evening, and at that time
  10     I had not gone through the files of the papers that had
  11     been suggested you might be referring to today, so I was
  12     not sure anything was in there or not, so I did not ask
  13     for a copy.
  14   Q. You were shown the paper by Mr Wisheart last week?
  15   A. Yes, I went to his home on Friday evening.
  16   Q. Was the document handwritten by Dr Joffe, or typed and
  17     signed by Dr Joffe?
  18   A. No, it was a typed document. It was a handwritten
  19     compliments slip.
  20   THE CHAIRMAN: May I interrupt just for a second? You said
  21     the Inquiry has seen it or has not seen it?
  22   MR MACLEAN: I have not myself seen it. We are checking
  23     whether the Inquiry has it on the database.
  24   A. I am sorry, Chairman, it was because I was... This was
  25     raised with me and I could not recall it as to why

   1     I actually went investigating to see whether I could be
   2     helpful today.
   3   MR MACLEAN: I myself was first aware of this document
   4     yesterday morning when Mr Nix mentioned it. We have not
   5     yet uncovered whether we have, but we do not obviously
   6     have it.
   7   THE CHAIRMAN: Thank you. Forgive me for interrupting.
   8   MR MACLEAN: Was there any other application for capital
   9     funding made before 1992?
  10   A. Not that I am aware of, that I can recall.
  11   Q. You suggested in your answer earlier that Mr Owen had
  12     apparently, so you understand, suggested that the
  13     application might be made?
  14   A. Yes, I believe that was actually written on
  15     a compliments slip from Dr Joffe.
  16   Q. So it would appear, would it, that Mr Owen had suggested
  17     that to Dr Joffe, and perhaps to Mr Wisheart?
  18   A. Certainly to Dr Joffe.
  19   Q. Do you know when that was suggested by Mr Owen?
  20   A. I am sorry, no.
  21   Q. But Dr Joffe's --
  22   A. The inference would be in 1992.
  23   Q. Do you know when in 1992?
  24   A. No. I know that I clearly had done some work on writing
  25     this paper, which is a list of issues to be considered

   1     in June of 1992.
   2   Q. So that was June 1992?
   3   A. Yes.
   4   Q. And the application was made after that?
   5   A. Yes; a couple of weeks. The document itself is dated.
   6   Q. Did you ever meet Mr Owen at any stage?
   7   A. I cannot remember meeting Mr Owen. I can remember
   8     meeting Mr Angilley.
   9   Q. And Mr Angilley was the Administrative Secretary of the
  10     Supra Regional Services Advisory Group?
  11   A. Yes, for a number of years.
  12   Q. And he was subsequently replaced by Mr Owen?
  13   A. Yes.
  14   Q. Do you think that, looking back on it, opportunities
  15     were available for applications to be made for capital
  16     funding to the Supra Regional Services Advisory Group in
  17     the late 1980s?
  18   A. Clearly there were, because of the paper from Dr Baker,
  19     yes.
  20   Q. Can you shed any light on why an application was not
  21     made until the last year in which -- or to take effect
  22     in the last year in which neonatal and infant cardiac
  23     surgery was designated?
  24   A. I can offer some explanations, but I cannot do more than
  25     that, which would be to say that clearly the

   1     organisation was receiving capital from the Regional
   2     Health Authority and was on a development programme that
   3     had been agreed which was quite substantial.
   4        That development has been completed and there was
   5     clearly a time for an element of consolidation, which
   6     occurred, but I cannot recall any discussions about
   7     should we or should we not make applications.
   8   Q. Can you think of any reason why an application should
   9     not have been made? Apart from the cost of filling in
  10     the form and the postage stamp, there was no cost to the
  11     Health Authority, or related to the Trust?
  12   A. The cost would have been in assessing whether or not it
  13     was feasible to achieve something, calling the Working
  14     Party together, working on that application as well as,
  15     as you say, the sheet of paper and the postage stamp.
  16   Q. But there were working parties working anyway on the
  17     development of cardiac services in Bristol and it was
  18     hoped money was going to come from the Regional Health
  19     Authority to fund that?
  20   A. Yes.
  21   Q. So the marginal cost of also asking the Supra Regional
  22     Services Advisory Group for some money would have been
  23     minimal, would it not?
  24   A. Yes.
  25   Q. Let us just go back to Dr Baker's letter, which I think

   1     we still have on the screen. He says the letter, that
   2     is the letter he has had about the supra-regional
   3     funding, makes request for financial and workload data
   4     from the service to be returned by June 1986.
   5        Until that time, that task had fallen to you and
   6     Mr Joomun?
   7   A. Yes.
   8   Q. He says "It may be appropriate for the matter now to be
   9     in the hands of the General Manager for the Central
  10     Unit", that was Mr Watson at the time?
  11   A. Yes.
  12   Q. And the General Manager for the children's surgery?
  13   A. Yes.
  14   Q. "Perhaps you would let me have your comment on these
  15     matters. I think it is important that we get the right
  16     managers to accept the right responsibilities in the
  17     future! However we must protect our own anxieties that
  18     the appropriate financial and workload data may not be
  19     forthcoming."
  20        What were those anxieties that you shared with
  21     Dr Baker?
  22   A. I would want to make sure that the data was consistent
  23     from year to year, and clearly, I would have wanted to
  24     have had a strong handle on any financial submissions
  25     that were made.

   1   Q. Was the suggestion by Dr Baker that it might be
   2     appropriate to put the matter in the hands of the Unit
   3     General Manager and the children's sub-unit General
   4     Manager in fact taken up?
   5   A. I would agree that the Central Unit General Manager and
   6     the General Manager for the Children's Unit needed to
   7     own what was being submitted. That did not necessarily
   8     mean that they had to do the work to create that data.
   9     I expect they were involved after this letter, but ...
  10   Q. Can we see UBHT 278/390? This is a typical example, is
  11     it not, of the expenditure and workload information
  12     return to the Supra Regional Services Advisory Group
  13     which was done annually?
  14   A. Yes.
  15   Q. And the information and workload and expenditure was
  16     used as a basis for the revenue allocation the following
  17     year?
  18   A. Yes.
  19   Q. You say in your statement at WIT 106/6 that Bristol was
  20     visited by the Department of Health and later by the
  21     National Health Service Management Executive on a number
  22     of occasions?
  23   A. Yes.
  24   Q. I think it is their paragraph 10. You mentioned that
  25     you met Mr Angilley. Do you recall who else from the

   1     Department of the Executive was involved in those
   2     visits?
   3   A. No, not by name, because any dealings I had were with
   4     Mr Angilley. My memory for names is not wonderful.
   5   Q. We have seen then that the amount of money you got from
   6     the Supra Regional Services Advisory Group was
   7     a straightforward multiplication of the cost by the
   8     number of the operations done?
   9   A. Yes -- not just operations: echocardiograms, cardiac
  10     cath's, outpatient attendances.
  11   Q. Procedures?
  12   A. Procedures, yes.
  13   Q. So the more procedures one did, the more money would be
  14     received in the following year, broadly?
  15   A. It was not the number that you did in the current year;
  16     it was about what your estimates were for the growth in
  17     the following year. You could not do the work until you
  18     actually had the money, so it was about what your
  19     estimates were.
  20   Q. If one's numbers were over a period of time to go up,
  21     then the amount of money would go up accordingly?
  22   A. Yes.
  23   Q. And so as the Treasurer or Assistant Treasurer at the
  24     time, you would have known that were the numbers to go
  25     up the income for the Health Authority would also go up?

   1   A. Yes.
   2   Q. Were you ever aware -- I think we touched on this
   3     yesterday -- of these visits leading to any express
   4     encouragement to perform more neonatal and infant
   5     cardiac procedures, particular operations, at Bristol?
   6   A. No.
   7   Q. If there had been any encouragement in any of these
   8     visits and somebody from the Department of Health had
   9     said "I am encouraging you, Bristol, to do more
  10     operations", how would that encouragement have been
  11     followed through?
  12   A. Certainly we would have had a discussion about how we
  13     might achieve higher numbers.
  14   Q. How might you have done?
  15   A. As Financial Director, you are always looking for
  16     mechanisms to bring more cash into your organisation to
  17     allow the clinicians to do what they wished to do.
  18   Q. Of course.
  19   A. The system we were operating was very much reflecting
  20     what was happening within the organisation rather than
  21     from my point of view of doing anything proactive about
  22     it.
  23   Q. Were you ever aware that those outside of Bristol, in
  24     the Supra Regional Services Advisory Group, or those
  25     advising the Advisory Group, thought that the numbers of

   1     neonatal and infant operations at the BRI was too low?
   2   A. No, I do not believe so. In some of these areas it is
   3     getting difficult to recall what I knew then and what
   4     I know now, because since 1995 I have been -- there are
   5     not many days that go by without me having something to
   6     deal with to do with cardiac surgery, paediatric cardiac
   7     surgery, but I cannot recall anything at that time
   8     related to that sort of drive.
   9   Q. The revenue and workload information we have just looked
  10     at was just that: it was concerned with numbers and
  11     money?
  12   A. Yes.
  13   Q. At the General Medical Council on Day 58 -- I think the
  14     reference is page 54 -- you were asked about the
  15     information gathering process for supra-regional
  16     services. I do not think we have this scanned in, but
  17     can I just remind you of the question?
  18        You were asked:
  19        "So you would be obtaining information from the
  20     clinicians for an application for supra-regional
  21     status?"
  22        You said:
  23         "Yes: every year we had to make a return of what
  24     we had spent, how many cases we had done both for
  25     inpatients and outpatients, and with the help of

   1     Dr Joffe, Mr Wisheart and others we had to give
   2     a forecast for the following year."
   3   A. Yes.
   4   Q. You were asked:
   5        "It was largely quantitative rather than
   6     qualitative?"
   7        You replied:
   8        "My side of that, yes."
   9   A. Yes.
  10   Q. But in fact there was no other side which was
  11     qualitative, was there?
  12   A. I do not believe that any returns were sent to the
  13     supra-regional services that I am aware of, no.
  14   Q. There were no qualitative returns sent to the Supra
  15     Regional Services Advisory Group?
  16   A. Not that I was involved with.
  17   Q. Certainly not by you?
  18   A. No.
  19   Q. And so far as you are aware, not by anybody else,
  20     either?
  21   A. No.
  22   Q. In due course there were contracts drawn up between each
  23     supra-regional centre in the NHS Management Executive
  24     for supra-regional services?
  25   A. Yes.

   1   Q. And in late 1990, I think as you say at page 7 of your
   2     witness statement, you were involved in discussions
   3     about the contract.
   4        If we go, please, to UBHT 64/73, this is called
   5     draft 2 of the contract?
   6   A. Yes.
   7   Q. I am not sure that we have draft 1. Whose writing is
   8     that in the annotations there, do you know?
   9   A. Ian Cameron's, who works for me within the Trust.
  10   Q. So the annotation on the left-hand side says "discussed
  11     13th December 1990". That is Mr Cameron, first of all?
  12   A. Yes.
  13   Q. Then you?
  14   A. Yes.
  15   Q. Mr Wisheart?
  16   A. Yes.
  17   Q. Dr Joffe?
  18   A. Yes.
  19   Q. And Dr Baird?
  20   A. No, I would imagine that is Ian Barrington, General
  21     Manager of Children's Services, I would think.
  22   Q. And three people, unidentified, from the Department of
  23     Health?
  24   A. Yes.
  25   Q. Do you remember who they were? Might they have included

   1     Mr Angilley and Dr Halliday?
   2   A. Yes.
   3   Q. Do you remember who the third person was?
   4   A. No.
   5   Q. If we go, please, to page 76, clause 11:
   6        "Quality: the unit will ensure that the quality of
   7     the service is clinically and socially satisfactory,
   8     cost-effective and will seek constantly to improve it.
   9     It will regularly monitor all relevant aspects of the
  10     service and make the results available to the
  11     purchaser. The variables to be monitored, the methods
  12     to be employed and the results will be the subject of
  13     regular discussion with the purchaser. Examples of
  14     improvements which have contributed to better patient
  15     care should be included in the annual report."
  16        Apart from the workload and costs type of return
  17     we have looked at an example of, were you involved in
  18     making any other results available to the Supra Regional
  19     Services Advisory Group?
  20   A. No.
  21   Q. Or the National Health Service Management Executive?
  22   A. No.
  23   Q. Were you a party to any of the promised regular
  24     discussions with the purchasers?
  25   A. From what I recall, they came once a year, but from

   1     1991/92 onwards other people were involved rather than
   2     myself.
   3   Q. Which people would be involved in those discussions?
   4   A. I might have a finance person there -- another finance
   5     person rather than me doing it personally.
   6   Q. But that was the regular annual visit that had always
   7     taken place?
   8   A. Yes. I did not think there was any -- I know there was
   9     no change from our point of view.
  10   Q. Can we go back to page 74? We see the whole page, first
  11     of all. If we go to the middle of the page, there is
  12     a clause there:
  13        "Reduced activity ..."
  14        This is about what is going to happen under the
  15     contract if fewer operations are done than anticipated,
  16     right?
  17   A. Yes.
  18   Q. The second paragraph of 9.3.2:
  19        "If the unit wishes to reduce the indicative
  20     volumes for any reason, prior agreement of the purchaser
  21     must be obtained and any change in the funded value of
  22     the agreement negotiated by the parties to the
  23     agreement."
  24   A. Yes.
  25   Q. Somebody, Mr Cameron, perhaps, has put a line through

   1     that?
   2   A. As being unacceptable to us.
   3   Q. The writing on the left-hand side, is that Mr Cameron's
   4     as well?
   5   A. Yes.
   6   Q. That says:
   7        "Occupied bed days, significantly more than other
   8     centres."
   9   A. Yes.
  10   Q. So that means that the under ones at Bristol were in
  11     hospital for longer than the under ones in other
  12     centres?
  13   A. Yes.
  14   Q. Do you remember any discussion of that fact?
  15   A. No.
  16   Q. Why should a line have been put through that part of the
  17     clause as being unacceptable to Bristol?
  18   A. Because, I mean, for us we would want to keep some
  19     stability in the funding coming into the Trust.
  20   Q. If we go back to 76, please, to clause 11, just looking
  21     at the last couple of sentences, variables are to be
  22     monitored; the results will be the subject of regular
  23     discussion with the purchasers; examples of
  24     improvements should be included.
  25        Can we split the screen and as well as that page

   1     have DOH 4/4?
   2        This is, I hope, the final version of this
   3     contract. We will not go back to the beginning of it,
   4     if you do not mind.
   5        Can you just highlight paragraph 11?
   6        What is missing, I think, are the last two
   7     sentences from the right-hand side:
   8        "Examples of improvements which have contributed
   9     to better patient care should be included in the annual
  10     report."
  11        That does not appear in the final version of the
  12     contract?
  13   A. No.
  14   Q. And the last sentence, "A check-list of quality
  15     measures, some of which may be applicable to the service
  16     being attached at Appendix B", does not apply either?
  17   A. No.
  18   Q. What we do have is that the purchaser, the Department of
  19     Health in this context, accepts the quality standards
  20     agreed with the unit's major participants, the Bristol
  21     & Weston Health Authority?
  22   A. Yes.
  23   Q. So the Department of Health is saying, in effect,
  24     "Whatever deal you have done with your major purchaser
  25     will be the standard to apply for this service as well"?

   1   A. That is the arrangement that we pushed through with all
   2     purchasers, because it would not have been manageable to
   3     have quality standards agreed with every purchaser that
   4     we had. So the drive was to make sure that the service
   5     specification and standards were adopted by all
   6     purchasers, i.e. the Avon Health Bristol and districts
   7     were adopted by all purchasers.
   8   Q. Do you remember any significant debate on that from the
   9     Department of Health, or were they content to go along
  10     with it?
  11   A. No, that was a line that we held with all purchasers,
  12     bearing in mind that at some stage we actually reached
  13     nearly 600 purchasers.
  14   Q. Let us go back to the document on the right-hand side,
  15     please. We can take away the other one. Clause
  16     12: "Information". Are those annotations all the same
  17     writing?
  18   A. Yes.
  19   Q. Still Mr Cameron?
  20   A. Yes.
  21   Q. "Quarterly review statements to be submitted to the NHS
  22     Management Executive --
  23   A. We did not submit quarterly statements to the NHS
  24     Management Executive, as far as I am aware.
  25   Q. No. This is a draft, of course?

   1   A. Right.
   2   Q. "Region of residence and source of referral of all
   3     patients", Mr Cameron has written "probably be deleted.
   4     They get info through other channels"?
   5   A. Yes.
   6   Q. The overall comment, perhaps, of the annotator,
   7      "Summary...", I cannot read the next word, "not too
   8     much detail required"?
   9   A. Yes.
  10   Q. Was that your impression as well, that the contracts
  11     with the Supra Regional Services Advisory Group were not
  12     requiring too much detail from the provider unit?
  13   A. Yes. Some contracts would have wanted a patient data
  14     set for every individual patient.
  15   Q. If we go to page 78, please, this is Appendix B to the
  16     draft contract. The first sentence:
  17         "The NHS Management Executive recognise that as
  18     the unit currently provides quality care."
  19        What was that recognition based on, so far as you
  20     are aware?
  21   A. I do not know.
  22   Q. Did a similar sentence appear in all of the providers'--
  23     if I can use that word, we are just a little bit before
  24     Trusts -- contracts? Did you always get purchasers to
  25     sign up to a recognition that you were currently

   1     providing quality care?
   2   A. I would not have expected a statement like that to have
   3     appeared, no, but I would have expected them to --
   4     I would have thought that we did provide quality care,
   5     yes, but I would not have expected it to be stated in
   6     a contract. This is a Department of Health contract,
   7     not ours.
   8   Q. Yes. Are you aware of the contents of the Department of
   9     Health contract with other centres?
  10   A. No.
  11   Q. So you cannot comment on whether that sentence would
  12     appear, as it were, in a standard form?
  13   A. No.
  14   Q. Perhaps we should just scan down the quality check-list
  15     while we are here?
  16   A. Presumably the Department of Health had files with their
  17     papers in it.
  18   Q. We have asked the Department of Health for the relevant
  19     files. We are not expecting to find those. Can we just
  20     have a look at the full page, please?
  21        We see that the quality check-lists -- it is a bit
  22     small now, but it includes, for example, if we look
  23     towards the bottom of the page:
  24        "9. Providing appropriate information and advice
  25     to patients and families ...

   1        12. Clinical audit from outcome morbidity and
   2     mortality from other appropriate variables ..."
   3        If we go finally under this section to DOH 4/1,
   4     this is the first page of the final version of the
   5     contract. We looked at clause 11 a moment ago. If we
   6     go to page 9, we will see that it is signed by
   7     Dr Roylance as Chief Executive of the Trust?
   8   A. Yes.
   9   Q. The Trust was able to enter into these contracts shortly
  10     before the inauguration date of 1st April 1991?
  11   A. Yes. We were required to sign all of our contracts
  12     before the end of March.
  13   Q. And if we scan down a little, we will see a signature
  14     from the Management Executive.
  15        If we go back to page 5, paragraph 4:
  16        "A copy of the return made by the unit to the UK
  17     cardiac surgical register ... was to accompany the
  18     annual report."
  19        That was the first time that that had been done?
  20   A. Yes.
  21   Q. Did you have any role in the sending of that register
  22     with the annual report?
  23   A. No, the only thing we did was submitted the financial
  24     information. We were not involved in submitting any
  25     annual report.

   1   Q. The contract for the following year, 1992/93, made
   2     provision for something called a "mid-year review". The
   3     reference for that -- we do not need to go to it, it is
   4     UBHT 64/265, and the mid-year review was said to depend
   5     on local circumstances.
   6        Are you able to help us with the nature of any
   7     mid-year review of supra-regional services that was
   8     carried out at Bristol?
   9   A. I do not think any mid-year reviews were undertaken.
  10     The only thing that I recall being undertaken was
  11     a management consultancy firm looking at our approach to
  12     costing which was BDO Consulting.
  13   Q. You learned in due course that neonatal and infant
  14     cardiac surgery was to be de-designated?
  15   A. Yes.
  16   Q. With effect from, as it turned out, 1994?
  17   A. Yes.
  18   Q. What did you understand the reason for that
  19     de-designation to be?
  20   A. I do not think I necessarily had one. The reason it was
  21     designated was to restrict the number of centres in the
  22     country undertaking neonatal and infant cardiac
  23     surgery. That was the aim of supra-regional. Why it
  24     was de-designated, I cannot now recall why. We were
  25     just told that that was what was happening and we had to

   1     make preparations for transfer of that funding back to
   2     the health authorities.
   3   Q. That caused some difficulty, did it not, because there
   4     was a concern, certainly on your part, that some of the
   5     money that went to the health authorities might not find
   6     its way back to the Trust?
   7   A. Yes. Financial Directors do not like change like that.
   8   Q. So did you enquire from any source as to why this change
   9     had come about?
  10   A. No. It was more about what will be the plan to transfer
  11     the funding and will we be in a position to achieve full
  12     funding in the following year. That would have been my
  13     main concern.
  14   Q. Did you know whether the de-designation had anything to
  15     do with Bristol's performance?
  16   A. Not at the time, although I have read documents
  17     subsequently that identified concerns about Bristol and
  18     one other centre, I think.
  19   Q. But at the time, you did not know whether it did or did
  20     not have anything to do with Bristol's performance?
  21   A. No.
  22   Q. The Supra Regional Services Advisory Group, or, perhaps
  23     more accurately, the Department of Health, planned to
  24     split up the money which had previously been spent on
  25     the supra-regional service on an occupied bed days by

   1     region or district of residence basis?
   2   A. Yes.
   3   Q. Rather than a finished consultant episode basis?
   4   A. Yes.
   5   Q. And Bristol was not happy about that?
   6   A. No.
   7   Q. Why not?
   8   A. Because it put all of the numbers of -- no matter what
   9     procedures were undertaken it was all being converted
  10     into an occupied bed day basis, yet there were
  11     significant differences in the unit costs of
  12     a catheterisation or a non-surgical admission and an
  13     open heart cardiac case and a closed heart cardiac
  14     case.
  15        I believed that each of the centres could possibly
  16     have differing ratios. What we did is a bench top check
  17     of the fact that health authorities, we would contract
  18     with health authorities in the New Year on the basis of
  19     finished consultant episodes and procedures, yet they
  20     would have been given the money on the basis of bed
  21     days. That gave us problems in that the amount of money
  22     going to each Health Authority did not match the bills
  23     that we would be sending them. That would lead to
  24     difficult contract discussions.
  25   Q. There was some correspondence about that, but in the end

   1     the Department of Health stuck to its guns?
   2   A. Yes, I lost.
   3   Q. And Bristol essentially lost that battle?
   4   A. I did not manage to change the Department of Health, but
   5     we always have to try these things, and then I had
   6     discussions with the Regional Health Authority on the
   7     basis that the money would have gone to the Regional
   8     Health Authority and it was up to them how they
   9     distributed it.
  10   MR MACLEAN: I think we will come to that in a moment.
  11     I wonder, sir, if this is a convenient moment for
  12     a short break?
  13   THE CHAIRMAN: Yes. Shall we say 15 minutes, and therefore
  14     until just after 11.15?
  15   (11.00 am)
  16               (A short break)
  17   (11.15 am)
  18   MR MACLEAN: Mr Nix, can I just deal with one matter? Do
  19     you remember the reference to Professor Stirrat and
  20     Mr Wisheart and so on about the waiting list initiative
  21     and the quality of surgery?
  22   A. Yes.
  23   Q. You asked me for the previous minute.
  24   A. I thought that might be helpful, because it did refer to
  25     the previous meeting.

   1   Q. It threw me only temporarily, I hope. Over the break we
   2     have gone through the database. Can I just say that the
   3     previous meeting of the Bristol & Weston Health
   4     Authority was on 21st January 1991. The minutes of that
   5     meeting we have. The reference is UBHT 249/0012. It is
   6     not yet published on any of the core CDs, but it will be
   7     published on the next one.
   8        If these minutes help, and they may not in fact,
   9     we will send them to you, Mr Nix, and if you care to
  10     have a look at them if they jog your memory in any way,
  11     perhaps you could put down in writing what your
  12     recollections are?
  13   A. Certainly.
  14   Q. I do not think I need to take up any more time at this
  15     stage over that.
  16        We were dealing with de-designation and your
  17     mention just before the break of the letters that passed
  18     between and you the Regional Health Authority Director
  19     of Finance.
  20        Can you go to UBHT 64/316? Just at the very top
  21     of the page, please, this is your reference GRM, this is
  22     your letter, your initials?
  23   A. Yes.
  24   Q. To Miss McDonald, Director of Finance?
  25   A. Yes.

   1   Q. You say in the middle of that first paragraph, you have
   2     discussed the paper with the relevant clinicians and
   3     managers, and considered the position both from the
   4     South West purchasers' and the UBHT's viewpoint and the
   5     implications for contracting for 1994/95?
   6   A. Yes.
   7   Q. You set out the two concerns, the first being the method
   8     of distribution. That is what I asked you about just
   9     before the break.
  10   A. Yes.
  11   Q. If we go over the page (317), the second concern is under the
  12     heading "Distribution between regions":
  13        "Whichever method of funding distribution is used,
  14     it is clear that the bulk of funding will be allocated
  15     to the South Western Regional Health Authority."
  16        That is because the bulk of the neonatal and
  17     infant cardiac surgery patients in the last year of
  18     supra-regional services had come from that region?
  19   A. Yes.
  20   Q. 25 per cent or thereabouts to Wales and about 5 per cent
  21     to Wessex.
  22        Your concern is really highlighted in the next
  23     paragraph:
  24        "The Trust was extremely concerned with the impact
  25     of the distribution of funds to the Welsh health

   1     authorities and the Welsh Office."
   2   A. Yes.
   3   Q. That was because, put shortly, the Trust was concerned
   4     that that money would not find its way back to the
   5     Trust?
   6   A. Yes.
   7   Q. The reason for that you speculate on in the next
   8     paragraph:
   9        "It was undoubtedly due in the main to the
  10     expansion of the well-funded unit at Cardiff". In other
  11     words, Welsh children were being sent to Cardiff rather
  12     than to Bristol?
  13   A. Yes, and there is statistical backup for that.
  14   Q. Yes, I think the Inquiry has seen that.
  15   A. I mean attached to this letter.
  16   Q. You sent a copy of your letter, I think, to the NHS
  17     Executive for the South and West, if we look at
  18     UBHT 295/651: the reference there is to the letter you
  19     prepared for the Regional Health Authority on behalf of
  20     the Trust. That is a copy there, you are enclosing
  21     a copy of the same letter?
  22   A. Yes. Bear in mind that there were two routes up to the
  23     centre: Regional Health Authority was dealing with the
  24     purchasing angle and there was a regional outpost of the
  25     NHS Management Executive, which was the provider side.

   1   Q. So the reason for copying the letter to the Health
   2     Service Executive was because of the first concern, the
   3     bed days versus finish consultant episode concern,
   4     rather than the 25 per cent of the money to Wales
   5     concern?
   6   A. Both, really. I wanted them to take that up centrally
   7     for me, concerns about funding going to Wales.
   8   Q. What did you hope or expect them to do?
   9   A. The hope was that they would follow what I had asked
  10     them to do, which was not to allocate that volume of
  11     money to Wales and to change the method of distribution.
  12   Q. Did they?
  13   A. No. That does not mean you should not try.
  14   Q. If we go to UBHT 64/297, that is a worked example.
  15     I think this is the Department's worked example, is it
  16     not, of how the money would be divided up?
  17   A. Yes. This was in their consultation -- I think it was
  18     a consultation document, or it may well have been just
  19     a document saying "This is how we are going to do it".
  20   Q. So that explains -- we need not go through the algebra
  21     of it; I think it is clear enough how the division was
  22     done.
  23   A. Yes.
  24   Q. That is how in fact it was done on that model?
  25   A. Yes.

   1   Q. After de-designation, Avon residents were treated as
   2     part of the block contract which the Bristol and
   3     District Health Authority had with the UBHT?
   4   A. Yes.
   5   Q. And within that contract, it is right, is it not, that
   6     no distinction was drawn between a paediatric open heart
   7     operation and an adult one?
   8   A. That is correct.
   9   Q. If we go to UBHT 295/618, this is a document, it has
  10     some handwritten annotations on the right-hand side. Do
  11     they matter?
  12   A. No.
  13   Q. We see below the heading "Inpatients", a third of the
  14     way down, if we highlight that block, the top line
  15     there:
  16        "Cardiac surgery, neonatal and infant cardiac
  17     services, and the National Health Service Management
  18     Executive was a block contract."
  19        Can we see at the top the columns, please? The
  20     total contract volume was 60 for 1994/95, and the total
  21     contract value was 322,000?
  22   A. Yes, for inpatients only.
  23   Q. In fact, the previous year, if we go to the right-hand
  24     column, 52 cases had been undertaken rather than the 60?
  25   A. Yes.

   1   Q. So that gives us the total number of cases done for that
   2     year -- and I think that year was 1993/94; is that
   3     right?
   4   A. The current year would be -- yes, 1993/94.
   5   Q. That is the last year in which supra-regional neonatal
   6     and infant services were designated as a supra-regional
   7     service?
   8   A. Yes.
   9   Q. The plan for the current year, the new year -- you see
  10     those columns in the middle of the table --
  11   A. Yes.
  12   Q. There is a zero besides NHS/NE, that is because
  13     de-designation had occurred and they were no longer
  14     going to be the purchasers?
  15   A. Yes.
  16   Q. What we then have to do, in order to find out what the
  17     contracted activity was for under 1s, is to add up the
  18     numbers in the rows which deal with under 1s. So, for
  19     example, open heart under 1, Bristol and District Health
  20     Authority, is the second row?
  21   A. Yes, 16.
  22   Q. If we look down, Cornwall and the Scilly Isles add 2,
  23     under 1s?
  24   A. Yes.
  25   Q. 16 ECR contract estimates, and so on?

   1   A. Yes.
   2   Q. I think the table goes over the page but I think there
   3     is a total of 56 cases contracted for that year,
   4     including the estimated ECR contracts.
   5        So the numbers were more or less expected to be
   6     static in the following year?
   7   A. Yes.
   8   Q. I think it is right to say that there were no contracted
   9     activity for under 1s from Wales. If we go to page 619
  10     we see the top of the page: Wales, Gwent; Wales,
  11     Mid-Glamorgan, but there is no under 1s shown as being
  12     sent from Wales?
  13   A. I think you will find that there were subsequent
  14     discussions to this for cardiac cases coming to Bristol.
  15   Q. Let us look at one of the relevant letters, then. Let
  16     us look at 295/14: this may be what you are getting at.
  17     It is your reference "GRN" at the top.
  18   A. Yes.
  19   Q. This is to the Clwyd Health Authority, March 1995, so
  20     now nearly a year after de-designation had taken place,
  21     and you refer in this letter to a general shift in
  22     workload away from Bristol, primarily to Cardiff, in
  23     respect of open heart surgery?
  24   A. Yes.
  25   Q. That is the first bullet point, do you see that?

   1   A. Yes.
   2   Q. You also refer, in the next bullet point, to the fact
   3     that the 1994/95 workload had become very low due to
   4     capacity problems at the BRI, in particular the blocking
   5     of ITU beds by paediatric and neonatal patients which
   6     was restricting the capacity in the emergency adult
   7     block.
   8        So this was the problem which was addressed at
   9     about this time by the plan to move all paediatric open
  10     heart cardiac surgery to the Bristol Children's
  11     Hospital, thereby freeing up some space in the BRI to
  12     expand the adult workload yet further; is that right?
  13   A. Yes.
  14   Q. We will come to see in a moment how the split site was
  15     dealt with.
  16        If we go to page 15, and just scan down a little
  17     bit. The proposal for 1995/96 -- this is dealing with
  18     the Clwyd contract, is it not?
  19   A. Yes.
  20   Q. Sets the contract at a lower level than 442,000 for
  21     1994/95, but at a higher level than the value of
  22     1994/95's workload. So the proposed contract was for
  23     œ258,000, including 1995/96 inflation at 3 per cent?
  24   A. Yes.
  25   Q. So what that tells us is that the contract for 1995/96

   1     had a value of 442,000, but in fact the value of the
   2     work done in that year for Clwyd was less even than
   3     œ258,000?
   4   A. Yes.
   5   Q. So there was a very significant failure to, as it were,
   6     hit that target in 1994/95?
   7   A. Yes.
   8   Q. And that was because, was it, in the main, adults who
   9     would otherwise have been referred to the BRI for
  10     surgery could not get in because of the capacity
  11     problem?
  12   A. Yes.
  13   Q. So at this stage we see that the blockage in the system,
  14     as it were, the lack of capacity at the BRI, is
  15     beginning to cost the Trust significant sums of money?
  16   A. The Trust would be getting its finances from other
  17     places, other than some of these more distant
  18     purchasers. We were still doing the volume of work, it
  19     was just coming closer to home rather than from
  20     a distance such as this, so it would have been impacting
  21     on Avon.
  22   Q. It was clear from this type of data that there was
  23     a potential to make significantly more money if the
  24     blockage in the system could be removed?
  25   A. Yes. There was potential to increase the incomes and

   1     therefore expand the service.
   2   Q. So were the service to be expanded, were more capacity
   3     to be found, this type of information would make the
   4     Trust confident that the increased capacity would be
   5     taken up?
   6   A. Yes.
   7   Q. So this type of position in terms of the under-hitting
   8     of the target was presumably not exclusive to Clwyd?
   9   A. No, it was across a number of areas and we also had
  10     purchasers who wished to expand their volume of care
  11     provided to this particular specialty.
  12   Q. So at that stage there is a clear economic incentive for
  13     the capacity of the Bristol Royal Infirmary to do open
  14     adult cardiac surgery to be expanded yet further?
  15   A. Yes.
  16   Q. If we just deal with the question of the split site --
  17   A. I think you will find that there is a similar situation
  18     in the year before, as well.
  19   Q. Can we just deal then, I hope fairly briefly, with the
  20     question of the split site. Obviously funding choices
  21     had to be made by the Health Authority before Trusts
  22     were on the scene?
  23   A. Yes.
  24   Q. As between the expansion of the service in area A
  25     compared to area B?

   1   A. Yes.
   2   Q. We have seen that in 1987 the cath' lab improvements and
   3     developments took effect. There was a catheterisation
   4     room at the BCH for the first time and the two existing
   5     cath' labs at the BRI had been updated?
   6   A. Yes.
   7   Q. We saw yesterday, and I do not want to go into it again,
   8     the expansions that had taken place in the number of
   9     open heart operations in the Bristol Royal Infirmary
  10     from 275 when you came on the scene, when the Inquiry's
  11     period began, more or less, up to 600 and beyond by the
  12     end of the 1980s?
  13   A. Yes.
  14   Q. We have, at HA(A) 6/19, if you blow up the top of that,
  15     a draft of the South Western Regional Health Authority
  16     Hospital Medical Advisory Committee, the Regional
  17     Hospital Medical Advisory Committee, strategic statement
  18     number 2.
  19        I am not sure when this document was produced, but
  20     if we look at page 22, paragraph 20, it is clear from
  21     that paragraph that it must be a document produced
  22     before 1991?
  23   A. Yes.
  24   Q. Because of the future tense, "will be reviewed"?
  25   A. Yes.

   1   Q. This report, if we go back to page 19, worked on the
   2     basis, if we just scan down to paragraph 3, that the
   3     rate of congenital heart disease was 8 per 1,000 live
   4     births?
   5   A. Yes.
   6   Q. Are you familiar with that type of estimate for --
   7   A. Not that specific one, but numbers like that I have seen
   8     before, yes.
   9   Q. The recommendation from the region in this report was
  10     that Bristol should be used by all the districts in the
  11     region and that Bristol only should be used to take up
  12     any excess of cardiac work in relation to adults.
  13        I perhaps do not need to comment on that
  14     specifically.
  15        As to children, which is what I am interested in
  16     at the moment, page 22, if we can just scan down there,
  17     please, "Services for children", it explains what the
  18     position was in paragraph 23. Paragraph 24 deals with
  19     the supra-regional status. Then paragraph 25:
  20        "The current split of cardiac surgery services for
  21     children onto two sites is unsatisfactory, particularly
  22     as the children in the Royal Infirmary are admitted to
  23     an adult ward. It is recommended [underlined] that all
  24     cardiac services for children should be provided from
  25     a comprehensive children's department or hospital."

   1        In fact, in 1989 -- we are not sure when this
   2     document was produced and I daresay we can find out, but
   3     it was before 1991?
   4   A. Yes.
   5   Q. I suspect it was before 1990. In 1989, a Working Party
   6     looked at the question of moving open heart paediatric
   7     surgery to the BCH.
   8        Do you recall that?
   9   A. I recall I think in my statement saying that work did go
  10     on, but I was not clear about when that was.
  11   Q. If we go to UBHT 159/26, this is a Working Party. If we
  12     go to paragraph 2.3, that is what it was to do?
  13   A. Yes.
  14   Q. You were a member of this Working Party, if you go to
  15     page 27?
  16   A. Yes.
  17   Q. You were on it; Mr Barrington, the Children's Hospital,
  18     was on it; Mr Hutter who was a surgeon, I think?
  19   A. Yes.
  20   Q. Dr Jordan, the cardiologist, and Mr Wisheart, and
  21     others?
  22   A. Yes.
  23   Q. In 1989, the cost of moving paediatric cardiac surgery
  24     to the BCH was thought to be prohibitive?
  25   A. Yes.

   1   Q. Was that the reason that the split site remained after
   2     1989?
   3   A. Yes.
   4   Q. Why was it prohibitive?
   5   A. I assume that the Regional Health Authority at that time
   6     said that the cash that was required to deliver that
   7     expansion, seeing as we had already expanded currently,
   8     was not affordable.
   9   Q. Was there any other source of funding that could have
  10     been tapped in order to do something about the split
  11     site?
  12   A. The only one we have talked about which presumably would
  13     have been the possibility, would have been
  14     supra-regional, part of, not all of.
  15   Q. But we know that no application was made to them until
  16     Dr Joffe's application in June, or subsequently in 1992?
  17   A. Yes.
  18   Q. Can we go to document JDW 1/241? This is I think at
  19     least a part of the Working Party report. If we go to
  20     244, it is dated at the bottom of the page 1st November
  21     1990.
  22        Those initials are whose?
  23   A. Janet Gerrish.
  24   Q. She was the Manager of the BRI?
  25   A. Yes.

   1   Q. The sub-unit at that time?
   2   A. Yes.
   3   Q. If we go to 241 and scan down to paragraph 2, the
   4     actual workload in 1989/90 for open heart operations for
   5     all children was 150.
   6   A. Yes.
   7   Q. If we go to 242, there were at this time four paediatric
   8     intensive care unit beds. That was the figure that was
   9     reached following the expansion that took place that we
  10     discussed yesterday. Do you remember, we were looking
  11     at the figures?
  12   A. Yes.
  13   Q. 4, 8, 8 and 4?
  14   A. Yes.
  15   Q. At the bottom of that page, it said that there was
  16     considerable pressure on beds in the Bristol Royal
  17     Infirmary especially in the ITU because of long
  18     occupancy periods by children?
  19   A. Yes.
  20   Q. If we go in the same file, 341, to 342, there is
  21     a reference here, is there not, at 4.2.2, to the South
  22     Western Regional Hospital Medical Advisory Committee
  23     statement of November 1989, so it may be that that is
  24     the same document we were looking at earlier,
  25     recommending that all cardiac services for children be

   1     carried out from a department or hospital with access to
   2     a full range of children's services?
   3   A. Yes.
   4   Q. I suspect that is a document we were looking at
   5     earlier.
   6   A. I would agree with that.
   7   Q. So from at least November 1989 that recommendation was
   8     in place?
   9   A. Yes.
  10   Q. At paragraph 4.3, "Operational constraints, the effect
  11     of the planned development of paediatric cardiac surgery
  12     in Cardiff is unclear. Approximately 40 per cent of
  13     present BCH workload is from Wales."
  14        In fact, by the time de-designation took place,
  15     that had come down to about 25 per cent. We have just
  16     seen that in the letter to the Regional Health
  17     Authority; is that right?
  18   A. Yes. That related, of course, to supra-regional rather
  19     than all children, which this presumably relates to.
  20   Q. Yes, you are quite right. What were seen as being the
  21     "disbenefits", if that is the right word, of moving all
  22     paediatric open heart surgery to the Bristol Children's
  23     Hospital at 1989/90?
  24   A. The only thing I can think of is the cost of actually
  25     achieving that move, because you will see above it says

   1     "theatre, no beds available", or theatre sessions, so
   2     it did require the provision of additional theatre
   3     intensive care and bed capacity at the Children's
   4     Hospital.
   5   Q. Any other reason, other than cost?
   6   A. I think there was certainly -- I recall, but whether it
   7     is correct or not -- there was an issue about staffing,
   8     availability of staff to manage two separate units
   9     through availability of perfusionists and medical
  10     staffing.
  11   Q. If we go to 343, and scan down, please, benefits of
  12     moving paediatric open heart surgery would be that the
  13     total paediatric cardiac service was on one site and the
  14     care of children would be in a dedicated children's
  15     environment. The disbenefits: major capital expenditure
  16     is required at Children's Hospital ... 2. Highly
  17     specialised service divided between two sites?
  18   A. Yes.
  19   Q. That "highly specialised service" is presumably cardiac
  20     surgery, is it?
  21   A. Yes.
  22   Q. So that would be lumping cardiac surgery and adults
  23     together with cardiac surgery in children as being one
  24     specialised service?
  25   A. Yes. I think that is referring to the technical backup

   1     to two sites rather than one, like with perfusionists.
   2   Q. If we go to UBHT 159/44, this is a paper stamped
   3     7th September 1990. If we go to page 47 --
   4   A. Can I ask what annex that document was to?
   5   Q. Yes. Can we go to the foot of the page, first? "SCJ"
   6     is Steve Jordan, is it not?
   7   A. Yes.
   8   Q. He is a cardiologist?
   9   A. Yes. He is an adult cardiologist who did a lot of
  10     paediatrics and then just did paediatrics.
  11   Q. Can we go to page 45? At the top of the page, Dr Jordan
  12     says:
  13        "Currently closed heart operations are carried out
  14     at the Children's Hospital, but for open heart
  15     operations, all children have to be admitted to the
  16     Royal Infirmary where they are cared for in
  17     a non-paediatric environment. This is against all
  18     current thinking on the management of children in
  19     hospital. The fragmentation of the service makes for
  20     considerable difficulties with staff of all types. No
  21     other centre in the UK has open and closed surgery split
  22     between two sites in this way."
  23        Then it goes on to make a point about
  24     transplantation, and then says:
  25        "An additional factor is that an amalgamation of

   1     all the children's heart services on the Children's
   2     Hospital site would allow a much-needed increase in
   3     adult cardiac surgery at the BRI."
   4   A. Yes.
   5   Q. So is it fair to say that the cardiologists, adult and
   6     paediatric alike, had been pushing for paediatric open
   7     heart surgery to be moved to the BCH for some time by
   8     the time of the decade 1990?
   9   A. From all the evidence you have given, yes, that is the
  10     case. There were also paediatricians pushing for other
  11     specialties to be centred on the Children's Hospital as
  12     well.
  13   Q. If we move on to 1993, can we go to JDW 3/303? This is
  14     a paper following a recent meeting of the cardiac
  15     surgery planning group, and it says, in the first
  16     paragraph, that "The possibility of transferring the
  17     paediatric workload currently being undertaken at the
  18     BRI to the Children's Hospital was a means of increasing
  19     throughput in adult surgery", so that was the motivation
  20     at this stage for looking at it again?
  21   A. Yes.
  22   Q. If we go to the end of the second paragraph, can I ask
  23     you to read that second paragraph, and then to explain
  24     the reference in the last sentence, if you can?
  25   A. That is saying basically that if this is to be

   1     successful, we have to make sure that it is fully costed
   2     properly, and that we have taken into account the
   3     revenue cost of investing capital, because that is
   4     something that came on to the scene with capital charges
   5     and in ongoing revenue. The reference to it -- another
   6     compromised arrangement -- may well refer back to the
   7     discussions we had with the Regional Health Authority
   8     back in the late 1980s where there was some concern
   9     about the level of investment to the service.
  10   Q. What was compromised, and by whom?
  11   A. It would have been compromised by the Health Authority
  12     in accepting, or allowing, I suppose, an expansion of
  13     the service beyond what was agreed as the limit, because
  14     you will recall that the unit was set up to do 600 cases
  15     but did reach 720, so whether there was -- there was,
  16     I think, from papers we saw previously, some discussions
  17     about the level of nurse staffing related to that volume
  18     of throughput.
  19   Q. So that discussion in the late 1980s was about the
  20     expansion to 750. You will remember we looked at
  21     documents yesterday about the Regional Health Authority
  22     agreeing to go along with the expansion that is planned
  23     in the late 1980s, as long as the cost did not exceed
  24     that which they had been told about?
  25   A. Yes.

   1   Q. So it is your recollection that the compromise that is
   2     referred to was the compromise with the Regional Health
   3     Authority about funding the expansion of the service?
   4   A. I would perceive that that is what that relates to, yes.
   5   Q. And the focus of that expansion, as we discussed
   6     yesterday, was adult cardiac surgery?
   7   A. It did not define "adult"; it talked about "total number
   8     of cases".
   9   Q. What is happening by this stage is that again, as there
  10     has been throughout this whole period, there is
  11     a pent-up demand for adult open heart surgery in the
  12     BRI?
  13   A. Yes, there is.
  14   Q. And the feeling of frustration that one might get from
  15     reading this memo is that steps that have been taken in
  16     order to deal with that pent-up demand continue to prove
  17     to be inadequate. Is that fair?
  18   A. Yes, and I think it would be fair to say that we still,
  19     even today, have pressures on open heart cardiac surgery
  20     in that the demand is exceeding our capacity to deliver
  21     at present, and we have expanded and expanded over the
  22     years.
  23   Q. But children's services in children's cardiac surgery
  24     had never been a commander of the same big numbers as
  25     adult cardiac surgery?

   1   A. No. As I have said, people did not actually pick it out
   2     separately. They did not pick it out separately, and
   3     therefore we tended to talk about all open heart cases
   4     rather than separating out children and adults.
   5   Q. In the end, what led to paediatric cardiac surgery being
   6     moved to the Children's Hospital was the necessity to
   7     free up further capacity in the BRI to take the extra
   8     demand for open adult cardiac surgery?
   9   A. Yes, and it brought with it, because of the demands from
  10     purchasers and the need that was shown in our waiting
  11     lists and the numbers of emergencies, that finance was
  12     available to cope with both the cost of the capital
  13     investment and the ongoing revenue cost of running the
  14     service at the Children's and at the Royal Infirmary.
  15   Q. Is it fair to say that Dr Jordan's concerns, starkly put
  16     in the paper stamped 7th December 1990, were heeded in
  17     the mid-1990s because they were allied to the pressing
  18     need to increase capacity for adult surgery at the BRI?
  19   A. Yes. You will find that in one of the business plans
  20     for the Associate Directorate of Cardiac Surgery it was
  21     raising the issue as well, that we needed to find some
  22     way of achieving this.
  23   Q. Can we go to UBHT 275/130, please?
  24        This is a memo dated 12th May 1994 to the Cardiac
  25     Expansion Working Party. Can we just move the cursor

   1     from the bottom of the screen? If we just scan down,
   2     alas we cannot see who is under the black mark.
   3   A. It is not me.
   4   Q. It is not, I think, you. Can we go over the page to
   5     131? This sets out the history. If we go to the third
   6     paragraph, please:
   7        "The feasibility of making the transfer has been
   8     investigated in the past, the most recent report dated
   9     October 1990."
  10        We have looked at documents from that date.
  11   A. Yes.
  12   Q. That of course postdated Dr Jordan's memo stamped
  13     17th September 1990, in answer to your question about
  14     the appendix, I think, but I do not know for certain
  15     that was appended to the report when the report was
  16     considered, because it was, as it were, putting
  17     a contrary view.
  18   A. Right.
  19   Q. I am not 100 per cent sure of that.
  20        "To date it has been concluded that the cost of
  21     such relocation involving the construction of a new
  22     cardiac theatre, additional ITU beds and additional
  23     staffing has been prohibitive."
  24        But now other matters had come on to the horizon.
  25        If we go over the page to 132, in the middle of

   1     the page, we see that the cardiac unit in the BRI was at
   2     capacity because it is treating 850 adults in 1993/94
   3     and it is anticipated that will go up to 950 in 1994/95?
   4   A. Yes.
   5   Q. But without any increase in the number of children?
   6   A. Yes.
   7   Q. So it says those facilities are at capacity.
   8        If we go to 134, under the heading "Qualitative
   9     Appraisal", option A was the option to continue to
  10     provide services at the current level?
  11   A. Yes.
  12   Q. National and local demand, and so on; the Health of the
  13     Nation; reduction in deaths from coronary heart
  14     disease. That of course is to be distinguished from
  15     congenital heart defects that people might be born with?
  16   A. Yes.
  17   Q. It was the former and not the latter that was the focus
  18     of the Health of the Nation, or one of the focuses of
  19     the Health of the Nation?
  20   A. Yes.
  21   Q. "UBHT is a centre of excellence, and is currently one of
  22     only two sites offering cardiac surgery in the South and
  23     West region (the other being Southampton)."
  24        So nothing had come of the Plymouth suggestion
  25     since the 1980s?

   1   A. Southampton was only included because there was a change
   2     in the regional office's boundary to join what was South
   3     West and Wessex. You have a much wider regional
   4     coverage.
   5   Q. "If capacity is not expanded to meet increased demand,
   6     purchasers will place increasing numbers of contracts
   7     with Southampton or other out-of-region providers,
   8     e.g. Oxford, Cardiff, London and Birmingham."
   9        Then there is a reference to Plymouth being at the
  10     planning stage and the presence of a further threat.
  11        "In addition to loss of new work, UBHT may lose
  12     current business as its unit costs will not be
  13     competitive. It will lose expertise due to lack of
  14     experience in volume of operations performed,
  15     particularly in paediatric procedures. Quality and
  16     outcomes which are directly related to numbers will
  17     fall, all of which could potentially lead to further
  18     loss of contracts and opportunities for cardiac surgery.
  19        "This situation is counter to UBHT's philosophy as
  20     a centre of excellence and a major Teaching Trust at the
  21     leading edge of health care."
  22        This is I think a document produced by that
  23     Working Party with a list of people?
  24   A. Yes, with the aim of getting the Trust to agree an
  25     investment in cardiac surgery.

   1   Q. If we go to page 135, paragraph 2, that sets out the
   2     position. That is essentially the explanation of the
   3     split site in the first sentence?
   4   A. Yes.
   5   Q. "Contrary to best practice and to current guidance in
   6     the management of children in hospital". There is
   7     mention made that Edinburgh had some other arrangement
   8     which it was, as it were, "fixing"?
   9   A. Yes.
  10   Q. If we go down the page, please, to letter B, "Skills
  11     differences":
  12        "Care of children in hospital demands
  13     appropriately trained staff. Paediatrically trained,
  14     experienced, competent medical staff in all specialties
  15     are constantly available in the BRCH but not,
  16     implicitly, in the BRI." Is that fair comment?
  17   A. You would have medical staff with experience of
  18     children, but not paediatricians.
  19   Q. Then there is reference made to the nursing staff:
  20        "70 per cent of Children's Hospital nursing staff
  21     are registered sick children's nurses, compared with
  22     only 2 full-time equivalents in the BRI cardiac unit."
  23        In the BRI cardiac intensive care unit at this
  24     time, there were the same number of adult beds as there
  25     were children's beds, 4 each?

   1   A. Yes, in that document we saw. Whether that had changed
   2     or not, I would not be able to tell you.
   3   Q. Then, if we go over the page, 136, paragraph (b)4:
   4        "The expansion of the ITU beds at the BRCH require
   5     support. Open cardiac surgery will facilitate improved
   6     training for staff of all disciplines". Yet more reason
   7     for moving open heart surgery for children to the
   8     Children's Hospital?
   9   A. Yes.
  10   Q. Then scanning down to (d)1, waiting time for priority
  11     paediatric cases was 4 to 5 months, the optimum period
  12     in terms of outcome would be 4 to 6 weeks and those
  13     waiting times for paediatric operations were longer than
  14     the major competitors.
  15        Obviously there is a worry that waiting lists,
  16     being a high profile visible indicator of something at
  17     least in the Health Service that the public are aware
  18     of, a centre with a longer waiting list might be less
  19     attractive to purchasers than a centre with a shorter
  20     waiting list, obviously?
  21   A. Yes, until you have cleared your waiting list.
  22   Q. Then (2), "The pressure to increase adult cardiac
  23     surgery combined with less complex care management and
  24     shorter lengths of stay tends to militate against
  25     selection of paediatric cases for admission in the BRI,

   1     resulting in unacceptably long waiting lists."
   2        Are you able to help us with how long that
   3     tendency had been evident?
   4   A. No. Clearly that is a clinical issue. I can understand
   5     what the sentence was saying, but not how that was shown
   6     in any practical way in the Royal Infirmary.
   7   Q. That would be the sort of thing Mr Wisheart could deal
   8     with?
   9   A. Absolutely. Someone within the Directorate would have
  10     written that, obviously.
  11   Q. If we turn to 137, Disadvantages: "There are no
  12     disadvantages in quality applicable to this option."
  13        Do you remember that second disadvantage we saw in
  14     paragraph 7.2.2 of the 1990 document, JDW 1/343?
  15   A. Yes the staffing and the --
  16   Q. Can we just look at that again, JDW 1/343.
  17   A. It was the cost of the split site.
  18   Q. At the bottom of the page, 7.2.2 has disappeared by
  19     May 1994?
  20   A. Yes.
  21   Q. But if the point at 7.2.2 was a good one in 1990, it
  22     would still have been a good one in 1994?
  23   A. Theoretically, yes.
  24   Q. Well, actually, yes?
  25   A. Okay.

   1   Q. So can we take it that in fact the real reason, the real
   2     disbenefit, for 1989 was 7.2.1?
   3   A. Clearly, at that time somebody must have believed that
   4     7.2.2 was an issue and that is why it was put down
   5     there. I mean, clearly the capital investment and the
   6     revenue, which is not listed there, interestingly, would
   7     have been a major hurdle to overcome.
   8   Q. If we go back to the 1984 memo, UBHT 275/138 -- that
   9     blanking out, I should say, has not been done as far as
  10     I know by the Inquiry. I think that is the same
  11     heavy-handed highlighter pen we saw at the beginning of
  12     the document, so I have no idea what is under that.
  13        What I want is the passage, "Opportunities and
  14     Threats".
  15   A. There is a handwritten sheet which shows the financial
  16     appraisal. I did personally check out the finances and
  17     identify the risks of this move.
  18   Q. Can I, before we go any further with this, just ask you
  19     when you were first aware of a perception that the
  20     quality of paediatric cardiac services of Trusts might
  21     fall below that elsewhere?
  22        In your view, was there such a perception?
  23   A. No, not that I was aware of. I think, obviously,
  24     I learned a lot from 1995 onwards, which was one that
  25     de Leval Hunter produced.

   1   Q. We promised each other yesterday we would not get into
   2     that at this stage. Can we just go back to page 130,
   3     please? Just the bottom half of the page. Professor
   4     Angelini is a Professor of Adult Cardiac Surgery.
   5     Is there anyone there who worked for you on the finance
   6     side of the Trust?
   7   A. Yes, Colin Hawkins.
   8   Q. Anyone else?
   9   A. No.
  10   Q. What was Colin Hawkins' role?
  11   A. He was the Financial Manager for the BRI or medicine,
  12     surgery, directorates and my deputy.
  13   Q. Your deputy?
  14   A. Yes.
  15   Q. If we go back, then, to 138, "Opportunities and Threats"
  16     if we scan down, if we can go over the page to 139:
  17        "(b) Threats: following the removal of
  18     supra-regional designation for under 1s from April 1994,
  19     the workload which has hitherto been protected is now
  20     open to competition from other providers. There is
  21     a perception that the quality of paediatric cardiac
  22     services in UBHT does not match the standards of the
  23     Trust's major competitors and it is imperative that the
  24     Trust demonstrates continued commitment to improved
  25     quality in waiting times and outcomes which will have an

   1     impact on mortality and morbidity in specialist areas."
   2        Do you remember ever having heard about that
   3     perception?
   4   A. I must have read it at the time, yes, but it is not
   5     something that registered with me like that. The big
   6     thing for me in this whole exercise that was going on
   7     was, could we financially deliver what people actually
   8     wanted to do, and at this stage, yes, we found
   9     a mechanism to do that by using the funding and the
  10     expansion of adults to allow that to happen.
  11   Q. You would have seen this document?