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Daily transcripts
Hearing summary
7th June 1999
Today the Inquiry heard evidence from Dr John Roylance, former District General Manager
of Bristol and Weston Health Authority and Chief Executive of United Bristol Healthcare
NHS Trust (UBHT). Dr Roylance confirmed that one of his primary concerns as District
General Manager and later as Chief Executive was to introduce and encourage the general
management function, which promoted the delegation of operational management. He described
his role, and that of the Trust Board, as being to create an environment in which carers
(usually consultants) could work with clinical freedom. He went on to discuss the
establishment of clinical directorates focussing on the delegation of responsibility for
providing services within a budget and confirmed that initially cardiac services were not
concentrated in one directorate. Dr Roylance then outlined the process by which problems
within a directorate would be addressed and how managers were encouraged to make decisions
to solve those problems. He went on to comment on the oral and paper cultures which
existed at the UBHT, emphasising his preference for face to face discussions. Dr Roylance
then described the evolution of the Trust Management Board and outlined its responsibility
to act in an advisory position to the Trust Board, and went on to comment on the
establishment of the new directorate for Cardiac Services. He discussed the role of the
Medical Director and concluded by describing the concerns regarding waiting times for
cardiac services, which prompted the transfer of paediatric surgery to the Bristol
Children’s Hospital in order to alleviate the pressure on adult surgery at the
Bristol Royal Infirmary.
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FULL TRANSCRIPT
1 Day 24, 7th June 1999
2 (10.30 am)
3 THE CHAIRMAN: Good morning, ladies and gentlemen. Good
4 morning, Mr Langstaff.
5 MR LANGSTAFF: Sir, good morning. This week the Inquiry is
6 going to hear from more witnesses dealing with the
7 management and the administration of the Health
8 Authority and subsequently the United Bristol Healthcare
9 Trust during the period 1984 to 1995 with which this
10 Inquiry is concerned.
11 Today, and for part at any rate of tomorrow, we
12 will hear from Dr John Roylance, who was both the
13 District General Manager from 1985 and the first Chief
14 Executive of the Trust from 1991 until his retirement in
15 October 1995.
16 Many of those here, or listening at a remove, or
17 picking this up on the Internet, will know that because
18 of events which happened during the 1990s, Dr John
19 Roylance lost his registration, he was struck off as
20 a doctor, by the General Medical Council.
21 It is right, therefore, to emphasise that the
22 purpose of the questions which we will be addressing to
23 him at this stage of the Inquiry are to do with the
24 management and administration. They will cover aspects
25 such as the culture of management, the philosophies that
0001
1 underpinned it, and to an extent, the general effects of
2 those approaches, but they will not, and this needs to
3 be made very clear, because otherwise those who watch
4 may wonder why questions are not being asked which they
5 think perhaps should be asked, they will not deal with
6 the events which led closely to his disciplining by the
7 General Medical Council.
8 This is not because those issues are not going to
9 be explored with him; they are, because those issues are
10 for a later stage in this Inquiry, and it is
11 a consequence of the way in which we have set about
12 presenting the evidence to you in blocks. This is
13 Block 3. This deals with the local scene, having set
14 the national scene in Block 2. It will be later in
15 Blocks 5 and 6 that we explore the expression of
16 concerns about paediatric cardiac surgery at Bristol,
17 the extent to which they were or were not justified, the
18 reaction of management at that time to them, and it is
19 at that stage, later on, probably I would anticipate
20 October/November time this year, that we will be looking
21 at those particular issues with Dr Roylance.
22 Just flagging ahead some of the evidence which we
23 will hear in the forthcoming weeks, the same is also
24 true of Mr Wisheart, who will be called in this block to
25 deal with his conduct and his approach of the management
0002
1 as Medical Director, as a clinician, and as Chairman of
2 the Hospital Medical Committee and, for that matter,
3 latterly, as Chairman of the Clinical Audit Committee of
4 the United Bristol Healthcare Trust.
5 He will not be asked, either, at this stage about
6 the events which led to his deregistration by the
7 General Medical Council.
8 Having said that, can I mention two more matters.
9 Today we will sit from 10.30 until 11.45, I understand,
10 Chairman. We will take a break from then until 12; we
11 will go on until a quarter past 1, and then we will take
12 a break until 2 o'clock; there will be a further break
13 in the afternoon between a quarter past and half past 3
14 and we will close the Inquiry hearing for today at
15 4.30. We will start again at 9.30. Sometimes it is
16 sensible to remind people on Monday we work to
17 a slightly different timetable than we do on other days
18 of the week.
19 The second supplementary matter I would like to
20 mention is this: that Dr Roylance's statement was
21 received in signed form by the Inquiry somewhat late in
22 the day. The reasons for that I need not go into. One
23 of the consequences of that has been that those who
24 represent interested participants, and indeed,
25 participants themselves, have been not as able as they
0003
1 would have wished to pass to me or to members of my team
2 areas of questioning and exploration which they would
3 like to see pursued with the witness. As you know, the
4 procedure is that in general, if there is a question to
5 be asked, then so far as possible, those who have the
6 question will approach Mr Maclean, Miss Grey or myself
7 with it, with a view to it being put by us in the course
8 of our questioning about other matters.
9 This procedure has been most helpful, but it is
10 a matter of regret that the somewhat late delivery of
11 Dr Roylance's statement dealing with the issues he has
12 to address today has made it more difficult than it
13 otherwise would have been for that material to come
14 forward to me. It may be that upon more mature
15 reflection, there will be some issues in some areas
16 which others would wish explored with Dr Roylance. Can
17 I simply say this: that we have, throughout the Inquiry,
18 telegraphed that if there is anything further that
19 a witness wants to say, they should feel at liberty to
20 say it. Where a witness is going to be recalled to deal
21 with other matters at a later stage in the Inquiry, then
22 questions which are not put or pursued at this stage may
23 of course be put and pursued at that stage, and it must
24 not be imagined simply because Dr Roylance is coming
25 back to deal with the expression of concerns and his
0004
1 involvement in dealing with them, that anyone who wishes
2 a question put to him relating to this part of his
3 evidence will be excluded from having that done in an
4 appropriate form.
5 I say that so that it is clear to everyone that
6 this Inquiry is, if you like, it is live; we go on
7 receiving evidence right up to the moment that you,
8 Chairman, and members of the Panel, begin to write your
9 report and draw your conclusions.
10 Having said that, I have spoken for too long;
11 perhaps we can have Dr Roylance.
12 Dr Roylance, would you mind standing to take the
13 oath, please?
14 DR JOHN ROYLANCE (affirmed):
15 Examined by MR LANGSTAFF:
16 Q. Dr Roylance, your full name is John Roylance, is it?
17 A. That is right, yes.
18 Q. You were, as you may have heard me tell the assembled
19 company, formally Chief Executive of the United Bristol
20 Healthcare Trust?
21 A. Yes.
22 Q. And before that, you were the District General Manager
23 of the Bristol & Weston District Health Authority?
24 A. That is right.
25 Q. You have prepared, for the purposes of this stage of the
0005
1 Inquiry, dealing only therefore with your management and
2 administration, and the management and administration of
3 the Health Authority and the Trust during the time that
4 you were the General Manager, and subsequently Chief
5 Executive of it, you have prepared a statement which we
6 find at 108. Can we have that on the screen, please?
7 If you just look at that for a moment, you may not
8 find it entirely familiar, to follow it on the screen,
9 Dr Roylance, but that, I think, is the start, is it, of
10 your statement?
11 A. Yes, that is right.
12 Q. If we go, please, to page 32, that is your signature?
13 A. Yes.
14 Q. Are the facts and matters which you state in that
15 statement true and accurate?
16 A. To the best of my knowledge and belief, yes.
17 Q. What I shall do is take that evidence as read, and
18 explore only parts of it; do you follow?
19 Can I have on the screen, please, UBHT 6/126?
20 This is a copy of the minutes of a meeting of the
21 Trust on Friday 16th April 1993. We see that you were
22 present. Can we go down, please, and go over the
23 page to page 127? Just pause there, thank you.
24 In the course of your report given to this meeting
25 in 1993, you say this:
0006
1 "Since becoming a Trust, local management policies
2 had been made locally ... [you give an example] Despite
3 initial anxiety, this had been a great success and had
4 resulted in a reduction in spending on bureaucracy.
5 UBHT had become a recognised pattern of management worth
6 copying, leading the field in management terms."
7 Just pausing there, is that the way, then, that
8 you regarded what you had achieved with the UBHT by
9 1993?
10 A. Not just me. I was reporting the situation.
11 Q. Can we, please, have WIT 103? This is the statement
12 made to this Inquiry by Margaret Maisey, from whom we
13 shall hear on Wednesday of this week.
14 Can we go to paragraph 107? It is page 43. It is
15 said there by Margaret Maisey that it was the policy of
16 the Trust to make your managers successful.
17 "We tried to select the right people with the
18 correct qualifications to give them the opportunities
19 for personal development and training and to keep them
20 properly supported in their roles."
21 Has she stated it accurately, as you would see it?
22 A. Yes. I see nothing unusual about that in management
23 terms.
24 Q. The primary concern which you had as a manager, first of
25 all the District General Manager and subsequently the
0007
1 Chief Executive, was what?
2 A. Can I give you a slightly detailed answer? I will try
3 to make it brief, but so it is understood.
4 In 1948 the Health Service was introduced and it
5 was expected at that time that once the amount of
6 disease in the community had been corrected, its cost
7 would fall. It was in 1950 that the first realisation
8 was that this was not so and that there was an
9 exponential increase in costs of the health service.
10 This has continued ever since. In fact, a second Health
11 Service Act in 1977 was passed which actually, to use
12 the words of Sir Brian Swaites (?), included a lot of
13 "weasel" words which meant that the Health Service was
14 only to be provided as the Secretary of State thought
15 appropriate.
16 As he explained, there has been overall an
17 exponential increase in expenditure on the Health
18 Service and an exponential increase in funding of the
19 Health Service. The trouble is that the funding has
20 been at a lower level, so since 1948 the gap between
21 what is possible and what is affordable has been
22 increasing.
23 Over a period of time, there have been recurrent
24 management changes designed solely to address this
25 mismatch between funding and spending; and the general
0008
1 management function introduced in Bristol in 1985 was as
2 a result of a report prepared by Sir Roy Griffiths in
3 which he believed that the general management function
4 would at least address this problem.
5 There was no anxiety at that time about the
6 quality of health care; there was an anxiety about the
7 professional and public pressure to spend ever
8 increasing amounts beyond that which was possible, which
9 was affordable.
10 So in 1985, being appointed the first District
11 General Manager, I had two primary responsibilities;
12 there were others, but the two primary responsibilities
13 were to introduce the general management function, by
14 which I mean getting rid of functional management,
15 nurses being managed by nurses, physiotherapists by
16 physiotherapists, administrators by administrators. It
17 could be said at that time when I took up the District
18 General Management role there were about 9 different
19 health services in the district coming together only at
20 district level.
21 In introducing the general management function, it
22 was expressly required to delegate operational
23 management decisions as near to the bedside as possible.
24 To relate that to the financial issues that I have
25 just mentioned, the district had been overspending
0009
1 annually by something of the order of a million pounds,
2 which was at that time well over 1 per cent of budget.
3 Until that time, there had been various sources of what
4 the Health Service calls non-recurring money which
5 bailed out the districts at the end of each year and
6 those sources had by then dried up. So in addition to
7 introducing the general management function, it had the
8 very real task of redressing the overspending and
9 ensuring that the health district provided the best
10 possible care from within the finite resources allocated
11 to it.
12 I hope that answers your question.
13 Q. I do not think it does. It may indicate what the answer
14 would be, but if I just repeat the question and see if
15 I have understood your answer, I was asking you what
16 your primary concern was as District General Manager and
17 then subsequently as Chief Executive. Do I understand
18 from your answer that the achievement of the best
19 possible patient care within the available resources is
20 the answer you would wish to give?
21 A. Yes. I mean, I hope you will forgive me. It goes
22 without saying that the business we were in was treating
23 patients, was preventing ill health, was diagnosing and
24 treating ill-health that occurred, and offering
25 palliative care where curative care was not possible;
0010
1 that is the business we were in. I was taking it as
2 read that in the reorganisation, that was directed to
3 improving the quantity and quality of that patient
4 care. But my appointment was contingent upon
5 a particular form of management to achieve that, and so
6 the answer to your question is, it is a two-level
7 question: what was the business we were in, what was the
8 organisation to which I had been appointed the District
9 General Manager? It was a health care organisation.
10 Therefore, the responsibility of the organisation was my
11 responsibility; that was patient care.
12 But there had been, over the years, an increasing
13 tension and difficulty in the provision of that health
14 care. That was the specific task that I had to address
15 in order to underwrite, to ensure, the continuation of
16 first class patient care.
17 Q. May I approach the question that I asked in the hope,
18 possibly, of encapsulating what you have to say in
19 rather more epigrammatic answer? Would it be fair to
20 describe your personal primary concerns as the safety
21 and best interests of the patient; the method of
22 achieving that being by fulfilling the management role
23 to which you had been appointed?
24 A. The trouble with describing the Health Service in, as
25 you say, epigrammatic terms is that it can mislead.
0011
1 Q. I am describing your role, not the Health Service.
2 A. I do not think you can distinguish the two. My role was
3 to facilitate the Bristol & Weston Health District part
4 of the Health Service. The two are synonymous. We did
5 not have an independent management exercise that was
6 divorced from the business we were in. I tried to make
7 that point.
8 Q. In the structure, first, let us look at the District
9 Health Authority, of which you were District General
10 Manager. Did you, as such, have responsibility for
11 patient care in that Health Authority?
12 A. It depends what you mean by "responsibility for patient
13 care". "Patient care" can mean a number of things. My
14 responsibility, and it was the same with others, was to
15 create an environment in which carers, particularly
16 consultants, could exercise clinical freedom; it was not
17 my responsibility to provide health care; it was my
18 responsibility to provide a Health Service within which
19 consultants could lead teams producing patient care.
20 There is a difference.
21 Q. Does that answer apply to your chief executiveship of
22 the United Bristol Healthcare Trust?
23 A. Yes. I mean, in no sense can a Health Authority or
24 a Trust Board provide health care; they can enable the
25 provision of health care; they do not provide health
0012
1 care. Professional staff do. In any of the management
2 discussions which took place there were arguments that
3 we should put the structure of the district upside down
4 because the real Chief Executives of the Health Service,
5 the people who made decisions, committed resources and
6 achieved patient improvement, were consultants.
7 Everything else was in support of that, not over it.
8 Q. Can we look, please, on the screen, at UBHT 6/200? This
9 is the notes of a meeting of the Executive Committee of
10 the United Bristol Healthcare Trust. It is Friday
11 21st May 1993. We can see from the attendees that you
12 were present.
13 Can we go to page 202, please?
14 "Discussion paper on Trust Values.
15 "Dr Roylance said that UBHT had delegated
16 responsibility to operational level and had pursued
17 a policy of management by values and not by
18 objectives ..."
19 You go on to talk about values.
20 Is that an accurate description of the policy
21 which you and the Trust adopted?
22 A. Yes. It would take too long, I think, to explain the
23 difference, but, yes, we managed by values: I do not
24 mean financial values; I mean by values.
25 Q. I did not think for a moment you did.
0013
1 A. I am sorry, I am talking to everybody, not just to you,
2 I think.
3 Q. Can I examine the values as opposed to the
4 objectives? Am I right in thinking that essentially
5 your concept of the organisation of the Trust and of the
6 Health Authority before it, was that it should be
7 medically led?
8 A. No. That was my observation, not my concept; health
9 care is led by consultants. That was not something
10 I imposed, that it was my concept; it was my recognition
11 of reality.
12 Q. Can we have your statement, WIT 108, page 20. I am
13 going to ask you in a moment about the paragraph
14 beginning:
15 "In respect of senior medical staff ..."
16 Did you regard medical staff as professionals?
17 A. Yes.
18 Q. In effect, once appointed, was it part of the
19 consequence of clinical freedom that they were
20 self-teaching and self-correcting?
21 A. Yes.
22 Q. Did you take the view, therefore, that it was not for
23 managers to interfere?
24 A. I recognised that it was impossible for managers to
25 interfere.
0014
1 Q. So essentially, the clinician at the bedside made the
2 decision which he or she thought was in the best
3 interests of the patient?
4 A. Yes.
5 Q. And management felt that it could not, and should not,
6 interfere?
7 A. And does not, in any part of the Health Service.
8 Q. You say in this paragraph, in respect of senior medical
9 staff, that you had "every confidence that any area of
10 incompetence or unsatisfactory results would be
11 identified and dealt with, not only by the audit process
12 but by the constant consideration and evaluation of
13 clinical work that was carried out as a matter of course
14 in Bristol as in any teaching hospital."
15 You meant by clinicians, did you?
16 A. Yes. By peers, by equal experts.
17 Q. So your view was that it was for doctors to identify
18 failings in doctors?
19 A. You keep asking if it was my view. It was the view.
20 Nobody else had a different view. I am really anxious
21 that I should not mislead anybody; that I had in some
22 way introduced a different concept into the Health
23 Service than that which existed throughout the Health
24 Service.
25 If I could explain to you, the Health Service has
0015
1 to rely upon the advice of the experts that as an
2 Appointments Committee, the representative of the Royal
3 College informs the District or Trust or whatever
4 Appointments Committee, that the person under
5 consideration is fit to exercise independent clinical
6 judgment, not judgment subject to anybody else's
7 supervision or accountability, but independent clinical
8 judgment.
9 The management accept that. It is a very clear
10 structure that allows that to happen.
11 Should that person's performance fall below that
12 which is necessary, the only persons who can recognise
13 that, identify it, are similar experts. It is not
14 possible at the moment, and I say this still because
15 I have been retired for some time, but I am quite sure
16 we have not reached the stage where that sort of
17 judgment can be exercised by anybody else.
18 Please, this is not a funny view of mine; I have
19 been in the Health Service one way or another since it
20 started, and I am aware of the situation, and so are
21 management experts and so is everybody else.
22 So I am having difficulty in answering your
23 question in terms of, this was "my" concept. It is not
24 "my" concept, it is the reality.
25 Q. The question, with respect, Dr Roylance, was perfectly
0016
1 fair; it was addressed to what your concept was. The
2 fact that it may be shared by others, I appreciate that
3 is your evidence, but please do not misunderstand the
4 question, the question I will repeat and put again.
5 Was it your view that effectively only clinicians
6 could identify defects in performance of other
7 clinicians?
8 A. Again, you use words that I have difficulty with, and
9 I am sorry; it was not my view; it was my recognition.
10 It was not an opinion; it was a fact. It was an
11 observation.
12 Q. Would you go back to page 20? The consequence of this
13 recognition by you appears, does it, in the paragraph:
14 that if there were incompetence or unsatisfactory
15 results, it was essentially a matter either for
16 clinicians within Bristol or the Royal Colleges as
17 bodies of clinicians outside Bristol, to identify and
18 make known concerns to management.
19 A. Yes. How else could management run?
20 Q. How was management to resolve any difficulties arising
21 as between one clinician asserting clinical freedom to
22 do what others thought was his incompetent best, which
23 he was maintaining was his competent performance?
24 A. A manager can only seek the appropriate professional
25 advice. If the individual is not performing to the
0017
1 standard which was expected following his appointment
2 that fact has to be established, and if there is
3 a difference of opinion then one seeks the advice of the
4 Royal College. The Royal Colleges are responsible for
5 the maintenance of standards within their specialties,
6 and exercise that. I have been a member, a fellow of
7 a Royal College myself, that is in radiology; I have
8 been on the Council of that College, and I understand
9 the mechanism.
10 What I am saying is that there is no way that
11 a manager, a General Manager, can form a judgment; no
12 way. He can take advice and clearly, as a manager, he
13 should know where to get that advice and how to resolve
14 differences of opinion. He cannot form an opinion
15 himself.
16 Q. Such a manager as you describe might possibly have
17 systems developed to enable him to address any such
18 problem that might arise as and when it arose. Did
19 you?
20 A. I dealt with problems as they arose. I do not wish to
21 reveal them now, but occasionally such a situation did
22 occur, and I dealt with it. I do not know what you mean
23 by "have a system". I had the ability and the knowledge
24 and was successful in dealing with a situation such as
25 you hypothesise.
0018
1 Q. And you did that on an ad hoc basis?
2 A. No, I did it by an understanding, a clear understanding,
3 of the Health Service and the way things are done.
4 Q. In accordance with any laid down protocol?
5 A. Well, there are protocols, but it depends entirely on
6 the situation. I cannot discuss this in a generality.
7 There were laid-down protocols at the Department of
8 Health. I think one of them -- I have written it down
9 here -- was HC(82)13 (you may or may not have it) which
10 could be invoked if the situation could not be resolved
11 more expeditiously. If you read the newspapers you will
12 see that dealing with this situation by a preconceived
13 policy tends to be very protracted and very expensive.
14 It is sometimes possible to reach a satisfactory
15 conclusion without that protracted course and without
16 that expenditure. But it depends on the situation. So
17 I was entirely competent to deal with any complaint
18 brought to my attention about the competency of clinical
19 staff, doctors or others.
20 Q. Can we go back to page 18 of your statement? The first
21 paragraph on the page:
22 "All consultant staff were expected to exercise
23 individual clinical judgment with respect to the health
24 care they provided."
25 That is what you have just been saying, I think?
0019
1 A. Yes.
2 Q. You set out how the Health Authority and subsequently
3 the Trust relied upon the Royal Colleges to determine
4 the qualifications and experience of applicants?
5 A. Yes. I have explained that already.
6 Q. And you go on to say, as you have said in evidence, how
7 consultants were expected to monitor their own
8 performance and to be self-correcting?
9 A. Yes.
10 Q. The role of management you deal with at the bottom of
11 the page:
12 "To provide and co-ordinate the facilities which
13 would allow the consultants to exercise clinical
14 freedom."
15 A. Yes.
16 Q. You define it. You say this:
17 "In practice, it was by delegating the total
18 budget to the operational level with as much freedom as
19 possible to use the resources to provide the maximum
20 good for the maximum number, that a rational provision
21 of health care was achieved."
22 I want to unpick that last sentence, if I may.
23 By "total budget", you mean the total budget of
24 the Health Authority or the Trust?
25 A. I mean the total budget for the health care provided at
0020
1 that operational level.
2 Q. Someone has to determine how much money the operational
3 level will require or will receive?
4 A. Yes.
5 Q. Who was that?
6 A. Well, in the latter stages, it was on the basis of
7 a workload agreement or contract with a purchasing
8 Health Authority or with a fund-holding general
9 practitioner.
10 Q. So the budget is the contracted budget, in effect, by
11 the purchaser to the provider?
12 A. We keep leaping about. When we were a Trust, there was
13 a separation of responsibility of determining the health
14 needs of the community and of determining how much of
15 that health need would be funded; it was the
16 responsibility of the providing unit to meet that
17 contract, to negotiate, agree it and meet it, so that
18 when a contract was drawn up for a particular service,
19 it was drawn up to include the total cost of that
20 service. It would include some elements outside the
21 actual provider units, the directorates as it was, and
22 would include a recognised element of pathology support,
23 of radiology support, and for that matter, management
24 support. So the contract was agreed in the knowledge of
25 how much was available at the operational level for the
0021
1 provision of the service, and what top-slicing there
2 would be to fund the necessary support from other parts
3 of the Trust for that service.
4 Q. And the total budget at the operational level, the
5 practice was to delegate that to those who were
6 concerned at the operational level, was it?
7 A. That is right. That was in accordance with the
8 recommendations of the Griffiths Report.
9 Q. And you go on to add, in your statement:
10 "With as much freedom as possible to use the
11 resources to provide the maximum good for the maximum
12 number."
13 A. Yes.
14 Q. You are describing here, are you, delegating a budget to
15 those clinicians most closely concerned with the
16 operational level?
17 A. Those that were providing the health care, yes.
18 Q. And you are saying it was for them to spend?
19 A. Yes. That is where the expertise lay in the balance of
20 resources that were needed to provide the health care.
21 Q. By giving them as much freedom as possible, you are
22 saying it was for them to make the decisions, for them
23 to spend the money as they chose?
24 A. Well, I keep saying, that was the requirement of the
25 Griffiths report. That is what I was doing from 1985,
0022
1 and endeavouring to achieve that. This was not some
2 funny idea I dreamt up; this was what I had been
3 appointed to achieve.
4 Q. Dr Roylance, I understand you may be concerned at
5 possibly the way some of these questions may be
6 leading. It may be helpful if you were perhaps in your
7 answers to try and answer the facts as I have put them
8 to you --
9 A. Please, could I interrupt --
10 Q. -- then, if you wish, you may comment upon the
11 justification for those facts.
12 A. Well, I am disagreeing with the way you put it; that is
13 why I am presenting an answer which is different. I did
14 not delegate the budget; it was not my novel idea.
15 I was implementing a policy recommendation from the
16 Department of Health. There is a very big difference.
17 Q. I am not going to debate with you the questions that
18 I ask, Dr Roylance.
19 Can I look, please, at the consequence, as you put
20 it, of the system. It would be this, would it: that
21 those involved at operational level would have the money
22 and decision-making power to spend it. It follows, does
23 it, from what you were saying on page 20, which I took
24 you to a moment or two ago, that so far as clinical
25 competence or incompetence was concerned, that was for
0023
1 clinicians to judge?
2 A. Yes.
3 Q. So it follows that, in the way in which the Trust was
4 administered and the Health Authority before that, that
5 clinicians determined both their competence or
6 incompetence and the immediate expenditure of money;
7 they had control over that?
8 A. No. If I understand your question correctly, what was
9 new was that the exercise of clinical freedom was
10 becoming an exercise within the available resources.
11 Until this form of management was introduced, the
12 exercise of clinical freedom, I regret to say, was
13 entirely independent of resources and that management,
14 up until that point, had to use quite crude measures to
15 try and prevent the major overspending of a service,
16 things like closing operating theatres, closing wards,
17 so it was not possible to overspend, because there was
18 a complete separation of the exercise of clinical
19 freedom from the responsibility of staying within
20 budget.
21 That is what the general management function was
22 intended to address.
23 Q. Do I understand from this that what happened was that
24 a view was taken, leave aside whose view it was, but
25 a view was taken that it was management's role in the
0024
1 Bristol Health Authority and the Bristol Trust, and
2 leave aside for the moment whether that may or may not
3 have coincided with what may have happened elsewhere,
4 but in Bristol, at any rate, the view was taken that it
5 was not for management to control either clinical
6 decision-making or decisions as to how money should be
7 spent at the operational level?
8 A. If you remove "in Bristol" from your question, I can
9 answer quite clearly "Yes". If you put in "in Bristol",
10 it implies in some way this may be different and the
11 description you make is a description of the National
12 Health Service, not a description of Bristol.
13 Q. So the answer is, yes, it happened in Bristol, but you
14 add that this was nonetheless the case in the National
15 Health Service as a whole?
16 A. Yes. We were no different in that respect from any
17 other part of the whole service.
18 Q. We are dealing with the values that informed the way in
19 which the Trust and the Health Authority here in Bristol
20 worked. It appears, have I got it right, that clinical
21 freedom was one of the values that you would stress?
22 A. No, you are confusing two things. The management by
23 values was management. The clinical freedom was
24 clinical care by consultants. The two were at that time
25 still different.
0025
1 Q. Was it part of the style of management within the time
2 that you were the District General Manager or the Chief
3 Executive that you sought to avoid any excess
4 bureaucracy?
5 A. I hope everybody avoided excess bureaucracy, by which
6 I mean, and I hope you mean, unnecessary bureaucracy.
7 Q. It has been described by another as you personally
8 having an abhorrence of process management.
9 A. What I have an abhorrence of is a misunderstanding that
10 budget on paper was a substitute for action. I have no
11 objection to the writing of a paper and I have to say
12 this Inquiry has been swamped by enough paper that arose
13 from Bristol to know that the writing of useful matters
14 was not abolished. What I am, and was, very keen on,
15 was the mistake to substitute writing and policy for
16 action, and I am afraid that that is often the case.
17 Q. Did the General Managers have job descriptions?
18 A. Yes. Not on Day 1, but they had job descriptions.
19 Q. Were they put in writing?
20 A. Yes. The Personnel Department had that responsibility,
21 but in 1985, when I introduced the general management
22 function, we were in a state of flux for some
23 considerable time, and to start with a job description
24 would have been quite the wrong way. I spent a very
25 long time discussing what general management meant with
0026
1 everybody concerned. I tried to do only that for 6
2 months and not actually managed the district. The
3 general management function was achieved by evolution
4 and not by sudden edict, so management, job
5 descriptions, emerged in the course of that evolution
6 and did not antedate it.
7 Q. Roughly when would you say that job descriptions for
8 General Managers were in common circulation?
9 A. They were not in circulation; they were owned by the
10 managers. I cannot tell you. We certainly did not have
11 any for six months. I think there is a paper that you
12 circulated showing the general management function was
13 going to be introduced firmly in the year after I was
14 appointed, so I suspect job descriptions occurred there,
15 or soon after. But, please, I cannot tell from this
16 distance, which six months they occurred in.
17 Q. You have shown us at the back of your statement,
18 helpfully, a couple of charts. It may be useful to go
19 to those.
20 Page 42: that is the diagram of relationships
21 operating in the Trust Board during the time of your
22 chief executiveship.
23 Can we go back one page, please. That, I think,
24 is the way it operated when you were the District
25 General Manager of the District Health Authority?
0027
1 A. These are snapshots of a constantly changing situation;
2 I would like to emphasise that. The management
3 structure was moulded as we learned, as we went along
4 and as problems arose and needed to be dealt with. So
5 it was a changing structure, an evolving structure, and
6 what I have tried to do is to give a snapshot at three
7 different points in that evolution.
8 Q. Is it, then, the case that there were no such
9 organisational charts available or promulgated at any
10 time; these are simply representations?
11 A. There was an abundance of organisational charts. We
12 were constantly charting the organisation and adjusting
13 it. There was no chart which was chipped in concrete
14 and said, "That's the chart", but we were constantly
15 addressing the structure arrangements of the
16 organisation. A great deal can be achieved by modifying
17 the structure to deal with the requirements of the
18 situation.
19 Q. So something like this, this particular diagram, in
20 1987, would have been produced, prepared and circulated,
21 would it?
22 A. I do not know what you mean by "circulated". People
23 concerned knew about it, yes. We did not post it to
24 6,500 members of staff, if that is what you mean, no.
25 Q. So who would have had this?
0028
1 A. The people who were on the structure.
2 Q. If one goes down to the sub-units, the Bristol Royal
3 Infirmary, the Children's Hospital, who there would have
4 had a copy of this structure?
5 A. Each sub-unit was managed at that time by a sub-unit
6 General Manager. You will notice that although we had
7 introduced general management, we had not, at that time,
8 incorporated the medical staff into the management
9 structure. That was fairly standard throughout the
10 Health Service, which first of all started to create
11 a general management structure, but it did not include
12 the doctors. We evolved this slowly because there was
13 considerable reluctance and anxiety on a number of the
14 functional management, shall we say, professions allied
15 to medicine, who, up until that time, had a district
16 manager of their professional staff as a separate
17 hierarchy within the Trust, and it took time to
18 determine how that could be changed into a professional
19 advisory structure and the members of the profession to
20 be incorporated appropriately into the sub-units. Each
21 one presented a separate problem and required
22 considerable discussion, and at times negotiation, in
23 order to achieve the introduction of general management
24 to incorporate that particular profession.
25 Q. Given the evolution that you have described and the
0029
1 approach that was taken to avoiding excess bureaucracy
2 and excess paperwork, how did people who were in the
3 district management group, or in the sub-units, know
4 what was expected of them with any precision?
5 A. We introduced this general management function across
6 the district in an educational way. We were a teaching
7 hospital and we had a large number of seminars, of
8 teaching exercises, often with outside management
9 experts, in order that we should, as far as we could,
10 all move forward with a common developing understanding
11 of what general management meant; it was not done by
12 issuing a series of documents and hoping that everybody
13 understood; it was done in an educational way so that we
14 brought everybody along, they understood the fundamental
15 change in the organisation. Nothing like this had ever
16 happened in the Health Service before; it was a totally
17 new understanding and it required a great deal of
18 educative effort.
19 Q. The process of management in the Trust has been
20 described, as you will have seen from looking at the
21 transcripts on another occasion, as an "oral" culture.
22 How far would you say that was a fair description?
23 A. I hope it was a fairly accurate description. What it
24 means is that people talk to each other. I think that
25 is very important, and I think it is a highly efficient
0030
1 and highly effective way of managing, that people should
2 talk to each other. It has been said in the management
3 textbooks that a memorandum is written to protect the
4 author rather than inform the recipient, and I subscribe
5 to that view.
6 Q. So is it the case that you would subscribe to the view
7 that the oral discussion and transmission of information
8 is sufficient in itself --
9 A. No, I did not say that.
10 Q. That is why I asked you.
11 A. That is why I am clarifying it for you.
12 Q. To what extent do you use paper to support the oral?
13 A. I use paper when it is necessary and it benefits patient
14 care. If it does not benefit patient care, then as
15 a Health Service we ought not to indulge in it. That
16 may be slightly difficult to comprehend as an outsider,
17 but I found no difficulty in distinguishing between
18 useful consumption of paper and distracting consumption
19 of paper. As I say, I was determined to avoid
20 unnecessary paperwork. I did not avoid necessary
21 paperwork.
22 Q. Your views, I suspect, on paperwork became fairly well
23 known, did they?
24 A. There is no secret about it; I hope it was well known.
25 I hope I encouraged everybody else to think twice before
0031
1 they diverted their efforts to a non-contributory
2 consumption of paper. That did not excuse anybody for
3 not writing down that which ought to be written down.
4 Q. One of the consequences of that might be thought to be
5 that information coming to you from others might rather
6 be given orally than come on paper?
7 A. I do not follow that. I am sorry. I encouraged people
8 to talk directly with me. If it was necessary to record
9 it, it was recorded on paper, but I would much prefer
10 that somebody rang me up and said "We have got
11 a problem" than to spend time dictating, having it
12 typed, transmitting it to me and for me then to have to
13 ring them up and say "What is this all about?"
14 Q. When the Bristol Health Trust was formed, was it one of
15 the seven largest in the country?
16 A. Certainly, yes. It may have been one of the three
17 largest, but it was certainly one of the seven largest.
18 There were not that many Trusts formed in the first
19 wave.
20 Q. So when it came to people within the organisation
21 wishing to communicate with you, how would they
22 communicate if you were not there or if you were engaged
23 in something else, not at the end of the phone? How
24 would they get the information to you?
25 A. I had a personal assistant who acted as a highly
0032
1 efficient answerphone.
2 Q. So they would tell her orally, and she would transmit
3 orally to you?
4 A. No, she would tell me the subject matter of what they
5 wished to discuss with me, and I would contact them. We
6 did have telephones. I do not wish to be flip, but they
7 were highly efficient, and it depended on what the
8 matter was, whether it could be dealt with straightaway
9 over the phone, whether I had to do some research,
10 whether it was best for me to go and meet them within
11 their directorate. Depending on what the message was,
12 clearly the response would have been appropriate.
13 Q. How able do you say you were to keep your finger on the
14 pulse of things with a tradition which militated
15 against --
16 A. Can I fundamentally disagree with you? My system you
17 describe as mine is not unique to me; it is
18 a well-recognised modern management system, which
19 actually improved communication, did not reduce it. It
20 actually improved communication, and as I say, it was
21 much better than a -- I mean, nobody runs a solely paper
22 communication exercise in a big organisation, nobody
23 does. I think my successor explained to you that he
24 talked to people and people talked to him. It is
25 a fundamental part and very efficient part of management
0033
1 communication and improves. You implied there was in
2 some way this inhibited communication. If there had
3 been, I would not have tolerated it; it is improved
4 communication.
5 Q. Would you say, then, that you had your finger on the
6 pulse of what was going on?
7 A. Absolutely.
8 Q. And the sources of information you would have would be
9 people talking to you and from time to time writing you
10 memos, and phoning you and so on.
11 A. No. There was a whole massive mosaic and pattern of
12 communication. I spent the whole of my time in
13 communication. I did little else, because in my
14 position it was the passage of information of one sort
15 or another that was my role. So that I spent the whole
16 of my time communicating, not just a bit of it; I spent
17 my time going around assisting managers, assisting, when
18 we had them, clinical directors, commercial managers.
19 I spent a lot of my time improving their chances of
20 success by talking to them, counselling them, by holding
21 countless training purposes and of course the very
22 structured committee arrangements and Working Party
23 arrangements of this Trust.
24 So I really have to emphasise that this was an
25 attempt to deal with one of the issues that all Trusts
0034
1 and all big organisations have of communication and we
2 spent a great deal of time ensuring that communications
3 were the best possible and that involved a substantial
4 amount of oral communication.
5 Q. I think in that you have answered the question which
6 I was addressing, which was the extent to which you
7 would say you had your finger on the pulse, you knew
8 what was going on in any part of the Health Authority or
9 the Trust that mattered?
10 A. Yes. I often knew what people were thinking before they
11 were doing.
12 Q. Can we have a look at something which supports that view
13 of yourself and of the structure? It is UBHT 291/1.
14 This is a document which was shown to Mr Ross, as you
15 will know, and a number of extracts were taken from it,
16 in inviting him to compare the Trust under his chief
17 executiveship with the way in which it was run under
18 yours?
19 A. Can I ask you, is this written by Marie Thorne?
20 Q. That is right. Can we go to page 7, please? Can we go
21 down, please? The paragraph now in the centre of the
22 screen:
23 "The core of the leadership style is centred on
24 a belief that it is not the Manager's job to solve
25 problems but to present them back to the individual to
0035
1 sort out for him or herself. Excellent organisational
2 antennae and sound political skills and a judgment help
3 to bring coalitions for achieving action. His
4 favourite achievements ..." This is all in reference to
5 you and it is all praiseworthy, one would think. "His
6 favourite achievements are those that have gone
7 unattributed but have been instigated by him. The lack
8 of need for recognition is important in his style of
9 encouraging and empowering others... competent in his
10 own capabilities ..."
11 There is a description given there of you.
12 Modesty aside, is that something you would recognise as
13 being moderately accurate?
14 A. Before I answer that, can I say that paper was written
15 by Marie Thorne, as I think you can deduce from the
16 start, as a provocative document to facilitate an
17 away-day seminar aimed at further development of I think
18 it would have been the Executive Directors or if it was
19 before that, of the leadership, anyway, the managerial
20 leadership of the Trust. It was not intended to be a,
21 what shall I say, "considered", formal, sober view of
22 the Trust. It was deliberately exaggerated. Although
23 the points she was endeavouring to raise I think were
24 true, I have to say, this is not meant to be a genuine
25 considered document but a provocative document to assist
0036
1 us in further developing our management style.
2 I have to be careful about how far that is
3 basically true and how far it is a gentle exaggeration.
4 Q. The first sentence of that paragraph:
5 "The core of the leadership style is centred on
6 a belief that it is not the Manager's job to solve
7 problems but to present them back to the individual to
8 sort out for him or herself."
9 Is that overstating it?
10 A. It is overstating it, because that could be taken to
11 mean if a manager had a problem and brought it to me,
12 I would simply give it back to him and say "Go away and
13 solve it". I was anxious that we should, over a period
14 of time, achieve genuine delegation of operational
15 decisions at operational level. That was something that
16 at that time was quite new, so I encouraged managers to
17 let me know if they foresaw a problem, particularly if
18 they foresaw one, if they did not see it in time and
19 they had one, to come and tell me, not to conceal it
20 from me, to come and tell me and I would assist them in
21 determining the solution. I would encourage them to
22 make the decision. And the right decision. It is
23 a skill one acquires to encourage people to resolve
24 their own problems. I mean, I think there is now
25 a whole profession called "counselling" in which people
0037
1 genuinely assist those in difficulty to resolve their
2 problems.
3 It is not, it appears to me, it was intended to be
4 flip, that if somebody had a problem they were told "Go
5 away and solve it", but when they came to me, I would
6 spend a very considerable time ensuring that they got
7 themselves into a position to see the right solution, to
8 make the right decision, and then to implement it. And
9 I would give them my full authority and support for them
10 to do it. What I knew would be unhelpful would be for
11 them to unload the decision on to me and for me to
12 assume the role of unit or sub-unit general manager and
13 solve the problem. Of course I could solve the problem;
14 that is why I was in the position I was in. I adopted
15 the same teaching role as I did in teaching
16 radiologists. If you do it properly, they know how to
17 cope with a similar problem the next time. I think it
18 is an entirely proper supportive management style; it is
19 well recognised. I was not the initiator of it; I was
20 the practitioner of it.
21 Q. So you are helping them to understand how they might
22 best address the problem so they might best address it
23 themselves?
24 A. Exactly.
25 Q. You have been quoted as saying to managers below you,
0038
1 "I do not want your problems; I want your solutions".
2 Is that something that you have on occasion said?
3 A. I have quoted other people. That is a standard
4 management statement and if you go into the management
5 books, that is what you will find. I am not sure who
6 started it, I suppose lots of people. From my memory,
7 and it may be wrong, it may well be that it was Henry
8 Ford who first originated that saying, and it is
9 a useful saying.
10 Q. The question I was asking was, was it one which you
11 adopted?
12 A. I thought I had already explained to you that that is
13 what I adopted, but there were times when managers could
14 not bring a solution and I helped them to devise it.
15 I hope I am making myself clear. If you consistently
16 withdraw decisions from developing managers and make
17 them yourself, the managers do not develop. If you
18 encourage the managers to pursue and resolve the problem
19 and make the decision and implement it, they develop.
20 What you have to do, if you are in my position, is
21 ensure in times of difficulty that they were
22 successful. That is why they came to see me.
23 I repeatedly met managers.
24 MR LANGSTAFF: Dr Roylance, it is just coming up to
25 a quarter to 11. We have dealt thus far with a number
0039
1 of the characteristics of the management under your
2 control. Whether they would fall as values rather than
3 anything else, I think you will probably tell us in due
4 course.
5 I am going to turn to a number of specific areas
6 in a moment, and this might be an appropriate time for
7 a break.
8 THE CHAIRMAN: Yes. Thank you, Mr Langstaff. We will take
9 a 15 minute break and therefore reconvene at noon.
10 Thank you.
11 (11.45 am)
12 (A short break)
13 (12.00 pm)
14 MR LANGSTAFF: Dr Roylance, we have dealt with a number of
15 the aspects of the way in which the Health Authority and
16 the Trust ran themselves. Can I be a little more
17 general before I come back to some specifics?
18 When you were first appointed you became District
19 General Manager and that was the first time I think that
20 there was a general management function in the Health
21 Service, following Griffiths?
22 A. Yes, that is right.
23 Q. Were you, do you think, somewhat unusual in being
24 a medical man?
25 A. Yes. There were a number of doctors who became District
0040
1 General Managers, quite a number, but they were mostly
2 what were called community physicians: people who had
3 been District Medical Officers and had had an
4 administrative role in the district management teams
5 that had existed beforehand. So it is not true to say
6 the doctors were rare, but I think you could probably
7 count on one hand in England the number of clinical
8 consultants who have become General Managers.
9 Q. Your specialism was radiology?
10 A. Yes.
11 Q. Had you been a practising radiologist up until the time
12 you became General Manager?
13 A. Yes.
14 Q. So your career had involved management only in so far as
15 you had had to manage your team as a consultant
16 radiologist?
17 A. No, that is not quite true. I had considerable
18 experience first as Secretary of the Medical Committee
19 and then Chairman of the Medical Committee. I had
20 chaired a number of committees which had
21 a committee-based management role. I had been on the
22 Board of Governors as a member of the Board of
23 Governors, and I had been a member of their Finance and
24 Executive Committee, and I had, at that time, chaired
25 the Professional and Technical Services Committee
0041
1 holding the salary budget, the whole of the professional
2 technical staff with the exception of doctors and
3 nurses. I was invited to be the first District General
4 Manager by the then Chairman because of my -- I think --
5 considerable management experience.
6 Q. Do you think it made a difference compared to the way in
7 which other people might have or did approach the role
8 of General Manager, the fact that you had recent
9 clinical experience, you had your own career, really, as
10 a consultant radiologist?
11 A. I expect so, but I do not know in what way you mean.
12 Q. I am asking for your own impression.
13 A. Every new District General Manager came from a previous
14 experience. Some were administrators, some had been
15 treasurers, some had been personnel officers, some had
16 been nurses, some had been community physicians. Of
17 course everybody brought their personal experience with
18 them. If you say, was my clinical experience
19 significantly different from other very experienced
20 managers within the health service, I have to say, I am
21 not sure.
22 Q. In terms of the approach that you took to the people you
23 had to manage, do you think it made a difference being
24 a doctor?
25 A. Yes, I think so, but I would not like, in that way, to
0042
1 denigrate the abilities and experience of others.
2 I held the view, before I was asked, in the many
3 discussions in the run-up to the introduction of general
4 management, that it would be by no means a disadvantage
5 for a health care organisation to be managed by a health
6 carer. I use a similar analogy, that the head of a big
7 comprehensive school is usually a teacher; the head of
8 a law firm is usually a lawyer. So I think an intimate
9 knowledge, I think it was Peter Jay said, an intimate
10 knowledge of the organisation is not a bar to leadership
11 of it.
12 Q. So you think that you gained, in effect, by having the
13 intimate knowledge, knowing how things were done as it
14 were at the chalk face, or the coal face, or whatever
15 the analogy might be?
16 A. Yes, I think so. I used to boast and nobody challenged
17 me, but when I became District General Manager I had
18 been the only person who had actually set foot in every
19 part of the then district twice. I really had very
20 intimate knowledge of the district at the time, how it
21 had got there, what the past history was, what the
22 aspirations of people were. I had an extremely intimate
23 knowledge of the whole organisation. I am not saying
24 that other District General Managers newly appointed did
25 not have a similar intimate knowledge of theirs; I am
0043
1 trying to be very careful that I am not disparaging
2 others, so I am not trying to be comparative; I am just
3 saying that I had an extremely detailed knowledge and
4 insight into the organisation I had accepted the
5 invitation to manage.
6 Q. Do I take it because you came from the organisation, you
7 knew many, if not all, of the consultants personally?
8 A. Yes. I think I knew all the consultants personally.
9 I knew a large number of other people personally, too.
10 Q. Having been Chair of the Hospital Management Committee,
11 your role had in fact been, I think you describe it
12 somewhere as the "shop steward" of the doctors, the
13 consultants?
14 A. I did not use that expression. Somebody else may have
15 done, but I would not use that expression. I find that
16 wholly inaccurate.
17 Q. It is certainly the way it has been put in one of the
18 statements given to us?
19 A. Well, could I reject that and say that is misguided.
20 Q. Certainly. In any event, that is a position which is
21 elected?
22 A. Yes, the Medical Committee chairmen are elected by the
23 whole of the consultant staff. I think I was the first
24 one that was ever elected unopposed. Whether that was
25 my ability or nobody else was fool enough to offer, I do
0044
1 not know.
2 Q. When the Health Authority had been going under your
3 general management for a short while, I think by 1989,
4 you began to develop, I say "you" being the authority,
5 began to develop the clinical directorate structure
6 which we see in the Trust?
7 A. Yes.
8 Q. In response, one gathers, to national encouragement?
9 A. Yes. And the anticipated changes, further changes in
10 the Health Service. I do not want to sound too cynical,
11 before we had completed the introduction of general
12 management, it was decided to add to it the
13 purchaser/provider split, and by 1989 we were beginning
14 to introduce shadow contracts or work agreements,
15 service agreements, and we were endeavouring to flex the
16 management in a way that responded to that new
17 requirement. It was also a way of endeavouring for the
18 first time to bring the consultant body within the
19 general management function, so it was partly the
20 continued evolution of general management, I think it is
21 fair to say precipitated by the new thinking of
22 purchaser/provider split.
23 Q. In any event, in the late 1980s, the early 1990s, the
24 Health Authority found itself, did it, with a number of
25 clinical directorates which were then developing which
0045
1 became the first 14 clinical directorates of the Trust?
2 A. I am not sure it was 14, it might have been 13. The
3 Health Authority did not "find itself", the Health
4 Authority took part in the discussions and the approval
5 of that change.
6 Q. The Clinical Director of each directorate would report
7 to whom?
8 A. To me.
9 Q. The General Manager of each directorate would report to
10 whom?
11 A. Can I explain that because it is a slightly complicated
12 answer in terms of evolution. In the discussion and
13 general run-up to the creation of directorates, there
14 was considerable anxiety and conflicting advice and
15 feeling about the introduction of what shall I say,
16 doctors into general management. The regional
17 philosophy, the philosophy that was being promulgated at
18 regional level in the many seminars that took place,
19 because I have to say, this was a regional initiative,
20 the view was taken that management was about resources
21 and there would be General Managers, Unit General
22 Managers, managing resources.
23 On the other side, there would be another health
24 service which was individual doctors treating individual
25 patients on a one-to-one basis, and it was recognised at
0046
1 that time that that was the way the Health Service had
2 always been, and there was said to be an unhappy
3 interrelationship whereby the Manager endeavoured to
4 influence patient care and the decisions on patient
5 care, and endeavoured to keep them within budget, and
6 the clinician tried to influence the management of
7 resources clearly in order to get more, so he could
8 exercise his clinical freedom. That was the recommended
9 management at that time by region -- or the regional
10 management experts that had been brought in, perhaps
11 I ought to say.
12 Shortly before that time, or around that time, can
13 I just say a major London teaching hospital had run into
14 very severe overspending difficulties and the management
15 which was managing resources made major cuts across what
16 was then the district, across the teaching hospital, in
17 the usual way to redress the situation. The medical
18 consultant staff, the clinical consultant staff, were
19 very displeased about this. I think they went to John
20 Hopkins, it may have been another American hospital and
21 had come back with the concept of clinical directorates
22 and had implemented them, as their way of addressing
23 what they found to be an unacceptable position in their
24 hospital.
25 This was not a secret, we all knew what was
0047
1 happening. There was no doubt that seemed to be an
2 admirable way of moving forward. We discussed it at
3 great length up and down, across the district, and there
4 were many issues and many problems to be resolved before
5 they could be introduced, but we pursued that as the
6 desirable aim to complete the introduction of general
7 management and to link the clinical directorates to the
8 contracts which seemed to be going to be negotiated in
9 the future. So that is what we did. It took time --
10 a long time.
11 Q. So far as the control of operations was concerned under
12 the Trust -- Mrs Maisey, your Director of Operations --
13 she would look after, would she, the management side and
14 the clinical side would be looked after by the
15 clinicians?
16 A. No, not strictly. Margaret Maisey had been a unit
17 General Manager and the Chief Nursing Adviser. You will
18 recognise that if you introduce the general management
19 function, then there is no managerial role for
20 a District Nurse, because nurses are managed by General
21 Managers.
22 When we became a Trust, along with other Trusts --
23 large Trusts -- there was a problem of what an
24 appropriate role would be for the nursing director, the
25 Director of Nursing, on the Trust Board, because as
0048
1 I explained, by definition she could not manage
2 nursing. That, and the general management function
3 could not co-exist. A number of solutions were produced
4 across the country on how to develop a role for the
5 Director of Nursing, so when we became a Trust, which is
6 after we created directorates, we agreed, following
7 a lot of discussion, not just woke up one morning and
8 said "That is what we will do", but we agreed that an
9 appropriate role for her would be a Director of
10 Operations.
11 In the many discussions about the
12 interrelationship between the Directorate General
13 Manager and the Clinical Director, the suggestion
14 emerged -- I remember who made it -- that we should not
15 argue about who was accountable to whom; that was
16 a sterile conversation; we should put them in the
17 managerial bubble and say between them, they would
18 manage the Directorate. That is how it started. The
19 bubble was accountable to me.
20 As time went on, over the next three years or so,
21 it became clearer that the Clinical Director would be
22 accountable to me and the Manager would support the
23 Clinical Director, so that was an evolutionary thing,
24 but it was in order to overcome considerable anxieties.
25 You will remember that for the very first time we were
0049
1 introducing consultants into the general management
2 function. I am sorry if I have not made that clear.
3 Q. You have indeed. I think we can trace a stage in the
4 evolution if we look at HA(A) 47/20: can we go down, and
5 can we go overleaf, please?
6 This is a document which we saw from the first
7 page is a letter from you to Catherine Hawkins?
8 A. Yes.
9 Q. It is dated 31st August 1990. You say, at the
10 letter D in the margin, you have been pleased to accept
11 the advice of the medical staff on the clinical
12 directorates appropriate for Bristol. "I enclose an
13 amended copy of a paper presented to the last meeting of
14 the District Health Authority listing the names of the
15 proposed directors". You deal with associated
16 directors. The Clinical Directors, you say in the
17 middle of the paragraph, "excluding the associated
18 directors, are expecting to meet regularly with the
19 Chairman of the Medical Committee (Medical Director) as
20 a Policy Board, which will elect its own Chairman and
21 will advise the provider board. The Director of
22 Operations (Margaret Maisey) and her deputy ... will be
23 in attendance at this meeting."
24 So that is the way in which the Clinical Directors
25 report, or devise policy is it?
0050
1 A. I am sorry, that was the intention at that time. It did
2 not materialise in that way. As I say, things kept
3 altering. That obviously antedated the suggestion that
4 was made that the managers and Clinical Directors should
5 be in a bubble. It also was at a time when we thought
6 the provider board would meet and elect its own
7 Chairman, because that did not happen, they met under my
8 Chairmanship.
9 That was at a stage where I was keeping the
10 Regional General Manager alive to the major changes
11 which were happening there; it was not just Clinical
12 Directors, we were creating two provider units,
13 a purchaser unit, a directly managed unit, which was the
14 ambulance service, and moving the supplies service from
15 the district to the national supply service. So there
16 was a great deal going on, and we had, in shadow form,
17 what was to emerge as a purchasing District Health
18 Authority and two Trusts.
19 Q. The next paragraph:
20 "Each Clinical Director will be supported by
21 a General Manager, who will be directly accountable to
22 the Clinical Director."
23 A. Yes.
24 Q. From what you were saying a moment or two ago --
25 A. It did not materialise.
0051
1 Q. That is what I wanted to ask you about. You were
2 telling us about the bubble, but this is not of course
3 the bubble, is it?
4 A. The bubble emerged. This was me keeping Catherine
5 Hawkins up to date. If you look at the beginning,
6 I expect it says, "I am reporting on the evolution of
7 the new structure."
8 Q. Let us go back to the previous page, so we can see that.
9 A. Yes.
10 Q. "I am pleased to provide further details of the
11 continuing evolution of the management structure. This
12 does not describe the definitive introduction of the
13 Trust status."
14 So back to page 21, just so I understand the
15 pattern in which this developed, the idea at this stage,
16 this being August 1990, was for there to be a clinical
17 directorate system?
18 A. Yes.
19 Q. You had been advised about that by the medical staff and
20 had accepted the advice that they gave you?
21 A. Yes.
22 Q. The clinical directorate was to be run -- I will use
23 that word and come back to it -- by the Clinical
24 Director supported by the General Manager accountable to
25 the Clinical Directors, so the Clinical Director was in
0052
1 charge?
2 A. That was the intention at that time.
3 Q. What you I think were telling us was that --
4 A. It did not materialise. We changed that and said what
5 we would do was to recognise the joint capacity of the
6 two people and they would be in a bubble. It worked
7 very well. As you know, pairing people to address
8 a major task is a very successful way of managing.
9 Q. Did I understand from what you were saying a little
10 while ago that the bubble changed so that the General
11 Manager in fact reverted to something of the role that
12 we see here?
13 A. Yes. I do not think at any stage I ever recall saying,
14 "Today we are going to remove the bubble". I am saying
15 the evolution of this system, people eventually became
16 comfortable with that which at the outset they were
17 extremely uncomfortable, so it developed as an evolution
18 of management style, and I was very happy for it to
19 evolve that way.
20 You see, if you introduce something that is, shall
21 I say, devastatingly new, as to the general management
22 function, including doctors, you have to take them along
23 with you very enthusiastically, because if we impose it,
24 the first time there is a difficulty, they will all
25 reject it as a silly idea and negate it. So it was very
0053
1 important for me to discuss with them the precise
2 structure of directorates, which could have been based
3 on architecture, on hospitals, on divisional
4 arrangements, or on service arrangements and we had
5 a very effective mixture of those three divisions, so we
6 identified which directorates there would be. I invited
7 the medical staff to nominate, to recommend, Clinical
8 Directors to me, and I approved them; I reserved the
9 right to refuse a nomination if I thought it was
10 inappropriate.
11 Q. Did you in fact ever do so?
12 A. I think I influenced the nominations to make sure that
13 necessity did not arise. I do not think it would have
14 been a happy way, but I had to reserve that right, but
15 you remember that I had been part of the medical bodies,
16 I had been a Chairman of them, and I had the ability to
17 influence them for good.
18 Q. So this is an example of the networking which you were
19 describing earlier, keeping your finger on the pulse,
20 not only receiving information but entering into
21 discussions, communicating yourselves with those who
22 might be influenced?
23 A. I attended every Medical Committee and took part in
24 their discussions and explained things to them as
25 necessary. I visited divisions, I had done as Chairman
0054
1 of the Medical Committee, I did as the District General
2 Manager; I was very close to them. This was something
3 which emerged; this was something that we all,
4 consultants, non-medical staff, all came to support and
5 accept and enthusiastically implement. It is not an
6 imposition, is what I am saying.
7 Q. I will come back in a moment if I may, to the
8 relationship between the Clinical Director and the
9 General Manager, but since the question was raised of
10 who was the Clinical Director, you had, or the Trust
11 had, an approach, did it, that it was looking for
12 leadership in the clinical directorates and that
13 leadership was, as I understand the concept, something
14 which would be recognised by one's fellows and so the
15 leader would evolve.
16 Is that an inadequate understanding?
17 A. I am not sure I recognise what went on as what you are
18 saying. I discussed at great length in a number of
19 fora, with large numbers of people, the concept of
20 clinical directorates, their structure and their
21 development, and then I asked what was effectively the
22 divisions, but it did not quite match. I asked the
23 medical staff to propose the names of the Clinical
24 Directors they would recommend to start off with.
25 I asked them for their recommendations; I received them,
0055
1 I confirmed them, and they were Clinical Directors.
2 Q. So there was no process of election as such?
3 A. I do not know whether they were elected. I mean, I have
4 to say that I was technically elected to be Chairman of
5 the Medical Committee, but no election took place, I was
6 the only candidate, so I do not know how many times
7 there was a competition resolved by election and how
8 often there was general agreement on a name with no
9 other name forthcoming because that person met the
10 acceptance of all the staff, but they made the
11 nomination. I suppose you could technically say it was
12 on a democratic basis, but I do not think they had
13 closed elections in any division. But the nominees had
14 the full support of their colleagues. That was
15 important.
16 Q. I am sorry to be technical, Dr Roylance, but when you
17 sit back, by all means do so, can you bring the
18 microphone with you? I am afraid it means you are
19 slightly less comfortable than you ought to be. I am
20 sorry for that.
21 A. I am sorry, I was trying to relax and still concentrate
22 on you.
23 Q. If you want to do that, just pull the microphone
24 a little towards you.
25 A. Please tell me if it does not work.
0056
1 Q. It is not a problem for me, but it is a problem I think
2 for others.
3 A. Thank you very much.
4 Q. Not at all. The relationship between the Clinical
5 Director and the General Manager you have described in
6 part obviously as an evolving theme. Roughly when was
7 it, would you say, after this that the General Manager
8 ceased to be regarded as being in a bubble and the
9 system reverted to that which had, at this stage, been
10 envisaged?
11 A. I do not know. I do not think it happened on one day.
12 It would be quite misleading to tell you when it
13 happened, because each partnership of Clinical Director
14 and General Manager, Director and General Manager,
15 formed a working relationship which was based upon their
16 individual expertises and abilities, and their
17 willingness to undertake tasks. They developed the role
18 together. Slowly, as I think was predictable, and
19 probably directorate by directorate, they found it
20 easier to converse and to be understood by others if it
21 was absolutely clear that the Clinical Director took
22 final responsibility and the General Manager's
23 responsibility was to make them successful. But I do
24 not think it happened on a particular day, so I think it
25 would be wrong to give you a date.
0057
1 Q. I appreciate the point. It was only a broad indication
2 of the time.
3 A. Some time between their creation in 1990 and the time
4 I retired in 1995.
5 Q. The development of the change, the evolution, I was
6 going to ask, and you rather anticipated it by saying it
7 may have been on a directorate by directorate basis?
8 A. Yes, I think when you create something new you have to
9 support it and help it; when I say "it", help the people
10 to develop their relationship, to address the task they
11 have, and their relationship develops. As I say,
12 inescapably, in the end the Clinical Director was seen
13 to be the lead and the General Manager to be in
14 support. I think Peter Durie always took the view, and
15 I think it was a good analogy, but not, as with all
16 analogies, entirely correct, he looked upon the Clinical
17 Directors as the Chairmen of the Directorates and the
18 General Manager as the Chief Executive of the
19 Directorate. In some ways, the directorate structure,
20 apart from the non-executive directors, was much more
21 akin to what had been envisaged for whole Trusts.
22 Q. The pace of evolution, the pace of the change from the
23 bubble to the line working or the separation of the
24 executive and chairmanship functions, did it proceed at
25 different paces in different directorates?
0058
1 A. Oh, yes.
2 Q. Was this a reflection of the fact, as I understand it to
3 be, unless you tell me to the contrary, that the
4 directorates were effectively self contained; they had
5 autonomy?
6 A. No. It was because they had different personalities in
7 them. I do not understand the "self-contained" bit.
8 They were all parts of the Trust. But they were parts
9 of the Trust in which operational decisions had been
10 delegated to operational level. It does not make them
11 separate.
12 Q. So the directorates, each of them, developed at their
13 own pace, depending upon personalities?
14 A. Yes.
15 Q. And if we look at the next sentence on the screen, the
16 General Managers, it was envisaged at the time of this
17 letter, "will meet regularly with the Director of
18 Operations and her deputy as a managers' group which
19 will facilitate the effective general management support
20 for all the Clinical Directors."
21 Is that something which happened or did not
22 happen?
23 A. Yes. She set up a regular monthly meeting. I think it
24 was monthly. I went to a number of them. The purpose
25 of that was to assist the General Managers to develop in
0059
1 their roles, and to facilitate communication, so it was
2 a direct relationship between, if you like, board level
3 information and directorate information, and Margaret
4 Maisey assisted me to a very great extent in supporting
5 the General Managers. They were not accountable to her
6 in any accountability sense, but she did give them
7 a great deal of managerial support.
8 Q. So they met with but were not accountable to her?
9 A. No, they were initially jointly accountable to me, and
10 eventually, as I have explained, were accountable to the
11 Clinical Directors who were accountable to me.
12 Q. And the meeting with her was used as a means of
13 transmitting information up and down the management
14 chain?
15 A. Most meetings are, if you analyse them, more
16 a communication-making exercise than a decision-making
17 exercise.
18 Q. How do the Clinical Directors report to you?
19 A. I met them monthly in what became known at some point as
20 the Management Board. They were responsible for the
21 clinical directorates and were responsible to me, and we
22 met formally once a month when I conveyed information at
23 board level to them and they conveyed information from
24 operational level to me, and we discussed issues that
25 transcended individual directorates.
0060
1 Q. Can we have a look, please, at UBHT 110/547? This is
2 24th July 1991, a little bit after, therefore, the
3 letter we have just been looking at, minutes of the
4 meeting of the Management Board. It is very shortly
5 after, a matter of 3 months after the Trust began,
6 because it began on 1st April 1991?
7 A. Yes.
8 Q. Can we scroll down, please?
9 This looks rather like the first meeting of the
10 group; I do not know, it may not have been. "Dr Roylance
11 suggested it would be appropriate for the group to be
12 called the Management Board."
13 A. I know for certain it was not the first meeting, because
14 the first meeting was chaired by the Medical Director
15 elect, who was Mr Dean Hart, and I was in attendance.
16 We started with that as the concept, but we felt that
17 inappropriate and at some stage, after two or three
18 meetings, I became the Chairman of that meeting.
19 I think it was a gentle way of introducing them, so that
20 they started off being chaired by their own Medical
21 Committee Chairman, and then chaired by me. This was an
22 evolution, a fairly sensitive delicate evolution, but it
23 was successful. So that was not the first meeting, by
24 any means.
25 Q. You say in the second line that you saw the purpose of
0061
1 the Board as being:
2 "He [this is you, I think] explained that he saw
3 the Board as the vehicle through which he would meet his
4 responsibilities to implement the policy of the Trust
5 Board. The Board would receive policy decisions from
6 the Trust Board and would advise the Trust Board on the
7 development of future policies."
8 That was the role, was it, as then envisaged?
9 A. At that time, yes. What we had to do, and I think the
10 then Chairman of the Trust was quite explicit about, was
11 to draw the box, the limits within which directorates
12 would have total freedom. He used to give a different
13 name to each side of the box, I have forgotten what they
14 were, but the concept was that we would define the
15 limits of the freedom of action within which they could
16 exercise operational judgments, but beyond which they
17 could not go. One, for instance, was that they could
18 not overspend. They did not have the authority to spend
19 money that did not exist.
20 So this is all part of the evolution and education
21 of how the system should work, and because it was new,
22 it was introduced before it was secure. We did not
23 train Clinical Directors and then say, "You will start
24 being a Clinical Director when you are trained", as
25 happens in a stable situation; we had to, as I say,
0062
1 appoint them and then develop the role and define it,
2 and even define the limits of the directorate. So this
3 was a very interesting evolution into a new management
4 system.
5 Q. How did the Management Board evolve from the position as
6 recorded in the first paragraph?
7 A. I think all that describes in the first paragraph is
8 that it was a mistake to call this a "Management Policy
9 Board" as if that board itself was determining policy.
10 The Board which determined policy was the Trust Board.
11 It was also important not to allow that board to
12 be an Executive Board to which Clinical Directors
13 brought problems and made corporate decisions. It was
14 not an Executive Committee that itself made decisions.
15 In the general management philosophy, the General
16 Manager or in this case the Clinical Director who was
17 assuming the General Manager function had to retain
18 personal responsibility for the decisions that were made
19 and it was not possible to let them fudge it and say
20 "Nothing to do with me, the Management Board made the
21 decision".
22 So that evolution was terribly important: I mean,
23 doctors up to that stage actually made policy and we had
24 to slowly develop the idea that it was the Trust Board
25 that agreed policy, on the advice of the management,
0063
1 through the Management Board, and the professions
2 through professional advisers, so that it was a properly
3 made decision, but this was a communication function in
4 which I made sure that at least once a month I would
5 meet them all together and we would discuss issues and
6 they would discuss issues from their point of view and,
7 as I say, resolve issues which transcended the
8 directorate structure.
9 From time to time, we decided we really ought to
10 have all the General Managers there, to shorten
11 communication lines, and then we decided that the
12 meeting was now too big to be effective, so we divided
13 it again. It had a definite evolutionary characteristic
14 to it.
15 Q. Can we have a look on the screen, please, at
16 UBHT 110/368?
17 We had better go back to see the start of the
18 document.
19 This is the Management Board, 27 November 1991, so
20 another four months further on.
21 Can we go back now to 368 and scroll down,
22 please?
23 "Any other business: (a) Dr Roylance was
24 concerned there should be no misunderstanding that this
25 Management Board should be a channel of advice from
0064
1 Clinical Directors to the Trust Board. He was anxious
2 that this should be a formal and productive advice
3 process."
4 Can we go over the page so you can be satisfied
5 nothing else follows, and back to 368.
6 It is described there as "a channel of advice from
7 Clinical Directors to the Trust Board"?
8 A. Yes.
9 Q. The way you described it a moment ago is that it was
10 communication working both ways?
11 A. Yes. That is one of those ways, is it not?
12 Q. Absolutely. Do I take it that this is only emphasising
13 one of the directions in which the communication was
14 travelling?
15 A. Oh, yes.
16 Q. And you were not, therefore, intending to say it is just
17 to advise the Board and not to receive --
18 A. I expect at the beginning of that one, if not at the
19 end, or another one, you will see that I made my report
20 to the Clinical Directors, but I do not think there was
21 any doubt that one of the functions of that meeting was
22 for me to bring them up to date with the very latest
23 thinking at Trust Board level, regional level, and so
24 on, to inform them. That implies -- I cannot remember
25 the precise meeting -- it is a very brief minute, a nice
0065
1 gentle minute, but I am sure I was urging them to make
2 sure that they used this meeting effectively to ensure
3 that I understood all their issues and all the advice
4 that they wished to make.
5 Q. Something must have led to your concern about potential
6 misunderstanding.
7 A. I was always concerned about potential misunderstanding.
8 Q. But to express it specifically?
9 A. I imagine so. I do not know.
10 Q. You cannot now recall what it might have been?
11 A. Please, I do not think I quite have given you to
12 understand, this was an educational development process
13 in which we were constantly endeavouring to improve both
14 our understanding of the structure and improve the
15 structure itself. So I would not see that as in any way
16 untoward; it was part of the educational process. I am
17 quite sure at that time we had a detailed, if you like,
18 mini seminar on what the function of the committee was,
19 what the function of the meeting was.
20 Q. When, in 1991, the Trust became a Trust, there were the
21 13 or the 14 clinical directorates. First of all,
22 Mr Boardman's point was that he considers this was,
23 putting it broadly, too many for a Chief Executive and
24 Board to manage efficiently and effectively. I am
25 putting it crudely in my own words, but you have seen
0066
1 the passage from Mr Boardman's statement. By all means,
2 we can go and look at it.
3 A. He must be pursuing the administrative orthodoxy that
4 you can only manage six people. That is not true, but
5 it is truly said in a number of books on structure and
6 there was a time when, and I think the Salmon structure
7 of nurses was one, a massive triangle of management was
8 created in order that each person managed 6, each of
9 whom managed another 6. It is not true to say there was
10 any difficulty because of numbers in supporting and
11 developing 13 Clinical Directors and their General
12 Managers. It is much smaller than the average school
13 class number, when a teacher is developing them, so I do
14 not believe in the philosophy. I think I and a lot of
15 other people, have demonstrated it to be wrong. There
16 are others who say that you can only know 80 people, up
17 to 80 people, personally and individually, and there are
18 conclusions drawn from that. I do not think 13 is too
19 big a span of support unless you are trying to
20 second-guess all of them and monitor their every
21 action.
22 Q. I suppose it must depend what you intend to do with the
23 13 and one's concept of management, possibly?
24 A. In management jargon, there is the "control and command"
25 style of management and the "empowerment" style of
0067
1 management. I think almost nobody believes that command
2 and control management is appropriate and that the
3 empowerment style of management is the one that is
4 effective. I am using short term management jargon and
5 I apologise for that, but I do not think this is the
6 appropriate time to have a seminar on management.
7 Q. No, I am quite sure that those who listen who need to
8 know will understand what you have in mind.
9 A. Can I just say, and I do not mean to be snide, I do not
10 look upon Steve Boardman, for whom I have a great deal
11 of respect, as an expert on general management of
12 a large Trust.
13 Q. At a later stage, the Director of Cardiac Services
14 developed. I want to trace with you the way in which
15 that began and developed.
16 At the time that the Trust became a Trust, am
17 I right in thinking that cardiology was part of the
18 Directorate of Medicine?
19 A. Yes.
20 Q. That paediatric cardiology was part of the Directorate
21 of Children's Services?
22 A. Yes.
23 Q. And that paediatric cardiac surgery was part of the
24 Directorate of Surgery?
25 A. Paediatric cardiac open heart surgery, yes, it was.
0068
1 Q. So if one was focusing upon the care of a baby or
2 a child with congenital heart disease, the care would
3 come under two directorates: the Directorate of
4 Children's Services for cardiology?
5 A. Yes.
6 Q. And if open heart surgery was required, the Director of
7 Surgery?
8 A. That is right. Can I just say, that was a reflection of
9 the actual reality. When paediatric cardiac surgery was
10 started, it was considered that the essential expertise
11 that was needed to be concentrated was that of cardiac
12 surgery and they were performed right across the country
13 by surgeons, cardiac surgeons, who performed operations
14 on adults and children.
15 In other specialties, that is still the case, but
16 as more and more neonates were operated upon, it became
17 increasingly apparent that a paediatric facility was
18 more important than a cardiac surgical facility.
19 Therefore, paediatric cardiac surgery was, as soon as we
20 could, moved to the Children's Hospital to a paediatric
21 environment, and a little time before that, adult
22 cardiac surgery was merged managerially with adult
23 cardiology. The Directorate of Cardiac Services,
24 strictly speaking, should have been called the
25 Directorate of Adult Cardiac Services, and was, shall
0069
1 I say, independent of the moves in paediatric services.
2 Q. Can we then have a look at DOH 200/95? I will have to
3 come back to that. UBHT 7/127, please. 13th May 1994.
4 Can we scroll down? It is the Executive Committee. Can
5 we go over the page, please?
6 "(d) Cardiology and cardiac surgery. For the last
7 12 months, cardiology and cardiac surgery had been
8 combined as the Associate Directorate of Cardiac
9 Services, but still linked to the Directorate of
10 Surgery. From 1st April, the Director of Cardiac
11 Services will become a directorate in its own right with
12 Professor Vann Jones as Clinical Director and
13 Miss Lesley Salmon as General Manager. The Trust is
14 working towards the same arrangement for
15 gastroenterology."
16 So this is recording, as I understand it, that
17 a year from the beginning of 1993, cardiology and
18 cardiac surgery had actually been combined as an
19 associate directorate and that was going to become
20 a full directorate.
21 Can you help me with how it worked linking
22 cardiology which was part of the Directorate of
23 Children's Services for paediatric cases and Medicine
24 for adult cases, and Cardiac Surgery, which was part of
25 the Directorate of Surgery, how that had worked as one
0070
1 associate directorate underneath the Directorate of
2 Surgery for a year?
3 A. Perhaps I should say, this was the attempt to introduce
4 into Bristol what was very successful in being the way
5 these services had developed in some parts of the
6 country and that was to structure the care provided in
7 relationship to patient groups rather than professional
8 groups, so that, instead of having physicians offering
9 a service with a separate contract for heart disease in
10 adults, and what was actually across the other side of
11 the main road, a structure of cardiac surgery offering
12 surgery to the same patients that we should provide
13 a single service for patients with heart disease. And
14 that we should attempt to combine their budgets, and in
15 the fullness of time, negotiate a single contract with
16 the purchasers for patients with heart disease.
17 I think the benefit of that is significant, but
18 there were considerable difficulties in persuading the
19 constituent elements that that was a better way of
20 grouping on patient need, rather than on professional
21 groupings, so it took some time. We did it, again,
22 slowly. We slowly identified that element of cardiology
23 from within the Directorate of Medicine, identified the
24 staff it meant, the budget it meant so we could, in
25 a sense, define a border between that which was going to
0071
1 move, and we moved it across managerially to be part of
2 the Directorate of Surgery which was on the other side
3 of the road, and at the same time we were trying to
4 define the budgetary and staff and, if you like,
5 geography limits of the Department of Cardiac Surgery so
6 that we could combine them managerially with the
7 intention, then, of combining them physically into
8 a single unit.
9 But that is a major change, it requires a lot of
10 support, requires a lot of discussion and has to be done
11 quite slowly. I am quite sure that the creation of
12 directorates, if you tried to do it then, we would set
13 the whole directorate enterprise back by a considerable
14 time.
15 So one of the issues in management is to identify
16 the right timing; it is not always possible to know when
17 it is the right timing, but you very soon know when it
18 is the wrong timing.
19 Q. If I can put a bit of flesh on this, as it were, suppose
20 there was a particular problem with inappropriate
21 behaviour by one of the nursing staff towards
22 a patient. Suppose the patient is a child who is
23 suffering from congenital heart disease, or it may be an
24 equipment failure -- let us take those two separate
25 examples -- and suppose that the nursing failure is
0072
1 really a failure to attend as and when attendance should
2 have been provided to the child.
3 Who, when the Trust began, would have had
4 immediate responsibility for, first of all, the nursing
5 failure, and secondly, the equipment failure?
6 A. As I said, we had devolved operational management
7 decisions to operational level, so the immediate
8 response would be for the appropriate operational
9 managers to deal with the problem, but they would get
10 very substantial support from, in the case of nurses,
11 from the nurses professional advisory structure and from
12 Margaret Maisey, who would know, I think, faster than
13 anybody would have known and would have been very
14 supportive to solve the problem. For an equipment
15 matter, we would almost certainly have called in MEMO,
16 which was our own Medical Equipment Management
17 Organisation.
18 So there would have been an immediate constructive
19 response which would have resolved the situation.
20 I cannot tell you precisely what it would be, because
21 you have not, and cannot, define specifically enough for
22 me to tell you what the response would be, but can I say
23 from time to time these things did happen and they were
24 dealt with.
25 Q. It is responsibility and accountability that I wish to
0073
1 examine, and I appreciate the inadequacy of many
2 hypothetical examples, but initially I think what you
3 are saying is that the responsibility for the actions
4 would go to the immediate manager of the nurse concerned
5 or the equipment concerned?
6 A. Yes. The Clinical Director was responsible for
7 everything that happened in his directorate. He had
8 a substantial amount of support, but in terms of
9 accountability, he or she was accountable to me for the
10 proper conduct of affairs within the directorate. So
11 the accountability line was quite clear. The, what
12 shall I say, "solution" to the problem would depend upon
13 the problem.
14 Q. So responsibility with the Clinical Director for the
15 nursing failure; for the equipment failure as well, or
16 not?
17 A. Everything that happened in his directorate, he was
18 responsible for. I do not mean that it was his fault or
19 he was to blame, but he was responsible for dealing with
20 the matter. If you talk about equipment failure, if
21 a piece of equipment blows up, you can hardly say to
22 a Clinical Director "It is your fault it blew up", but
23 you can say to him "It is your fault it was not dealt
24 with".
25 Q. Suppose the hypothetical example of the nursing failure
0074
1 or equipment failure happens on an intensive care ward.
2 The intensive care ward may have, in its staffing,
3 consultant anaesthetists; it may have intensivists, it
4 may have consultant surgeons who have operated upon the
5 child, let us suppose, who is in the intensive care, and
6 each of those would have a different directorate to
7 report to, would they?
8 A. No, no. I mean, you have not been specific enough.
9 There was an intensive care unit which was the
10 responsibility of the Director of Anaesthesia; there was
11 a cardiac intensive care unit which was the
12 responsibility of the Associate Director of Cardiac
13 Surgery. There was no part -- there was in the first
14 few weeks, but one of the things we were very careful
15 about for a whole variety of reasons is that every
16 square metre of the Trust and every individual in the
17 Trust knew which directorate they were in -- I am sorry,
18 we knew which directorate the square metre was in --
19 I do not want to say something quite stupid, but we knew
20 the specific content of every directorate.
21 Q. So the nurse on the ITU would have no doubt to which
22 directorate he or she belonged?
23 A. She should not have. I mean, with 7,500 staff, I cannot
24 say that every member of staff was up to date with
25 everything, but we certainly tried to make sure they
0075
1 were.
2 Q. And there should be no doubt about the responsibility
3 and accountability of the Clinical Director for --
4 A. No doubt at all.
5 Q. -- any action and to you for that action. And I suppose
6 you ultimately had the overall responsibility for
7 everything that happened in the hospital and Trust, did
8 you?
9 A. Yes, and I was accountable to the Secretary of State for
10 health who was responsible for everything that happened
11 in the Health Service.
12 Q. Audit was devolved, was it, to the clinical
13 directorates?
14 A. I am sorry, could you rephrase that question? It does
15 not actually mean -- when you say "audit", we started
16 with --
17 Q. The resources for audit were devolved, were they, to
18 directorate after directorate, individually?
19 A. That is where the staff were, and that is who had the
20 pay structure, yes. There was nowhere else to put the
21 money.
22 Q. So if the responsibility that we were considering was
23 not a nursing failure or an equipment failure but was
24 a responsibility for carrying out audit, that would
25 again be the responsibility of the appropriate Clinical
0076
1 Director, would it?
2 A. Eventually. It was not at first. It is a complex
3 evolution and I have not recently reviewed all the
4 papers, but I do know that when medical audit was
5 introduced, it was introduced on the professional line,
6 not the managerial line. The then Regional Medical
7 Officer, in conjunction with the Regional Hospital
8 Medical Advisory Committee, made a series of proposals
9 directly to the divisions, which was the medical
10 consultant advisory machinery, not to management, to
11 develop audit. So it started on that axis. Slowly, the
12 responsibility of management emerged to facilitate that
13 professional activity.
14 Does that answer your question? It is the start,
15 anyway.
16 Q. It is the start. I will come back to it if I may, and
17 build upon that which you have given us.
18 Turning for a moment from the hypothetical example
19 I have used to what we have on the screen, you focused
20 upon the development of the Directorate of Cardiac
21 Services. Could we, please, have the statement of
22 Dr Vann Jones? You will have to give me a moment while
23 I find the reference. We think it is WIT 107 -- it is
24 WIT 115, I am grateful to Mr Maclean. I am sorry for
25 the hiccup; we have not had very many of them.
0077
1 Professor Vann Jones was the first Clinical
2 Director, was he, of cardiac services?
3 A. So I recall, yes.
4 Q. Page 2 of his statement --
5 THE CHAIRMAN: Mr Langstaff, may I interrupt for a moment?
6 Has Dr Roylance had an opportunity to see this?
7 MR LANGSTAFF: I do not think he has. I am going to take it
8 slowly.
9 THE CHAIRMAN: Perhaps either that, or over the luncheon
10 adjournment one could come back to it later?
11 MR LANGSTAFF: Certainly. Let me tell you what I would
12 wish you to comment on, so you may have it in mind. It
13 may be that you want time to look at the statement as
14 a whole and if so, by all means, you will have it.
15 Can we go down to paragraph 7?
16 He says this:
17 "In its initial stages, the Directorate of Cardiac
18 Services was little more than a concept. The paediatric
19 cardiologists ..."
20 He sets out what had happened. You told us that.
21 "I and my General Manager, Lesley Salmon, had to
22 try to establish what form the new Directorate of
23 Cardiac Services would take, e.g., would it include the
24 cardiac anaesthetists and/or the cardiac radiologists,
25 or would they remain with the Directorate of
0078
1 Anaesthetics and Radiology respectively."
2 He describes it as "little more than a concept, in
3 its initial stages". I think he is talking about 1993
4 there, but he may not be. How far would you accede to
5 that description?
6 A. It was bound to start as a concept. It was something
7 that I personally, not uniquely but I personally, was
8 very supportive of, that we should try and create
9 modified clinical directorates as far as we could to be
10 patient based, disease based, and not professional
11 based. Now that is very easy to say, extraordinarily
12 difficult to define. The definition has to be made by
13 the experts in the field, as what they feel is the
14 minimum content of a viable directorate.
15 Let me take something that is mentioned there as
16 an example. You mentioned radiology. The cardiac
17 radiologist at that time was a specialist cardiac
18 radiologist who did virtually nothing but cardiac
19 radiology. But his department was within, physically
20 and supported by, the Directorate of Radiology. So that
21 he took advantage of the pool of radiographers, the
22 filing system, all the accoutrements of an x-ray
23 department. There were very serious discussions and
24 I do not think there is a right way and a wrong way, of
25 whether it was possible to annex the cardiac
0079
1 investigation rooms with the cardiac radiologists and
2 make them managerially part of the new Directorate of
3 Cardiac Services, or whether it should remain part of
4 the Department of Radiology servicing the Directorate of
5 Cardiac Services. What makes it even more complicated
6 is that a substantial number of the cardiac
7 investigations performed on the x-ray equipment in the
8 x-ray department were performed by cardiologists. So
9 the optimal way forward was a matter of judgment and
10 discussion, and that had to be led by the director
11 designate of Cardiac Services.
12 So we must not confuse the development process and
13 the achievement of a directorate with the successful
14 running of a created directorate. There was
15 considerable time, and as far as I remember rightly,
16 I may be wrong, we had managed to achieve a viable
17 Directorate of Cardiac Services before I left.
18 Q. I do not wish to confuse the development process with
19 the stable directorate, once established. What
20 Professor Vann Jones appears to be describing there is
21 his appointment as Director -- if there is going to be
22 a Director of Cardiac Services, he is appointed, the
23 appointment of his General Manager, Lesley Salmon, he or
24 she is appointed, and having appointed them to be
25 Director and General Manager of the cardiac services, it
0080
1 would appear from what he describes in the last sentence
2 that no-one actually was very clear as to what it would
3 comprise?
4 A. Well, we had not defined the limits. To say we had not
5 defined the limits and equate that with 'nobody had any
6 idea what it would be', is slightly over-egging it.
7 There was a whole series of issues like radiology, but
8 we did know it was going to be a directorate that was
9 going to serve the needs of patients with heart
10 disease. It says here, I and my General Manager, Lesley
11 Salmon, the same paragraph, had to try to establish what
12 form the new Directorate of Cardiac Services would take,
13 and that is what I asked them to do.
14 Q. If we go down to the last paragraph on the page:
15 "As far as paediatric cardiology and paediatric
16 cardiac surgery were concerned, I never envisaged that
17 they would be part of the cardiac services directorate
18 which I perceived as an adult service."
19 A. Yes.
20 Q. So what Professor Vann Jones appears to be saying is
21 that he was appointed to do a job; the margins, from
22 your last answer, were fuzzy, because they were being
23 developed and described, but here one might have thought
24 that a decision would have been made perhaps at Trust
25 Board level, or --
0081
1 A. They did not know anything about cardiac services;
2 please, can I interrupt because your philosophy and
3 concept is wholly ill-founded. The expertise on what
4 should be a Directorate of Cardiac Services lay with the
5 providers of cardiac services. There was no expertise
6 with the Trust Board or in my hands as to what was the
7 better relationship, whether parts of it should be
8 within or without. The people I charged with making
9 recommendations as to what the content and what the
10 structure and what would be a viable Directorate of
11 Cardiac Services were to be led by John Vann Jones,
12 supported by Lesley Salmon. They were charged with
13 making -- we gave them a great deal of help and
14 I discussed with them and helped and so on, but it would
15 be a complete misunderstanding to think that -- I could
16 name them -- but the members of the Trust Board had any
17 expertise whatever to offer on what the precise content
18 of the Directorate of Cardiac Services should be. So
19 when you say to me, you would have thought the Trust
20 Board would have made the suggestion, I have to say,
21 that is wholly misguided.
22 Q. I am grateful for being corrected, but the answer you
23 have given, I think, is one which I had anticipated that
24 you might. It is consistent, as one might see it, with
25 the view taken that if the clinicians essentially dealt
0082
1 with matters of clinical responsibility and
2 organisation, that they should, between themselves,
3 decide what was the proper compass of such
4 a directorate. Have I got it right or not?
5 A. I did not say that. I said they should lead on the
6 subject. That is very different from saying "There you
7 are, teach yourselves, I am not interested". They
8 should lead on the subject, and all these, if I may say
9 so, demarcation issues had to be discussed with the
10 people involved in the demarcation. If I can
11 illustrate, seriously, there was quite clearly
12 a possibility, when we introduced directorates, that the
13 anaesthetists should be part of those directorates in
14 which they had their sessions. The anaesthetists, for
15 a whole variety of reasons I do not need to go into now,
16 convinced me and everybody else that that was not
17 a viable arrangement and that there should be a separate
18 Directorate of Anaesthesia, which I believe they still
19 are.
20 For anybody outside, on the basis of virtually
21 total ignorance, to ordain what the structure should be,
22 would not be a mechanism that I could tolerate. But the
23 suggestions and recommendations that emerged from all
24 the work had to be agreed by me and by the Trust Board.
25 Q. So your role, essentially, was to agree the
0083
1 recommendations having been made by those who knew, to
2 you?
3 A. My role was to make them successful, and I did.
4 Q. The way in which it worked was first of all it having
5 been decided that a Director of Cardiac Services was
6 a good idea, the exact content of it was left for those
7 who knew to work out, to recommend to you, for you to
8 agree and the Trust Board beyond you to agree with that?
9 A. Yes. That included, at times, substantial
10 redistribution of ward beds and so on. It was not just
11 a hypothetical structure on a board; it was to create
12 a genuine unit that dealt with adults with heart
13 disease.
14 Q. This is part of the way in which you as General Manager
15 used your approach of empowerment, was it, to manage
16 such a change?
17 A. Yes. I tried at all times to ensure that those experts
18 in a problem were the people who were asked to resolve
19 the problem. One needs a certain amount of judgment to
20 know who are the experts in a problem at times, but it
21 was very important that when we had an issue, that
22 I made sure that those who could solve the problem did
23 so.
24 If I may drop names for a moment, when I was
25 privileged to go and have dinner with Sir John Harvey
0084
1 Jones, I discussed this very issue with him. He was at
2 that time a television personality and a management guru
3 who had written several books. I presented to him
4 several problems like this one and said "What is your
5 advice?" and he said, "You have to give it to the
6 doctors: make sure that they accept it, they respond to
7 it", and I think that amongst others, that was a very
8 sound piece of independent management advice to me.
9 Q. In order to finish that last point, I have rather gone
10 past the 1.15 time which was envisaged. I do not know,
11 sir, whether you want to return at 2.05 or 2.00?
12 THE CHAIRMAN: Let us say 2.00. So we will adjourn now
13 until 2.00, thank you.
14 (1.20 pm)
15 (Adjourned until 2.00 pm)
16 (2.05 pm)
17 MR LANGSTAFF: Dr Roylance, just picking up a couple of the
18 themes that we explored this morning, before we come
19 back to where we were at a quarter past 1, the first is
20 this: under the way in which you personally saw your
21 role as Chief Executive, how would you respond to
22 someone who came as a General Manager and said, "Look,
23 I have a problem with a child". Let us suppose that the
24 child needs surgery; that it is suggested that -- well,
25 let me tell you. Rather than give it to you
0085
1 theoretically, let me give it to you in bones and flesh,
2 as it were.
3 Can we have WIT 89/28 on the screen? This is the
4 statement of Rachel Ferris.
5 A. Yes, I have seen that.
6 Q. You have seen that statement, I know. Can we look at
7 paragraph 75? She is dealing here with whether there
8 was a system for critical incident monitoring or not,
9 but it is the nuts and bolts of the example which
10 follows that I just want to go through, so that
11 I understand what your perspective is on it.
12 She describes an incident in March 1995 -- I am
13 not going to ask you at this stage about the way in
14 which concerns were or were not expressed to you; it is
15 not that which this is aimed at -- involving a child
16 whose parents were concerned about the length of wait
17 for operation. The parents contacted the press. She,
18 Rachel Ferris, was asked by the Press Office to
19 investigate. She spoke to Mr Wisheart, was told the
20 child would have to wait until the new surgeon, Mr Ash
21 Pawade, arrived in May 1995.
22 She was concerned about that in view of recent
23 publicity. She was not offered an up-to-date condition
24 report on the child by Mr Wisheart. She, the General
25 Manager, telephones Dr Alison Hayes, the paediatric
0086
1 cardiologist, and was advised that the operation would
2 be needed soon because the child had been blue at
3 Christmas. So she then asked Mr Dhasmana's advice. He
4 suggests transferring the child to Birmingham, and is
5 asked to arrange it. She feels, and this is the part
6 which I want to ask you about, that that is something
7 that Mr Dhasmana, as Clinical Director, should have
8 taken on and resolved for her, and says that she asked
9 you for your advice. She says this:
10 "I was dismissed from his office [your office] and
11 told not to interfere in clinical decision making, and
12 the child remained on Mr Wisheart's list until 1995."
13 Leave aside what follows, it is the question of
14 the approach, whether what she says is accurate and so
15 on. Let me take it in stages.
16 If such an incident occurred, would your approach
17 have been to say, "This is not an administrative
18 management matter; this is a clinical matter"?
19 A. Not in quite so many words. The solution was clinical.
20 If there was an issue about waiting lists, then the
21 Manager clearly might be involved. But the solution to
22 the problem is that for Dr Alison Hayes to institute,
23 because it was she who had the continuing responsibility
24 of the child and she had the freedom and responsibility
25 to refer that child, wherever she felt that child's best
0087
1 interests would be catered for. Perhaps that is badly
2 worded. It is in the child's best interests, I should
3 have said.
4 There is no way that a manager can transfer
5 a patient. There is a quite clear protocol that doctors
6 receive patients on referral from another doctor, not
7 from a manager.
8 I do not remember this particular incident, it
9 does not stand out in my mind. But I am absolutely sure
10 that I would have explained to her that it was beyond
11 her capacity to refer that child anywhere; that it was
12 for Dr Alison Hayes to make that decision in the light
13 of the fact that she had referred the patient to
14 Mr Wisheart, who had, as far as I understand this,
15 declined to offer an operation but to wait until Mr Ash
16 Pawade arrived.
17 Those were two clinical judgments that had been
18 made. It was certainly proper for the Manager, Rachel
19 Ferris, to make Dr Alison Hayes aware that the parents
20 had presumably expressed concern about having to wait
21 a long time. It was for the Manager to make that
22 information available to Dr Alison Hayes and, if
23 necessary, to arrange with Alison Hayes for the parents
24 to go and see her to discuss the situation of their
25 child.
0088
1 So the answer is quite clearly that management,
2 and Rachel Ferris, did have a role, but it was not her
3 role to take on the clinical management of the case and
4 transfer the child. That was beyond her capacity and
5 I am quite sure no cardiac surgeon would have accepted
6 a patient referred by her. It had to be referred by
7 Alison Hayes.
8 Q. Was she right or wrong to raise the issue with you?
9 A. Managers consistently, as I think I explained this
10 morning, came to me when they had a problem, and it was
11 my philosophy to help them resolve the problem. I do
12 not remember this but it looks as though Rachel Ferris
13 really wanted me to do something quite different and
14 authorise her to transfer the child, or refer the child
15 myself, I do not know what perception she had, but
16 I would have taken time to discuss the issue with her
17 and ensure that she understood the situation so that if
18 it occurred with another child, she would know what to
19 do.
20 Q. Or perhaps wanted you to say to Mr Dhasmana, or to
21 Alison Hayes, "Please refer this child elsewhere if that
22 is where you think this child ought to go"?
23 A. I do not know why I should have said that, any more than
24 she should say it. She was the developing manager, and
25 I would have encouraged her to do that. Only if she had
0089
1 been rebuffed, and by the time she told me she would not
2 have been, would I have so to speak stood behind her or
3 gone with her to see whoever was appropriate, but
4 I would not marginalise her and say, "This is not for
5 you, this is for me"; I would have ensured that she saw
6 through her management responsibility and I am sure she
7 did.
8 Q. The second question which may have a resonance in the
9 last one is this -- I will come to it at a later stage,
10 forgive me.
11 Can I now return to where we were with Professor
12 Vann Jones? We have been looking at WIT 115. We have
13 been looking at paragraphs 7 and 8. If we go over the
14 page, we can go down to paragraph 10, this is Professor
15 Vann Jones describing his job as a Clinical Director.
16 He describes it as a "demanding one" and no doubt you
17 would expect it to be such, would you?
18 A. Yes, it was a demanding job. Can I say, quite clearly,
19 a Clinical Director had a substantial role.
20 Q. He makes the point in the next sentence that he still
21 had to take care of his heavy clinical load, both in
22 cardiology and in general medicine, as well as his
23 research and teaching commitments. Then this:
24 "No help was forthcoming from the Trust for the
25 additional load of Clinical Director."
0090
1 First of all is that, do you think, accurate?
2 A. No. There was a national agreement that doctors
3 assuming such roles as Clinical Director could either be
4 paid two additional sessions salary in respect of the
5 out-of-hours work, the extra work they were going to do,
6 or that money could be used to employ a locum to do part
7 of the incumbent's work. So the national agreement was
8 that for a job like Clinical Director, across the week
9 there were two additional sessions of work that could
10 and would be funded. I do not remember about
11 individuals, but I do know that some Clinical Directors
12 accepted the additional pay and put in the
13 additional hours; some used the money for a locum to
14 take some of the burden from their shoulders, and some
15 declined either and said they would take it all in their
16 stride. But the choice was theirs.
17 Q. The choice was theirs with the offer being made
18 automatically to them, or did they have to ask?
19 A. No, they knew that those were the national terms and
20 conditions for taking up such posts. The same applied
21 to the Chairman of the Hospital Medical Committee and
22 that was known.
23 Q. So he would have known?
24 A. Yes, and he would have made a decision. I do not know
25 what he meant by "no help", in that way. He may have
0091
1 felt he did not want the two sessions. That was the
2 established help.
3 Q. He goes on:
4 "At that early stage, not only did we not know
5 what cardiac services would embrace but we did not have
6 a budget to run the directorate until April 1994."
7 A. That means that the creation of the clinical directorate
8 must date from April 1994. Without a budget and without
9 a definition, there was no directorate.
10 Q. But he appears to think that he was the Director for the
11 year before that, and he appears to think that he had
12 the assistance of Lesley Salmon for the year before
13 this?
14 A. But he also clearly says that he did not have
15 a directorate, because without a budget there is no
16 directorate. He was leading the creation of
17 a directorate.
18 Q. In the time that he had been leading the creation of the
19 directorate, would he have had anything that might be
20 described as help from the Trust?
21 A. Yes, there were a number of people helping with the
22 various discussions and the negotiations that took place
23 at that time, so the additional load of the Clinical
24 Director is what it says: until April 1994, he clearly
25 was a Clinical Director elect, defining, creating, the
0092
1 directorate and receiving the budget. Until April 1994,
2 the elements of it were being run by the existing
3 directorate structure.
4 Q. Would he have been told that his position was elect and
5 therefore had no power until it became actual?
6 A. Yes, there would have been no difficulty about that.
7 You cannot be charged with something you are not in
8 charge of. The clarity of whether the responsibility
9 was his, there was no difficulty about that.
10 Q. So no responsibility until the budget?
11 A. Well, one of the responsibilities of a directorate, and
12 I imagine he says it here somewhere I think I saw, was
13 to stay within budget. You cannot stay within budget if
14 you do not have one.
15 Q. That is one of the responsibilities?
16 A. Yes.
17 Q. But you are saying, and I do not want to repeat it lest
18 I have it wrong, but you are saying without there being
19 a budget, there could be no directorate, therefore there
20 could be no Clinical Director?
21 A. Exactly.
22 Q. And therefore, there was no status with which anyone
23 could exercise the powers and functions other than
24 a budgetary one of Clinical Director?
25 A. No, that is right. I mean, it is a clear understanding
0093
1 that until the situation is changed, the existing
2 management arrangements continue.
3 Q. So if anyone were to have thought differently, there was
4 plainly some lapse in comprehension or communication?
5 A. I think there is more likely to be a failure of memory
6 at this date than a failure to understand that.
7 Q. Can we have a look at the document I was trying to find
8 earlier on, and failed to do, UBHT 200/95. I want to
9 look at this first because it predated the ones we have
10 been looking at. This was the Bristol & Weston Health
11 Authority, Division of Surgery, special meeting. We see
12 the meeting was convened in an attempt to complete the
13 earlier deliberations to discuss the clinical
14 directorates.
15 Can we scroll down, please?
16 "Several views were put forward ..."
17 We see those. The last sentence in that
18 paragraph:
19 "It was suggested, therefore, that there were
20 three clinical subdirectors grouped as follows: general
21 surgery, plus urology plus ENT; accident and emergency,
22 casualty, plus trauma surgery plus orthopaedics and,
23 (3), cardiac surgery."
24 Can we scroll down, please, and go overleaf?
25 "The role of management relative to the Clinical
0094
1 Directors was discussed. It was the view of the
2 Division of Surgery that the Clinical Director should be
3 directly responsible to the Clinical member of the
4 Health Board. The general management would still need
5 strong management ability. It would hope the Clinical
6 Directors would work closely with their Senior Clinical
7 Manager within the hospital to facilitate communication
8 with the Health Board and at the same time ensure
9 efficient running of the hospital. At the end of the
10 day, the General Manager, Dr Roylance, would make his
11 own decision on these outlined recommendations." And it
12 goes on.
13 I apprehend from what took place that what they
14 had been floating in this meeting did not in fact occur
15 as they had at one stage looked for it?
16 A. Not in its totality, no.
17 Q. So far as the subdivision of cardiac surgery is
18 concerned, how did the subdivision relate to the
19 directorate? First of all, I should ask you, was such
20 a subdivision established?
21 A. I can tell you what happened, and that is that
22 a clinical directorate was created with a number, rather
23 more than was recommended there, of what became to be
24 known as "associate directorates", so the Directorate of
25 Surgery, if I remember rightly, consisted of five
0095
1 associated directorates, one of which was cardiac
2 surgery.
3 Q. So the paediatric cardiac surgery would come underneath
4 the Associate Directorship of cardiac surgery?
5 A. Yes.
6 Q. And that itself under the Clinical Directorship of
7 surgery?
8 A. Yes.
9 Q. And in turn, reporting direct to you?
10 A. The Clinical Director, yes.
11 Q. Can I look now at the way in which paediatric cardiac
12 services developed and your knowledge, input and
13 involvement with that?
14 Can I, please, have a look at UBHT 92/2.
15 This is 8th May 1987. Can you scroll down,
16 please? This is to deal with what may be called the
17 "Welsh problem", the little local difficulty that there
18 was with Wales which we have explored on other occasions
19 in this hearing room.
20 Let us go on to the next page and see who the
21 letter is from: from Mr Baker, copied to you. Can we go
22 back, please? The middle paragraph:
23 "Unless the Welsh Office and the constituent
24 authorities decide where they wish to spend their
25 resources and organise the referral patterns through the
0096
1 relevant cardiologist, we cannot be confident about the
2 volume of service which will be required from our units
3 here in Bristol. If this is not agreed, we cannot
4 sensibly determine the implications for our services in
5 terms of space and staffing nor can we make appropriate
6 charges upon the Welsh Office or any other DHSS funding
7 source to cover the cost of the service."
8 He says he is meeting with Dr Skone.
9 It is three lines down:
10 "Until we have formal agreements with the Welsh
11 Office and individual health authorities, I do not think
12 that we should be undertaking any services to Welsh
13 patients other than to neonates and infants from
14 Gwent ... Even with Gwent, we do not have full formal
15 agreements."
16 Pausing there, this was something which went
17 across your desk and which you subsequently read some
18 letters about, the problem of referrals from Wales?
19 A. Yes.
20 Q. Did you understand at this stage that there was a need
21 to increase the numerical throughput of neonatal and
22 infant cardiac cases that you at Bristol were doing?
23 A. At this stage, no -- not in the sense I understand the
24 question, no.
25 Q. If we go to UBHT 62/364, it is November the same year,
0097
1 and it is a letter which, although it bears Mr Baker's
2 reference at the top of the page, if we go overleaf, it
3 has your signature at the bottom.
4 A. Yes.
5 Q. Is it then of your drafting, or is it Mr Baker's
6 drafting and you signed it?
7 A. I am quite sure he wrote it, because at this stage in
8 the negotiations, he was, as the District Medical
9 Officer, leading planning and leading this sort of
10 health care planning, but quite obviously, at that
11 stage, he thought the letter ought to come from the
12 District General Manager, so he dictated it, had it
13 typed and brought it to me for signature, which is why
14 my reference does not appear on the top in any way.
15 Q. Can we go back, then, please, to the first page, 364?
16 It is the opening words of the second paragraph:
17 "It is our intention to restrict the number of
18 referrals we can accept to the number of referrals
19 accepted during 1985 when we believe the service was
20 funded adequately, unless arrangements are made
21 regarding funding with those authorities who wish to
22 refer patients in excess of these numbers. Neonatal and
23 infant cardiology and cardiac surgery services can be
24 funded as supra-regional services through the Welsh
25 Office and the DHSS directly if future workloads are
0098
1 forecast."
2 It talks about the bed needing to be identified by
3 your authority -- that is the Welsh Office -- in
4 relation to an agreed workload and costs.
5 Is the letter saying that Bristol intends to limit
6 the number of referrals it will accept from Wales of
7 paediatric cases and infants who may require cardiac
8 surgery?
9 A. Yes. Can I explain that: Wales has a separately funded
10 Health Service and this is clearly a negotiation that
11 Ian Baker had been pursuing for some time, that the
12 service that Bristol was providing to Wales should be
13 funded by the funds in the Welsh Office provided for the
14 care of Welsh inhabitants. So this is a cross-border
15 issue of trying to get the funding correct and not
16 providing health care to Welsh patients at the direct
17 expense of South West patients.
18 Q. Tell me when it was that you first became aware that the
19 numbers of open heart operations for infants and
20 neonates was -- I use the words I hope correctly -- "too
21 low", throughout the 1980s and perhaps early 1990s, for
22 the purposes of the supra-regional services funding?
23 A. After I retired.
24 Q. The effect of taking an approach such as was taken in
25 this letter in respect of Welsh referrals would be to
0099
1 discourage referrals rather than encourage them?
2 A. No, it was intended to encourage funding, not discourage
3 referrals. It is part of a continuing negotiation with
4 South Wales that they should fund the service we
5 provided for them. This is part of that negotiation.
6 Q. If the intention referred to in the start of the second
7 paragraph were to be honoured in the event, then it
8 would have the effect of restricting numbers?
9 A. Can I explain that if they were to stop referring, we
10 were to stop receiving referrals, they would then have
11 to refer them to somewhere else which would require them
12 to fund somewhere else, so this was a situation which
13 obliged the Welsh Office to fund the service they were
14 receiving. I am quite sure if it was thought at that
15 time, it was perceived that -- this is a judgment I am
16 now making in retrospect: I am quite sure that at that
17 time it was expected that the Welsh Office, if it had to
18 pay, would prefer to pay Bristol than to tell its
19 clinicians they could not exercise their judgment with
20 regard to the specialist centres to whom they sent their
21 patients.
22 Q. So have I read it right: that this in a sense is a bluff
23 or negotiating posture to say, "If you do not pay us, we
24 will not treat", hoping that the answer will be, "We
25 will pay you" and then you can?
0100
1 A. Expecting that to be the answer, yes. That was the aim,
2 I am quite sure.
3 Q. And taking the risk that the effect might be to
4 discourage referrals to Bristol, rather than referrals
5 elsewhere, albeit at a cost elsewhere?
6 A. That would not have been my interpretation. If the
7 Welsh Office had decided it was now going to fund
8 referrals, shall we say, to, I do not know, Oxford,
9 London, they would then have to tell all their relevant
10 clinicians that they were preventing them exercising
11 their clinical judgment and would require to refer them
12 to the unit of the Welsh Office's choice. That I would
13 not have thought, then, and do not think now, would have
14 been a step the Welsh Office could have taken. This
15 was, if you like, putting pressure on -- it was not
16 bluff; it was putting pressure on to bring the Welsh
17 Office into reality, into the real world, and requiring
18 them to fund services provided by England.
19 Q. You said in the course of your answer a moment or two
20 ago that you had no knowledge, until after your
21 retirement, about the concern that there had been in
22 certain quarters about the numbers of cases of open
23 heart surgery performed in Bristol from 1984 onwards,
24 under the supra-regional auspices?
25 A. No, certainly.
0101
1 Q. In your statement, if we just go to that for a moment,
2 WIT 108, page 9, in the last paragraph you deal with the
3 position of the Medical Director.
4 A. Yes.
5 Q. You say he advised you as Chief Executive on medical
6 issues. You met with him, and if we go down to five
7 lines up from the bottom:
8 "Although the post was designated as one of the
9 executive directors, his role was, in many ways,
10 non-executive and advisory ... his position was not one
11 of authority or of command but was advisory. He headed
12 the medical advisory structure and was responsible for
13 giving medical advice to the Trust Board. During the
14 time that Mr Wisheart was Medical Director, I was never
15 given any reason to doubt his advice to me."
16 At the time we have been looking at, the question
17 of the numbers in Wales, of course, Mr Wisheart was not
18 Medical Director; there was no such post at that stage,
19 as I understand it.
20 If any concern had been expressed by officials in
21 the Department of Health to Mr Wisheart or others in the
22 Bristol Royal Infirmary about the small numbers of open
23 heart operations being performed and if the suggestion
24 had been made to them that for purposes of
25 supra-regional designation throughput should be
0102
1 increased, would you expect to have been told about it?
2 A. Yes.
3 Q. This next question may not be one you can answer: on the
4 assumption, which I invite you to make, that such
5 a communication was made to Mr Wisheart or others in the
6 Bristol Royal Infirmary, can you help us at all as to
7 why it might be that you did not hear of it?
8 A. Well, it depends on the nature of the communication. If
9 the communication said that "We do encourage you to
10 increase the numbers", no, I would not have thought
11 I would be told about it. If it said, "We are concerned
12 that the service is unsatisfactory with such low
13 numbers", I am sure they would have told me because that
14 would have been quite paradoxical from an organisation,
15 a group that had designated the service as
16 a supra-regional centre. They were designated before
17 I was a District General Manager. I understood the
18 concept of supra-regional designation, and if it had
19 been brought to my attention that they had designated us
20 as a proper centre for doing neonatal and infant work
21 while they thought we were not a proper centre, then
22 I would have expected to be told, and indeed, I would
23 have expected to communicate with them and asked them
24 which it was.
25 Q. We have seen at an earlier stage in this hearing chamber
0103
1 a record of a visit made by Dr Crompton, amongst others,
2 of the Welsh Office in late 1987 to Bristol, with a view
3 to review the Bristol facilities, in the course of which
4 it is recorded -- by all means, we can go to the
5 document if we need to do so -- words to the effect that
6 the outcomes at Bristol, it was expected, would improve
7 when the numbers, expansion of numbers, went up, as it
8 was, indeed, anticipated they would.
9 That would suggest a concern to the expertise, the
10 expertise that was being displayed in the operating
11 theatre and paediatric cases, was something which could
12 be improved upon by increasing numbers.
13 Was that anything that ever reached you in
14 anything like those terms?
15 A. No, it did not. I have to say that there was no service
16 in UBHT that was not the subject of a desire to improve,
17 so I suppose if they told me there were aspirations for
18 improvement, it would have made no impact on me because
19 I would have expected that for every department. If it
20 had been said to me that the current throughput was too
21 low, then clearly I would have wanted to discuss with
22 them the necessary steps to address that situation.
23 Q. Can I turn to a slightly different but related topic in
24 respect of what you can tell us about what you knew
25 about the operation of paediatric cardiac surgery.
0104
1 Can I have UBHT 111/236, please? It is a letter
2 about admissions to the Children's Hospital, 16th March
3 1987. Can we go overleaf, please?
4 It is from Martin Mott, Chairman of the Division
5 of Children's Services. If we go back to the first
6 page, it is talking here about waiting lists and so on
7 in the Children's Hospital generally. It says, in the
8 second last paragraph:
9 "Data on waiting times are more difficult to come
10 by, but on March 5th there were two patients who waited
11 between 3 and 4 hours for admission and on March 9th,
12 7 patients waited more than 6 hours for planned
13 admission. On March 3rd two of the patients that had
14 been sent for had to be sent back home without being
15 admitted at all. I think this sample from the last two
16 weeks is a fair representation of the kind of problems
17 the Children's Hospital is having to deal with now as
18 a routine. There are, of course, times when the
19 pressure on beds is less extreme and we can cope, but
20 the emotional trauma that parents and children are being
21 subjected to, to say nothing of the intolerable
22 pressures on the medical and nursing staff in trying to
23 provide a service under such circumstances, can, I am
24 sure, be imagined by anyone familiar with working in
25 a hospital. I would reiterate that these problems arise
0105
1 despite every attempt and manoeuvre that we have devised
2 over the last few years in an attempt to ease the
3 situation."
4 It goes on to talk about the problems in respect
5 of waiting lists and so on.
6 That is, I imagine -- tell me if I am wrong --
7 a fairly common form of complaint throughout the 1980s
8 and 1990s, and by no means unique to Bristol?
9 A. No, I respected the fact that the providers of all
10 services felt their own service should have primary
11 paramount funding, even if that were at the expense of
12 everybody else's service and it was -- I mean, it
13 underpins the conversation I was having this morning
14 about the need to provide such care as was funded, and
15 of course, everybody felt the funding was too low.
16 Q. Can I take you a little bit further down the page? The
17 answer may be the same, but I would welcome your
18 consideration of it.
19 "We recognise that, with a limited budget at their
20 disposal, the members of the Health Authority have to
21 make judgments about relative needs and priorities. We
22 can point out that the 25 per cent of the population who
23 are children and adolescents in this Health Authority
24 are manifestly provided with a less than optimal
25 hospital service due to underfunding. We should again
0106
1 point out that it is government policy that all
2 children, where possible, should be nursed in children's
3 beds by children's trained nurses ..."
4 He goes on to deal with orthopaedics and ENT.
5 The distinction which the author is making would
6 seem to be the way in which children and adolescents
7 were dealt with compared to adults, and suggesting that
8 they are provided with a less than optimal service due
9 to underfunding?
10 A. No, I do not think he was comparing them with adults, he
11 was saying that the population for which he was
12 responsible, the care for which he was responsible, was,
13 in his view, clearly underfunded. He was not saying
14 that the other services, to his knowledge, were
15 relatively better funded, and I am sure if you pursued
16 it at the time you would find similar letters going in
17 different directions making the same kind of point for
18 every other service.
19 He is suggesting that the proposals -- this may be
20 the time when the proposal was first made -- that moving
21 children from Winford Orthopaedic Hospital, which was on
22 the outskirts of Bristol and the ENT patients from the
23 General Hospital into the Children's Hospital, with
24 their support, would enable them to flex the budget and
25 open one of the closed wards. I cannot tell you right
0107
1 now how they were going to do that, but it may be one of
2 those issues of being able to nurse children of
3 a particular age group with surgical or medical things
4 wrong with them in the ward that at that time was empty.
5 Q. He goes on about government policy means:
6 "That all children, where possible, should be
7 nursed in children's beds by children's trained nurses."
8 A. Yes.
9 Q. At the time he wrote this, back as we see in March 1987,
10 that would be true, would it?
11 A. The government had, by that time -- it must be by that
12 time, because he says it has -- swung behind the
13 recommendations of those concerned with the care of
14 children; that children were different and should be
15 nursed preferably in children's facilities with
16 children's trained nurses. It does say that the
17 government policy was that all children "where possible"
18 and there was the rub: it was the achievable end which
19 mattered.
20 And we were aware of that.
21 Q. You would then be concerned, would you, for the
22 paediatric cardiac service, because the surgery
23 performed on the neonates, infants, would be performed
24 in the Royal Infirmary and not at places where
25 children's nurses were regularly and constantly
0108
1 available in the ITU?
2 A. Can I see the date of that, so I do not make a silly
3 statement? That is 1987. Shall I say, I was aware, and
4 I was aware in 1985, of desire to move paediatric
5 cardiac surgery to the Children's Hospital. That was
6 not a universally supported view. There were still
7 those who thought that the expertise in cardiac surgery
8 lay at the BRI and that it might be better to import
9 paediatric expertise into the BRI. But I was aware, and
10 by 1987, I think by then -- I think it was by then, or
11 soon after -- more neonates were being operated on than
12 before, which precipitated the problem and made it
13 clearer to everybody that it would be better if the
14 neonates were in a paediatric unit.
15 So I knew, at that time, and we tried from that
16 time, James Wisheart in particular, with my enthusiastic
17 support, to try and find a means of achieving that
18 desired aim, so that round about 1987, I think there was
19 no longer an argument that it would be preferable for
20 children to be nursed in the Children's Hospital, at
21 that time. There were no facilities at the Children's
22 Hospital physically available to allow that, and you
23 will see that it does not say it here, but at the time,
24 or some time afterwards, the general paediatricians at
25 the Children's Hospital actually took the view that such
0109
1 a move would unacceptably imperil the provision of
2 general paediatrics. So the desire was there. The
3 achievement was much more challenging.
4 Q. In whose hands did the solution lie?
5 A. Well, I think in the Regional Health Authority's hands,
6 because they were funding cardiac surgery. It was held
7 by many people that the South West was singularly
8 underfunded in adult cardiac surgery.
9 Q. So far as moving the paediatric cases to the Children's
10 Hospital, if that option had been determined upon, that
11 would require funding which came from the DHSS rather
12 than from the Regional Health Authority?
13 A. No, it depends on how it was done. How it was done, it
14 depended on funds coming from the South West, in that
15 eventually, by funding adult cardiac surgery into the
16 space used by paediatric surgery, we could release the
17 funds to reprovide paediatric cardiac surgery in the
18 Children's Hospital. We engineered a situation, a very
19 welcome situation, whereby, to achieve the latest
20 increase in adult cardiac surgery, we either had to
21 build more adult cardiac facilities at the BRI or build
22 children's facilities at the Children's Hospital, so
23 creating space for the adult surgery.
24 Q. Mr Nix told us about that when he gave his evidence, and
25 he told us about the way in which the decision was
0110
1 ultimately taken to move from the BRI to the Children's
2 Hospital so far as the children's cases were concerned.
3 That, of course, was a decision taken in the
4 1990s, I think. I will show you the documents in
5 a moment.
6 A. I am sorry, we found a solution in the 1990s.
7 Q. But the solution was one which really depended on
8 funding?
9 A. Absolutely.
10 Q. Had there been a source of funding available to move the
11 children's cases from the Royal Infirmary to the
12 Children's Hospital earlier than the 1990s, would you
13 have taken advantage of it?
14 A. Yes, but if there were funds available for that move, we
15 would have spent it on that move.
16 Q. Can we have a look, please, at UBHT 278/414? This is
17 the Secretary of State's announcement in respect of
18 supra-regional services for 1987 to 1988. It is a 1986
19 document. Paragraph 2:
20 "Health Authorities were informed in January 1986
21 that capital allocations would be made under the
22 supra-regional arrangements for the first time in
23 1987-88".
24 It deals with the capital funds applied for.
25 What we understand -- and please tell me if it
0111
1 does not coincide with your understanding -- is that as
2 from 1987 to 1988, capital was potentially available
3 (depending obviously on applications being accepted)
4 from the DHSS for the development of supra-regional
5 services?
6 A. Yes.
7 Q. We understand that in 1992 Dr Joffe on behalf of the --
8 I do not know which directorate it might have been, but
9 on behalf of Bristol, made an application to the Supra
10 Regional Services Advisory Group which was due to be
11 funded, if it was at all, during the last year of
12 supra-regional services, and for reasons relating to the
13 application itself, was not considered.
14 What I would like to know is whether you, for your
15 part, ever had it drawn to your attention that a source
16 of funding might have been available for such a move?
17 A. Well, sources of funding were usually brought to my
18 attention. I cannot tell you now whether it was.
19 I will say that the Advisory Group recommended that
20 priority be given to applications relating to services
21 where significant workload expansion was expected, and
22 I suspect that was the reason why this was not a pathway
23 that could be trodden.
24 You see, we were relying on a significant workload
25 expansion in adult cardiac surgery. What we had been
0112
1 saying, and what we have been talking about,
2 a significant workload expansion was not expected, as
3 I understand it, in 1987 and 1988.
4 I cannot be certain, all I can use is my
5 experience and these documents, and what is implied is
6 that in order to get capital for expansion, one had to
7 demonstrate a realistic expectation of that expansion.
8 We were looking for money for translocation, not
9 expansion.
10 Q. Can we look, please, at UBHT 38/349? This is 5th March
11 1992. It comes from the Associate Directorate of
12 Cardiac Surgery and the Directorate of Surgery. It is
13 a proposal to the region to develop cardiac services at
14 the Bristol Royal Infirmary.
15 If we can scroll down to 351, the strategy for the
16 development of the cardiac surgery:
17 "2.5: Paediatric cardiac services will be united
18 in Bristol Royal Children's Hospital and provision for
19 this is included in the proposal."
20 A. Yes.
21 Q. If we scroll down, and the next page, and the next
22 page again, please, and again (to UBHT 38/357), the
23 paper, the conclusion, as you have said, was about
24 a major expansion of cardiac surgery which purchasers
25 were interested in. It then deals with the various
0113
1 possibilities.
2 Can we go to 88/132?
3 This is a document in 1994 which we will see
4 later on. We may need to go down through it before we
5 come to the date. If we go to the bottom of the page,
6 it describes there that the feasibility ...
7 "UBHT is fortunate in having Bristol Royal
8 Children's Hospital which enjoys an international
9 reputation as a centre of excellence for the provision
10 of dedicated paediatric care for a wide range of
11 conditions. A significant exception is the provision of
12 open heart surgery which is located in the BRI separated
13 from all other aspects of paediatric cardiac services.
14 It is a long-held view of all the professions concerned
15 that paediatric open heart surgery should be located in
16 the BRCH as part of an integrated paediatric cardiac
17 service."
18 It deals with the question of costs in the next
19 paragraph. So the strategic aim which was to be
20 achieved was achieved as a result of the expansion of
21 adult cardiac surgery releasing funds which were not
22 otherwise obtainable from elsewhere, but funds which
23 were necessary to achieve the aim?
24 A. The capital we got to increase adult cardiac surgery, we
25 were able to divert to create paediatric cardiac
0114
1 services at the Children's Hospital. That then created
2 a space in the BRI which would provide for the expansion
3 of the adult cardiac surgery with very little further
4 build. So we were creating the space at the BRI, not by
5 building new facilities there, but by transferring the
6 paediatric service to the Children's Hospital.
7 Q. Can we have a look at page 136? And scroll down,
8 please? We had better go back to the page before so we
9 can see the heading. The options -- doubtful whether it
10 is (b) or (c) -- would indicate whether paediatric
11 cardiac surgery should go to the Bristol Royal
12 Children's Hospital. The benefits fall into four key
13 areas: (a), (b), (c) and (d).
14 Now can we go over the page:
15 "(a) Patient focused care.
16 "1. The key feature: the philosophy of the
17 management of children is being cared for in an
18 environment supportive of their physical, emotional,
19 social and development needs. This environment can only
20 be fully achieved within the BRCH which is an
21 established service exclusively orientated to the
22 delivery of paediatric care."
23 That would always have been the case, presumably,
24 when paediatric surgery was performed at the Bristol
25 Royal Infirmary and other paediatric care was provided
0115
1 at the Children's Hospital?
2 A. No, I think I pointed out, and it still is the case with
3 other specialties, that I am sure it was considered at
4 the time that the requirement to provide cardiac
5 surgical skill which was available at the BRI
6 transcended the importance of providing paediatric
7 skill. I was not managing at the time but I think that
8 when that was first created, children were rather older
9 when they were operated on and the concentration of all
10 the supportive skills to cardiac surgery lay at the
11 BRI.
12 I think, I have already said, but could I be
13 allowed to say again, as the age at which children were
14 operated on fell, so these considerations became much
15 more important. So although it was not always agreed,
16 to my knowledge, it became increasingly agreed that
17 paediatric cardiac surgery should take place at the
18 Children's Hospital.
19 Q. So what you are saying, is it, is that if we look at
20 patient-focused care under 1 and 2 -- one can read it
21 for oneself -- and under 3, these are all aspects of
22 developing approaches to care?
23 A. Yes. I have lived through the stage where children were
24 by and large treated by experts, by consultants, whose
25 primary role was in the treatment of adults, but who
0116
1 extended their expertise, whether it was pulmonary,
2 cardiac, renal or whatever, to the care of children, so
3 the children were usually cared for by what we would now
4 describe as adult consultants.
5 I have lived through the development first of all
6 of general paediatricians, and then all the specialties
7 within paediatrics, and during this evolution, the
8 quality of care to children, the expertise in care for
9 children, has continually improved so that when I was
10 trained as a radiologist, I was trained as a general
11 radiologist and was first employed interpreting films
12 and investigating children as I was with adults, and we
13 slowly have gone through in radiology, as with
14 everything else, a specialisation in which there is now,
15 at the UBHT, I think it is one and a half paediatric
16 radiologists who just do paediatrics.
17 Perhaps it is a measure of my age, but this is
18 a view that has developed over the years. As far as
19 I understand it, for neurosurgery and ophthalmology, the
20 children are still treated in a paediatric environment
21 within the adult facility.
22 Q. If we can scroll down, point number 4:
23 "Patients and parents sometimes experience
24 considerable trauma due to the requirement to transfer
25 between sites after forming initial relationships with
0117
1 one care team. Relocation ... would remove this source
2 of stress ..."
3 That is observational, rather than depending on
4 changes in culture?
5 A. Except that it was a supra-regional service. Patients
6 were being transferred from the far end of the region,
7 so there were those who felt that to say the move from
8 the Children's Hospital to the BRI was unacceptable,
9 that the move from Penzance to the Children's Hospital
10 was acceptable, was not always found credible.
11 Q. The focus, I think in this paragraph, was the need to
12 form two sets of relationships with two different care
13 teams: "Now that I have a relationship with care team
14 number 1, does my child have to be cared for by care
15 team number 2?" The distress that that might
16 understandably cause parents. I think that is what it
17 is focusing on.
18 A. Yes. Please, can I say I entirely support everything on
19 this document. It was written to convince everybody at
20 the time, the source of capital, that there was a proper
21 development so I agree with every word that is said
22 here. What I was trying to indicate is that this was
23 the situation in 1990 whenever it was, but it had not,
24 as you asked earlier, always been the case. But we had
25 reached the stage where, before we made the decision,
0118
1 before we actually produced the document to justify it,
2 but we were pursuing the transfer of children and in so
3 doing, we had to meet the health service's quite natural
4 requirements to specify the advantages and disadvantages
5 of why this was the best option.
6 Q. I was not suggesting for a moment that you disagreed
7 with the contents of the document; I would not have
8 expected you to. It was, as you say, used as
9 a springboard to examine how the attitudes may have
10 changed over the period since 1984, and --
11 A. No, I am sorry, this was a document where the sole
12 purpose was to achieve the capital investment we
13 required; it was not a social or philosophical document;
14 it was part of the planning process to achieve the
15 transfer of paediatric cardiac surgery to the Children's
16 Hospital. It is a requirement in the Health Service,
17 where everything we did, this all had to be written down
18 and quite properly to demonstrate this was not some wild
19 scheme that was not supportable.
20 Q. Can we then look at what is said under "Skills
21 Differences". Point 1, plainly you would agree with, at
22 the time this document was written. That had been
23 appreciated in the 1980s, had it not?
24 A. Well, it was an evolving situation. Certainly in the
25 late 1980s it was, but there were skilled competent
0119
1 children's nurses at the BRI.
2 Q. Paragraph 2:
3 "Concern has been expressed nationally regarding
4 the availability of paediatric trained nurses."
5 That is obviously talking in the Health Service
6 generally?
7 A. That is right.
8 Q. "70 per cent of BRCH nursing staff are registered sick
9 children's nurses, compared with only two whole-time
10 equivalents in the BRI cardiac unit. In addition, staff
11 in the Children's Hospital receive further specific
12 training ..."
13 Those figures, only two whole-time equivalents in
14 the BRI cardiac unit, that obviously again is taking an
15 historical snapshot at the time that this document was
16 prepared. Does it, however, reflect what had been the
17 reality up until that stage throughout the 1980s?
18 A. I cannot tell you what the -- I mean, I am aware that
19 there were always children's trained nurses there within
20 the BRI. There were also adult trained nurses who had
21 acquired, as I understand it, children's skills, skills
22 in treating children, but I think it had reached the
23 stage where there was a shortfall nationally of
24 paediatric trained nurses, but it was felt that it would
25 ease recruitment issues at that time if we were
0120
1 recruiting nurses, children's trained nurses, into
2 a children's hospital rather than as part of an overall
3 cardiac surgical unit.
4 So I think there are two elements to that. One is
5 the shortfall, you see, and the other is how many --
6 I mean, I do not know whether there were only two there
7 because at that time that was all they had recruited and
8 there were some vacancies for two more, but there was
9 usually only one, at most two, children in the BRI at
10 any one time as far as I understand it. Over the period
11 of time, as I have said, this was becoming more and more
12 generally accepted nationally and locally, and this is
13 the position that is being very carefully and I think
14 skilfully presented, to ensure that we could actually
15 achieve what we wanted.
16 Q. For an intensive care bed, you would normally have
17 a nursing complement of what, 5, 6, nurses?
18 A. You have a one-to-one nurse, but you have to nurse them
19 24 hours a day, and cover for sickness and holidays and
20 training, so I would have expected it would be of the
21 order of 5 per occupied bed.
22 Q. So if the two whole-time equivalent nurses reported at
23 the time of this document reflected a position which had
24 been so for some time, there would have been only what,
25 less than a third, or about a third, of the number of
0121
1 nurses for one bed, let alone for two or three or four,
2 depending on how many were occupied by the children's
3 cardiac cases at the BRI.
4 A. Yes. That is the case. What I do not know is whether
5 that was a skilfully presented argument for what
6 actually was the case when that document was written, or
7 whether it reflected the generality. I do not know
8 that.
9 Q. Are we to understand by the expression "skilfully
10 presented" that it may have been inaccurate?
11 A. No. It says "70 per cent of the nursing staff are
12 RSCNs, compared with only 2 ... in the cardiac unit."
13 I suspect that statement is true. You are asking
14 me whether it had been true for some time. I say, I do
15 not know.
16 Q. Go overleaf, "Caseload management". The point made at
17 number 1, that would undoubtedly have been the case,
18 would it not, throughout the 1980s?
19 A. Yes. I mean, this is the specification of what we had
20 known for some time and what we have been trying to
21 achieve, yes.
22 Q. Can we look at number 3? That, too, would be something
23 that would have applied for some time, would it?
24 A. I mean, in that sense, it had not been implied to me in
25 any way. What I am trying to say is, we were seeing an
0122
1 evolving situation, but certainly, by the time this was
2 written, there was -- I mean, I think we had achieved
3 total agreement that it was perfectly proper, and had
4 been for some time, to move children's paediatric and
5 paediatric cardiac surgery to the Children's Hospital.
6 We had now found the mechanism for doing it. This is
7 part of the way that mechanism could be implemented.
8 Q. Was a matter such as number 3 shown there one of the
9 factors which would have persuaded those arguing the
10 case in the 1980s for the transfer to the Children's
11 Hospital, that that would be a desirable object?
12 A. Oh, yes. There is no doubt paediatric cardiologists
13 saw this as a desirable move before most others. In the
14 1980s it achieved universal support. That is what we
15 wanted to do. This specifies, rather elegantly, a whole
16 series of valid reasons why this move should be
17 achieved.
18 Q. Two more questions before it is time, I think, for
19 another break. (d)1: can we see the whole of it,
20 please?
21 "BRI waiting times for priority paediatric cases
22 are 4 to 5 months when the optimum period in terms of
23 outcome would be 4 to 6 weeks. These waiting times are
24 longer than the Trust's major competitors ..." it lists
25 them and notes that the need to compete for
0123
1 supra-regional designation will go, suggesting that
2 moving to the Children's Hospital will shorten the
3 waiting time.
4 Just focusing upon the first sentence, again,
5 although this may be a document designed to produce
6 a result, was it in fact probably accurate to say that
7 the optimum period in terms of outcome would be 4 to 6
8 weeks, compared to the waiting time of 4 to 5 months?
9 A. At the time this was written, yes. What I cannot tell
10 you is what the situation was the year before, the year
11 before or the year before. I do know that the
12 increasing pressure of adult cardiac surgery, on a unit
13 that was not funded to meet the total demand, did
14 produce very considerable clinical problems in fitting
15 in paediatric cases which themselves took longer in
16 hospital than the adults. That was something which was
17 developing.
18 Q. I may be able to help you with what it was like in the
19 year before, the year before and the year before that,
20 if we look, please, at the last document before the
21 break, UBHT 311/436.
22 THE CHAIRMAN: I have a suspicion that may be the wrong
23 number, Mr Langstaff.
24 MR LANGSTAFF: It has not been entered yet.
25 THE CHAIRMAN: It is entered on my machine. I am getting
0124
1 a distinct signal from the back of the room.
2 MR LANGSTAFF: In that case, I shall have to review it over
3 teatime.
4 THE CHAIRMAN: Thank you. I apologise, Dr Roylance, for
5 a problem in our technology which involves our
6 communication. Let us adjourn now for 15 minutes, so
7 until just after half past 3.
8 (15.20 pm)
9 (A short break).
10 (15.35 pm)
11 MR LANGSTAFF: It is marvellous what a cup of tea can do,
12 Dr Roylance. I have found the document at UBHT 38/436.
13 I should say, this is a non-core document, so it will be
14 released on to the Internet in due course, and be part
15 of the next core production.
16 It is a letter from Mr Wisheart, or prepared by
17 Mr Wisheart for you to sign to send back to Catherine
18 Hawkins. I will come to her in a moment. It is
19 a letter you will be familiar with. It is responding to
20 a letter, as you can see:
21 "Thank you for your letter of 20th November and
22 for drawing my attention to the view/perception of 'how
23 poorly the Bristol Trust is now performing on cardiac
24 surgery contracting ...', and 'of the gross
25 dissatisfaction region-wide'. We are dismayed to hear
0125
1 criticism expressed in such broad and general terms as
2 only one purchasing DHA (Exeter) has voiced concern to
3 us."
4 Then it deals with the various criticisms, to
5 rebut them. I am not interested in those because it was
6 in response to your point about waiting times that
7 I went, inadvisedly, not having the correct reference to
8 this document, and that we see at page 437. At the top
9 of the page:
10 "Quality of care, organisation, e.g., waiting
11 times."
12 So we have here Mr Wisheart, 12th December 1991,
13 saying:
14 "Waiting times for surgery is the least
15 satisfactory part of the service we offer. The waiting
16 time is the legacy of the old waiting list, which, for
17 the cardiac surgical unit, reflected the fact that
18 facilities in the South West (i.e. in Bristol) have met
19 about half the calculated need throughout the last
20 decade, and this situation remains the same following
21 the 1988 expansion; a conservative estimate would
22 suggest that the 1400 to 1500 operations are needed
23 annually for citizens of the South West region. This
24 estimate is likely to be revised upward in the next year
25 or so. The excess of demand over provision is
0126
1 illustrated by the fact that although immediately after
2 the expansion the number waiting and the time of waiting
3 fell for 6 to 9 months, by the second half of 1989 the
4 number of referrals were rising rapidly, so that by 1990
5 the numbers waiting were greater than before the
6 expansion. At present, only a small per cent wait over
7 a year, but for our patients this is too long. The
8 average time to operation is approximately 6 months.
9 "Contracting has highlighted this issue ..."
10 Pausing there, what he appears to be saying is
11 that the waiting times for Bristol, for cardiac
12 surgery -- that is, both, presumably, adult and
13 paediatric, are really --
14 A. I am sorry, this is about adult cardiac surgery, this.
15 Q. Just adult, is it?
16 A. Yes, only adult, because this is talking about
17 negotiating in the South West at a time when infant and
18 neonatal cases were subject to national contract, so
19 this is South West contracting with the adults.
20 Q. Tell me, without a dedicated paediatric cardiac surgeon,
21 would not the throughput of adult cases necessarily have
22 an effect upon waiting times for elective paediatric
23 surgery?
24 A. Yes, I am sorry -- no, I was saying this letter is about
25 adult cardiac surgery.
0127
1 Q. I misunderstood. But the letter about adult surgery
2 plainly demonstrating 6 months as a usual average
3 waiting period?
4 A. Can I explain? This is symptomatic of the problem
5 I acquired, inherited, when I became a District General
6 Manager. We spent a long time, mostly James Wisheart,
7 and before him -- his name has gone -- Gerald Keen
8 particularly, were constantly pressing the Department of
9 Health and the South West to increase the funding for
10 cardiac surgical services and the fact that the funded
11 workload was, I think it said there, about half of the
12 need and there was no mechanism to restrain referrals.
13 We were getting into a very difficult situation where
14 only the urgent cases ever got off the waiting list, and
15 the non-urgent elective cases were being transferred to
16 London and so on. It was an unacceptable situation,
17 solely due to the fact that the perceived need and the
18 referred need was not met by a funded workload.
19 Q. It would be the case for adults, obviously; it would
20 also be the case, would it not, for the over 1s?
21 A. No, they were all treated. There was no problem
22 about -- because they were small volume. All the
23 children were treated. The shortfall was in adult
24 cardiac surgery.
25 Q. There would be a contractual situation for the over 1s
0128
1 just as there was for the adults?
2 A. But compared with the adult need, they were almost in
3 on the edge of the contract. As far as I am aware, and
4 I am sure I am right, they were effectively funded.
5 There was no question that what was needed was
6 a substantial increase in funding for adult cardiac
7 surgery.
8 Q. We entered this letter because I was following your
9 comment about waiting times --
10 A. Yes.
11 Q. -- and your inability to say from what was, after all,
12 a document designed to urge a particular result, that
13 waiting times had been poor in the interim, during 1992,
14 1993 and 1994. My reason for taking you to this
15 document, which was at the end of 1991, was to suggest
16 that, taking a snapshot at that stage, it would appear
17 that in cardiac surgery generally waiting times were
18 poor?
19 A. The adult cardiac waiting list was poor, yes. I do not
20 know what the paediatric waiting time was.
21 Q. One intuitively might think that if the surgeons
22 operating on the adult list are also doing paediatric
23 surgery, in other words, there is not a dedicated
24 paediatric cardiac surgeon, that if there were a waiting
25 list for one, there would probably be something of
0129
1 a similar waiting list for the other?
2 A. I do not understand your comment about a dedicated
3 paediatric cardiac surgeon. The cardiac surgeons had
4 paediatric sessions to meet the paediatric workload.
5 They were, together, a paediatric cardiac surgical
6 service.
7 What may well be the case, and I can only
8 speculate, is that with pressure from adult cardiac
9 surgery there may be times when an adult may present
10 such a commanding urgency that they were admitted in
11 preference to a child. That I can guess at, but
12 I cannot tell you it happened.
13 Q. The surgeons, the directorate, I think, pressed, did it,
14 for a dedicated paediatric cardiac surgeon to be
15 appointed?
16 A. Yes. It was recognised for quite a long time that we
17 should follow the latest improvement in paediatric
18 cardiac surgery by attempting to appoint a paediatric
19 cardiac surgeon. In fact, efforts were made to do just
20 that: a dedicated specialist, with the aim that he would
21 work with Janardan Dhasmana and that James Wisheart
22 would direct his efforts to adults, so that we had
23 a two-man paediatric cardiac service.
24 The scheme that had been achieved, as I think you
25 know, was a charitably funded Professor of Cardiac
0130
1 Surgery, which we -- James agreed with the Heart
2 Foundation, I think it is called, to fund at Bristol
3 University, and Bristol University agreed to make such
4 an appointment. Every effort was made to achieve an
5 application from an established paediatric cardiac
6 surgeon, the plan being that that professor would
7 provide half time to paediatric cardiac surgery, and
8 that Janardan Dhasmana would provide the remaining time
9 so there would be cross-cover and two people providing
10 the service. That was the scheme that was engineered to
11 appoint a paediatric cardiac surgery.
12 It does not in any way relate to the continuing
13 problem that adult cardiac surgery was grossly
14 underfunded.
15 Q. Could I turn away, then, from the document which was
16 comparing the advantages -- can we go back to it for one
17 last comment. We will leave it, I think, for a moment.
18 I was pursuing the line of questioning that I was with
19 you to compare the advantages as demonstrated by the
20 document which we saw with the position as it might have
21 been in the 1980s, and plainly, by your answers, you
22 have indicated that you were well aware of the pros, at
23 any rate, of moving from the BRI to the Children's
24 Hospital?
25 A. Yes, and some of the cons.
0131
1 Q. What were the cons?
2 A. General paediatricians were strongly of the view that to
3 move paediatric cardiac surgery to the Children's
4 Hospital would seriously impede on their efforts to
5 provide a general paediatric service for Bristol. It
6 was their view that the Children's Hospital was becoming
7 a collection of super specialties and that general
8 paediatrics would suffer. And I think that you showed
9 me a letter earlier from Martin Mott saying that there
10 was great difficulty in getting general paediatric cases
11 into the Children's Hospital.
12 Q. So far as paediatric cardiac surgery itself was
13 concerned during the 1990s, can we have a look at
14 UBHT 22/73? Can we scroll up? It is the last
15 paragraph, report from the Medical Director, Mr Dean
16 Hart at that stage:
17 "Mr Dean Hart was pleased to report that there are
18 now no doctors within the Trust", this is 1992, as you
19 see from the minute, "who are required to work more than
20 83 hours per week which is statutorily required of us,
21 with the exception of cardiac surgery where special
22 circumstances exist. Region are aware of this and have
23 given a 3 month extension for matters to be brought
24 under control."
25 So was it the position, as appears to be recorded
0132
1 here, that within cardiac surgery, doctors were required
2 to work more than 83 hours a week?
3 A. Well, it says so.
4 Q. Do you recall that as being the case?
5 A. Well, I recall the time when we were attempting to meet
6 the national requirements for junior doctors' hours and
7 in fact I gave very strong support in leading that and
8 I believe we achieved it months ahead of anybody else,
9 but not to divert too far. It is a question here of
10 what is meant by "work" and a whole series of
11 complications of how long actually working, whether
12 being on call and available is work, and so on, and I do
13 know that we were able to reduce the hours of virtually
14 all of them, but had not produced a mechanism for
15 reducing the ones in cardiac surgery, who were working
16 many more than the rest had been working.
17 It was a question of a delay in reducing
18 their hours. It says there, there are special
19 circumstances, and I suspect if somebody went ploughing
20 through enough, they may be able to produce a document
21 of what the special circumstances are. I do not know
22 what they were, not today.
23 Q. The issue of those hours were, it would appear,
24 resolved, and I will show you those documents in
25 a moment, but on the question of hours and the workload
0133
1 of the surgeons in the cardiac surgery directorate, can
2 we look at JPD 1/7, please? This is 1989, a shade
3 earlier, and this is from Mr Dhasmana to you:
4 "I wish to draw your attention to the problem with
5 my theatre session at the Children's Hospital. I have
6 been given a morning session once in a fortnight. This
7 means that I can operate on only one major or at the
8 most two minor cases, like closure of persistent ductus
9 arteriosus in a fortnight. This does not give me enough
10 time to deal with my patients during routine hours. As
11 a result, I have been at times operating on children
12 during the nights and on some weekends. In addition to
13 causing inconvenience to a lot of people working out of
14 routine hours this also adds to costs."
15 He goes on to argue, if you just go down the page,
16 for a regular session to accommodate them at the
17 Children's Hospital.
18 But it is the question of hours that I want to
19 raise with you. Here he is saying "Because of the
20 pressure of work that I am under, I have to operate in
21 the evenings, late at night, in such circumstances".
22 First of all, was that probably right?
23 A. I have no doubt that what Janardan Dhasmana wrote there
24 would have been true so far as he knew. I cannot
25 remember the precise letter, but it was fairly common
0134
1 for people who were having local difficulties with their
2 colleagues, to appeal to me for help. As I have no
3 memory of a continuing problem, I am quite sure
4 I assisted him in solving it but this was of course
5 closed cardiac surgery.
6 Q. Secondly, the hours that he was working: were they
7 ideal, as recorded?
8 A. I do not know any consultants that are not working what
9 would be called excessive hours. I did my best to stop
10 people overworking. I used to go round at times and
11 send people home, or try to. But when you say
12 "excessive", I am sure it was more than he was paid
13 for. I am sure he was working longer than his
14 contractual hours. I did not know any consultant that
15 was not. You say "unacceptable". I do not know what
16 his actual hours were, so I cannot answer that.
17 Q. Is it one of the problems with the Health Service that
18 doctors who may be conscientious may wish to give of
19 their time to meet the demand which is unending, and as
20 a result, spend far too long for both themselves and
21 perhaps for the patients that they are treating?
22 A. It was my experience that that applied to the whole
23 staff, consultants certainly, but all staff, even the
24 appointments clerk would stay late to ensure that they
25 had their notes for an outpatient the next day. The
0135
1 commitment in the Health Service is astronomic. They
2 are all committed to providing the best possible health
3 care and as much as possible, and from as long as I have
4 known it, they have all worked well beyond their
5 contracted hours, all staff.
6 So, yes, everybody did.
7 Q. My question was not directed to the commitment, it was
8 directed to the effects.
9 A. Well, the effects were that more patients were treated
10 than were funded.
11 Q. What I was asking was whether there might be an adverse
12 effect upon the doctor, him or herself?
13 A. I think occasionally, across the country, some people
14 did suffer from stress and it is known that some doctors
15 have had difficulties, so, as a generalisation,
16 certainly doctors do suffer from their excessive
17 commitment to the Health Service.
18 Q. Again, as a generalisation, someone who is working
19 over-long may find it difficult, if not impossible, to
20 give of his or her best consistently to the patients
21 upon whom he or she is operating?
22 A. The evidence for that is not very strong. I have heard
23 it argued by junior doctors, but I believe that people
24 trained in the Health Service are trained to provide of
25 their best for long periods.
0136
1 Can I say, because I do not think they should give
2 that commitment, I would wish to believe you, but I have
3 no evidence that as a generality, it is true.
4 Q. So looking at it through your eyes, if I may, and it is
5 your personal view on this that I am looking for, you
6 would not see a particular risk in the general of
7 doctors overworking, that is, a particular risk to their
8 patients?
9 A. It depends what you mean by -- yes, I mean, you have
10 said "overworking". If overworking is working more than
11 they can provide a satisfactory service, then you have
12 answered your own question.
13 Q. Yes.
14 A. If you say "working well beyond their contracted hours",
15 then I have to say, that has been the pattern in the
16 Health Service for a very long time, and I do not know
17 that there is any real evidence at all that patients
18 suffer; there is very good evidence that a lot of
19 patients benefit.
20 Q. I have said I was going to show you the documents which
21 resolved the problem over the hours which we saw in the
22 last document, that is, the 83 hours plus in cardiac
23 surgery. If we can have a look at UBHT 2/310, under
24 "cardiac surgery", we will read it and then see the
25 date of it:
0137
1 "Mr Wisheart reported that he had prepared
2 a proposal to bring the hours of work of SHOs and
3 Registrars down to 72, based on an SHO funded by the
4 Division and a staff grade post funded by the Region.
5 They were also hopeful of a research worker who would
6 join the Registrar rota for nights and weekends."
7 So the answer appears there to be more staff, in
8 effect?
9 A. It would have been more than that. Yes, it is more
10 staff, but there would have been a different rota, and
11 I think this one was actually related to rotations
12 through the Thoracic Surgical Unit at Frenchay, and so
13 forth, so it is a much more complex thing than just
14 adding the number of hours that is required and it is
15 a solution. There was very substantial work on
16 rejigging the duty rota, and so on, to bring the hours
17 down.
18 Q. The next item, children's services, relates as well:
19 "The hours of work had been reduced to 83 and
20 progress was under way to achieve 72 ... a week. This
21 is dependent on staff grade appointment funded by
22 region, in the Casualty Department. With regard to the
23 surgical cover, although this can be achieved, there
24 could be a slight reduction in the services."
25 So we see that in both cardiac surgery and
0138
1 children's services, there are particular efforts being
2 made to reduce hours.
3 Can we go back to see the start of the document,
4 so we can put a date to it?
5 A. Could you say where it says it is children's -- it is
6 paediatric cardiac surgery, we are talking about.
7 Q. No, it says "children's services."
8 Can we go back to where we were, please? It
9 is 310. It just says "children's services", it does not
10 say "paediatric cardiac surgery", but it does talk about
11 surgical cover, which of course may be general
12 paediatrics?
13 A. There was a general surgical unit at the Children's
14 Hospital, yes.
15 I think my memory is quite clear that there was
16 a regional committee set up to support -- I think they
17 were Trusts at the time -- every Trust in the South
18 West, to achieve this reduction in working hours for
19 junior staff and a whole series of quite ingenious ways
20 were developed, partly changes in rota, partly changing
21 the appointments of junior staff to more than one
22 consultant, and partly by agreeing with Region
23 additional non-training posts for cover. My memory is
24 clear, and I hope I am not wrong in saying this, my
25 memory is, we were the first as a teaching hospital,
0139
1 although we had the biggest problem, to actually solve
2 the demand to reduce junior doctors' hours.
3 Q. 20/499, please. This is now 1993, "clinical care".
4 "(b) A detailed review of junior doctors' hours
5 would take place in the second and third week of
6 October. Mr Wisheart was hoping for close to 100 per
7 cent response from junior doctors and from consultants.
8 Contracts of 72 hours had now been almost totally
9 achieved."
10 The picture that is painted by these documents
11 appears to suggest on the face of them that doctors had
12 been working in cardiac surgery and possibly in other
13 parts of the hospital, for hours in excess of 83; that
14 they were reduced for all but the cardiac surgery
15 department for particular reasons; and by the middle of
16 1993, the cardiac surgery had followed on behind and had
17 achieved pretty well 72 hours throughout. That would be
18 the implication, but I would welcome your comments as to
19 whether that is a fair inference from the documents or
20 not.
21 A. I do not know from the documents, but I can tell you
22 that the situation is that the Children's Hospital, in
23 line with everybody else, had over the years acquired
24 a practice of working junior doctors for
25 substantial hours, over 83 hours. I will not go through
0140
1 the arguments about this and the fact that they were
2 training posts and so on, but there was no doubt, and
3 you will be aware, most people will be aware, of the
4 national campaign that was launched and is still being
5 addressed to reduce hours down to reasonable levels.
6 The decision at that time was that they should be
7 reduced first to 83 hours per week with a deadline, and
8 then to 72 hours per week with a deadline, and I think
9 overall, we met that well within the deadline, with the
10 exception of one or two areas that needed a little more
11 imaginative approach to solve the problem.
12 But I was satisfied at the end of this that junior
13 doctors were working less than 72 hours.
14 The review of junior doctors' hours was to confirm
15 that what was contractually then the case was factually
16 the case, because there were all sorts of ways of
17 cutting corners and saying that, having done their
18 72 hours, if there was a teaching opportunity, they
19 could indulge in teaching, or indulge in research and
20 that did not count against their hours. So there were
21 all sorts of ... So we naturally said, having achieved
22 this, we actually wanted to know how long they were
23 working to make sure we had achieved what we thought we
24 had achieved.
25 Q. So far I have covered in paediatric cardiac surgery the
0141
1 desirability or otherwise of the split site, the
2 question of whether waiting times were poor or good or
3 not, the availability of paediatric nurses in the Royal
4 Infirmary so far as one can judge from the
5 documentation, and the long hours that doctors may seem
6 to be working, which you tell us was a general position
7 which you have taken the steps you have just described
8 to combat.
9 Two other aspects that I would wish to focus on:
10 could we have PAR (2) 2/176, this is an Audit Committee
11 medical audit meeting report dated 22nd January 1992 for
12 paediatric cardiology, chaired by Dr Martin. It sets
13 out those in attendance.
14 Can we scroll down, please? The criterion
15 reviewed: "closure of the patent ductus by a transvenous
16 insertion of the Rashkind device...", they set out their
17 findings and observations, the inferences and
18 hypotheses, "transvenous occlusion has comparable
19 results to surgical ligation but causes less trauma and
20 much shorter hospital stay."
21 That is obviously a reference to using the
22 Rashkind device. Action taken, "clinical changes
23 instituted, unable to implement due to lack of finance."
24 If we scroll down to the bottom, the brackets as
25 to the cost over and above the cardiac catheterisation.
0142
1 On the face of it, this is a document which --
2 I may have to ask those more closely connected with the
3 delivery of the cardiac service about it, but this is
4 a document which might suggest that a lack of finance
5 was preventing the delivery of optimal care.
6 A. Yes.
7 Q. Have I misunderstood or not?
8 A. No, I mean, I believe you have not misunderstood. This
9 is a new development. Somebody has developed
10 a particular implement. I imagine this is something
11 they put either in the catheter or at the end of the
12 catheter to place within the patent ductus, aiming to
13 produce occlusion. It is a new way. It has just been
14 developed. They reviewed it on 22 of 24 children. I do
15 not know how those results compare with what anybody
16 else may seem to say. It is much the same, but 4 had
17 high persistent flow and 3 with technical problems, that
18 is 7 out of 22 had problems with it, and what they are
19 saying is that they wish that their budget, their
20 funding, would increase so they could do this. If I put
21 that in perspective, that is the sort of thing happening
22 right across the Trust, and I expect across teaching
23 hospitals, that somebody produces an infinitely more
24 expensive way of doing something rather better.
25 Q. If I, having looked at that document, ask you to look at
0143
1 PAR (1) 8/5, I am not concerned with much of the
2 material in the particular document. I want to make it
3 plain I shall ask you about those on some later
4 occasion, but this is a letter from Mr Bolsin dated
5 25th July 1990 to you. Can we scroll down, please? He
6 talks in the second paragraph complaining about various
7 things that have been said in the application for Trust
8 status, but the burden of the complaint, the third line
9 down:
10 "As a consultant with a specific interest in the
11 subject, having undertaken 18 months research at the
12 Brompton Hospital, I have applied on numerous occasions
13 for equipment to maintain and protect cerebral function
14 during routine open heart surgery. On each occasion,
15 funding has not been identified by the management side
16 for this equipment to provide the service to patients.
17 As a result, we are unable to undertake any research on
18 this subject ..."
19 He goes on to deal with the situation.
20 What he appears to be suggesting, in that
21 paragraph at any rate, is that important equipment to
22 maintain and protect cerebral function during routine
23 open heart surgery has not been made available to him.
24 Whether this applies to paediatric or whether this
25 applies to adult, or both, is not clear, but is this
0144
1 again, if it is true, an example of the funding problem
2 that you have just been describing, that there cannot be
3 funds for everything and that there has to be some
4 rationing?
5 A. Yes. I mean, at the time I have to say, politically it
6 was not accepted for us to use rationing. We had to use
7 the term "targeting" or "prioritising".
8 Q. The effect is the same, presumably?
9 A. If I can tell you that in our South West region we were
10 deemed to be above our RAWP target. We started off,
11 when I took over, as a million pounds or so overspent in
12 recurring money that had to be addressed, and because we
13 were over our RAWP target we got minimal development.
14 So we were not quite at a static position, but we
15 certainly did not meet what I would call "medical
16 inflation". Medical inflation, I mean, is not
17 financial, but the way people constantly find better
18 ways of doing things.
19 So this was not for better patient care, although
20 it said that, it is that it was for him to pursue
21 research to establish whether it was better patient
22 care. This was not something that was an established
23 service, we were all waiting to put it in, this was
24 something that he wanted, as I read the final sentence
25 of that first paragraph:
0145
1 "We are unable to undertake any research on this
2 subject."
3 Q. It is not altogether clear whether it is for clinical or
4 research reasons. Research is rather emphasised,
5 I agree.
6 A. I have no doubt that this is a research project that he
7 had started elsewhere and wished to continue, and was
8 having difficulty competing with all the other good
9 research ideas for such money as was available, and the
10 money that would have come from that would have come
11 from the special trustees, who I think traditionally
12 always spent a third of its income on research.
13 Q. The problem with whether you call it rationing or
14 targeting or prioritising, the problem is, is it one of
15 allocation of resources?
16 A. Yes, the problem of not having enough resources to
17 allocate.
18 Q. It may be that in that situation someone has to make
19 a decision as to where those resources are best
20 allocated, who gets the bigger slice of the cake?
21 A. Yes. In cardiac surgery it was regional, it was not
22 a district decision. The Region decided how much
23 cardiac surgery to fund and we had to work within their
24 funding limit.
25 Q. Could you have a look, please, back to Professor Vann
0146
1 Jones's statement, 115, page 14. It is paragraph 51.
2 If we just read it through for a moment, as
3 I appreciate you have not seen this before today, is it
4 right that it was difficult to persuade you to commit
5 funding to develop cardiac services?
6 A. Well, I did not have any funding. We were at that time
7 funded through contracts with purchasers. The only
8 money I got was top-slicing it from his contract, so the
9 only thing I could do about cardiac surgery was take
10 money away, if that was the right thing, I had no other
11 money to give them.
12 Q. Anything involving capital input would have to be funded
13 from somewhere?
14 A. Yes, but at that time, if I can explain, capital was
15 looked upon as a loan, so there were limits to the total
16 capital. Any capital that was spent had to be serviced
17 from the revenue budget. I have forgotten what the
18 percentage was, whether it was 10 per cent or 7 per cent
19 or something, so if we spent a million pounds on cardiac
20 surgery, then we had to take œ70,000 out of that every
21 year to give back to the Department of Health to service
22 the capital we had spent.
23 So, although capital and revenue at that time he
24 was talking about were separate concepts, the capital
25 had to be serviced rather like a permanent mortgage.
0147
1 Q. So the answer is, it could have been done, but it cost?
2 A. Not by me it could not be done. What was needed was for
3 the purchasers to buy the improved service that he
4 wished to provide, not for me to fund it.
5 Q. Who would persuade the purchasers that they ought to
6 commit to such a service?
7 A. He and his colleagues, with help from community
8 physicians and any other pressure we could bring to
9 bear, remembering, of course, that every other specialty
10 took the same view and was pressing the purchasers in
11 a similar way.
12 Q. So when he complains that it was difficult to persuade
13 you to commit funding to develop cardiac services, it
14 never seemed to be a priority, what he should have been
15 complaining about, you would say, is that he had not
16 used his freedom to persuade the purchasers to pay extra
17 so that he, on behalf of the Directorate of Cardiac
18 Services, could fund a loan which the Trust would take
19 out in order to improve and develop those services?
20 A. Well, I think he had not been successful, not that he
21 had not used his freedom, he had not been successful in
22 using his freedom. All Clinical Directors were involved
23 directly in the negotiation of contracts.
24 Q. He goes on to observe that adult cardiology and surgery
25 are four floors apart. There is not the funding to
0148
1 physically integrate cardiac services. He talks about
2 facilities having barely changed in adult cardiology and
3 he deals here with adults?
4 A. Yes.
5 Q. He points out that it causes difficulty to work.
6 He goes on, in paragraph 52:
7 "There was competition for resources."
8 From what you have just been saying, that would
9 not be the case?
10 A. I am sorry -- no, there always was competition for
11 resources and there has been since time immemorial. The
12 difficulty, if you work in a teaching hospital, it is
13 a hotbed of innovations and very few innovations which
14 improve patient care cost less. They normally cost an
15 inordinate magnitude more. I worked in and eventually
16 managed and a District and a Trust which was full of
17 people developing and implementing new developments
18 which were expensive and were competing with each other,
19 and eventually all the other districts in the region,
20 for funds.
21 That is the very nature of the Health Service and
22 at one time before this was written, the Health
23 Authority itself had the resources for the local
24 population. The region retained the resources for the
25 regional services we provided, and within that what
0149
1 everybody naturally felt was a wholly inadequate budget,
2 they were all competing for their share. They all used
3 to impress me as best they could that the service they
4 were providing needed -- their needs were greater than
5 anybody else's and I should top-slice the whole budget
6 to satisfy their needs and share what was left amongst
7 the others. If there was only one service with
8 a problem, of course it would be easy, but the whole of
9 the Health Service was in that position.
10 Whilst I was the District General Manager and the
11 District Health Authority that made that responsibility,
12 we had a whole series of meetings. The first was,
13 I invited every part of the service, every department,
14 if you like, to meet the planning committee, I think it
15 was the GPR -- Policy, Planning and Resource Committee
16 of the Health Authority, and each one made
17 a presentation of what their current position was and
18 what their aspirations were, and as each walked out,
19 I would turn to the committee and say, "Are they
20 overfunded, since we are looking for some money?" The
21 answer was, none of them were overfunded.
22 I then set up a committee which was called
23 a Choices Committee for the Health Authority and others,
24 in which we invited a whole series of experts to come
25 and address this committee on how choices could be made,
0150
1 how these invidious choices could be made on scientific
2 and moral grounds. It did not produce any more money,
3 but it produced a little bit more of what shall I say,
4 confidence in the Health Authority that was having to
5 make the decisions.
6 Q. Could we have a look at WIT 89/11?
7 This is the statement of Rachel Ferris which you
8 have seen. She describes her personal action plan at
9 16, the last bullet point was development of a high
10 profile directorate within the Trust.
11 17, please. She says that what she had in mind
12 was that the directorate would determine a strategic
13 direction, followed by a commitment to investment and
14 development at Trust Board level, complaining that it
15 seems to her almost as if the creation of the
16 directorate had been an end in itself, and pointing out
17 that cardiac disease is one of the major causes of death
18 and demand is high, they were not meeting the demand for
19 cardiac services, and describing her feeling that the
20 Trust was not committed to developing the service.
21 It is the same point, I think, that Professor Vann
22 Jones was making, or it may be seen as the same point,
23 and what she appears to be looking for and criticising
24 the Trust for failing to provide was a commitment to
25 investment and development in cardiac services.
0151
1 A. I left the Trust in 1995, and I cannot obviously give
2 a comment on what has happened since then, but could
3 I say that up until that point, we had gone through an
4 enormous effort to separate the responsibilities for
5 determining the volume and pattern of care to be funded
6 for the community from what I would call the management
7 expediency of delivering that care.
8 I would not say its sole advantage, but the major
9 advantage of the creation of Trusts was the separation
10 of management expediency from health care policy.
11 The people who decided that the pattern of cardiac
12 disease treatment should be in the South West were the
13 purchasing Health Authorities, not the providers and not
14 the Trust Board.
15 The Trust Board had no direct health care money as
16 of right. It only received that money from the
17 purchasers that the purchasers wished to provide for
18 that source of treatment, and for regional service by
19 that time, this meant, and I expect Graham Nix explained
20 to you, a large number of separate purchasers.
21 The Trust Board itself could not and should not
22 determine whether cardiac services were going to expand
23 or orthopaedic services or care in the community should
24 expand. That was the separate responsibility of
25 a purchasing Health Authority.
0152
1 What we, as a Trust, had to achieve was a very
2 flexible service that could respond to whatever the
3 purchasers want.
4 Of course, the experts there, and I mean the
5 experts, not the Trust Board, could use their very
6 considerable knowledge and ability to persuade the
7 purchasers of the critical need to fund the patients
8 they were specialised to treat. But this is, I have to
9 say, a gross misunderstanding and if that is the
10 thinking, it has slipped back that the Trust Board
11 determines what the community should need. The
12 community belongs to the purchaser. The Trust responds
13 to provide that service. In my time, and I expect
14 since, I doubt if the Trust has ever been unable to
15 accept a contract to provide care. That is the
16 important thing. Once the purchasers have said "This is
17 what we want you to do", the Trust has to be able to do
18 it. If the purchasers suddenly say, "But we do not want
19 you to provide that service any more", the Trust has to
20 cope with that, it is a management problem.
21 Q. May I explore that just a little? If I understand your
22 earlier evidence correctly in what you say in your
23 statement, you, when you were Chief Executive, left the
24 day-to-day control of the operational side of the Trust
25 principally to Margaret Maisey as your Director of
0153
1 Operations?
2 A. No, I did not say that. I am sorry, if I did, I misled
3 you. The operational decisions, management decisions,
4 were delegated to operational level and made by the
5 General Manager and the Clinical Director with the
6 supporting staff they had. Margaret Maisey's role as
7 Director of Operations, amongst other things, was to
8 support the General Managers and ensure, as far as she
9 could, their development.
10 My role, amongst many other things, in terms of
11 that was to support the Clinical Directors and ensure
12 their development, so that between the two of us, and we
13 often met the clinical directorate team together with
14 others, it was our job to make them successful.
15 Q. You had a role in strategic planning, did you?
16 A. Yes. I mean, I had a role in strategic planning, but
17 let me tell you, as a Trust, the only strategic plan
18 that was directly viable was to be in a position to meet
19 the strategic plan of the purchaser. We could not have
20 an independent strategic plan. That was nonsense.
21 Q. That was going to be the point of my question, you have
22 answered it for me: that strategic planning would make
23 no sense if, in effect, the strategy was entirely in the
24 hands of others?
25 A. Well, it was.
0154
1 Q. And you had no choice but to respond to them?
2 A. If there was any other choice, then the whole country
3 had wasted its time in the very expensive business of
4 separating purchasers from providers.
5 May I say, there was a strategic issue, and I was
6 there at the beginning -- I do not want to say
7 I initiated it because these things emerge out of
8 conversations one has -- where it was my view that if
9 the purchasers were going to continue to require
10 providers to make what was called "cost improvements",
11 that is, they were supposed to provide again what they
12 provided last year but for a given cost improvement
13 reduction, 5 per cent, that the providers would reach
14 the stage where they could no longer meet this without
15 having a pan-Avon strategy amongst providers of how they
16 were going to meet this economy.
17 We discussed a whole variety of things in great
18 detail, and I am happy to say one of the things that
19 I recommended at the time has now happened and the
20 Southmead and Frenchay Trusts have merged, and that is
21 the sort of strategic planning providers have to do to
22 make sure that the provider services within the area are
23 in a position to meet the needs.
24 There is another strategic plan -- which I am sure
25 if I have not mentioned I will, and was going to -- and
0155
1 that was to rebuild and reprovide the Children's
2 Hospital. We had to do that on no more than an
3 understanding that the purchasers would continue to
4 provide, would purchase children's services from us and
5 indeed some children's services which are currently
6 purchased from others.
7 Q. You have almost anticipated my line of questioning.
8 I was going to ask you, if it was the case that
9 strategic planning meant no more than being able to
10 respond to that which other people had determined and
11 their strategic plans, how on earth does one plan
12 a major development such as the development that is just
13 taking place?
14 A. I have to say, with difficulty, and I was very pleased
15 that before I left, plans had reached an achievable
16 position and the Children's Hospital is being built, but
17 I would not like to minimise the very substantial
18 difficulties with that.
19 Q. So put another way, the planning for the future of the
20 Trust and the hospitals within it may depend upon the
21 reaction of other people, but on the other hand, the
22 reaction of purchasers may to an extent be anticipated
23 and plans placed, formed, on that basis?
24 A. I think that is right. I think that is right.
25 Q. So there is scope for strategic planning,
0156
1 notwithstanding that whether the plans ultimately come
2 to fruition may depend upon the co-operation of others
3 who hold the purse strings?
4 A. If you strategically plan a new unit like the Children's
5 Hospital and then do not get contracts for it, I think
6 somebody ought have the situation discussed with them.
7 I mean, what I am saying here is that the cardiac
8 disease was a major cause of death and demand in the
9 regional services is high and so on, and this is an
10 issue that we are not meeting the demand for cardiac
11 services and we were not committed to developing the
12 service. Of course the Trust is and was committed to
13 developing the service, but only as far as the
14 purchasers were committed to buying that service.
15 Q. You see, going full circle from the point which you
16 accepted in questioning a moment ago, that there may be
17 strategic planning notwithstanding that it is not easy
18 and it does depend upon the decisions of others, it
19 would no doubt be helpful, would it not, taking Rachel
20 Ferris's point in paragraph 17, for the Trust Board or
21 the Trust to have a strategic plan, if it wished to do
22 so, to encourage purchasers to behave so that investment
23 and development of cardiac services might take place?
24 A. That is usurping the purchaser role. That is the
25 provider saying that we, as providers, would like to
0157
1 provide this service. I mean, we are discussing just in
2 relation to cardiac surgery. It would have been not
3 difficult for you, if you had wished, to go to every
4 other directorate and saying "We are not getting
5 sufficient support to make sure we get a share of the
6 future funds available to major purchasers".
7 In my view, and you have to remember that I was
8 involved in the whole run-up to Trusts as the first-wave
9 Trusts and listening to the philosophy developing and
10 listening to the aim, the purpose of the separation of
11 the purchaser from the provider was to ensure that the
12 purchaser would decide what the community's needs were
13 and make the appropriate funding, and that the
14 provider's role was to put themselves in a position to
15 accept that contract.
16 If the provider, if the Trust, had got itself in
17 a position of being unable to meet the demands for
18 additional cardiac surgery made by the purchasers,
19 I would consider they had failed. If, on the other
20 hand, the providers had said, "We will do the same work,
21 we will ask our Trust Board not to oversee the effective
22 delivery of health care, but we will sit down looking at
23 what sort of pattern of health care the community needs
24 and we will decide what is needed", then that negates
25 the whole basis of the advantage that was purported to
0158
1 come from the situation of purchaser and provider.
2 Q. Going back to the way you put it a couple of paragraphs
3 ago, you said that it was no function of the provider to
4 usurp the position of the purchaser?
5 A. Yes.
6 Q. I want to understand this, and so please do not
7 misunderstand the next question, but there is nothing,
8 is there, intrinsic in the system of purchaser and
9 provider which would amount to the provider usurping the
10 function of the purchaser, if that which the provider
11 does is to encourage the purchaser to take certain
12 decisions and anticipate that the purchaser probably
13 will or might take those decisions?
14 A. This is one purchaser apparently putting pressure on the
15 provider Health Authority and saying, "We are not
16 satisfied that you are not making the decision that
17 additional cardiac services should be provided". What
18 the provider board, at the present time and when I was
19 there, had to do, was to address the issue of being able
20 to provide whatever additional service the purchaser
21 provided. That is the management problem. Deciding
22 parallel the purchaser what that pattern of care should
23 be is introducing back into the argument what I would
24 describe in a shorthand way as the "management
25 expediency" of imposing a pattern of health care.
0159
1 It was very important, and is still important, if
2 you want to pursue this separation of purchaser and
3 provider. As I understand it, that has continued to be
4 desired. If you have a separation of purchaser from
5 a provider, then you have to make sure that what happens
6 is not that the roles are reversed. You have to
7 remember that in the provider was most of the expertise
8 of what the community needed and in the purchaser by
9 definition, because they were the senior management of
10 the previous district, was the expertise in delivering
11 the service that actually happened in a number of
12 districts.
13 The District General Manager remained the Chief
14 Executive of the purchaser and there was a tendency the
15 whole time, which I see here, to reverse the roles.
16 I have to say that that may be desirable in some
17 people's eyes, but it undermines and negates all the
18 advantages that are to be achieved from the separation
19 of the purchaser from the provider. It is very
20 important to recognise that. The decision of whether
21 cardiac services should be increased and that money
22 should be allocated to it at the expense of the
23 allocation of the same money to other services is the
24 sole responsibility of the purchaser.
25 Q. Can I go back to the question that inspired your last
0160
1 answer, which is, is there anything intrinsic in the
2 system which means it is the usurpation of the
3 purchaser's role for the provider to encourage the
4 purchaser to make a particular purchase and to
5 anticipate that he might do so?
6 A. Yes. In the decision of the purchaser to place
7 contracts, there is a negotiation. The negotiations, by
8 necessity, are specialty by specialty. What is needed
9 is to influence the purchaser in their determination of
10 the balance of resources they wish to put to each
11 service. They are put under intense pressure by a whole
12 variety of lobby groups, quite properly, and interested
13 parties. They are put under pressure for funding new
14 drug therapies, some of them very expensive. They are
15 put under pressure for improving care in the community.
16 They are put under pressure to put more money into
17 learning difficulty services, into mental illness and
18 into the high tech services. Of course it is right that
19 the purchasers should be subjected to all that pressure
20 and advice from the community; after all, it is
21 a National Health Service, it is a public service.
22 What I think I am trying to say in great detail is
23 that the provider Trust has a very real and challenging
24 problem of being in a position to provide whatever
25 service the purchasers in their wisdom decide they
0161
1 need. But it is not the role of the provider as
2 a Trust. It may be as members of the public, but as
3 a Trust it is not their role to decide the pattern of
4 care that the purchasers should provide.
5 Have I made it clear?
6 Q. That, you have. If I pursue the question I hope you for
7 your part will understand. It is open to the purchaser,
8 if the provider, as you say, has to be in a position to
9 answer the demand placed upon it by the purchaser, then
10 the provider must necessarily anticipate to some extent
11 the demands which a purchaser is likely to make upon it?
12 A. Yes, and it is for the directorate who are entering into
13 that sort of conversation to advise the Trust Board what
14 he believes the purchaser might buy. This says, it is
15 for the provider to decide what the purchaser should
16 provide; it is the other way round and that is wrong.
17 Q. I just wonder, and this is for your comment, and I hope
18 it may be one of the last questions that I ask today,
19 because I appreciate we have gone a little past 4.30, it
20 may be perhaps saying, "Well, if we are to answer demand
21 which we, in the Directorate of Cardiac Surgery, think
22 is high, we think the purchaser wants service, we cannot
23 satisfy the service unless...", let us suppose there is
24 a development -- not this paragraph but it might be the
25 case -- the building of a couple of new wards, or a new
0162
1 theatre or something of that sort. The directorate
2 could not take a decision of its own in principle to
3 carry out such work, whatever the demands of the
4 purchaser might be, that would have to be for the
5 provider to say "This is the appropriate response to the
6 anticipated demand", would it not?
7 A. Precisely, so that when James Wisheart negotiated the
8 substantial increase in adult cardiac surgery to be
9 purchased by the region, it may by then have been
10 purchased by all the purchasers in the region, but the
11 region would have had a significant strategic role in
12 guiding that new pattern of care.
13 Once that contract was agreed or was anticipated,
14 even before it was signed, the Trust Board would then
15 respond to the advice, and we have seen some of the
16 advice that was being given, to work out a way of
17 investing the money that was going to be received in
18 order to deliver the contract. It has to be that way
19 round.
20 Q. Because he could not sign or make the contract unless he
21 knew there were going to be the facilities in place to
22 deliver it?
23 A. I said, it is for the provider to ensure that whatever
24 the purchaser wishes can be provided.
25 Q. So somebody within the provider structure has to
0163
1 anticipate that the contract might be available and to
2 indicate at least in principle a willingness to provide?
3 A. Yes. I thought I made that clear. Let us take it
4 specifically, because it is much easier to talk about
5 a concrete example. James Wisheart, with his
6 colleagues, agreed with the region or with the
7 purchasers, through the region, perhaps, that there
8 would be another significant increase, whatever it was,
9 four new cases a year or whatever the figure was -- it
10 is a long time ago and I cannot tell you what it was.
11 They said, "We are going to want to buy from you next
12 year an additional 400 cases".
13 The Trust, at that time, was in a position of
14 flexible management and innovation to say, "Fine, we
15 will help you deliver. We will deal with the necessary
16 documentation to justify capital expenditure, we will
17 identify the capital expenditure, but what we will do is
18 not a direct enlargement of the unit for the additional
19 400 cases, we will create the space by moving the
20 children up to the Children's Hospital and we will
21 develop and deliver that capital".
22 That is what the Trust Board actually did.
23 What the Trust Board did not do is say "We want to
24 increase cardiac surgery. We will now build a unit at
25 the Children's Hospital, create a space, and now the
0164
1 purchasers have to buy it". That would have been
2 wrong. That would have been management expediency
3 determining pattern of population care.
4 I feel strongly about this because I was one of
5 the project leaders for the first-wave Trusts. I was
6 a supporter of it because I see enormous advantages in
7 separating that responsibility for purchasing from that
8 responsibility of providing. What I see as terribly
9 dangerous, and it may happen from time to time, is if
10 those two authorities invert their roles. All the
11 advantage of all that work, all that trauma, all that
12 heartbreak, will all have been wasted.
13 Q. Returning to paragraph 17, and this really will be the
14 last question, if what Rachel Ferris was saying there
15 was no more than saying, "We would wish to respond to
16 the demand of a purchaser to provide certain services,
17 but for that we need the support of the Trust", the
18 support you were latterly to give to James Wisheart, as
19 you have told us, "but the support does not seem to be
20 forthcoming", if that is what she was saying, there
21 would be nothing necessarily inconsistent in that
22 paragraph with a misunderstanding of the role of
23 purchaser/provider, would there?
24 A. I do not know what she thinks now, but I used to know
25 her, and I read this in the situation of my
0165
1 understanding of the Health Service, and she is saying
2 the Trust Board should decide to increase cardiac
3 services and develop the facilities and then market
4 them. I am saying, "No, the directorate should achieve
5 a contract for increased cardiac services" and the Trust
6 Board and the Trust support that there is now should
7 enable the directorate to deliver that contract.
8 MR LANGSTAFF: I have kept you longer than we had
9 anticipated, I am sorry for that.
10 DR ROYLANCE: I am quite willing to help.
11 MR LANGSTAFF: I am grateful. I apologise to the
12 stenographers for making them work overtime.
13 THE CHAIRMAN: Mr Langstaff, thank you very much, ladies and
14 gentlemen. Thank you, Mr Langstaff. We reconvene
15 tomorrow morning at 9.30.
16 (16.47 pm)
17 (Adjourned until Tuesday, 8th June 1999, at 9.30 am)
18
19
20
21 I N D E X
22
23 Statement by Mr Langstaff .................... 1
24 Dr John Roylance (affirmed)
25 Examined by Mr Langstaff ................ 5
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Published by the Bristol Royal Infirmary Inquiry, July 2001
© Crown Copyright 2001