Home Page Search Final Report Interim Report Evidence - Transcripts - Witness Statements - Submissions - CCNR Report and associated documents - Statistical Reports and associated documents - Background Papers - Expert Papers Inquiry Seminars About the Inquiry Help		Daily transcripts Hearing summary 8th June 1999   Today the Inquiry heard further 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 today answered questions about the evolution from medical to clinical audit which took place during the late 1980’s to the mid 1990’s. He said that the role of the UBHT Audit Committee was to monitor audit activity rather than to be involved in the actual auditing of services. Responsibility for carrying out audit, and action resulting from audit, was devolved to Directorate and Divisional level, with funding from the Regional Health Authority. He went on to describe the ways in which staff could raise concerns about the activity of colleagues and outlined the process known as ‘the three wise men’ by which staff could confidentially discuss anxieties with senior members of the medical staff. Dr Roylance then went on to discuss the establishment of the Chair of Cardiac Surgery at Bristol University in 1992 and commented on the unsuccessful quest to appoint a paediatric cardiac surgeon to the position. He confirmed that the ‘split site’ which existed, with open heart surgery taking place at the BRI and other procedures being undertaken at the Bristol Children’s Hospital, had been an issue for one potential applicant for the post. He then went on to discuss the role and workload of the Medical Director and concluded by describing his personal management style. Dr Roylance will return for re-examination tomorrow morning at 9.30 a.m. to be followed by Margaret Maisey, former Director of Operations and Nurse Advisor at UBHT and Director of Nursing to 1997.

FULL TRANSCRIPT

   1                       Day 25, 8th June 1999
   2   (9.30 am)
   3           DR JOHN ROYLANCE (RECALLED):
   4          EXAMINED BY MR LANGSTAFF (CONTINUED):
   5   MR LANGSTAFF: Good morning, sir. Today we begin, as you
   6     know, at 9.30. Can I say now, for the interests of
   7     those in the hearing chamber, that we will sit until
   8     10.45 or thereabouts; we will begin again at 11.00. At
   9     12.15 there will be a break of 45 minutes for lunch, and
  10     then an afternoon session which will go from 1 o'clock
  11     until 2.15, and if necessary, if Dr Roylance has not
  12     finished his evidence by then, from 2.30 until somewhere
  13     round about 3.30.
  14        Dr Roylance, you have heard that; you know what is
  15     in store for you?
  16   A. I am obliged, yes, thank you.
  17   Q. Dr Roylance, suppose that you were aware, or became
  18     aware, that part of the service provided by the Bristol
  19     Royal Infirmary, or for that matter, the Children's
  20     Hospital, was or had severe shortcomings in the sense
  21     that it was performing, so far as one could tell, much
  22     less adequately than other similar institutions
  23     elsewhere in the United Kingdom.
  24        Dividing my question up into the time when you
  25     were District General Manager and Chief Executive, as

   1     District General Manager would you have conceived it as
   2     any part of your role to do anything about it?
   3   A. Yes. If it had been brought to my attention that any
   4     part of the service, anywhere, was substandard, and
   5     particularly -- it would usually be I expect in the
   6     terms that it is unacceptably substandard, then I would
   7     take the appropriate steps.
   8   Q. Does the same answer apply when you were Chief
   9     Executive?
  10   A. Yes.
  11   Q. If it appears that the shortcomings were institutional
  12     in the sense that there were insufficient facilities or
  13     a lack of equipment which could not be funded, something
  14     which did not rely upon human beings as such but upon,
  15     as it were, bricks, mortar, money, so that they could
  16     not easily be remedied, would you, as part of your
  17     appropriate action, consider stopping the service?
  18   A. I am sorry, I am pausing because I am trying to put some
  19     flesh on that hypothesis. If, for any reason, the
  20     service provided was unacceptable, it would stop. I am
  21     not sure I would even need to stop it; I am quite sure
  22     the clinicians, having discussed the situation, would
  23     stop it themselves, but certainly, I would not tolerate
  24     and I would not expect anybody else to tolerate an
  25     unacceptable service.

   1   Q. Suppose that the clinicians immediately responsible for
   2     the service wished to continue it, even though it was to
   3     the objective view, the outsider's view, unacceptable,
   4     would you take action or would you say that was a matter
   5     for the clinicians themselves?
   6   A. I find that hypothesis difficult to grasp, because
   7     I cannot imagine this happening, so I am sorry, but if
   8     somebody had so little insight into a situation, then
   9     I think I would ensure that the "three wise men" would
  10     advise me. It is the wrong way round for the three wise
  11     men, they are supposed to have matters referred to them
  12     by colleagues and not for Chief Executives or District
  13     General Managers to know, but I really think that if
  14     anybody took that posture, I would be concerned about
  15     their health.
  16   Q. Suppose that the issue was not one of bricks and mortar
  17     or money, or equipment, but suppose that the issue were
  18     one of individuals, individual performance. Leave aside
  19     whether one would classify it as competence or not, but
  20     suppose the performance of an individual surgeon or
  21     clinician was unacceptably low in standard. Again
  22     splitting it between the Health Authority and the Trust,
  23     would you conceive it as part of the role of the
  24     District General Manager to do anything about it?
  25   A. We are tending to jump the hurdle of establishing

   1     whether this complaint is well-founded, whether it is
   2     real, but as I understand your hypothesis, you are
   3     saying that it is brought to my attention that there is
   4     a genuine substandard service from somebody's
   5     incompetence, I would act.
   6        Could I make it less hypothetical and actually
   7     describe a situation that occurred, not in paediatric
   8     cardiac surgery at all?
   9        It was brought to my attention that a consultant
  10     was not meeting his obligations, it was not a question
  11     of life or death. If I describe what the situation was,
  12     then I am afraid it is a public meeting and the person
  13     would be identifiable, so I am not going to do that, but
  14     it was brought to my attention that the contribution of
  15     a consultant to the service at Bristol was inadequate.
  16     I met him, discussed it with him, and he agreed the
  17     shortcoming and agreed to put it right. He did not, so
  18     I saw him again. I discussed it and said, this would
  19     not do, but I would give him two days to decide his
  20     future. At the end of that time, I would initiate the
  21     processes resulting in his dismissal. He took early
  22     retirement and the situation was solved.
  23   Q. So the answer is, not only you would take action, but
  24     you did in an appropriate case?
  25   A. Yes.

   1   Q. You rightly say that whether you were in a position to
   2     take action or not would of course depend upon the
   3     information that came to you, and whether or not there
   4     were a proper case for action?
   5   A. The one thing I could not do is make the judgment as to
   6     whether the criticism was genuine and was well-founded.
   7     I could not, myself, make a judgment as to whether the
   8     quality of care or the competence was inadequate. But
   9     if it was made clear to me that it was, I would act. If
  10     it was made unambiguously to me as an accusation, as an
  11     anxiety, then I would institute the necessary
  12     investigation. Again, I cannot tell you what it would
  13     be unless we actually spend a long time specifying the
  14     example, but one would normally seek the advice of
  15     experts in the field who could make the judgment, and if
  16     there was some real concern, then it would be my
  17     responsibility -- and this happens about the country --
  18     to suspend the individual concerned until the facts of
  19     the matter were established and agreed upon.
  20   Q. Just completing this particular part of your evidence,
  21     you mentioned the possibility of referring the clinician
  22     who failed to recognise that his service was substandard
  23     to the "three wise men" procedure, and you indicated you
  24     would do so on the basis that it would show that there
  25     may be something, as it were, medically wrong with that

   1     individual in failing to have that perception?
   2   A. I do not want to use exaggerated terms, but I would not
   3     think that somebody was in possession of their faculties
   4     if they were producing a substandard service and did not
   5     know, or did know and wished to continue to do so.
   6     I mean, I do not find that compatible with an
   7     intelligent, fit, consultant.
   8   Q. You mentioned yesterday a Health Circular (82)13
   9     which I understand to have laid down the "three wise
  10     men" procedure. May we have a look at it? It is
  11      UBHT 61/266. Can we, having identified it, scroll down,
  12     please?
  13        The recommended procedure. Can we scroll down
  14     further? We see first of all the recommended procedure:
  15        "There should be a special professional panel set
  16     up by the District Hospital Medical Committee or Medical
  17     Executive Committee consisting of members of the senior
  18     medical or dental staff for which in each case a small
  19     sub-committee should be appointed. The sub-committee
  20     should receive and take appropriate action on any
  21     reported incapacity due to physical or mental
  22     disability, including addiction ...", and so on.
  23        This is what became known as the "three wise men"
  24     procedure, is it?
  25   A. Yes. I think that is often the process and in Bristol,

   1     if I can tell you, the three wise men consisted,
   2     comprised, the Chairman elect, the Chairman and the past
   3     Chairman of the Medical Committee, ex officio, so there
   4     was permanently three wise men and everybody knew about
   5     it. The staff were regularly reminded, not just medical
   6     staff, all staff, and at some time in my experience,
   7     I cannot remember quite when, a fourth was seconded to
   8     them as a psychiatrist, normally the Chairman of the
   9     Division of Psychiatry.
  10   Q. This procedure, if we scroll back to the top of the
  11     page, it is intended to deal with physical or mental
  12     disability of staff?
  13   A. Yes.
  14   Q. It is incapability rather than incompetence?
  15   A. Well, I think in practice it is a moot point where one
  16     starts and the other ends. If somebody is showing signs
  17     of not being able to do their job, then this is the
  18     mechanism that is adopted, because you cannot prejudge
  19     in a situation like that why they are not doing their
  20     job.
  21        So suspected incompetence, for whatever unknown
  22     reason, would have been referred to them. I mean,
  23     I was, for six years, having been a Chairman, therefore
  24     a Chairman elect and a past Chairman, one of the "three
  25     wise men", and I know the system well.

   1   Q. Can we have a look at paragraph 15 of the circular, on
   2     the next page, please. "The recommended procedure", it
   3     says there, "is intended to deal with cases where
   4     disability, including addiction, is suspected in
   5     a member of medical or dental staff which might be to
   6     harm or danger to patients. It is not intended to
   7     replace or detract from the procedure set out at
   8     HM(61)112 and section 34 of the Whitley Council
   9     conditions of service. It may be appropriate to use the
  10     procedure recommended above where it is possible that
  11     disciplinary action could arise but where there is
  12     reason to suspect disability."
  13        That appears to draw a distinction between the
  14     incompetence case and the incapability case. You are
  15     saying you creatively would have used the procedures to
  16     deal with a case of incompetence by labelling it because
  17     of your suspicions as to the faculties of the individual
  18     concerned as a capability case.
  19   A. Well, can I just try and make that clear? You are
  20     rather presuming that from the outset it is obvious that
  21     somebody's incompetence is due to mental ill-health or
  22     disability, or due to incompetence or some other
  23     reason. That actually in practice is not the case.
  24     What is needed is a system like this where there is the
  25     possibility for anybody on the staff who has any anxiety

   1     about the quality of care of the consultant, to share
   2     that anxiety anonymously with three wise men, one of any
   3     of the three wise men, and be satisfied that the
   4     appropriate steps would be taken.
   5        Clearly, the person making the complaint will not
   6     be in a position to judge the cause of the incompetence,
   7     I mean, even the psychiatrists working with them may not
   8     be able to determine that until after considerable
   9     discussion, and so on, so you cannot prejudge the case.
  10        Should a matter of clear-cut discipline arise,
  11     then the other procedures would be set out, but it is
  12     more difficult to get the information we are discussing
  13     on that basis.
  14        So I would think in practice, not because we
  15     thought it was kind, but because it worked, in practice
  16     matters of incompetence would firstly be reported to the
  17     three wise men. They certainly were to me when I was
  18     one of the three wise men, and if, as a result of the
  19     deliberations of the three wise men, and anybody else
  20     they chose to invite to help them, it made it clear that
  21     this was a disciplinary matter to be dealt with by the
  22     authorities, then that would happen.
  23   Q. In any event -- perhaps I should ask you, if you had
  24     a complaint from a patient or for that matter a general
  25     practitioner which related purely to competence, would

   1     that go to the three wise men?
   2   A. No. If it came from a patient, it would be dealt with
   3     as a complaint for a clinical matter and if they were
   4     not satisfied by the original investigation and
   5     response, then that patient or relative would be told
   6     they have the option of referring it for formal clinical
   7     review, and there was a mechanism in which appropriate
   8     experts would be set up to investigate the matter,
   9     interview the complaint and interview the subject of the
  10     complaint.
  11        But that is the clinical complaints procedure. It
  12     is quite different from this.
  13   Q. If it came from the GP, the same would apply, would it?
  14   A. Well, I think the GP would likely communicate. I do not
  15     know what the GP would do. It would depend who he
  16     told. But I imagine -- I do not think a GP is excluded
  17     from asking for a clinical review. I do not remember
  18     anything in a document that precludes that. If it did
  19     and he wanted it, he would ask the patient to ask for
  20     it. I do not see that there is a difficulty there.
  21   Q. In any event, before any action could be taken, you
  22     would have to be satisfied as to the circumstances in
  23     which action might or might not be called for?
  24   A. Oh yes, I mean, no Chief Executive or District General
  25     Manager could behave in an irresponsible individual

   1     way. You could only respond in matters of expertise of
   2     this nature on the basis of very clear-cut unambiguous
   3     advice.
   4   Q. You say at page 30 of your statement, the very last
   5     sentence, that you consider that the structure and
   6     attitudes within UBHT were probably comparable with most
   7     organisations involved in risky activities?
   8   A. Yes.
   9   Q. So you took the view that UBHT was involved in a risky
  10     activity, did you?
  11   A. Well, I do, but I would want to make sure that you and
  12     I understood what I meant by that.
  13   Q. Tell me.
  14   A. Well, if, for instance, you are providing a, shall we
  15     say, an operative service in a serious condition with
  16     a high mortality rate, I think that would conform to
  17     what I mean by a "risky procedure", a risky activity.
  18   Q. I had thought that is what you would have meant, but
  19     I am grateful for your confirmation. In essence, if
  20     things are not done right, then there is a risk --
  21   A. No, there is more than that. There is a risk if they
  22     are done right. I mean, virtually everything that is
  23     done has a risk. I mean, I was a radiologist in my day
  24     and performed investigation of kidneys in people with an
  25     excretion urogram and we were not able to establish for

   1     certain whether the death rate from this purely
   2     investigational exercise was one in 8,000 or one in
   3     3 million.
   4   Q. I accept that --
   5   A. So what I am trying to say is, I do not know of anything
   6     of significance that is done to patients that does not
   7     carry a risk. It does not have to be done badly to
   8     carry a risk.
   9   Q. That is entirely accepted. The issue, I think, is when
  10     an organisation is involved in a risky activity of
  11     patient care, which may, for reasons completely
  12     unconnected with the organisation, but for reasons
  13     connected with the condition of the patient, involve
  14     a risk to their survival or continuing good health.
  15        It is also the case, is it not, that that risk can
  16     be amplified or reduced by measures taken by the
  17     hospital institution?
  18   A. No, I do not think that is true. Not the hospital
  19     institution. I do not think anything I did raised or
  20     lowered mortality rates in treatments.
  21   Q. So you saw your work as Chief Executive as having no
  22     effect upon hospital treatments and their success?
  23   A. I am not sure I understand your question. I did not
  24     treat people and I did not increase or reduce the
  25     capacity of the consultant staff to be successful or

   1     not. I created an environment in which they exercised
   2     their skills.
   3   Q. An environment in which there was inevitably risk to
   4     patients?
   5   A. Well, we have already established, have we not, that
   6     there is, for virtually every procedure, a hazard, even
   7     giving drugs, there is a hazard. Everything carries
   8     a hazard. They are not always as accurately quantified
   9     as we would like, but they are recognised.
  10   Q. "Other organisations involved in risky activities"
  11     is the comparison you draw at page 30, in that last
  12     sentence.
  13        Other organisations involved in risky activities
  14     have mechanisms and measures for quantifying the risk?
  15   A. Just hold on. No, I must be very careful about this,
  16     because you are talking about, if you are, management
  17     cultures. There were two sorts of management cultures
  18     on which we have been peripheral at the moment. There
  19     is the role model management culture, the administrative
  20     one which is full of job descriptions, policies and
  21     protocols, which is designed to maintain a stability and
  22     a status quo. It works very well if you are canning
  23     baked beans or making Ford Fiestas.
  24        There is another sort of organisation where what
  25     happens is a series of individual interactions between

   1     the skilled person and the recipient of that skill.
   2     Each interaction is totally unique. In order for the
   3     experts to make sense of them, they group them into
   4     heterogeneous groups and try and make some deductions
   5     about it, but each individual interaction consists of
   6     a unique situation in which the expert exercises
   7     personal professional decision-making within a situation
   8     of professional freedom.
   9        The thought that you can standardise that into
  10     some sort of protest is mistaken. The only time it is
  11     done satisfactorily to my knowledge is in a teaching
  12     situation when the person making the decision is not yet
  13     fully competent, so there are guidance and guidelines.
  14        But I could just finish, perhaps, by saying that
  15     should I become ill, I would not want to be treated by
  16     somebody keeping to guidelines; I would like to be
  17     treated by the person who drew up the guidelines. In
  18     a teaching hospital, that is what happens.
  19   Q. Is the object to reduce whatever risk there may be to
  20     the lowest level reasonably practicable?
  21   A. Yes, that is the responsibility of the expert treating
  22     the patient.
  23   Q. Is it also the responsibility of the structures and
  24     systems within which that expert operates to contribute
  25     to the expert's potential success in so reducing the

   1     risk?
   2   A. You would have to specify what sort of policy you meant
   3     for me to be able to answer that. The sort of policies
   4     I am thinking of is a security policy and a fire policy
   5     and so on, to make sure that the accommodation is
   6     appropriate, but if you are saying that I should ensure
   7     there is a protocol or a policy which that person must
   8     follow, then I would say that is not true.
   9   Q. Let me give you an example. It may be a silly or
  10     extreme example, but I would welcome your comment on
  11     it. Suppose one had a doctor who, having gone through
  12     the teaching process, became a consultant, so he is [let
  13     us assume he is a "he"] a proper professional man
  14     entitled to exercise professional judgment and skilled
  15     at doing so.
  16   A. Yes.
  17   Q. Suppose that he then exercises his clinical skills
  18     without ever picking up another medical journal, going
  19     to any medical conference, and doing what he does
  20     entirely in isolation from the wider medical community,
  21     albeit that he operates within the hospital.
  22        That individual would not, would he, be keeping
  23     abreast of the latest developments in medical thinking
  24     and medical approach?
  25   A. Well, I cannot talk about where it might happen

   1     elsewhere. I would tell you that such a person would
   2     not survive a year in a teaching hospital. Perhaps they
   3     would not survive three months in a teaching hospital,
   4     but they would not survive a year in a teaching hospital
   5     if they took no part in the development of care and in
   6     keeping up to date. The whole culture of a teaching
   7     hospital could not countenance that.
   8   Q. So it would be part of his job, would it not, to keep
   9     himself up to date, and part of management's role,
  10     I suggest, to give him the opportunities to do so?
  11   A. Yes. I mean, when you say "management's role", it was
  12     usually done because there were things like that within
  13     the consultant's process, but there was, for example,
  14     a study in budget which was delegated usually to the
  15     Medical Committee, the internal Medical Committee, who
  16     would make judgments on the best way of allocating that
  17     resource. I did my best within the directorate system
  18     to try and enhance that limited budget.
  19        So, yes, there were ways in which medical staff
  20     facilitated members of the medical staff pursuing it,
  21     and if I could say, more recently, it has been
  22     formalised into a documented continuing medical
  23     educational system, again supervised by the Colleges.
  24   Q. And the process of clinical audit is essentially an
  25     educative tool and informative tool, is it not, which

   1     will assist any medical professional in doing their
   2     best?
   3   A. The formal audit system, if that is what you are talking
   4     about, was intended to become such. It certainly was
   5     not by the time I left, and I cannot tell you, but
   6     I suspect it is not yet. It is a developing audit
   7     process and the time I was there, there were more
   8     problems about how to engineer circumstances so that the
   9     time could be found how to make sure that we had
  10     competent audit assistance and how we could develop and
  11     streamline and make more appropriate the information
  12     technology to support audit. I think it would be quite
  13     wrong to say that audit was taking place, in the sense
  14     that I would mean audit, in 1995 in the Health Service.
  15   Q. Does audit not consist of monitoring performance against
  16     agreed standards?
  17   A. Yes, but you have to first of all agree the standards,
  18     and then find a way of monitoring against it. I do not
  19     think there were any agreed standards by 1995.
  20   Q. And again --
  21   A. I cannot say for certain there was not one somewhere,
  22     but as a generality, there were not.
  23   Q. Again a hypothetical question: do you conceive that it
  24     was part of management's responsibility to take any
  25     steps in respect of any clinician or department which

   1     was found, on monitoring their performance against any
   2     agreed standard, to be dropping some distance below that
   3     standard?
   4   A. Well, as I say, it would have been by the time we
   5     reached that situation. It is a hypothetical question
   6     because we had not reached the situation where that sort
   7     of information was available when I was there, not from
   8     the formal audit process. I have to be careful in
   9     words, because in teaching hospitals, we all, when I was
  10     a radiologist and everybody else, reviewed the care of
  11     patients as topics often resulting in a publication in
  12     a literature, recommending from that review what might
  13     be the best way to diagnose a condition, what might be
  14     the best way to treat a condition, so that sort of
  15     study, retrospective and prospective study, was
  16     continued; it was called in those days "research", not
  17     "audit".
  18        When audit was introduced, there was a fundamental
  19     difference and that is that audit was aimed,
  20     eventually -- and I was an enthusiastic supporter of
  21     this -- to have credible realistic standards of outcome
  22     right across the board and the continuing monitoring
  23     against those standards. That is what audit will be,
  24     I hope, one day. But it was not in 1995.
  25   Q. I appreciate the change of approach from time to time

   1     throughout the period with which we are concerned. Can
   2     we look, please, at UBHT 234/177?
   3        It is a letter to you from Mr Reynolds. Can we
   4     scroll down, please, leaving the heading as it is?
   5        "The development of quality assurance - general
   6     management aspects."
   7        It talks about the development of quality
   8     assurance.
   9   A. Yes.
  10   Q. Quality assurance, obviously, looks for standards of
  11     quality in patient care?
  12   A. Yes.
  13   Q. This being 1986, are we looking here at a forerunner of
  14     what became known as medical audit?
  15   A. No, it is quite different. I find difficulty in
  16     producing a simple word. There is therapy applied to
  17     patients, not just clinical, not just medical, the
  18     nurses and all the rest of it, applying care to
  19     patients. This is the quality of the environment in
  20     which that care was taken. It is an early start;
  21     eventually it became Charter standards, I think
  22     Patients' Charter standards and we got the Charter
  23     Mark. It was in a sense whether the patient enjoyed the
  24     experience, whether telephones worked, whether the
  25     television was available, the whole environment, but it

   1     was non-clinical and had nothing to do with therapy.
   2     Well, please, everybody would say the environment
   3     assisted therapy, so this is why -- what I am talking
   4     about is, it had nothing to do with the exercise of
   5     professional judgments on the part of carers.
   6   Q. Right. Can we move then to UBHT 271/19? This is
   7     a clinical audit review meeting of the UBHT on
   8     11th November 1992. We see that you were there, as were
   9     others from the Health Authority. This is after the
  10     purchaser/provider split.
  11        Can we go overleaf, please? "Bristol and District
  12     discussion paper on clinical quality."
  13        So we are now looking at clinical issues.
  14        "John Roylance commented that in his view the way
  15     that care is carried out is the responsibility of the
  16     Trust, but the outcome is Bristol and District's domain,
  17     both in terms of patient acceptability and health gain."
  18        Pausing there, was that your view?
  19   A. Well, it says so. I do not know whether I signed it and
  20     agreed it, but I think, looking back, what I was trying
  21     to say is that it was for Bristol and District, who were
  22     responsible for the community, to satisfy themselves
  23     that the health care that they were purchasing was
  24     producing a maximum benefit for their community.
  25     I think I was trying to encourage Bristol and District

   1     to accept the totality of their responsibility as
   2     a purchaser.
   3   Q. The distinction, as expressed, and I appreciate that
   4     they are not your words, but the distinction appears to
   5     be between methods, clinical methods, which you are
   6     recorded as saying -- or "you" for the Trust -- and
   7     results, which was for somebody else to be concerned
   8     about?
   9   A. Yes. What I think I was trying to say, and please,
  10     I have not seen this document since it was written,
  11     I suspect. What I wanted to say is that Bristol and
  12     District, in placing contracts either with us or with
  13     other Trusts, could not disassociate themselves from the
  14     benefit that those contracts were achieving for
  15     patients.
  16        I actually was encouraging -- I mean, I think at
  17     that time, if not shortly afterwards, I was urging us to
  18     start very gently moving forward to the time where
  19     clinical outcome was put in the contract. If I could be
  20     simple: that if they bought 100 operations for
  21     reconstructing the arteries of the lower limb, the
  22     contract could ultimately, one day, include how many
  23     patients would still have the leg on after a year.
  24        If they were not interested in that, then they
  25     started going back to concentrating on the process

   1     rather than the value of the process. I was trying to
   2     encourage everybody to look at audit. I think this
   3     antedated the national initiative on clinical audit --
   4     it may not have done -- but we were discussing together,
   5     as we often did, how we could assist in the improvement
   6     in contracts to make them more, what shall I say,
   7     patient benefit sensitive.
   8   Q. Is it then the case that the Trust were concerned and
   9     interested in the outcomes of the methods of treatment
  10     which they applied?
  11   A. Well, of course we were interested in it. I was trying
  12     to make sure that the purchasers of the health care were
  13     interested in it. I mean, if I can use a simple
  14     analogy, because I am not experienced in commerce I may
  15     be wrong, but if a major store places a contract with
  16     a manufacturer to produce goods, I believe that the
  17     major store should be concerned about the quality of the
  18     goods.
  19        Now of course the provider has to be concerned
  20     about the quality of the goods or they do not sell any
  21     more. What I was trying to say, it would not be enough
  22     for the purchasers employed by the store to satisfy
  23     themselves that they just bought the stuff and stuck it
  24     on the shelves.
  25        Does that explain my meaning?

   1   Q. I follow your statement that it was in essence a dual
   2     responsibility, that both purchaser and provider had
   3     responsibilities?
   4   A. There was no way the Trust, the staff in the Trust, can
   5     absolve themselves of an interest in the outcome. There
   6     was no question about that at the time. Clinicians then
   7     and clinicians now were very concerned in the outcome.
   8     I wanted to make sure that Bristol and District
   9     addressed their interest in the outcome.
  10   Q. So what you needed then was the systems within the Trust
  11     to identify the outcome, so that you could be concerned
  12     with them?
  13   A. Yes, and the purchaser to pay for them so that we could
  14     have them.
  15   Q. Can we have the witness statement of Mr Stone,
  16     WIT 112/27.
  17        Can we go over the page? Can we go back to
  18     page 11, paragraph 27? It is my fault. Can we
  19     highlight paragraph 27, please?
  20        What Mr Stone is saying here is that the
  21     prevailing view within first the District and then the
  22     Trust was that the medical staff were professionals and
  23     thereby self-correcting, "their clinical work as against
  24     workload contracts and issues did not need to be
  25     controlled through the management process."

   1        That was the prevailing view, was it?
   2   A. I think it was an observation. I am not sure about the
   3     "did not need to be". I think that relieves management
   4     of the process. It is not the prevailing view, it is an
   5     actual situation, part of the contractual employment of
   6     consultants was that they could exercise free clinical
   7     judgment.
   8   Q. And the last sentence of the preceding paragraph:
   9        "The medical audit was part of an initiative led
  10     by the Regional Medical Officer and was very much the
  11     preserve of the medical profession", so that this was
  12     controlled professionally rather than managerially?
  13   A. Yes, I think that reflects the introduction of it,
  14     because the medical audit, it became clinical audit
  15     after that, but medical audit was introduced on the
  16     professional network from the Regional Medical Officer
  17     and his Regional Hospital Medical Advisory Committee to
  18     the consultants within the staff through the Medical
  19     Committee and their divisions; it was not through the
  20     management process; it did not come from the Regional
  21     General Managers.
  22   Q. Can we please have WIT 89/34? This is Rachel Ferris's
  23     witness statement. She says in the third bullet point
  24     down -- she is looking at the 1994/95 period -- systems
  25     of audit did exist but they were crude in 1994/95. It

   1     must, I think, follow that they were no less crude
   2     before that. "These are now multidisciplinary and the
   3     systems themselves provide more accurate and complete
   4     information. I would say that our audit systems are now
   5     amongst the best in the country."
   6        Is she right in saying that such systems of audit
   7     as existed were, at least in 1999 eyes, crude in
   8     1994/95?
   9   A. Well, we would all use different descriptions. I would
  10     say non-existent, because I was unaware, I do not think
  11     anybody had agreed standards, certainly not across the
  12     board. As far as I was concerned, we were desperately
  13     trying to encourage the introduction of this and we got
  14     as far as 1993, I think it was, and we had something
  15     from high, something I should have been the start of,
  16     saying effectively we should not have medical audit, we
  17     should have clinical audit, and the philosophy of that
  18     is that we should audit patient care against the outcome
  19     and not just one element of it. It represented
  20     a recognition that it was not just care by a doctor by
  21     which patients had good outcome. I do not need to
  22     emphasise that nursing had a major part in patient
  23     benefit and so did the professions allied to medicine.
  24        So we started again in 1993, all over again, to
  25     create a medical audit system and if you can imagine it,

   1     the information technology that had been developed was
   2     now inappropriate; it had to be changed. The structure
   3     was inappropriate; it had to be changed. As I recall,
   4     in 1993 we were very much urged by the Department of
   5     Health to do everything we could to get it up and
   6     running by 1998, not by 1995, 1996; the actual message
   7     from the centre, the great enthusiastic encouragement,
   8     helped us all to work very hard so that we could at
   9     least try to achieve it within five years. I think that
  10     was a realistic estimate. So, I am really not --
  11     I mean, I think that second half is no more accurate
  12     than complete. It is optimistic, shall we say.
  13   Q. Do I understand that the way in which the audit systems
  14     operated whilst you were Chief Executive was for the
  15     responsibility for the audit to be devolved to the
  16     directorates?
  17   A. From where? It started -- I mean, audit was at
  18     directorate level, it was not devolved there. Can
  19     I remind you that audit introduced by the Regional
  20     Medical Officer was introduced directly to caring,
  21     consultant members of staff and they were in
  22     directorates.
  23        That is where audit was introduced. It was not
  24     introduced at Trust level and delegated; it was
  25     introduced at operational level and Trusts, with some

   1     initial difficulty, tried to pick up the pieces and
   2     introduce a little bit of management competence to make
   3     sure it was introduced effectively and more speedily
   4     than was the case. So the Finance Director said, "You
   5     cannot have money going straight from Region into
   6     divisions. You put it in my bank and I will allocate
   7     it", and that sort of thing.
   8   Q. So each directorate had the responsibility for auditing
   9     its own work?
  10   A. No, not the directorate. Please, the director and the
  11     directorate is a management structure. We still had, in
  12     effect, a divisional advisory system, and it was
  13     introduced as a professional system at divisional and
  14     not directorate level.
  15   Q. Thank you. Can we have a look at UBHT 98/13?
  16        These are minutes of the Steering Committee with
  17     chairmen of divisions for 5th January 1994. Can we go
  18     to page 17, please?
  19   A. Can you just remind me, this is now two years later?
  20   Q. This is now January 1994.
  21   A. Yes.
  22   Q. "Clinical audit". We see Dr Thomas reporting that it
  23     was "the government's intention that Trusts should move
  24     towards multidisciplinary clinical audit and although
  25     there are several problem areas, a number of

   1     departments, specialties, were in fact already carrying
   2     this out. However, there was concern that medical audit
   3     will be marginalised under the pressure from clinical
   4     audit."
   5        It goes on.
   6        The second paragraph is what I want to ask you
   7     about. Can we scroll down, please?
   8   A. Could I just emphasise, you will notice this is all
   9     being discussed not in a management forum but in
  10     a medical advisory forum. The Steering Committee is the
  11     Steering Committee of the Medical Committee, not of the
  12     Management Board.
  13   Q. Thank you.
  14        "Dr Thomas said we have been criticised for the
  15     way in which audit money has been distributed in the
  16     past via the clinical directorates as it could be
  17     construed that there is no clear evidence that these
  18     funds were spent on audit."
  19        Just stopping there, was the money for audit
  20     distributed in the past, up to 1994, via the clinical
  21     directorates?
  22   A. I think you really ought to ask Graham Nix about this,
  23     as the precise mechanism. It started off as something
  24     that was a bit of a shambles, and Graham Nix talked to
  25     his colleagues at Region and said "You must formally

   1     give this to the Finance Department", which they did,
   2     and he ringfenced it and authorised its use for the
   3     payment of clinical assistants and for the purchase of
   4     equipment.
   5        The clinical directorates, although they employed
   6     their staff, they did not write their cheques, they did
   7     not pay them; the Finance Department did. So I think,
   8     in all honesty, it does not mean anything other than
   9     that the money was held and monitored by the Finance
  10     Director, and he would have incorporated it so that the
  11     Trust and everybody understood what was going on within
  12     the budget of the appropriate directorates.
  13        The medical advisory structure did not have
  14     a budget; it was the medical advisory structure. So it
  15     could not have been delegated to them; there was no
  16     mechanism to do so.
  17        This is what I said. When it started off it was
  18     a professional-to-professional introduction and we had
  19     to rationalise it and make sure that we knew and could
  20     tell Region where every penny of audit money was spent
  21     and to satisfy Region that it was spent on audit.
  22   Q. What is suggested in the first sentence here is that
  23     money for audit was not being spent on audit?
  24   A. Well, I can guarantee that not a ha'penny of audit money
  25     was spent on anything but audit. It was a ringfenced

   1     sum of money in addition to the Trust's allocation and
   2     there was no way the Trust could quietly filch it, or
   3     anybody else.
   4   Q. So whatever the source of Dr Thomas's view that there
   5     was no clear evidence that the funds were in fact spent
   6     on audit, he must be wrong?
   7   A. He is wrong.
   8   Q. Can we look at UBHT 30/24, please. This is now April
   9     1994 and the Chairman inviting committee members to give
  10     their views on clinical audit, and the role of the
  11     Clinical Audit Committee?
  12   A. I am sorry, this is a Steering Committee, is it?
  13   Q. Can we go back a couple of pages and we will see what it
  14     is?
  15   A. I am sorry to be awkward, but it does make
  16     a difference.
  17   Q. It is the UBHT Clinical Audit Committee.
  18   A. No, this is the reforming Clinical Audit Committee. You
  19     will see that I was invited by special invitation to try
  20     and give some lead and clarity to what we were trying to
  21     do.
  22   Q. Then back to the next page, please. Can we scroll down
  23     to what it had to say. You pointed out the function of
  24     the group, I think that must be the Clinical Audit
  25     Committee, "would be a supportive one to directorates

   1     because in future, clinical audit will form an important
   2     part of contracts. There will therefore be
   3     a requirement for the development and nurturing of
   4     acceptable outcome measures. The committee would
   5     obviously have a role in advising the Trust Board,
   6     probably via the Medical Director. It was clear that
   7     members had some concerns that the committee had no
   8     specific resources and that its influence on the conduct
   9     of audit would necessarily be an indirect one."
  10        Was it right that the committee set up to deal
  11     with audit had no specific resources?
  12   A. Yes. This is at a time when it was developing and
  13     I remember some of the turmoil, and in fact some of this
  14     did not materialise, so this was an early discussion.
  15     A number of things changed with the introduction of
  16     clinical audit. It was no longer, as somebody said,
  17     a "pursuit by consenting adults in private", in other
  18     words, it was no longer a matter for the medical staff
  19     to pursue in private. It had now become
  20     a multidisciplinary process and therefore could not
  21     reside, if I may say so, in the professional advisory
  22     structure of the Medical Committee, the Steering
  23     Committee, and through the Chairman of the Medical
  24     Committee to the Trust Board.
  25        It had now to be on a management basis, because it

   1     was multidisciplinary and we had to get it up and
   2     running.
   3        I think Dr Thomas had a number of concepts of how
   4     this should go. He was worried about immediate medical
   5     audit disappearing, he wanted it to continue and so on,
   6     and he had anxieties about this new initiative. As
   7     I remember, he resigned as Chairman of this committee
   8     after a while because it did not seem to be doing what
   9     he wanted to do. We eventually, after much discussion,
  10     of which this is a small part, made the Clinical Audit
  11     Committee report through the Patient Care Advisory
  12     Committee, and through that committee to the Board. The
  13     Chairman of the Clinical Audit Committee was invited to
  14     attend that committee, to shorten the lines of
  15     communication.
  16        I think Trevor Thomas -- I do not want to malign
  17     him and you may be able to ask him, but I think he,
  18     having chaired the Medical Audit Committee, wanted to
  19     control medical audit outside management as
  20     a professional thing, and himself being in charge. That
  21     could no longer be appropriate. What the Clinical Audit
  22     Committee had to do was to monitor the activities now of
  23     management and of audit activity, and report in the
  24     manner I have said to the Trust Board, and to me, to
  25     assure us that it was continuing.

   1        The committee in my view, was developing --
   2     probably always had -- a clear monitoring role to ensure
   3     audit was taking place; it was not itself managing
   4     audit. Therefore, it was to one side of it. I think
   5     I could best describe what I believe Trevor Thomas
   6     wanted was a separate management structure going back to
   7     a system I may have described yesterday, when I became
   8     District General Manager of having a quite separate
   9     management structure for audit, and clearly, that could
  10     not have survived.
  11   Q. So the system at this stage was for the Clinical Audit
  12     Committee to monitor audit to report to the Patient Care
  13     Advisory Committee and report through them to the Board?
  14   A. Not at this stage. We had not got that far. This is an
  15     element of the considerable discussion that took place
  16     in order to achieve what was ultimately achieved, and
  17     that was achieved, as I remember, shortly before
  18     I retired, so I would not like you to think that this is
  19     a definitive step forward; this is a discussion which
  20     I was invited to, to get the views of the expanded
  21     Clinical Audit Committee to inform them, have a thorough
  22     exchange of information, so that that was one step in
  23     the consultation process which we went through in order
  24     to achieve clinical audit. I mean, there were a lot of
  25     other people to talk to, there were nurses doing their

   1     own audit, physiotherapists and so on all doing their
   2     own audit, and I had to go around with others and talk
   3     to those and say "How can we bring this all together?"
   4   Q. The Regional Health Authority had a responsibility for
   5     monitoring audit, did it not?
   6   A. The Regional Hospital Medical Advisory Committee
   7     certainly set itself up to audit the introduction of
   8     medical audit. I am not sure about your next step.
   9     I mean, the Regional Health Authority, I think it was
  10     becoming an outpost of the Department of Health by then,
  11     had an interest in everything that went on, but whether
  12     they had charged purchasing Health Authorities to pursue
  13     audit or not, I cannot tell you. I think they probably
  14     did.
  15   Q. We will come to it in a moment. We have been looking
  16     here at a 1994 document. Can I trace something of the
  17     development of audit by going back to HA(A) 34/89, which
  18     is 16th January 1990.
  19        This is a memo from Dr Baker, the Director of
  20     Public Health Medicine. In 1990 he talks indirectly
  21     about medical audit?
  22   A. Yes.
  23   Q. He mentions that one area that needs to be tackled, the
  24     second paragraph, was that of medical audit, and he
  25     would wish through meetings with you to determine what

   1     changes are necessary to achieve the right level of
   2     medical audit. His initial view is that most medical
   3     staff spend time already on audit or audit related
   4     issues and that if this time was used more efficiently
   5     then little change in programmes would be required.
   6        Then he adds this at the end:
   7        "This view, although strongly pragmatic, seems to
   8     be some distance from the view given by the Regional
   9     Medical Advisory Committee."
  10        Is he right that there was a difference of view
  11     between your approach and that of the Regional Medical
  12     Advisory Committee?
  13   A. I do not know at that moment. I mean, that is but part
  14     of the very early development steps of trying to get
  15     medical audit up and running. I mean, at this stage now
  16     I think that is an entirely transient document, and
  17     I really do not know. I mean, I do not know whether
  18     I was some distance from the view given by the Regional
  19     Medical Advisory Committee or Ian Baker had a different
  20     view of what the Regional Medical Advisory Committee --
  21     I really do not know. We had a whole series of very
  22     constructive discussions, and this is so early on that
  23     I really cannot -- I mean.
  24   Q. Let me move it on a little. UBHT 63/161: the District
  25     Audit Committee, annual report for 1990/991, with

   1     Dr Thomas as Chairman, and it reports in the second
   2     paragraph, it has been produced by the newly constituted
   3     District Audit Committee, successor to the disbanded
   4     District Medical Information Working Party.
   5   A. Yes.
   6   Q. Then go down to the second paragraph:
   7        "The process of audit ... in 1990 has not been
   8     well documented, largely because of the lack of guidance
   9     and monitoring associated with the changing committee
  10     structure."
  11        Just pausing there, this, one understands, was at
  12     a time when Trust status was on the horizon, so there
  13     may have been a number of management changes, but what
  14     is complained about there is that there was an absence
  15     of documentation to enable one to see what process audit
  16     had made, a lack of guidance, a lack of monitoring.
  17        Is that historically right in respect of that
  18     time, or not?
  19   A. I would not like -- I mean, I find it difficult because
  20     we are all talking as if audit is going on, and I have
  21     to say at this stage we were all struggling for the
  22     introduction of audit, so to talk about monitoring the
  23     process of audit at that stage was wholly premature. We
  24     were monitoring the introduction of clinical -- I do not
  25     know that we necessarily had all the audit support

   1     people in by then. This is the early stages of the
   2     introduction of a system and you are asking me questions
   3     as if we are talking about monitoring the system. By my
   4     standards, it did not exist. What did exist was a great
   5     deal of effort right across the Trust to try and
   6     establish a sensible process of audit. But if you had
   7     walked round with me at that time, you would not have
   8     seen anything that you and I would now recognise as
   9     audit.
  10   Q. Can we have a look at UBHT 58/26, and take it a year
  11     further on? This, I think, indicates that the medical
  12     staff have had some reservations about audit which are
  13     now resolving. Am I right to draw that conclusion?
  14   A. Yes. I remember at the time the Freudian slip of the
  15     spelling of "duel".
  16   Q. Yes.  UBHT 67/81; the Medical Audit Committee. Can we
  17     go down the page and go across, please, to 83?
  18        "Purchaser's access to audit information."
  19        This is June 1992?
  20   A. Yes.
  21   Q. Dr Thomas is referring to constant pressure from
  22     purchasers to have some access to audit information. We
  23     see that the meeting to which he refers of the Steering
  24     Committee, Mr Wisheart referred to the confidentiality
  25     of audit and confirmed that purchasers were requesting

   1     more detailed information but Dr Thomas had assured him
   2     that he would resist any attempt by any purchaser to
   3     breach confidentiality. Should they require
   4     information, they would be referred to the relevant
   5     Clinical Director.
   6        Do I take it that there was at that stage,
   7     mid-1992, resistance for whatever good or bad reason
   8     from the medical staff to the audit results being
   9     available to purchasers?
  10   A. I think the resistance was led by Dr Thomas properly as
  11     the Chairman of that committee, again in the medical
  12     advisory structure, and he consistently reassured people
  13     this was a confidential audit process, and I think he
  14     was trying to make sure that he could deliver that
  15     promise, that it would be confidential. I mean, he may
  16     not have the letter, but there was clear instruction
  17     written, agreed at the Regional Medical Advisory
  18     Committee, Hospital Advisory Committee, or it was the
  19     sub-committee, the Regional Audit Committee, on which
  20     Trevor Thomas I believe also sat, that every care should
  21     be taken to ensure that the actual results of audit, the
  22     audit figures, should not come into the hands of
  23     management.
  24        The reason for that was that it was felt it would
  25     set back the introduction of clinical audit, or medical

   1     audit, as it was then, very substantially; it would not
   2     profit. For that reason, because I was Chief Executive,
   3     and known as a doctor, and known to know his way round,
   4     I was extremely careful to be seen to be outside the
   5     audit process.
   6   Q. There are two stages in the answer you have given.
   7     I was asking about the position in so far as purchasers
   8     were concerned, and do I take it from your answer that
   9     you sympathised with the view expressed through
  10     Dr Thomas in that entry, that purchasers should not, at
  11     that time, have access to information because it was
  12     confidential to the clinicians?
  13   A. Yes. I was aware that for the effective introduction of
  14     audit, we needed to sustain the active support of the
  15     very people who could achieve audit or torpedo audit,
  16     and I was aware myself, and this was not a unique view,
  17     the Regional Hospital Advisory Committee and the
  18     Regional Audit Committee, I think there was one, were
  19     both instructing that audit and the outcome of audit,
  20     the actual figures, must remain confidential to those
  21     people who had done work which was audited.
  22        I was extremely keen that we should move very
  23     quickly to set up and introduce a viable audit system.
  24     I was extremely keen that the outcome of those audits
  25     should eventually form part of future contracts. I was

   1     aware, and I think Trevor Thomas was more aware even,
   2     that we would run into a brick wall if we allowed the
   3     information to emerge from the actual audit level.
   4   Q. I am not clear from your answer whether you are saying,
   5     yes, you sympathised with the view at the time which was
   6     a necessary and pragmatic view --
   7   A. Yes.
   8   Q. -- to achieve the introduction of audit?
   9   A. Yes.
  10   Q. Or whether you are saying that whatever may have
  11     happened since, you think that this view nonetheless
  12     ought to hold good today as it did in 1992?
  13   A. What, the confidentiality bit, do you mean?
  14   Q. Do you maintain that is the case now?
  15   A. I do not know whether the clinicians have been
  16     reassured. I do not know whether that problem of
  17     anxiety has been overcome. Normally, when you change,
  18     when you do something new that appears threatening, and
  19     a lot of people find anything new threatening, you have
  20     to wait until reality has been experienced for some time
  21     for that anxiety to ameliorate.
  22        I would guess, and I can only guess, that we are
  23     nowhere near the position yet of making clinical audit
  24     a management tool.
  25   Q. That was the second part I was going to explore with

   1     you. Is it your view that it should be a management
   2     tool?
   3   A. Eventually, but whether it ever will be, I cannot tell
   4     you.
   5   Q. But it plainly was not used as a management tool in
   6     Bristol Trust; it may be elsewhere, in 1992?
   7   A. I do not think it was used anywhere else. I do not
   8     think anywhere else had got audit as far as we had got
   9     it. I do not think the situation when I was there had
  10     arisen anywhere else, but I do not know. I can only
  11     talk about the South West.
  12   Q. You took yourself out of the loop so far as audit was
  13     concerned, because it was not management's business, is
  14     the way I understand you --
  15   A. No, I got myself out of the audit loop because I was
  16     absolutely certain that if I was seen in the audit loop,
  17     the audit would stop.
  18   Q. I see.
  19   A. Not that it was not my business, but that I had the
  20     ability seriously to delay the introduction of audit and
  21     I was not going to exercise that.
  22   Q. So the position I ask for your comment on is, if audit
  23     had revealed in any department or in respect of any
  24     particular surgeon an unsatisfactory result when
  25     monitoring performance against standard, management

   1     would, for practical and pragmatic reasons in 1992, not
   2     have wanted to know?
   3   A. In 1992 the information you are hypothesising would not
   4     materialise. What I am trying to say is that audit
   5     requires a whole series of things and that is the
   6     establishment of standards and so on. What was being
   7     gone through here was audit of specific events.
   8     Perhaps, I do not know, but I would give you an example,
   9     they might audit the incidence of deep vein thrombosis
  10     in long operations, and audit the value of elastic
  11     stockings no doubt because that was something we audited
  12     years ago in my youth as a consultant, but they audited
  13     those sorts of specific features. We saw yesterday, did
  14     we not, somebody auditing the success of putting in
  15     a particular occlusive device in patent ductus
  16     arteriosus. That is -- I have used the expression
  17     elsewhere -- light years away from sorts of audit you
  18     are postulating could produce the sort of information
  19     you are postulating.
  20        Being told that this new device was not bad,
  21     perhaps ought to be used, is so far away from the sort
  22     of information you are postulating that I find it very
  23     difficult to give a sensible answer in terms of 1992.
  24   MR LANGSTAFF: Dr Roylance, we will take a break now,
  25     Chairman, until 11 o'clock?

   1   THE CHAIRMAN: Yes. We meet again at 11, thank you.
   2   (10.50 am)
   3               (A short break)
   4   (11.00 am)
   5   MR LANGSTAFF: Dr Roylance, I take the point that you made
   6     just before the break, that the content of audit in
   7     1992/93 consisted in items such as the acceptability of
   8     the Rashkind device for occlusion of a patent ductus,
   9     and may not therefore have extended to what one might
  10     call the broader picture, the monitoring, for instance,
  11     of mortality rates from particular types of surgery.
  12        Did management, as you see it, have any role in
  13     saying to those who were conducting audit, "Well, ought
  14     you not to look at this? Ought you not to look at
  15     that?" To select the topics upon which audits could and
  16     should be carried out?
  17   A. No, early on I believe that would have been
  18     devastating. We did gently do it later, as I think you
  19     have seen, through the purchaser/provider link with the
  20     purchaser saying "We are going to buy a contract and we
  21     are going to include, audit money, and we would like you
  22     to include these things", but it does not say "We want
  23     you to do across-the-board audit of mortality". That at
  24     that time was not feasible.
  25   Q. Does it follow when assertions were made as to the

   1     quality of the service which was provided, at least up
   2     to this stage, that there was no empirical statistical
   3     basis for making such a claim?
   4   A. What assertions are you addressing?
   5   Q. I am talking in terms of general assertions as to
   6     quality service.
   7   A. I am sorry, I do not understand. I really would like
   8     to answer your question, but I do not understand it.
   9   Q. In the first contract between the Health Authority and
  10     the purchasers, which we have copies of, for the
  11     provision of cardiac services in 1991, there is
  12     a commitment to providing a quality service by the
  13     Health Authority.
  14   A. Yes.
  15   Q. If necessary, we can look at the document. I was
  16     asking --
  17   A. If that is what it says, that would be entirely
  18     unexceptional. You would hardly put in the contract to
  19     provide poor service.
  20   Q. I was asking how management could assure itself of the
  21     quality of the service without --
  22   A. Management could not. I do not know why you suddenly
  23     introduced management. Management could not. In fact
  24     I tried to explain repeatedly that the involvement of
  25     management in medical audit at that time was recognised

   1     throughout the South West region, not just Bristol,
   2     would have been an enormous hindrance.
   3   Q. Can I go back to an answer you made a moment ago? You
   4     suggested it would not have been feasible for management
   5     to direct the topic of audit in 1992/93, although that
   6     is what you did later.
   7        Why would it not then have been feasible?
   8   A. I hope I did not say that. I said it would not be
   9     appropriate for management to attempt to direct audit,
  10     and in fact the response to the sort of audit I think
  11     you are talking about would not have been feasible; the
  12     information technology, the time, the organisation,
  13     simply was not there.
  14        I am really trying -- we are dodging about.
  15     I perhaps have not made it absolutely clear, but
  16     clinical audit was an enterprise recognised as
  17     developing over a considerable period of time and as
  18     I say, before medical audit was up and running and in
  19     any sense robust, it was changed to clinical audit, and
  20     even with clinical audit, it was not expected to produce
  21     anything effective, anything that you could rely on as
  22     an audit thing, for another five years.
  23        So, really, when you keep asking me about the
  24     outcome of audit, I have to say that misrepresents the
  25     situation. What we were talking about is reporting the

   1     developing process of audit and even the Audit Committee
   2     was charged with monitoring the development of the
   3     process of audit: Did people go? Were there meetings?
   4     How often were they? Was anything discussed? Was
   5     anything improved as a result of it? That was the
   6     purpose and the function of the Audit Committee -- the
   7     Medical Audit Committee.
   8        For you and I to be discussing that as what we
   9     were doing with the results of this audit process,
  10     I have to say, we had not got near that. I was spending
  11     my time encouraging people that this different form of
  12     audit was in their best interests and the patient's best
  13     interests, and so forth. I was not going around saying,
  14     "Have you got mortality figures for your hip
  15     replacements?"
  16        I mean, that is nowhere near the situation we were
  17     in at the time.
  18   Q. Can we have a look, please, at UBHT 29/78?
  19        What was the function of the Regional Audit Team?
  20   A. They were set up as a resource to try and encourage the
  21     development of audit. You see, it was not just local
  22     initiative, it was a regional initiative, it was
  23     a Department of Health-driven initiative and what the
  24     Region does on this scale is to try and develop a source
  25     of information, a source of expertise at regional level,

   1     which was available to District, so we were not all
   2     inventing the wheel simultaneously.
   3   Q. Can we scroll down, please? It records the UBHT Audit
   4     Committee -- this is in 1994 -- is currently being
   5     restructured in line with requirements to move towards
   6     clinical audit. You have dealt with that already.
   7   A. Yes.
   8   Q. It says how the committee has opened its doors to two
   9     nominated therapy/paramedical staff, and so on.
  10   A. Yes.
  11   Q. The last paragraph on that page:
  12        "The organisation and direction/development of
  13     audit within UBHT has been significantly different to
  14     that of all other Trusts within the region. There has
  15     been a devolvement of the budget and all audit staff to
  16     a directorate level. This is in line with the
  17     decentralised philosophy of the Trust as a whole and
  18     operates successfully in the main by virtue of the
  19     immense size of the Trust."
  20        Just pausing there, are you in a position to say
  21     how similar the pattern and organisation of audit was in
  22     UBHT to other Trusts the Regional Audit Team might have
  23     looked at?
  24   A. I mean, I have only vague ideas now. I may have had
  25     some idea what was happening, we often did, we talked

   1     a lot across-region, but I cannot tell you now what was
   2     happening. If the question is what was happening in
   3     other Trusts, I have to say today --
   4   Q. That is not the question. The question is, are you in
   5     a position to comment? You say you are not, really?
   6   A. On other Trusts?
   7   Q. Yes.
   8   A. Today I could not possibly speculate how far they had
   9     got at that time.
  10   Q. And it describes, does it, accurately, the way in which
  11     audit was organised in the UBHT at this time. Let us go
  12     back to the bottom of page 78, so we can look at it
  13     again.
  14   A. It was the way audit was developing at this time.
  15     I keep trying to be specific.
  16   Q. No, forgive me. It says in the second last sentence:
  17        "There has been a devolvement of the budget and
  18     all audit staff to directorate level".
  19   A. If I can explain that --
  20   Q. Dr Roylance, forgive me. The question is simple:
  21     was there or was not there not a devolvement of the
  22     budget and all audit staff to a directorate level? The
  23     answer must be "Yes" or "No".
  24   A. I am anxious you allow me to explain why that was right
  25     and why it was different to other Trusts.

   1   Q. Let me please give you that opportunity. If you follow
   2     my questions, we will get it.
   3   A. Yes, but I was trying to expedite the thing. Forgive
   4     me.
   5   Q. So, I hope, was I, but let us not argue about who is
   6     going faster. Is the answer "Yes" to that sentence?
   7   A. It says there, I mean, it is an accurate description.
   8   Q. This is a document and I am asking whether that
   9     corresponds with your --
  10   A. If it had been wrong, I would have had it amended, so
  11     I am quite happy that that was what was said. I am
  12     sorry, I did not understand, you were asking me whether
  13     people wrote the truth and they usually do.
  14   Q. That may not always be the case. Can we look at the top
  15     of the page? "This is in line with the decentralised
  16     philosophy of the Trust as whole and operates
  17     successfully in the main by virtue of the immense size
  18     of the Trust."
  19        The question is, was the decentralisation, the
  20     devolvement referred to, which you agree happened, was
  21     that a consequence of the decentralised philosophy of
  22     the Trust?
  23   A. In part, yes, but in part, can I say, there was
  24     something they did not understand. The Audit Committee
  25     was a monitoring committee and there is an implication

   1     here that the people responsible for making it work
   2     should also be the monitoring committee, and as
   3     a radiologist, I understand monitoring radiation
   4     protection and if you make the people actually
   5     irradiating people the same people monitoring whether
   6     they are doing it properly, you get a substandard
   7     monitoring. The Audit Committee was to monitor that the
   8     thing happened properly. To say, "Well, we will make
   9     the Audit Committee make it happen properly" would then
  10     mean I would have to have another audit of the audit
  11     committee to make sure it was happening properly. Do
  12     you understand my meaning?
  13   Q. I understand the point. May I persist with this
  14     paragraph and then invite you to comment further,
  15     because I am sure you may wish to.
  16        "The control of audit", it is said, "lies
  17     ultimately with the Clinical Directors"?
  18   A. It could lie nowhere else.
  19   Q. "The Audit Committee is not, however, constituted of
  20     Clinical Directors, which means its role has been
  21     relatively powerless."
  22        What do you say about that?
  23   A. I do not want to be unkind to the person who was
  24     directing that sort of thinking, and I think I have
  25     mentioned that he resigned. The Audit Committee, by

   1     definition, was set up to monitor the implementation of
   2     audit; not to audit, but to monitor it. When it became
   3     multidisciplinary, it had to come out from the medical
   4     professional machinery and the Chairman of the Audit
   5     Committee was rather sad about that.
   6        It had to come into management. The management
   7     structure existed. I mean, if you want me to criticise
   8     what is written there, I find the words "in the main" in
   9     the top and second line absurd, but the
  10     multidisciplinary audit could only take place, the
  11     machinery for it, the process, could only take place now
  12     at directorate level; it could not take place at
  13     divisional level. And the Audit Committee was there to
  14     reassure me, to reassure the Trust Board, through the
  15     Patient Care Advisory Committee, that audit was
  16     developing; that things were happening and if there was
  17     any inhibiting factor, to tell us what it was so we
  18     could help resolve it.
  19        This was a development of a process, you will
  20     remember, that was expected to take five years. In fact
  21     it was expected to take longer than five years, so we
  22     were urged to reduce the timespan to five years.
  23        There clearly is a misunderstanding and
  24     a difference of opinion, but the idea that the Audit
  25     Committee could be set up as a separate management

   1     structure of audit, I believe, then, and I think now,
   2     was a misunderstanding of this new concept we were
   3     introducing.
   4   Q. What the author appears to be looking for is power in
   5     the Audit Committee; what you were looking for, as
   6     I understand your answer, was information coming from
   7     the Audit Committee to say, "Well, this is happening" or
   8     "That is happening"?
   9   A. Yes. Well, I mean, not everybody understood the
  10     introduction of general management, but if there is
  11     a general manager personally responsible for everything
  12     that happened in his directorate then that precludes
  13     somebody else having personal authority for things that
  14     happened in his directorate. I hope that is clear. The
  15     concept that seems to be being suggested in this paper
  16     is contrary to the introduction of general management.
  17        In other districts, in other Trusts, general
  18     management, by definition, was not introduced.
  19   Q. The concept which appears to be suggested is that the
  20     Audit Committee should have a role in to an extent
  21     controlling, organising, running audit and for that it
  22     needs the Clinical Directors because they are the people
  23     who have the power in the directorates. That is the
  24     suggestion, is it not?
  25   A. That is a misunderstanding, as I hope I have explained,

   1     at that time, that the role of the Audit Committee would
   2     be to audit. That kept coming up from time to time.
   3     There was also the wish that the audit process should
   4     remain outside the management structure and in the
   5     professional advisory structure. There were a lot of
   6     sensitivities about that, and I understood and had
   7     sympathy for how they arose, and it was our job and my
   8     job, to resolve these misgivings so that audit could
   9     take place.
  10        The role of the Audit Committee -- quite clearly,
  11     all the documentation that was produced was to
  12     facilitate and monitor the development of an audit
  13     process; it was not to control it and be powerful; it
  14     was to monitor it. That was a very important function
  15     which I, as a Chief Executive, and the Board, required.
  16        If the Chairman of that committee did not want to
  17     do that, then we had to take steps to adjust the
  18     situation.
  19   Q. If we read on, "the tight directorate structure and
  20     approach operated at all levels and for most issues and
  21     has therefore led to a confusion for the Audit Committee
  22     over its role ..."
  23   A. Yes, I was explaining the confusion.
  24   Q. So the question is, was there in fact any confusion in
  25     the Audit Committee over its role?

   1   A. There was in the mind of the Chairman of it.
   2   Q. The second paragraph of the page:
   3        "There was direct admission from a representative
   4     of the management team that issues of audit which they
   5     (the managers) feel need to be addressed or are asked to
   6     address by purchasers tend to be implemented via the
   7     Clinical Directors rather than by any central overview
   8     from the Audit Committee."
   9        That would be consistent with your explanation, as
  10     I understand it, that it was for the Clinical Directors
  11     to run the directorate and the Audit Committee's role
  12     was not to control audit but to monitor it?
  13   A. Absolutely. I mean, people who, like, spin on it
  14     a direct admission, that always implies that they did
  15     not want to let it be known but eventually released it.
  16   Q. Leave aside the spin. What it indicates is that the
  17     author of this document from the region, the Regional
  18     Audit Team, envisaged audit in a very different way from
  19     the way in which it was in fact being delivered?
  20   A. No, that is quite wrong. That is quite wrong. He
  21     actually attended the Audit Committee, and he was
  22     reflecting the view of some of the Audit Committee.
  23     I talked to him directly. I talked to the audit group
  24     directly, from Region. I spent a lot of time ensuring
  25     that audit was set up.

   1        The implication is that somehow these people are
   2     right and I was wrong. I have to say that that would be
   3     an incorrect conclusion.
   4   Q. I am exploring the issue, not putting a conclusion to
   5     you.
   6   A. Can I say, the issue is self-explanatory. What you are
   7     exploring, as I see it, is in some way that the view
   8     expressed there has relevance and stands up. It does
   9     not, and it did not. We actually pressed forward with
  10     the development of a proper clinical audit machinery.
  11     If I say, there is a contract that the purchasers have
  12     with the provider; that contract is agreed between the
  13     Clinical Director and others, and a contract manager and
  14     others, and the purchaser, they sign the contract.
  15        If the purchaser wishes to include in that
  16     contract audit, then it is clearly for the signatory of
  17     the agreement on the part of the Clinical Director to
  18     implement the requirements of the contract. That is
  19     what the contracting process was. I have difficulty
  20     understanding your difficulty in understanding that.
  21   Q. Can we scroll down the page, please? The paragraph
  22     second from the top of the screen as it now stands
  23     refers to something which has been a theme of some of
  24     your evidence, as to the sensitivity and fragility of
  25     audit.

   1   A. Yes.
   2   Q. It goes on, in the next paragraph:
   3        "There appeared to be an urgent need for detailed
   4     debate between the Audit Committee representatives and
   5     the senior management team to establish firstly a common
   6     language on audit and its role and purpose within the
   7     organisation and secondly to establish clear groundrules
   8     on the role and approach of the management team and
   9     Audit Committee for moving audit forwards".
  10   A. Yes.
  11   Q. You have already told us there was a confusion in the
  12     mind of the Chairman of the Audit Committee as to his
  13     role and purpose?
  14   A. Yes.
  15   Q. Do I take it that this detailed debate then happened?
  16   A. Yes.
  17   Q. The next paragraph:
  18        "A strong philosophy on quality as everyone's
  19     business is held within UBHT. Thus unlike many other
  20     Trusts, no single person holds responsibility for the
  21     overview of quality issues."
  22        Is that an accurate statement?
  23   A. Yes.
  24   Q. Is it a danger that if quality is everybody's business,
  25     it becomes ultimately no-one's particular business?

   1   A. There is a danger, but if you have a problem when you
   2     adopt management style, you have a problem, so you
   3     appoint somebody whose title is the problem, and then it
   4     immediately becomes nobody's business. I have no
   5     sympathy with the view that if punctuality at meetings
   6     in a Trust -- I give a facetious example so I am not
   7     criticising any particular event in the Trust, but if
   8     punctuality were considered to be a problem, I would not
   9     admire the management approach which says "We will
  10     appoint a punctuality officer", because it does not
  11     work. It costs money and it does not work. I would
  12     want to improve punctuality. I cannot understand
  13     anybody who believes that anybody in the health care
  14     business is not intimately concerned with policy.
  15     I would not wish to be a Chief Executive of an
  16     organisation where sections of the staff had no
  17     responsibility for quality: I was accountable for the
  18     delivery of that quality and I would not have an
  19     unworkable system.
  20        This, you have to remember, is being recommended
  21     by somebody with no management experience at all.
  22   Q. If we go down to the bottom of the page:
  23        "It is recommended that some mechanism for
  24     bringing issues which cover all such areas", and that is
  25     a reflection back to the paragraph immediately above,

   1     "and audit together is established. Again, this is
   2     currently seen as via the management team direct to
   3     Clinical Directors and yet in practice it may be worth
   4     exploring the role the Audit Committee might take in
   5     this."
   6        Did you make anything of that recommendation or
   7     not?
   8   A. I have to say, looking at it in retrospect, I do not
   9     even understand it. I may have done at the time, but
  10     I do not understand what that says.
  11   Q. Can we go over the page --
  12   A. Yes, I can speculate, but I do not think it would be
  13     helpful.
  14   Q. The first paragraph, the top of the page, I invite you
  15     to read. I do not at the moment invite your comment on
  16     it. Can we go to the next page, please, UBHT 29/81?
  17        Dealing with the resources that were devoted to
  18     audit, first of all, time, half a day per month for all
  19     medical staff, but at this stage, no time allowance for
  20     nursing and therapy staff.
  21        Is that an accurate historical reflection of the
  22     position at that date?
  23   A. I expect so, but I do not think it means anything. This
  24     is at a time of development and you must remember that
  25     the introduction of other professionals into the audit

   1     process had just started; it was not established.
   2     I suspect at that time -- I mean, the half day a month
   3     is the takeover of medical audit. We are now faced at
   4     this time with the development of clinical audit. You
   5     will see the first step, and you may think they are
   6     rather niggardly, is to invite two nurses and somebody
   7     else to a Medical Audit Committee and think it is
   8     multidisciplinary. We made a lot more progress after
   9     that.
  10        So this is a very transient situation for
  11     reflecting the very early introduction of clinical audit
  12     and the change from medical audit. We had had enough
  13     trouble creating medical audit, and we were having
  14     trouble, as you see, converting that to
  15     multidisciplinary audit. We succeeded, but these are
  16     the early birth pains.
  17   Q. What is plainly called for there is time and audit
  18     support staff?
  19   A. Yes.
  20   Q. Was such time, were such support staff, subsequently
  21     made available?
  22   A. Some were already available and we did a lot of work to
  23     try and create them as a cohesive whole. So, yes, I do
  24     not know how many at that time were actually in post,
  25     but I suspect -- yes, they were in post, for medical

   1     audit. This is now saying, if these audit assistants
   2     are going to have to cope with multidisciplinary audit,
   3     then that is a much bigger task and we will have to
   4     address by how much we need to expand the resource.
   5   Q. When Dr Bullimore subsequently became head of the
   6     Clinical Audit Committee and produced her first report,
   7     she commented that there was a problem in getting
   8     information for the report because there was no central
   9     co-ordination of audit.
  10   A. She was actually talking about a bureaucratic process to
  11     collect all the things. I mean, I think that that had,
  12     at that time, yet to be set up. We were having
  13     difficulty setting it up in the directorates. What was
  14     needed was to resource the Audit Committee so it could
  15     fulfil its new function, and when she was appointed the
  16     first thing that happened, and one expects that to
  17     happen, is for her to make recommendations or criticisms
  18     in order to establish that.
  19   Q. Mr Ross told us when he gave evidence [Day 19, page 89,
  20     lines 19 to 23] that he found there was no central
  21     co-ordination in terms of managing and gripping audit in
  22     the way that he felt was necessary.
  23        That is his view. Was there a difference of
  24     approach as you define it between him so far as audit
  25     was concerned and you?

   1   A. There had to be. He had no medical qualification. He
   2     was somebody with an administrative background, and
   3     I would expect him to wish to implement an
   4     administrative solution.
   5        So I think it is highly unlikely that he and
   6     I could or would resolve any solution in the same way.
   7   Q. The difference being your medical background?
   8   A. Absolutely.
   9   Q. Why should it be that your medical background would make
  10     the difference between whether there was a central
  11     co-ordination of the audit process or not?
  12   A. I should have thought that was self-evident. I would be
  13     more interested in showing that audit was taking place
  14     and putting my effort at the operational end of the
  15     spectrum and persuading consultants to actually produce
  16     it. This was something that, with the greatest respect,
  17     Hugh Ross could not do, and he would have to set up an
  18     administrative process which he then would hope would
  19     reassure them their audit, but I have to say it was
  20     difficult enough for me to talk to people about audit.
  21        I mean, I do not want, please, to comment on how
  22     Hugh Ross would do something, but when we created Chief
  23     Executives across the country they came from a wide
  24     variety of backgrounds and all used their particular
  25     experience and talents to achieve the same end result in

   1     different ways. That is inevitable.
   2   Q. Can we see what followed after this report by going to
   3      UBHT 30/29, and scrolling down, please? 11/9? The
   4     second paragraph:
   5        "The clinical audit committee agreed", it is not
   6     the context, it is the inference which matters, "that it
   7     is entirely appropriate that PAMs audit activities could
   8     and should be part of the directorate based on clinical
   9     audit, but that some unidisciplinary PAMs audit would
  10     also be appropriate."
  11        This is a minute I selected since it comes from
  12     June 1994, after the Regional Audit Team's report would
  13     have been received. Am I right in thinking that
  14     whatever the reception of that report may have been,
  15     there was no change as a result to the patterns in which
  16     audit was monitored by the Clinical Audit Committee
  17     within the UBHT in consequence?
  18   A. This was an evolving situation. I am sure it did not
  19     stand still, any of it. If you are asking me, ever
  20     achieve a stationary situation by June 1994, I have to
  21     say that that is quite impossible. What they are
  22     talking about is what I was saying. Within the
  23     professions allied to medicine, there was audit
  24     activities within their professional advisory structure,
  25     which would be across directorates and would address the

   1     activities of their professional members. This is
   2     saying that in drawing in those professionals into
   3     multidisciplinary audit, it was entirely appropriate, it
   4     is saying there, that they should continue their own
   5     independent audit. I cannot say what the argument was
   6     at the time and what sort of audit we are talking about,
   7     but I find that unexceptional. I cannot draw the
   8     conclusion from it that you have asked me to draw.
   9   Q. Can we have a look at Mr McKinley's statement,
  10     WIT 102/11?
  11        He starts at 38 talking about clinical outcomes:
  12        "As regards clinical outcomes and adverse events,
  13     these were fundamentally a matter for the audit meetings
  14     of the particular services involved."
  15        He is describing the position historically here,
  16     I think.
  17        He was your Chairman, was he not, in the period
  18     leading up to your retirement?
  19   A. Yes, immediately before my retirement.
  20   Q. "These were not, as a matter of course, reported to the
  21     Board."
  22        Is that right?
  23   A. They were not reported anywhere; they were confidential
  24     to the source of the audit, I think. They were
  25     fundamentally a matter for the audit meetings, which is

   1     why I explained, in this sensitive area of developing
   2     audit, that was an understanding throughout, so he is
   3     reflecting the situation.
   4   Q. Paragraph 39:
   5        "Control of individual situations was in the hands
   6     of the clinical teams and the Trust Executive
   7     Management. A yearly audit report covering clinical
   8     performance was produced by the Medical Audit Committee
   9     under a senior consultant. In my time, it was not
  10     practice in UBHT for this report to be seen by the Board
  11     or the Board Committee."
  12        So again, that is an accurate statement, is it?
  13   A. I did not think the final sentence was accurate, but the
  14     audit report was initially introduced along the
  15     professional line from Region down to District, it was,
  16     and then became Trust. I was anxious that what was
  17     being reported outside the Trust should be made known to
  18     the people responsible for the Trust, but I had to move
  19     very gently and delicately, because at this time the
  20     reassurance given to the staff is that it was nothing to
  21     do with management.
  22        I thought we had achieved the report by that time
  23     but, I mean, he and I overlapped for so short a time it
  24     may well be that he did not see a report before
  25     I retired, I do not know. But there certainly was

   1     a difficulty initially as to whom the audit report,
   2     which was a report about the process of audit and not of
   3     audit, should be made available and I think we have seen
   4     before Dr Thomas's view that anything out of the audit
   5     committee could only go where he said.
   6   Q. So we had the position, did we, because of the
   7     sensitivities which you describe, perhaps, that Medical
   8     Audit Committee, and after that the Clinical Audit
   9     Committee, had a responsibility to monitor the progress
  10     and process of audit, but their reports did not go to
  11     the Trust Board?
  12   A. Not initially, no. I thought they had done, before
  13     I retired, which is why I --
  14   Q. Which is why you take some issue with the last sentence?
  15   A. But it is not a big issue. They started off not being
  16     available to the Trust Board and they became available,
  17     and we are just talking about which side of October 1995
  18     that happened.
  19   Q. Who actually then made any use of the work done by the
  20     Clinical Audit Committee?
  21   A. The region did. They summated them, had a look at them
  22     and they issued an encouraging document, so say, to say
  23     "Look what has been happening across the region and
  24     please, would other people like to do a similar thing",
  25     but it was a report on the introduction of the process

   1     of audit with a few encouraging notes to say, "and we
   2     have found something we can improve on".
   3   Q. Did the Clinical Audit Committee have any internal
   4     purpose, apart from satisfying the region?
   5   A. I am sorry, this Clinical Audit Committee were
   6     responsible for monitoring the introduction of audit.
   7     I think I have said that.
   8   Q. Yes. You may not have followed or understood what I was
   9     asking you in the last couple of questions.
  10   A. That is entirely possible, yes.
  11   Q. It may be my fault; please do not blame yourself. I was
  12     asking, if the reports from the Clinical Audit Committee
  13     did not go to the Board, what use was made of the
  14     Clinical Audit Committee and its deliberations within
  15     the Trust?
  16   A. Are you asking me what use was made of the report or
  17     what use was made of the committee? What use was made
  18     of the report is that it went to Region and was, as
  19     I say, processed with all the others, and returned as an
  20     encouraging document, to say what everybody else is
  21     doing, and so on, and that works.
  22        If you say what function did the Audit Committee
  23     have, I think I told you: the Audit Committee was
  24     charged with encouraging and monitoring the introduction
  25     of the process of audit.

   1   Q. Did it report on that to the Trust Board?
   2   A. That is what the annual report was. What it was
   3     supposed to do, to me -- these were very early days and
   4     I cannot really discuss sensibly what we did with the
   5     outcome of audit because there was very little outcome
   6     of audit at that stage, it was only the process of audit
   7     we were concentrating on, but the Chairman of the Audit
   8     Committee was clearly responsible for informing me as
   9     the Chief Executive, directly and urgently if necessary,
  10     if any management action was required for the
  11     introduction, for the Department, of audit, and in
  12     theory, to deal with any adverse result of audit,
  13     although that was necessarily some time in the future.
  14   Q. Mr McKinley goes on:
  15        "To an outsider used to an open statistical
  16     approach to performance monitoring" -- he had come from
  17     the aircraft industry?
  18   A. Yes.
  19   Q. "I was not comfortable with the activities of the
  20     medical audit committee. They seemed to carry out
  21     audits without established criteria."
  22        They did not actually carry out audits themselves,
  23     from what you have said, the Medical Audit Committee?
  24   A. No.
  25   Q. "I personally saw only one report. In that report,

   1     I could not find the criteria used, the information was
   2     expressed in a generalised manner, and I could not get
   3     a clear picture of areas where there should be concern
   4     and the actions which might be taken. I, of course,
   5     recognise and respect the need to maintain patient
   6     confidentiality."
   7        Is that an accurate description of a position as
   8     it was in that stage of its evolution, or not?
   9   A. In part I think I could say what it says is, in general,
  10     true. It is written as though he -- I can understand
  11     this -- comes to an organisation and we say we have an
  12     Audit Committee and we have an auditing process, and he
  13     could not find much evidence of it. There was a reason
  14     for that: there was not much of it. He came from an
  15     organisation where audit clearly had been established
  16     for a very long time. He comes to an organisation where
  17     it is very new, it has just been changed, we have taken
  18     the whole thing to pieces and are rebuilding it with
  19     some difficulty, and there were no standards against
  20     which audit could be taken until a great deal of audit
  21     had been done to identify a standard.
  22        If you pick a standard out of the air and say "Are
  23     we meeting that?" that is ridiculous. It would carry
  24     the confidence of nobody. So the first task in the
  25     introduction of audit is to introduce the process of it

   1     and we have seen some difficulties about how we provide
   2     time, information technology, audit assistants and so
   3     on. You also have to produce a cultural change that
   4     people actually want to do it.
   5        That is the first stage.
   6        The next stage is a great deal of observation,
   7     discussion, cross-district, cross-regional discussion
   8     takes place, to try and establish what standard there
   9     should be, and there was not one then. That is why he
  10     could not find one.
  11   Q. There are two steps as you describe it: one is the
  12     setting of criteria, and the second is the collation and
  13     collection of information or statistics to be measured
  14     against those criteria?
  15   A. You have to collect all the information to create the
  16     standard. That is the thing. That is where the
  17     standard comes from. Let us say, we are talking about
  18     something I understand --
  19   Q. I follow the point. What you are saying is that
  20     throughout the time of your chief executiveship, you
  21     were not in a position to set criteria because they had
  22     not yet evolved from the material which was being
  23     collected elsewhere?
  24   A. I did not set the criteria anyway. The only criteria
  25     I could have helped set was in my own specialist area.

   1     What I am saying is that one of the first things the
   2     experts and the specialists had to do was to establish
   3     an agreed standard, not ask the Chief Executive to tell
   4     them what the standard was: (a) that would have been
   5     totally incompetent and (b) it would have been
   6     disastrous.
   7   Q. You see in the next paragraph Mr McKinley goes on to
   8     that. In the area of audit he says Hugh Ross moved
   9     towards setting criteria and logging statistics.
  10        Leaving aside whether it was Hugh Ross who set the
  11     criteria or whether he adopted the criteria established
  12     and suggested by others, "While maintaining patient
  13     confidentiality, he moved to set up specific people in
  14     each directorate with the responsibility of logging data
  15     into the audit system."
  16   A. Yes.
  17   Q. Taking each of those sentences separately, was there
  18     any, and if so what, any reason that could not have been
  19     done beforehand?
  20   A. Because it was an evolution. Hugh Ross had the benefit
  21     of developing and progressing clinical audit from the
  22     stage to which we had managed to move it before
  23     I retired. If he had stayed at the same position, as
  24     I had retired, you and I would think he had failed. If
  25     what he did as a further development of the service is

   1     offered to me as a criticism of why we did not do it
   2     before, then I am not even prepared to discuss that.
   3        Can I say, this was a five-year programme.
   4   Q. I think we follow that.
   5   A. Thank you.
   6   Q. Can I turn from audit to another issue that you cover in
   7     your statement. Can we go to page 24, please, where you
   8     deal with mechanisms and structures available to staff
   9     members to raise and secure action on matters of concern
  10     to them, what in some situations might be called
  11     "whistle-blowing"?
  12   A. Could you define what "whistle-blowing" is, please, at
  13     the beginning, because it has a number of meanings?
  14   Q. Let me ask you specific questions, and we will see where
  15     we get to. Can we have UBHT 115/113, please?
  16        1995: there is a letter about the Allitt Inquiry
  17     report: "serious untoward incidents". It went to you,
  18     no doubt, in 1995. Let us look at the signatory,
  19     please; and looking for the "notification of serious
  20     untoward incidents".
  21        The Allitt incident involved the performance of
  22     her duties by a member of staff, did it not?
  23   A. I am sorry, I mean, you will have to remind me.
  24   Q. Beverley Allitt.
  25   A. Yes, but there were so many things.

   1   Q. The Munchausen's by proxy case?
   2   A. Yes, I remember, was it the nurse or the mother?
   3   Q. It was the nurse who succeeded in killing a number of --
   4   A. Yes, I think I remember the case.
   5   Q. The Allitt situation, I think, came -- you may not
   6     remember it quite so clearly as others do, but it
   7     certainly achieved great prominence in the press.
   8   A. I am sorry, I was trying to identify which one, not
   9     that -- I did not know that one. I could not relate the
  10     name to the incident, but I am quite happy to accept
  11     that.
  12   Q. Can we look at UBHT 6/200? This is 1993. Can we scroll
  13     down, please? And go over the page. Further on down --
  14     I am sorry, I have missed the reference here. Can we go
  15     to page 6/26? I am sorry, Dr Roylance, it is my fault
  16     entirely.
  17   A. That is all right. I am lost in admiration in the
  18     linking of these.
  19   Q. These are the minutes in 1993, the same minutes but
  20     a different reference. "Matters arising: Dr Roylance,
  21     Mr Stone and Mr Wisheart would meet to discuss how
  22     members of staff could express any concerns they had
  23     about colleagues' behaviour."
  24        In the middle of 1993, at this time, was it
  25     necessary to have such a discussion, because the lines

   1     of procedure were unclear?
   2   A. I cannot draw that conclusion. We were always having
   3     discussions trying to improve things and if for some
   4     reason -- and I cannot remember it now -- there was some
   5     reason where greater clarity or a change in attitude,
   6     a different policy was desired by the Trust, that would
   7     be a natural way to start it and it would be natural to
   8     inform the Trust that that is what was happening.
   9        I do not know the background, I do not know the
  10     outcome.
  11   Q. Suppose that somebody, a consultant, let us suppose, or
  12     a junior doctor, even, in one or other of the divisions,
  13     had a concern about the performance of one of his
  14     colleagues, or a nurse having a concern about an
  15     Allitt-type character who appeared to be harming
  16     patients under his or her care.
  17        How would such a person, at least before 1993 --
  18     let us divide this up into looking at it in terms of the
  19     Health Authority on the one hand and the Trusts
  20     secondly: how would they go about making any complaint
  21     in respect of that behaviour?
  22   A. They would share it with somebody who was appropriate,
  23     and did. I cannot specify it unless you actually
  24     hypothesise a much more specific situation, but can
  25     I say that there was a situation where it was thought

   1     that something of an Allitt nature was happening,
   2     whether it was before the Allitt case or afterwards I do
   3     not know, and the anxiety was, I think it was changing
   4     settings on a particular automated drip injector,
   5     something like that, and they thought somebody was going
   6     around and rigging it, which was very worrying. I seem
   7     to remember the outcome was that the switching itself
   8     was defective rather than a member of staff doing it.
   9        The moment there was that suspicion, that was
  10     shared with somebody -- I cannot tell you specifically
  11     whether it was a nurse with a ward Sister, whether it
  12     was a nurse directly to Margaret Maisey, or whether it
  13     was through one of the enormous number of pathways which
  14     were open, but there was no doubt that if anybody had
  15     a concern of the nature you are specifying, there was no
  16     impediment to that being brought to the attention of
  17     somebody who could deal with it. In a ward, it normally
  18     went to the ward sister, who normally resolved it, and
  19     if she had a continuing anxiety she would normally go
  20     directly to Margaret Maisey.
  21   Q. Suppose it was in the Directorate of Surgery and one
  22     surgeon had a concern about the operative technique of
  23     another?
  24   A. Yes. That happened.
  25   Q. With whom would that surgeon raise the concern?

   1   A. Me.
   2   Q. You directly?
   3   A. Yes. I cannot tell you precisely why, because is it
   4     would start identifying the source of the anxiety,
   5     but it was raised directly with me and I talked to the
   6     person concerned and took the necessary advice and
   7     established that it was a one-off failure in
   8     communication between two surgeons, and a patient who
   9     was referred across the specialty and back again, and
  10     they both were sure the other one was looking after
  11     them. It was a great pity, but I give this as an
  12     example of something that should not have happened which
  13     did happen, and it was immediately shared with me.
  14   Q. If the concern were about any other doctor, then, it
  15     could be raised directly with you. If you were not
  16     available, with whom?
  17   A. Well, with a responsible doctor. Once we had a Trust,
  18     we had two quite separate routes that overlapped at
  19     times. One was the professional advisory route, through
  20     the profession to the Chairman of the Medical Committee;
  21     the other was a management route through the directorate
  22     and to me. There was no shortage, anywhere, of people
  23     with whom to share the sort of anxieties you have
  24     expressed.
  25   Q. How would a clinician know that they should raise the

   1     matter with you, rather than with their, let us say,
   2     immediate Clinical Director?
   3   A. They did not need to know. They could please
   4     themselves. They would raise it with whoever they
   5     thought was appropriate. I mean, these are highly
   6     intelligent people who see a problem, suspect a problem
   7     and quite naturally wish it to be resolved immediately.
   8     Depending upon the nature, the identity of the person,
   9     there is a whole host of people they can go to. They
  10     can go to the Chairman of the Board; they can go
  11     anywhere. They have the judgment to consult the staff
  12     to resolve an issue. That is what they spend doing
  13     every day with patients.
  14   Q. Does it follow from your answer that because of the
  15     intelligence and status of the staff who might be making
  16     complaints, there was no need for any formalised system
  17     as to whom a complaint should be raised with in the
  18     first place, or for that matter in the second place?
  19   A. If you are saying, should we have constrained and
  20     restricted the opportunities of staff to choose an
  21     appropriate route to resolve a situation, then I would
  22     say "No".
  23   Q. I am not sure that answers my question, but --
  24   A. I am sorry, I thought it did.
  25   Q. -- unless it is that you are saying that such a system

   1     could have been done, but it was not done because it
   2     would have constrained and restricted?
   3   A. That is what I thought I said. Thank you for repeating
   4     it.
   5   Q. The other side of that same coin is, is it not, that if
   6     there is to be a system of going to whomsoever one
   7     chooses, people may need to be encouraged to know that
   8     that is what they should do in such an event?
   9   A. I find that insulting to the sort of staff that I had
  10     in my Trust.
  11   Q. It would inevitably be the case, would it not, that if
  12     there were a concern which one clinician held about
  13     another with whom he regularly worked, that there would
  14     also be a concern that raising the issue might prejudice
  15     relationships at the working level, the operative level?
  16   A. Please, I have to put back to you, I mean, I do not
  17     think that is true, but I have to put back to you, it
  18     depends what the nature of the complaint is. If the
  19     nature of the complaint, as an example I cited, is that
  20     patient care is unacceptable, then I would not accept,
  21     as an excuse, that some interpersonal relationship
  22     somewhere was a bar to having something done about it.
  23        Now, it is perfectly possible, and happened, that
  24     some complaints were made known to the three wise men on
  25     the understanding that the source of the complaint would

   1     for ever remain entirely anonymous. That would totally
   2     resolve the problems you offer. That sort of
   3     information was regularly made available so that the
   4     medical staff and other staff, they were frequently and
   5     regularly reminded of that opportunity.
   6   Q. But the three wise men, I thought we looked at the
   7     document this morning, from 1982, was essentially
   8     a capability procedure rather than an incompetence
   9     procedure?
  10   A. I thought I explained to you that that is a prejudgment
  11     of an investigation.
  12   Q. So that anyone with a concern would appreciate that
  13     anonymously they could approach one or other of the
  14     three wise men directly or indirectly?
  15   A. Absolutely, and if I as a radiologist had suddenly
  16     started doing bizarre things, nobody would wonder
  17     whether it was because I was mentally ill or
  18     incompetent, they would have shared their anxieties
  19     immediately with the three wise men.
  20   Q. They would have this appreciation this was the route
  21     simply because they were doctors working in the
  22     hospital, not because anybody had encouraged them in any
  23     official statement to take that step?
  24   A. I thought I explained, I am sorry, the availability of
  25     that route was a matter which was recurrently the

   1     subject of remindings to the staff; it was raised at
   2     Medical Committee regularly, it was minuted at the
   3     Medical Committee, it was raised in the other sorts of
   4     fora in which doctors and others meet and I am satisfied
   5     that the mechanism was known to the staff.
   6   Q. Returning to the matter which I raised a moment ago, of
   7     a clinician who you accept would have the duty to report
   8     upon a fellow clinician who was providing dangerous care
   9     for patients --
  10   A. Yes, immediately and unambiguously, yes.
  11   Q. Such a clinician, although his duty will be clear, would
  12     no doubt be concerned as to the working relationships he
  13     might have with the "guilty" clinician, if I can call
  14     him that, and also with those others with whom he
  15     worked. No-one likes a snitch, is the plain reality?
  16   A. I do not accept that is an excuse for not making the
  17     information available, and I did tell you that that
  18     information could be made available in absolute
  19     anonymity, which would remain for all time.
  20   Q. I accept that. If it became known who had -- I use the
  21     expression, "blown the whistle" -- to be the situation
  22     of informing upon a colleague providing dangerous care,
  23     if it became known that such a person had provided the
  24     information and anonymity was not conferred, what, if
  25     any, steps would be taken to ensure that such a person

   1     was not victimised by his colleagues?
   2   A. Well, there was -- I mean, I currently emphasise to
   3     everybody -- it must be in documents here and there, in
   4     minutes -- that whistle-blowers would never be
   5     persecuted. You actually postulated that if one of them
   6     had reported the matter to the "three wise men", then
   7     there was a possibility that his identity would be
   8     released. I have already said that is not so. But if
   9     he chose to do something else and write a letter or
  10     raise it, if he sat in his division and said "The chap
  11     sitting next to me is incompetent", you have to do
  12     something about it, then the source of complaint would
  13     be known.
  14   Q. The question was, would any steps be taken to protect
  15     such an individual from victimisation of his colleagues?
  16   A. I do not know what sort of victimisation you might
  17     imagine. I made absolutely certain that management
  18     would prevent victimisation. If you are saying to me
  19     that as a result of the hypothetical situation I have
  20     said, the chap next to him said "I will never speak to
  21     you again", I do not know that management can say, "Yes,
  22     you will". I mean, I am trying to answer the question
  23     as I understand the question. Management would make
  24     sure there was no tangible victimisation of anybody, but
  25     I cannot ordain interpersonal relationships, if that is

   1     what you mean.
   2   Q. How would the individual who might be contemplating
   3     writing such a letter have any assurance of that? Would
   4     that be from the statements, the repeated references
   5     that you mentioned a moment ago? How would an
   6     individual who was contemplating writing a letter of
   7     complaint about a colleague have any assurance that,
   8     having done so, he would, whilst within the Trust, be
   9     protected against victimisation? What would he rely on
  10     for that assurance?
  11   A. My personal word, which he would have heard many times.
  12     But please, can I re-emphasise, we have to be careful
  13     what you mean by "victimisation". If all his colleagues
  14     will not speak to him, then I would have to engineer
  15     some form of rehabilitation, some sort of
  16     reconciliation, conciliation meetings, and you may know
  17     that on one occasion I did that.
  18        But in terms of tangible retribution, that would
  19     be easy to stop. In terms of interpersonal
  20     relationships, that would present difficulties and on
  21     one occasion did, and I took advantage of the
  22     counselling expertise of some of my colleagues to
  23     attempt to address it.
  24   Q. You say, page 29 of your statement, in relation to
  25     complaints both of poor standards of care and of what

   1     I have been taking as whistle-blowing, which is
   2     informing upon a colleague providing dangerous care:
   3     can I ask you two questions about what you say there
   4     in (g)?
   5        You say:
   6        "Any complaint of poor standards of care made ...
   7     was always taken very seriously and the commitment of
   8     staff to high standards was looked upon as ancillary
   9     monitoring system. A full investigation would always be
  10     made either discreetly or publicly ..."
  11        When you use the words "a full investigation", can
  12     you give us some idea of the nature and scope of that
  13     investigation which made it full?
  14   A. Anything from me talking to the people concerned to
  15     inviting a team from the appropriate Royal College to
  16     investigate the situation and advise me, anything along
  17     that spectrum. I cannot specify, it depends on the
  18     nature of the complaint, as I have said, but I would
  19     have to satisfy myself it had no foundation, in which
  20     case I would reassure the complainant, or if it had,
  21     I would have to take the appropriate action.
  22        How I would make that judgment would depend
  23     entirely upon the nature of the complaint that was made.
  24   Q. You are looking on this as a matter which would
  25     inevitably come to you, because you are talking

   1     personally about your response?
   2   A. You asked me what I would do about it, so I told you
   3     what I would do about it.
   4   Q. I think I asked you what you meant by full
   5     investigation, but let me depersonalise it. Would there
   6     be occasions when the matter would not come to you and
   7     it might be investigated by somebody else?
   8   A. If it was reported to the three wise men it would not
   9     come to me unless some formal management steps were
  10     required. When I was a member of the three wise men and
  11     people shared their anxieties with me, the three wise
  12     men together, with the help when necessary of the
  13     nominated psychiatrists and with the help of anybody
  14     else, there were no constraints on how we could deal
  15     with it; we would deal with it. If we came to the
  16     conclusion that management action was required, we would
  17     furnish management with the necessary evidence and
  18     expect them to deal with it.
  19   Q. So the fullness of the investigation, when you conducted
  20     it, obviously depended upon your view of what was
  21     required?
  22   A. Yes.
  23   Q. When others investigated it, let us suppose the three
  24     wise men, you would not know what was being done but you
  25     would still have confidence, would you, that the

   1     investigation was full?
   2   A. Absolute confidence.
   3   Q. That is because you have, presumably, confidence in the
   4     three wise men?
   5   A. Yes, and my experience of how the system worked, and
   6     sometimes had more contact with them than would normally
   7     be the case with a Chief Executive, and I knew that they
   8     were totally to be relied upon and there were recognised
   9     national resources constantly available to assist them
  10     in what they were doing.
  11   Q. To what extent would it be likely, in any postulated
  12     case, for someone in the position of Medical Director to
  13     be involved in determining an investigation or
  14     conducting one?
  15   A. If he were Chairman of the Medical Committee, he would
  16     be one of the three wise men.
  17   Q. And if he was not?
  18   A. Then I would expect the Chairman of the Medical
  19     Committee to be involved.
  20   Q. So if a complaint were made to the Medical Director, he
  21     would pass it on, would he, to the Chairman of the
  22     Hospital Medical Committee?
  23   A. We had a funny situation, where the Medical Director was
  24     also one of the three wise men, because he was the past
  25     Chairman, so -- I am trying to be real, I am trying to

   1     be honest, but I would expect professional matters, and
   2     I believe everybody else would, normally to be addressed
   3     in a discreet professional way by the three wise men and
   4     that if, at the end of their deliberations, appropriate
   5     to the situation, management action was required, then
   6     they would make a clear unambiguous recommendation to me
   7     as the Manager.
   8   Q. If the complaint were about one of the three wise men,
   9     would that be something that you would expect to come
  10     straight to you?
  11   A. No. That is why we had three wise men. If it was about
  12     two wise men, the third one would deal with it. If it
  13     was about all three wise men, then I think they would
  14     have a problem, they might have to come to me, but they
  15     might go to the past-past-Chairman of the Medical
  16     Committee. But, I mean, I have to say, there were three
  17     wise men and you could approach any of the three
  18     confidentially with confidence and absolute anonymity.
  19   Q. Looking again at the realities of the situation as you
  20     did a moment ago, the three wise men, during your time
  21     of office, as Chief Executive: did they get on with each
  22     other?
  23   A. Yes. They changed every two years, of course. But --
  24   Q. Were they not only colleagues but also close
  25     acquaintance of each other?

   1   A. I cannot imagine that the Chairman, elect Chairman and
   2     past Chairman, could be other than very close colleagues
   3     in the professional advisory machinery, even if they
   4     worked at the far ends of the Trust or District before
   5     they were so elected.
   6   Q. Did you see any potential problem in a system in which
   7     a complaint might be made to one of three close
   8     colleagues and acquaintances about one of those other
   9     three?
  10   A. None at all. None at all. Quite unthinkable that there
  11     should be. All the three wise men were charged, quite
  12     clearly, with dealing with complaints which are made
  13     known to them, and they had that ability.
  14   Q. Does it follow from what you said that you trusted them
  15     to do their duty whatever their personal feelings might
  16     be?
  17   A. I cannot think of how personal feelings might enter into
  18     it, so I do not think that I would even think whatever
  19     their personal feelings were. This was a statutory
  20     responsibility, if that is the right term, laid down by
  21     the Department of Health, and it was met.
  22   Q. Did you conceive at all that others, albeit of the three
  23     wise men, might not perhaps share your personal approach
  24     and dedication to doing duty whatever the personal
  25     consequences?

   1   A. I think that is inconceivable. I think anybody who did
   2     not want to act as one of the three wise men would not
   3     want to act as Chairman of the Medical Committee. They
   4     would not allow themselves to be nominated. I cannot
   5     imagine the situation you are asking me to imagine.
   6   Q. Dr Roylance, your answers are most illuminating. Can
   7     I thank you for them? Sir, it is time for a break.
   8   THE CHAIRMAN: Yes. Thank you, everyone. We will break now
   9     for three-quarters of an hour and reconvene at
  10     1 o'clock.
  11   (12.18 pm)
  12            (Adjourned until 1.00 pm)
  13   (1.05 pm)
  14   MR LANGSTAFF: Dr Roylance, you deal on page 31 of your
  15     statement -- let us go there, please -- with the split
  16     site. I asked you a number of questions about this
  17     yesterday. You say, at the bottom of the page:
  18        "In 1991 Mr Wisheart secured the agreement of the
  19     British Heart Foundation to fund a chair in cardiac
  20     surgery at Bristol. It was everybody's intention that
  21     the person appointed should be a specialist paediatric
  22     cardiac surgeon."
  23        You go on to describe how it was unfortunate that
  24     it did not prove possible to appoint a paediatric
  25     cardiac surgeon at that time, and how an adult cardiac

   1     surgeon was appointed because funding was available.
   2        Why was it, as you now recollect it, that it was
   3     not possible to appoint a paediatric cardiac surgeon?
   4   A. Because when I was involved in the shortlisting and
   5     subsequent interviewing for the post, there was not one
   6     on the long list that had got as far as the shortlist.
   7     I mean, I was not involved in the -- if I may put it
   8     this way -- headhunting that went on in any way.
   9   Q. Is that right? My reason for asking you will emerge
  10     when we look at the next document. It is not a core
  11     document: JDW 3/102.
  12   A. Can I say that I cannot remember, and I feel I would
  13     have remembered -- I cannot remember being involved in
  14     any way.
  15   Q. Let me see if this helps your memory. If it does not,
  16     so be it. This is a letter -- go back to the top of the
  17     page -- from the Hospital for Sick Children. Go on to
  18     the next page, so we can see who it is from.
  19   A. This is Martin Elliott, I expect.
  20   Q. Martin Elliott was a paediatric cardiac surgeon, was he
  21     not?
  22   A. Yes, well, I learned he was. It was not in my sphere of
  23     immediate knowledge, so I did not know of his existence,
  24     I have to say, until --
  25   Q. Let us go back to the letter.

   1        "I will have spoken to you by now about the
   2     Chair. I have decided not to apply. My reasons are as
   3     follows ..."
   4        He says he cannot afford it. His prospects at
   5     Great Ormond Street remain reasonable. Research
   6     opportunities are at least equal to Bristol. Thirdly,
   7     lingering doubts -- and this is the way it is expressed
   8     -- "... about the security of the paediatric volume
   9     for a worry about the separation of cardiology from
  10     cardiac surgery which would, I think, take some time to
  11     resolve."
  12        The English of that is not entirely easy, but
  13     I think one understands what he is saying.
  14   A. He is a good surgeon nevertheless.
  15   Q. So he turned down the opportunity to be put forward for
  16     interviews which our understanding is took place a week
  17     or so later?
  18   A. Yes.
  19   Q. He prepared a document which -- can we have a look at
  20     JDW 3/106? Can we see what he says, and then I am going
  21     to ask you whether you knew he had said this at the
  22     time, or something like it.
  23   A. No, I mean, I learned about this at a later date,
  24     whether it was just before the interview or after the
  25     interview or what not, I do not know. James was on the

   1     interview committee as well, and he may well have told
   2     me he had failed to attract a paediatric cardiac
   3     surgeon. What I said and what I meant was that I was
   4     involved in no way in an attempt to attract Martin
   5     Elliott to Bristol. In fact, I still do not know why,
   6     because potential applicants for senior jobs normally
   7     met the Chief Executive, and he clearly met Peter Durie
   8     and he did not meet me and I must have been somewhere
   9     else. I do not know where the somewhere else was, but
  10     he failed to see me. I sometimes ponder that if he had
  11     seen me whether I could have persuaded him about the
  12     security of expectations in Bristol. I am not sure
  13     I could have helped him with his other problems.
  14   Q. The comments he makes at page 106, and I think it is
  15     probably easiest if you read them through when you are
  16     ready if you ask for the screen to be moved down ...
  17        When you have finished that, we will go overleaf.
  18        I am sorry that there is a highlighting which has
  19     come out in the photocopying. My understanding is that
  20     it says, or appears to say, "Move all paediatrics to the
  21     Children's Hospital. Assuming this is possible, this
  22     would", and then you have the bullet points which
  23     follow.
  24        If we scroll down to the bottom of the page --
  25   A. I think, I mean, he is saying what we by that time

   1     knew. He is not saying it, other people said it, but
   2     the overall drift of the paper is something we knew.
   3   Q. If we go over to 108 and look at the first sentence
   4     under "Conclusions":
   5        "Paediatric cardiac surgical services should be
   6     moved to the Children's Hospital. I believe this is
   7     fundamental to the whole appointment of a Chair of
   8     Cardiac Surgery, particularly for a paediatric based
   9     Professor."
  10        I do not think it is necessary to read it any
  11     further, but essentially, he was a potential applicant
  12     who, it appears, withdrew in part, as one of the three
  13     reasons he gives, because what was in his view essential
  14     for a Chair in Paediatric Cardiac Surgery was not going
  15     to be provided at least when he got there.
  16        Did you know of that as his reason for turning
  17     down possible appointment?
  18   A. Yes, I mean, there were problems even at that time as
  19     to how we were going to achieve what the designed
  20     intention was. In general terms there is always an
  21     issue as to whether you create a department and then
  22     advertise for somebody to come and work in it, or you
  23     achieve the person you want and avail yourself of their
  24     experience and knowledge to create the Department that
  25     they would want. I do not know whether I can explain

   1     that, but we had hoped that in a phased way, if we could
   2     appoint to the Chair in Surgery a paediatric surgeon,
   3     then he would be able to assist us in designing and
   4     achieving a move to the Children's Hospital.
   5   Q. So you would see that as encouraging the move rather
   6     than the move being necessary to encourage the
   7     applicant, that way round?
   8   A. Yes. I mean, we had not moved and we wanted to, and we
   9     thought, if we could achieve the appointment of
  10     a Professor in paediatric cardiac surgery, we would have
  11     a lever and some knowhow to design what was necessary
  12     and find a way of achieving it.
  13   Q. Pausing there for a moment, I am going to come back to
  14     the story of the appointment, just to make sure you are
  15     happy with the way you put it in your statement, having
  16     looked again at the documents. But supra-regional
  17     designation of the cardiac surgical service for the
  18     under 1s, Bristol had enjoyed since 1984?
  19   A. That is right. It was before I was involved in
  20     management.
  21   Q. I was going to say, you were not in post when it began
  22     so you cannot help us with why it should have been
  23     Bristol that attracted the designation, I imagine. But
  24     perhaps you can tell me this: from 1984 up until this
  25     time, 1992, it must have become increasingly apparent

   1     that the split site, amongst other things, was a problem
   2     with paediatric cardiac surgery?
   3   A. Well, there was room for improvement. That improvement
   4     we wished to achieve.
   5   Q. It was of the essence of supra-regional services that
   6     they were provided for any child from wherever they
   7     might come?
   8   A. Yes.
   9   Q. Irrespective of region or district funding, irrespective
  10     of the purchaser/provider split.
  11   A. Yes, that is right, it was top-sliced and allocated
  12     centrally to designated units, yes.
  13   Q. So in terms of the quality of care for children in the
  14     Bristol area, the important thing, no doubt, for the
  15     child or the parent was getting the optimum care
  16     wherever it was provided?
  17   A. Yes.
  18   Q. And it did not have to be in Bristol; it could easily
  19     have been in Cardiff or Birmingham or somewhere else?
  20   A. Yes. Oxford, I think. Were they designated? I think
  21     so.
  22   Q. They were not.
  23   A. Then it would have been London.
  24   Q. Southampton was.
  25   A. Yes.

   1   Q. London.
   2   A. Southampton was at that time, and still is I think,
   3     a rather more awkward journey than going up to London.
   4   Q. Yes, and there were proposals to develop the service in
   5     Cardiff?
   6   A. Yes.
   7   Q. Given that there may seem to have been some difficulties
   8     with the split site for the various reasons identified
   9     in this paper, the ones we looked at yesterday, was
  10     there any particular reason why Bristol chose to
  11     continue being designated?
  12   A. Bristol did not choose it. It was the central
  13     designation committee, whatever its title was, that made
  14     the decision that Bristol should be designated and
  15     continued to be designated.
  16   Q. We have understood from the evidence which has been
  17     given to us in respect of the Supra Regional Services
  18     Advisory Group that the Royal College of Surgeons and
  19     for that matter the group, were actively looking for
  20     a unit which would be de-designated because it was their
  21     view there were rather too many of them in the country.
  22        I think what you are saying is that it was not
  23     a concern of yours in particular why Bristol should
  24     remain designated. Was it something that you ever
  25     considered?

   1   A. No, I have to say, this central group never discussed
   2     designation, continued designation or de-designation,
   3     with me. I was unaware that there was any process other
   4     than that the central group, there were designated
   5     supra-regional services in a number of specialties.
   6     I assumed, I think quite fairly, that they were
   7     satisfied that Bristol should be designated and it was
   8     their decision on the disposition of the national
   9     provision of under-1 cardiac surgery.
  10   Q. Given the pressures that we have seen were created by
  11     the demand for adult cardiac surgery, so far as you
  12     know, did it ever occur to those who were in charge of
  13     the Directorate of -- this would be, I suppose, the
  14     Directorate of Surgery, the Associate Directorship of
  15     Cardiac Surgery -- that de-designation might be offered
  16     as a means of freeing up some space for adult cases?
  17   A. No. I am unaware that anybody even contemplated that,
  18     but if they did, they did not communicate it with me.
  19   Q. If they had done, what might your reaction have been, do
  20     you think?
  21   A. Supportive of whatever their advice was. I would have
  22     no opinion.
  23   Q. Was there a funding implication so far as the Trust were
  24     concerned?
  25   A. No. I mean, there was a lot of hype when Trusts were

   1     coming that we were going to move outside the Health
   2     Service and we were going to survive or fail on our
   3     ability to strike contracts. That never materialised
   4     and was an unrealistic ambition in a monopolistic Health
   5     Service in which supply was adequate to meet the limited
   6     purchasing power of the health authorities. So, as
   7     a Trust, it would have been in the ripple. I cannot
   8     believe any of us would have made any decisions in
   9     respect of paediatric care from a financial point of
  10     view. I really do not think it would have made any
  11     difference.
  12   Q. Can I return to the story as the documents suggest it
  13     might be in respect of the appointment of Professor
  14     Angelini.
  15        Can we have JDW 2/219? Again, I think, it is not
  16     a core document as yet. It will of course be released
  17     in due course.
  18        This is a letter from the British Heart
  19     Foundation, 3rd March 1992, to Professor Stirrat, and it
  20     concerns the application for a personal Chair for
  21     Mr Angelini.
  22   A. Yes.
  23   Q. Again, if you read it through, the process that appears
  24     to have been at work was for indicative funding to have
  25     been suggested by the British Heart Foundation, but once

   1     an appointee had been selected, a potential appointee
   2     had been selected, by the appointment committee an
   3     application was made with the name to the British Heart
   4     Foundation for them to consider whether they would
   5     support the application or not.
   6        Have I got it right?
   7   A. That is right. I mean, the Heart Foundation did not say
   8     "Here is the money, appoint whomever you like". The
   9     University, therefore, at its Appointments Committee,
  10     agreed to offer Gianni Angelini the post, subject to the
  11     prior approval of the Heart Foundation.
  12   Q. Can we go to the next document? It is a memo from
  13     Professor Stirrat to the Vice Chancellor, copied to
  14     Professor Farndon and Mr Wisheart:
  15        "Re Chair of Cardiac Surgery: John Farndon and
  16     James Wisheart and I met on Saturday morning to discuss
  17     the current highly unsatisfactory situation. Gianni
  18     Angelini was very disappointed by this seeming lack of
  19     confidence in him by the British Heart Foundation",
  20     obviously a reference to the lack of any final
  21     decision. "We agree the Foundation could hardly have
  22     found a worse way of proceeding with this whole affair
  23     and at some point this needs to be spelt out to them.
  24        "The two major issues were, however, what should
  25     be our response ... and what are our contingency plans."

   1        Can we go down to the last paragraph on the
   2     screen:
   3        "In discussions about contingency plans,
   4     Mr Wisheart and Mr Farndon felt it important that we try
   5     to put together a package which would allow Angelini to
   6     come to Bristol without the BHF support on offer.
   7     I agreed, but stated that the University would not be
   8     able to contribute towards his salary."
   9        Just pausing there, the process of thought between
  10     Mr Wisheart and Mr Farndon was that the appointment was
  11     wanted whether or not it was supported by the British
  12     Heart Foundation?
  13   A. Yes, the appointment was wanted because James,
  14     particularly, was driving for the creation of an
  15     academic unit in cardiac surgery in Bristol, so that was
  16     wanted anyway. There was a need for academic cardiac
  17     surgery.
  18        We also hoped that if we could achieve the
  19     appointment of a paediatric cardiac surgeon, that would
  20     solve the problem that we have been talking about.
  21   Q. The way you put it in your statement -- the bottom of
  22     page 31 -- after you said how unfortunate it was that it
  23     was not possible to appointment a paediatric cardiac
  24     surgeon, was:
  25        "Rather than decline the offer of funding from the

   1     British Heart Foundation, an adult cardiac surgeon,
   2     Professor Angelini, was then appointed."
   3        Which rather suggests that because the money was
   4     on offer, therefore the appointment was made?
   5   A. Yes.
   6   Q. Whereas this document, going back, please, to JDW 2/220,
   7     might suggest that the appointment was wanted and those
   8     who wished the appointment were looking around for
   9     a source of funding; if it was not the British Heart
  10     Foundation, it would be some other funds?
  11   A. Yes. They did not find any and they did not need to
  12     find any, because the British Heart Foundation agreed to
  13     appoint him.
  14        At this stage, can I say this was an intriguing
  15     situation where the Heart Foundation and the University
  16     both wanted to be the final decider. Neither wanted to
  17     say it was up to the other. What happened was after the
  18     University offered Gianni Angelini a provisional chair,
  19     subject to him being approved by the Heart Foundation,
  20     he then put his application, his CV and whatever, to the
  21     Heart Foundation and, as you see, their first response
  22     was that they wanted more information. That was the
  23     Heart Foundation's business, to be sure that their money
  24     was being spent on a "winner".
  25        In the interim, the other two were saying, "Well,

   1     because, after all, James had worked very hard to create
   2     this money; he is now saying, if this proposal falls
   3     through, we must try and find some other money". Of
   4     course, he wanted a paediatric cardiac surgeon. The
   5     fact is, that this wishful thinking that we could just
   6     appoint a Professor on NHS money was not realistic. If
   7     that had been the case, we would have offered to fund
   8     the Professor right from the start.
   9   Q. I follow the process, but one might get, you see from
  10     your statement, the impression that the overriding aim
  11     was to obtain the appointment of a paediatric cardiac
  12     surgeon. What I am querying, and this is what I would
  13     welcome your comments on, is that if, it being the case
  14     that Professor Angelini is not a paediatric cardiac
  15     surgeon, and it being the case that it appears that
  16     Mr Wisheart and Mr Farndon wanted his appointment
  17     irrespective of funds coming from the British Heart
  18     Foundation, how strong was the desire that the cardiac
  19     surgical appointment should be paediatric?
  20   A. You are asking me to balance two things when we clearly
  21     wanted the penny and the bun. We wanted a paediatric
  22     cardiac surgeon, full stop. We wanted an academic
  23     department of cardiac surgery. We hoped that we could
  24     achieve both, but clearly, it was not one or none, even
  25     two or none; we wanted both things.

   1        The fact that there was a hiccup with the Heart
   2     Foundation approving it really makes no difference and
   3     the fact that the two were scratching their heads and
   4     saying "If it does not happen can we find a fallback
   5     position?" is a natural response of people with
   6     a desire, but that did not materialise and it was not
   7     necessary.
   8   Q. What you have helpfully outlined for us, I think, is
   9     that there were two objects: the penny and the bun?
  10   A. Yes, I am sorry, I thought I made that clear.
  11   Q. It is clear. It leads on to this question. This is
  12     obviously an approach which was inspired by the
  13     Directorate of Cardiac Surgery, which covered both the
  14     adult and the paediatric.
  15   A. Yes.
  16   Q. How, within the directorate, were the conflicting
  17     demands of the paediatric on the one side and the adult
  18     on the other reconciled and dealt with?
  19   A. I do not understand your meaning that they are
  20     conflicting. Both were wanted and we delayed the
  21     replacement of one cardiac surgeon so --
  22   Q. Forgive me for stopping you. I was no longer pursuing
  23     the question on the basis of the appointment. I follow
  24     your answers on that. I was asking you the more general
  25     question as to the way in which paediatric surgery, part

   1     financed as it was by the supra-regional services
   2     funding, how that was dealt with and the demands of that
   3     service reconciled if it had to be with the demands of
   4     the adult cardiac services?
   5   A. It did not have to be. I mean -- I am sorry, I cannot
   6     understand the question. Can I just say, there was
   7     a vacancy for an adult cardiac surgeon. In the event,
   8     Gianni Angelini was appointed, providing half time
   9     service to the hospital, funded by the University, and
  10     the other adult cardiac surgeon's post was used to pay
  11     for a senior lecturer, so between the two posts the
  12     University had a whole-time equivalent academic and the
  13     NHS had a whole-time equivalent NHS consultant.
  14        Had he been a paediatric cardiac surgeon, we would
  15     not have appointed a consultant senior lecturer in adult
  16     cardiac surgery and James Wisheart would have used his
  17     time in adult cardiac surgery.
  18        So the sum was complete either way. Where I was
  19     having difficulty was your hypothesis that there was
  20     a conflict. I do not understand the conflict.
  21   Q. I am grateful for establishing what you have to say on
  22     that. You make the point in your statement that the
  23     adult and paediatric cardiac beds at the BRI were
  24     sharing the same ward. Let me just see if I can find
  25     it. It is page 11. We ought perhaps to start at the

   1     very bottom of page 10, so we see the full paragraph.
   2     Go overleaf:
   3        "In Bristol Royal Infirmary the operating theatres
   4     were used for both paediatric and adult cardiac surgery
   5     and there was only a degree of separation of paediatric
   6     from adult accommodation in the ward area. The
   7     Intensive Care Unit was used for both adults and
   8     children."
   9        You do not there comment on how desirable or
  10     undesirable you understood that to be.
  11   A. I do not think I was asked to.
  12   Q. No, as a matter of fact you do not comment. What would
  13     your comment be?
  14   A. That by that time, by when we were pursuing a paediatric
  15     cardiac surgeon, it was, I think, unanimously agreed
  16     that the national recommendations that children should
  17     be in a paediatric unit were accepted. They had been
  18     initiated by the paediatricians, who always wanted all
  19     children in their unit, and it was gradually achieving
  20     acceptance by everybody.
  21   Q. If it was not -- I am sorry to cut you short.
  22   A. No, go on.
  23   Q. If it was not possible to move the surgery of paediatric
  24     cases to the Children's Hospital, was there any reason
  25     why it would not have been possible to achieve a greater

   1     degree of separation of the paediatric from the adult
   2     accommodation in the Intensive Care Unit?
   3   A. Not in the Intensive Care Unit, I do not think, but in
   4     the ward, I do not know. Nobody made suggestions to me
   5     that we should, but I suspect, because they were going
   6     flat-out to solve the problem by moving it rather than
   7     by tinkering -- I cannot answer your question.
   8     I suspect if we challenged everybody or they had thought
   9     that way, some further separation may have been
  10     necessary. I do not know.
  11   Q. Again, from your answer, it is something which really
  12     you are commenting on with hindsight rather than
  13     something you knew about at the time?
  14   A. It was not an issue put to me at the time that we should
  15     endeavour, in our maintenance programme, to, shall we
  16     say, use some maintenance money to produce a change as
  17     well as an up-grade. So it was not suggested to me.
  18   Q. If you had become aware of the point without necessarily
  19     anyone from the clinical directorate speaking to you,
  20     would you, given your management philosophy, have taken
  21     a proactive role in suggesting it, or would you have
  22     waited to react to that suggestion coming from the
  23     clinical directorate itself?
  24   A. I mean, I do not think either. I think that if it had
  25     been put to me or it had been a serious suggestion, the

   1     first thing I would have done is discuss it with them.
   2     When I discussed it with them, an agreed solution would
   3     emerge and I would try to ensure that the directorate
   4     owned that solution and implemented it.
   5        But I do not think I would have gone, as a Chief
   6     Executive, along and said "Do this, that and the
   7     other". That would have been unrealistic.
   8   Q. There is one matter, before I move on to another issue,
   9     which I should perhaps pick up from this morning. Can
  10     we go to UBHT 61/161?
  11        This is dated 25th March 1992, medical audit
  12     meeting report. The specialty is paediatric cardiology.
  13        In the middle of the page as we see it, the words:
  14        "Results of previous audit interventions"; I am
  15     sorry to go back to audit, but this point has arisen.
  16   A. I am sorry, I cannot see the second bit you said.
  17   Q. Do you see where it says "Results of previous audit
  18     interventions"?
  19   A. I see what you mean.
  20   Q. Written there is "first on this topic".
  21   A. Yes.
  22   Q. The next, we look to see what the topic is, that this is
  23     the first audit of:
  24        "Paediatric cardiac surgical mortality for 1991,
  25     and comparisons to previous."

   1   THE CHAIRMAN: Mr Langstaff, help me if you can. You said
   2     that we had seen this before. This, to me, seems
   3     a different --
   4   MR LANGSTAFF: No, I am sorry if I gave that impression.
   5     I said "I am sorry to go back to audit", not back to the
   6     document. My apologies.
   7   THE CHAIRMAN: Then forgive me for interrupting.
   8   MR LANGSTAFF: It would appear, therefore, that what is
   9     being said is that in March 1992 the Medical Audit
  10     Committee were for the first time looking at paediatric
  11     cardiac surgical mortality for 1991 onwards.
  12   A. It is not the medical audit. It is the paediatric
  13     audit, just looking at it, not the medical audit.
  14   Q. Can we scroll back up? We can see who was in
  15     attendance, Mr Wisheart chairing.
  16   A. Yes. That is not the Medical Audit Committee.
  17   Q. I am sorry, it is a standard form for the Audit
  18     Committee for paediatric cardiology, with, in
  19     attendance, the paediatric cardiological team. I have
  20     it right, have I not?
  21   A. Yes, it is the clinicians in paediatric cardiology who
  22     are meeting in the audit.
  23   Q. What was said this morning by you in respect of 1992,
  24     when I was asking about audit, was that the information
  25     which I was hypothesising, that was, if you remember,

   1     mortality data, would not materialise, is what you said?
   2   A. Within -- yes.
   3   Q. You went on to comment that the source of information
   4     that I was postulating was so far away from 1992 that
   5     you found it difficult to give a sensible answer to me?
   6   A. Yes.
   7   Q. What I want to do is to reconcile with you, if I can,
   8     your answer, which was obviously general to the concept
   9     of audit across the hospital with the particular
  10     situation, if we go back to the document, which plainly
  11     pertained in cardiothoracic services.
  12   A. Yes.
  13   Q. Is it the case that there was available, so far as you
  14     knew, to the cardiothoracic surgeons, a source of
  15     information which was not available generally to others?
  16   A. Yes. I think we are getting into difficulty, I am
  17     getting into difficulty because we are using terms
  18     rather loosely here. Audit is the establishment of an
  19     agreed standard and the audit against that, and that, in
  20     1992, did not exist. There were ways in which efforts
  21     were being made to establish what those standards should
  22     be. What I said was that audit of mortality or anything
  23     else against agreed standards was still a long long way
  24     away.
  25        If you think I said that clinicians were not

   1     auditing their cases, then I misled you; they were
   2     auditing their cases. But that is in a general concept
   3     of audit. In the specific context of audit in which we
   4     were discussing this, audit is complete when, after
   5     considerable time, which it takes, an agreed standard
   6     emerges, is accepted, and against that standard, future
   7     results are compared.
   8        Does that help with our misunderstanding?
   9   Q. Only partly, because what I think you were telling me
  10     yesterday, and those who want to look at the transcript
  11     may do so, was you were drawing a comparison, if you
  12     remember, between the sort of audit topic that would be
  13     looked at such as, and we used as an example, the use of
  14     a Rashkind device for sorting out or creating an
  15     occlusion of a patent ductus. You say it is little
  16     topics like that rather than generalised mortality which
  17     would be looked at.
  18        The point I am putting to you for your comment is
  19     that it would appear that although plainly something
  20     such as the Rashkind device was looked at, it could also
  21     appear from this document to be the case that, in 1992,
  22     the cardiac surgeons or cardiologists were at least able
  23     to look at generalised mortality data?
  24   A. I have never said they were not able to look at general
  25     mortality data. I did say they had not reached the

   1     stage where that was audited, because audit has
   2     a specific meaning. I expected all clinicians to know
   3     whether their patients died or not. There is nothing
   4     new about that. But this, for any purposes, is
   5     comparison to previous. It might say the results are
   6     getting better, it might say the results are getting
   7     worse, but it will not say in this sort of audit whether
   8     they are acceptable, unacceptable, whether they are very
   9     good, very poor. It does not mean anything. So in
  10     terms of audit in that sense, it does not exist.
  11        These are the early stages to moving towards what
  12     I hope ultimately will be achieved and that is
  13     a continuous routine audit of matters like mortality
  14     against agreed standards so that -- it is a very
  15     complicated circumstance to make sure they are valid
  16     comparisons, so that it can be established whether the
  17     service is as it should be and whether it is improving
  18     or not.
  19        This is not audit, this is simply a review of what
  20     has been happening in the recent past.
  21        Do I make myself clear?
  22   Q. May we scroll down a little and see the findings and
  23     observations which are made.
  24        We see the approach, "findings and observations,
  25     inferences and hypotheses, action taken, clinical

   1     changes instituted."
   2        You are right in saying that there is no standard
   3     against which the results are measured, which is the
   4     point you are making?
   5   A. Therefore it is not audit.
   6   Q. But the process is one described as "audit" at this
   7     time, in 1992?
   8   A. No, it is a process that is being undertaken in the
   9     emerging process which one day will be audit.
  10   Q. No, forgive me. The top of the page. Whatever it may
  11     yet become and whatever it may have been hoped that it
  12     would become, it was called "audit" at the time?
  13   A. I am trying repeatedly to explain that I do not mind
  14     what it was called at the time; what it was not, was
  15     audit. It was not audit. The fact that it is on a form
  16     which says "audit" which hopes at some time in the
  17     distant future will be audit, does not make it audit.
  18   Q. Let me ask you this about it, then: the information of
  19     this sort, looking at the generalised mortality data,
  20     would, obviously, have a very useful part to play if one
  21     could set standards against which one could measure
  22     performance?
  23   A. No, because the numbers are far too small and what was
  24     contemporaneously going on is these very small numbers,
  25     when you broke them down, were being summated with the

   1     numbers right across the country and there was
   2     a national audit.
   3        One of the problems when audit was introduced is
   4     that in many Trusts there were insufficient cases being
   5     done to allow audit to have any meaning, and, to solve
   6     that, there were developing processes whereby these
   7     small number specialties -- and it is not easy to define
   8     what I mean by "small number" because it depends on the
   9     outcome proportions -- were being summated across the
  10     South West to provide useful information. But for
  11     paediatric cardiac surgery where individual cases each
  12     year were so small they were being summated annually and
  13     the audit was hoping, they were hoping, I expect, to
  14     produce a national figure against which the national
  15     outcome could be compared.
  16        It requires a sufficient number of cases to make
  17     their comparison useful.
  18        If you have a mortality rate of 1 in 10, it does
  19     not mean that 9 patients survive and the tenth one died,
  20     it means that here and there will be clusters of
  21     deaths. If in those 10 cases they are spreading one
  22     year between three units. It could be in one unit two
  23     patients died and in the other unit no patients died.
  24     That in itself is not a valuable audit, in itself,
  25     because you cannot then project back to the two small

   1     figures from the total.
   2        At that time audit required the determination and
   3     acceptance of standards. I look upon this as simply
   4     a review of recent outcomes; it is not audit. It might
   5     be on a piece of paper with "audit" written on it, but
   6     it is not audit.
   7   Q. So you are saying that there could not be any
   8     satisfactory audit of figures such as these?
   9   A. Other than by what they were doing, which was a national
  10     summation, no.
  11   Q. So, if that is the case, what were these eight
  12     professionals wasting their time doing?
  13   A. They were reviewing the recent outcome of their cases.
  14     Because they were doing that, I find that entirely
  15     healthy and I hope doctors always do that, but to
  16     glorify that with the term "audit" would be quite
  17     misleading.
  18   Q. With respect, what they say they are looking at is
  19     paediatric cardiac mortality for 1991, which, on the
  20     basis you and I have been discussing, could not have
  21     told them anything, because the numbers were too small?
  22   A. Not in terms of audit, no. It is not an audit. I keep
  23     trying to say that, but they need to know what is going
  24     on. You do not have to audit to have useful information
  25     about the outcome and the results of recent patients,

   1     otherwise nobody doing two cases a year would ever
   2     bother to find out whether they survived or died, would
   3     they?
   4   Q. So what use do you expect this group to make of
   5     statistics such as those referred to in this document?
   6   A. Could you move it up, and I will have a look and see
   7     what is there. (Pause). Well, the first one, they are
   8     saying they are increasing the number of infant open
   9     heart surgery, which I think they ought to know and
  10     ought to count up from time to time. They say, if I can
  11     read it right, that it is 33 per cent of the overall
  12     workload which is done on infants and the UK average is
  13     31 per cent. That does not mean the UK standard; that
  14     means to get some idea whether their proportion of cases
  15     is the same as the national one. For the last three
  16     years, mortality, 3 out of 37 is 9 per cent. I have
  17     always talked in the use of statistics, and I believe
  18     I am entirely justified, if the numerical size of the
  19     statistical figure is greater than the actual number,
  20     then you should interpret that with great caution.
  21        4 out of 20 is 20 per cent, I mean, these are
  22     facts, but I do not know that you can draw any
  23     conclusion from them. I certainly could not.
  24        "Good results from many conditions in infancy so
  25     should aim to increase the infant and neonatal

   1     workload."
   2        That is a conscious decision that we have heard
   3     about elsewhere, that they want to improve it. So that
   4     is useful. That is not audit, that is a wish.
   5        "High mortality in total anonymous family venous
   6     drainage group needs further detailed review." That is
   7     audit, you see.
   8   Q. That I think relates back to poor results in TAPVD of
   9     54 per cent and truncus at 66 per cent?
  10   A. I am sorry, I went past that. They are saying -- those
  11     figures look funny, we ought to go and look and see what
  12     has been happening. What they appear to be doing here,
  13     I do not think is in any way a waste of time. To
  14     discuss it under the heading of "audit" is misleading.
  15     This is the sort of thing that has being going on for
  16     years in the Health Service. What the Health Service
  17     did, and I welcomed it, was to say, "Instead of these
  18     ad hoc chats amongst ourselves about what has been going
  19     on, let us put it on a formal audit basis". That is not
  20     a formal audit basis. They would have been doing that
  21     if they had been operating in 1980.
  22   Q. Leave aside the name. If I were to understand the
  23     process which is demonstrated by this particular
  24     document, the process is one of comparison of local
  25     performance with national average data?

   1   A. Yes.
   2   Q. The result is to look more closely at those areas where,
   3     on the face of it, it appears that local performance
   4     falls below that indicated by national average data?
   5   A. That might be so, it does not say so.
   6   Q. "Too high mortality in TAPVD group", that must relate to
   7     mortality in the national data?
   8   A. I think if you are treating people and half of them are
   9     dying, it is a high mortality rate. It may be that
  10     there is a high mortality rate elsewhere, but it is
  11     still something that I would expect interest to be paid
  12     to. So I do not know.
  13   Q. Accepting the point perhaps --
  14   A. Well, it does not say it is comparison with anything.
  15   Q. The figures would appear to lead to further Inquiry,
  16     further investigation?
  17   A. Yes.
  18   Q. So the process is one, is it, of using figures which may
  19     lack as much meaning as they might subsequently be
  20     given, but are nonetheless used to found further
  21     investigations?
  22   A. It must be. That has been going on since they first
  23     started cardiac surgery in anybody, and all the recent
  24     specialties, and there are a number of them, are
  25     characterised by a concern to count up their results.

   1     That has been going on for a long time. I have been
   2     talking about a major new initiative which is quite
   3     different, and that is the introduction of audit.
   4     I think it is important not to confuse the two. That is
   5     of considerable academic and practical value to the
   6     surgeons themselves, the group there, they are not just
   7     surgeons, they are cardiologists, they are
   8     anaesthetists, which has minimal, if any, value to
   9     anybody else.
  10   Q. Can I take you away from that and thank you for your
  11     answers on that, and turn to a different topic.
  12        You had, for a while, as a Medical Director,
  13     Mr Wisheart?
  14   A. Yes.
  15   Q. And he had two sessions per week to do the job of
  16     Medical Director?
  17   A. Yes.
  18   Q. We know from what Mr Ross has told us that the current
  19     Medical Director has more time and more support to do
  20     his role. Are we properly to understand from that that
  21     there was insufficient time for that role allotted to
  22     Mr Wisheart?
  23   A. No. Could I say, Hugh Ross met me before he took up
  24     this appointment and asked me what the outlook for the
  25     Trust was, what the problems were, and so forth. One

   1     piece of advice I gave him was because of his background
   2     he would be very wise strongly to reinforce the medical
   3     advisory machinery and he would be well advised,
   4     I suggested, to strengthen the planning support he had,
   5     and, over-simplifying the reasons why I gave him that
   6     advice, was that for (1) he was not a doctor and for
   7     (2) he did not have my experience of the history, the
   8     background, the current arrangements and the very real
   9     issues that existed in Avon.
  10        That was my advice to him and I am glad he took
  11     it.
  12   Q. In terms of the hours available for Mr Wisheart to do
  13     the job of Medical Director, there came a time, did
  14     there, when combining those hours with his work as Chair
  15     of the Hospital Medical Committee and his job as
  16     a clinician, it was simply too much for him?
  17   A. That was both our judgments, yes, and I can explain
  18     that if you would like me to.
  19   Q. That, obviously, must have been a situation which
  20     developed before you and he both appreciated that that
  21     was the case. Did it develop over time, or was it
  22     always the case?
  23   A. I do not think there was a lag before we noticed. No,
  24     I do not think there was. I think we discussed the
  25     matter and dealt with it appropriately. There was

   1     another issue, apart from the level of workload, and
   2     that was that I was going to retire within the period of
   3     office of the new Chairman of the Medical Committee.
   4        I think it would be easier for us both if I said
   5     that when we were a District, we had a Chairman of the
   6     Medical Committee which headed the professional advisory
   7     machinery and who was available to the Health Authority
   8     to give professional advice, the summated professional
   9     advice of the medical profession.
  10        At that time, or before I took up, there was
  11     a district management team and the Chairman of the
  12     Medical Committee was always the consultant member of
  13     the district management team. That is a role
  14     I fulfilled when I was Chairman of the Medical Committee
  15     and I was on the DMT, it was a role everybody did. Not
  16     every district did that, but that is what we did in
  17     Bristol because we all felt that there was no point in
  18     us having a professional advisory machinery and somebody
  19     else advising the DMT. There were different opinions
  20     about this about the country and some of that based on
  21     personality, but in Bristol the Chairman of the Medical
  22     Committee was always a member of the DMT.
  23        When we became a Trust, a lot of authority work
  24     stayed with the Health Authority. That was the
  25     determination of workload and the allocation of

   1     resources and so on, and we were left with the
   2     implementation of contracts. The role of the Chairman
   3     of the Medical Committee remained identical, but instead
   4     of sitting on the DMT he sat on the Trust Board.
   5        So nothing from the medical point of view had
   6     changed. The name had changed, but the role had not?
   7        As time went on, a number of issues arose, and
   8     I remember two that took time. One was the junior
   9     doctors' hours issue and the other was the introduction
  10     of the Calman report changing junior doctor training
  11     things, which does take time. As I say, in addition to
  12     that, I was going to leave and I thought I ought to
  13     prejudge the situation so far as possible and invite, as
  14     always, the new Chairman of the Medical Committee on the
  15     Trust Board, but retain James so we doubled the
  16     contribution. And I left the two of them to sort out,
  17     if they could, just by mutual agreement, the difference
  18     between professional, advisory and, in a sense,
  19     executive work, and there was some heart-searching as to
  20     whether appointing new consultants was professional,
  21     advisory or medical executive. But we decided,
  22     I encouraged and I made these recommendations to the
  23     Trust Board, and you will not be surprised that they
  24     accepted my recommendations.
  25        When I retired and I was replaced with somebody

   1     with an administrative background, what seems to have
   2     happened is he has fulfilled the Director of Operations
   3     function previously provided by Margaret Maisey and he
   4     has replaced the medical activity previously provided by
   5     me with other doctors. I do not find that at all
   6     surprising, because of the knowledge, experience and
   7     background of the two Chief Executives. If he had been
   8     a new Chief Executive with a personal background, he may
   9     well have replaced the Personnel Director on the Trust
  10     Board with a planning Director or something else, which
  11     better matched the needs and advice at Trust Board
  12     level. If you study the make-up of Trusts, you will
  13     find that the fourth Executive Director has a variety of
  14     backgrounds; the others are required, a Chief Executive,
  15     a Treasurer, a Medical Director, a Director of Nursing,
  16     that is what is the Trust Board, but there is another
  17     Executive Director and in Bristol that person was the
  18     Personnel Director, for me.
  19   Q. Just exploring that a little further, so far as
  20     Mr Wisheart was concerned, when he combined the role of
  21     Chairman of the Hospital Management Committee and his
  22     role as Medical Director, ultimately you told us he
  23     could not cope with the workload?
  24   A. No, I did not. If I used those words, then I think that
  25     was naughty of me.

   1   Q. No, it is my reflection of what you said, and plainly it
   2     is wrong, from your response?
   3   A. He did cope with the workloads and it would be quite
   4     wrong for me to say he could not, but for a whole
   5     variety of reasons, not one, I encouraged the Trust and
   6     got their approval to retain the services of James
   7     Wisheart as Medical Director and to add to that, the
   8     services of the new Chairman of the Medical Committee.
   9   Q. Was there an appreciation that asking him to do both
  10     jobs was too much for him, before he surrendered the
  11     Chairmanship of the Hospital Medical Committee?
  12   A. No, "too much" suggests he could not do it and that was
  13     not true; more than it was reasonable for us to ask
  14     somebody, perhaps, yes, certainly towards the end.
  15     Perhaps yes, but --
  16   Q. Dealing with it on that basis, did he, a matter of
  17     months after that, become for a time Chairman of the
  18     Clinical Audit Committee?
  19   A. Yes, he did. Yes, he did, because, as I implied this
  20     morning, the Chairman resigned precipitately and it took
  21     a little while for there to be agreement to find
  22     somebody who was both suitable and willing.
  23   Q. Was it not equally unfair to ask him to do that task as
  24     well as the task of Medical Director in terms of time
  25     and the time that he might be able to commit to the job?

   1   A. No. The task of chairing the Audit Committee was not
   2     onerous, at that time. I was hoping it would become
   3     onerous, but at that time it was not. Anyway, it was
   4     only a temporary standing and for obvious reasons it
   5     would have been inappropriate for me to do it for the
   6     time being. But no, I have to reassure you that the
   7     concept that James Wisheart was overstretched and could
   8     not do the job would be unfair, both to him and to me.
   9   Q. Why would it be unfair to you?
  10   A. Because you are implying I tolerated a situation of
  11     overburdening somebody to the extent they could not do
  12     the job.
  13   Q. And that was not something you were doing?
  14   A. Of course not.
  15   Q. The role of Medical Director: did the Medical Director
  16     have any specific authority as such?
  17   A. Not that I can think of. I mean, he was on the Trust
  18     Board but I do not know. I mean, as the Medical
  19     Director, there was no authority. In fact, we felt for
  20     some time that in the early days, anyway, it was
  21     effectively more akin to a non-executive role in that he
  22     was giving professional advice. He was not managing
  23     anything.
  24   Q. I was going to ask: if one wanted to reflect his role,
  25     one would perhaps better replace the word "Director"

   1     with the word "adviser", would one, to get an
   2     appreciation of what he was doing?
   3   A. I do not know whether that is right. He was a Director
   4     because he was a Director on the Trust Board. To call
   5     him anything else would have confused everybody. He was
   6     a full member on the Trust Board and if he ever voted,
   7     he would have voted. I cannot remember him ever voting,
   8     but that is what happened. What he was doing was
   9     a continuation of the role previously met by the
  10     Chairman of the Medical Committee, so -- I am sorry,
  11     I am trying to think of all the things he did. He
  12     oversaw the appointments process for replacement of new
  13     consultants. But that had previously been done in the
  14     professional advisory structure. I am not sure he had
  15     any additional power because the government chose to
  16     call him a Medical Director. No.
  17   Q. If one were to tease out, then, the extent to which
  18     managerial concerns were his business, he had no
  19     managerial role, you tell us --
  20   A. No, he was not in line management. If you drew the line
  21     management out, you would not find his name anywhere.
  22   Q. The advice, however, that you would be giving the Board
  23     would be upon matters which would include matters of
  24     management, would they?
  25   A. He would present the distilled and summated views of the

   1     medical staff, and medical staff may have an opinion
   2     about anything, so there was no constraint about what
   3     they had an opinion about. If they did not like the
   4     parking arrangements, the medical staff would say so.
   5     There was no constraint on it, but there was -- he
   6     presented what the medical staff's advice was to the
   7     Trust Board.
   8   Q. Was he elected or appointed?
   9   A. He was elected by the medical staff as a Chairman of the
  10     Medical Committee, and he was appointed by the Board to
  11     Medical Director because he was Chairman of the Medical
  12     Committee, I have to say. It was not a coincidence; the
  13     Board wanted the Chairman of the Medical Committee as
  14     their Medical Director; unlike the other executive
  15     directors, he did not get paid as a Medical Director
  16     because he was a consultant. He was paid the national
  17     two-session allowance which we have been talking about,
  18     the two sessions, but he was not paid as a Medical
  19     Director, which is why I keep saying he was very much
  20     like a non-Executive Director.
  21   Q. Did you have any role in advising at Board level, or you
  22     as Chief Executive, about the quality or success of his
  23     own work?
  24   A. If you mean, did he report the outcome of his work, no.
  25     Did he report the outcome of anybody else's work, no.

   1     Did we have, what was it called, clinical governance,
   2     no.
   3   Q. Did he have any role to play in discipline other than
   4     as a member of the three wise men?
   5   A. Well, if we wanted to, we could have used him as an
   6     Executive Director to sit on such Board level
   7     disciplinary panels as we wanted to, so he had --
   8     I mean, he was entitled to do it and I was entitled to
   9     ask him. I am thinking back. I cannot remember ever
  10     asking him.
  11   Q. I was going to say, the expression "could have done"
  12     suggests that you did not?
  13   A. No. I cannot remember the situation arising, but,
  14     please, we had all sorts of meetings and I may be wrong;
  15     there may have been occasions when it was appropriate to
  16     appoint him to something as Medical Director, something
  17     of that nature, but I cannot remember it.
  18   Q. He obviously, as Chairman of the Hospital Medical
  19     Committee, would be one of the three wise men for the
  20     time, presumably, that he maintained that appointment,
  21     and then he would remain one of the three wise men,
  22     would he, as the immediate past Chairman?
  23   A. He would start being one of the three wise men the day
  24     he was elected, the day he took up the post as Chairman
  25     elect, which was two years before he took up post as

   1     Chairman, so he would be one of the three wise men for
   2     six consecutive years.
   3   Q. For a time, we can see, he was Associate Clinical
   4     Director of the Directorate of Surgery?
   5   A. Cardiac surgery, yes.
   6   Q. I think at the same time as he was Chairman of the
   7     Hospital Management Committee -- the Hospital Medical
   8     Committee, and Medical Director.
   9   A. I do not think he was when he was Medical Director, no.
  10     I am not sure he was when he was Chairman of the Medical
  11     Committee. I should think that is unlikely.
  12   Q. He would have been Associate Director when there were
  13     directorates, would he not?
  14   A. Yes, starting to be.
  15   Q. Directorates began in 1989/90, did they not?
  16   A. That is right.
  17   Q. And he was Chairman of the HMC?
  18   A. 1992, was it? Trusts started in 1991. Christopher Dean
  19     Hart, Medical Director of the first year of the Trust,
  20     so it would have been April 1992, he became Medical
  21     Director.
  22   Q. So far as Mr Dean Hart was concerned, had he been
  23     Chairman of the HMC?
  24   A. Yes. That is why he was the first Medical Director.
  25   Q. And it was therefore because of the election to Chairman

   1     of the HMC that Mr Wisheart secured the recommendation
   2     of the Board and the appointment by the Board as the
   3     post of Medical Director?
   4   A. I do not know that I can technically say it was
   5     ex officio, but in practical terms it was ex officio.
   6     They wanted the Chairman of the Medical Committee as
   7     their Medical Director. So did I.  I do not want to
   8     say 'they', 'we' did.
   9   Q. Turning, it may seem to be to a different topic, but
  10     I may link the two depending on your answer. You tell
  11     us in your statement that you encouraged General
  12     Managers of directorates to adopt a leadership role.
  13        What did you envisage, briefly please, as
  14     a leadership role?
  15   A. I think the easiest way is to quote Rosemary Stewart,
  16     and say "Leaders have followers, managers have
  17     subordinates, and administrators confirm in writing".
  18     That is her quotation. I remember it because I happen
  19     to agree with it. Anybody who can understand my
  20     peculiar ideas I agree with and I remember.
  21        I did not want to introduce or allow to continue
  22     in the Health Service a failure of what I would describe
  23     as the failure orientated management by objectives with
  24     subordinates, described in some books as "management by
  25     fear" rather than management by objectives. It is very

   1     difficult to ensure that even when you are trying, the
   2     recipient does not think it is management by fear.
   3        So I wanted very much people to follow managers
   4     enthusiastically to want to do it. It was certainly my
   5     style, and I expected everybody else to.
   6        We could have a long seminar about what it means
   7     about leadership and I hope you do not ask me for one.
   8   Q. No, I did ask you to be brief.
   9   A. Can I ask you whether that is sufficient?
  10   Q. It is, thank you. You mention in the course of that
  11     answer that it was no part of your style, indeed, it was
  12     the antithesis of the style you encourage that there
  13     should be management by fear?
  14   A. Yes.
  15   Q. You will have read the witness statements which, in the
  16     Inquiry, tell us that there was, in the perception of
  17     the authors, a feeling that there was a culture of fear
  18     or "blame and shame" which related at least to
  19     relationships between the, if one calls them the "middle
  20     managers" and those in the executive Board of Directors.
  21        Do I take it that you reject that accusation?
  22   A. Yes. I did say that it is very difficult to ensure that
  23     everybody recognises that they are secure and that there
  24     is not management by fear and, please, I am not sure
  25     that I can necessarily say it in two words, but there is

   1     a great deal of management recognition that the more,
   2     what shall I say, promotion people get, the bigger the
   3     salary they get, the more they tend to introduce a sense
   4     of fear that they may lose those things which are dear
   5     to them.
   6        If I tell you that in UBHT I insisted on a "no
   7     redundancy" policy, so that nobody was going to be made
   8     redundant. I could not stop people electing to use
   9     their redundancy rights, so to speak, and say "I want to
  10     be made redundant", that was part of the national terms
  11     and conditions, but there was no compulsory redundancy
  12     in Bristol.
  13        There were some people who have what is called
  14     a role model personal culture, not pure, but predominant
  15     and they get their satisfaction from the position they
  16     hold, the authority that is formally delegated to them,
  17     and they get pleasure from the accoutrements of their
  18     position. We have things about the size of office,
  19     carpets and so on. It is all rather amusingly but very
  20     effectively reported in this book (Indicating).
  21   Q. This book is what, for the record?
  22   A. This is Charles Handy, "Gods of Management". It is not
  23     heavy going. It shows a remarkable insight into the
  24     problems of management, particularly of large
  25     organisations.

   1        If you have somebody of a role model culture, they
   2     want issues like job descriptions; they want delegated
   3     specified power; they want policies; they want
   4     procedures and they want the status quo. If you use
   5     these people in a culture which is different, which is
   6     a task-orientated culture, for example, they become very
   7     insecure. We had to try our best to help people to move
   8     to a task orientated culture and not into a stultifying
   9     process because I think what may be obvious to everybody
  10     is the one thing UBHT could not be is remaining the same
  11     year on year.
  12   Q. Dr Roylance, I want to ask you for the publisher of the
  13     book to which you referred, not for my own immediate
  14     purposes, I am sorry to say, but so that we properly
  15     inform those who will follow this on the Internet.
  16   A. It is Arrow Business Books.
  17   MR LANGSTAFF: I am grateful. That having been heard, may
  18     we now, sir, take our next break?
  19   THE CHAIRMAN: For 15 minutes, then, until half past 2,
  20     thank you.
  21   (2.20 pm)
  22               (A short break)
  23   (2.32 pm)
  24   MR LANGSTAFF: Dr Roylance, may we have page 20 of your
  25     statement up to screen? In the middle paragraph you

   1     visit a topic which we have had some discussion about,
   2     that of discipline of clinicians. You say that you had
   3     every confidence that any areas of incompetence or
   4     unsatisfactory results would be identified and dealt
   5     with not only by the audit process, but by ... and you
   6     go on.
   7   A. Yes.
   8   Q. So you saw it, did you -- just give me a "Yes" or
   9     a "No", that the audit process had a role to play in
  10     identifying areas of incompetence or unsatisfactory
  11     results?
  12   A. The trouble is, I cannot answer "Yes" or "No". It was
  13     going on, but the review which was going on in the early
  14     stages of the introduction of audit, the review which
  15     I call it, yes, I would expect that to happen. I am
  16     trying, and perhaps I am being too semantic, because
  17     I was so keen on the introduction of this new system
  18     which was totally new, but which carried a word as
  19     a name which had been bandied about for other things in
  20     the past. I have been trying mentally ever since to
  21     restructure that word and say it means one thing only.
  22        If we say clinical reviews that went on, and were
  23     being developed during introduction of the development
  24     and audit process, then there is no doubt that is what
  25     I am talking about.

   1   Q. It is your word. I took you to it but I follow what
   2     you are saying. You go on to say:
   3        "The constant consideration and evaluation of
   4     clinical work as in any teaching hospital ..."
   5        And you also considered that the Royal Colleges
   6     had an overall responsibility for the maintenance of
   7     standards if concerns were made known to them and
   8     a solution could not be found, they would notify you?
   9   A. Yes.
  10   Q. What that in total suggests, I think, is that discipline
  11     was essentially, was it, a matter for the Trust rather
  12     than for the Royal Colleges?
  13   A. Yes. The Royal College had a number of sanctions and
  14     I do not know whether you would like to use that as
  15     under the heading of "discipline" but the Royal College
  16     could interfere with what was going on, to quite major
  17     effect. But discipline in terms of what I understand is
  18     a Trust or District disciplinary procedure, that had
  19     nothing to do with Colleges.
  20   Q. So, so far as Bristol was concerned, did they ever
  21     threaten in any specialty to withdraw teaching status?
  22   A. Yes.
  23   Q. Did you, in consequence of that, take what you describe
  24     as "appropriate management action" in this paragraph?
  25   A. What usually happened is, if they were displeased with

   1     something, they would threaten that if it was not right
   2     by the time of their next visit, they would cease to
   3     recognise the junior staff post as a training post,
   4     something like that, and normally the people to whom
   5     they were speaking would deal with it, because this was
   6     a professional matter. It is not surprising that
   7     sometimes they would join together and say "If the Trust
   8     does not produce a very expensive library facility or
   9     better canteen for the staff we are going to
  10     deregulate", then would wave it at me and I would have
  11     to make a judgment of how we could properly meet the
  12     requirements of the College.
  13   Q. So whether it came to you or not depended on whether it
  14     was classified as professional or management?
  15   A. Yes. Sometimes I used to hear about it anyway, but what
  16     I am saying is that sometimes it was professional issues
  17     that were important, and not managerial ones.
  18   Q. With what sort of frequency do you recollect was it that
  19     the Royal Colleges identified concerns where appropriate
  20     management action might be required, generally?
  21   A. I can remember one instance; I am trying to think of
  22     another. It was rare.
  23   Q. So far as the process by which the Royal College would
  24     get in touch with you, was there anything which was
  25     formalised about that?

   1   A. They would all send a team and I think invariably --
   2     I have to be careful because if they did not do it and
   3     I did not know about it, I would not know -- I think
   4     invariably within their plan programme I would join them
   5     for tea, or something like that, towards the end of
   6     their visit and discuss with them and have directly from
   7     them matters of joint interest. But that was not
   8     a formal reporting to me, of course, they would be
   9     reporting to the professional staff who were training
  10     their doctors.
  11   Q. I dealt with the way in which discipline or changes
  12     might originate in the management of the Trust. You
  13     deal in the proceeding paragraph, at the top of the
  14     page, with the possibility of retraining, helping
  15     a clinician with a particular problem that he or she
  16     might have.
  17   A. Yes.
  18   Q. And can I again ask similar questions? Was this
  19     a frequent or rare occurrence, or somewhere in-between?
  20   A. It was quite rare in that sense, but being a teaching
  21     environment, if somebody's competence fell, I used to
  22     take the view, if we trained them once, we could train
  23     them again. I only remember one occasion when that
  24     failed, but it did not happen very often. We were not
  25     a hotbed of retraining.

   1   Q. Was it done in Bristol, or was it done at some other
   2     centre?
   3   A. It would depend entirely on what it was about. I must
   4     say, my memory is more of other people from other
   5     centres coming to Bristol than I can remember other
   6     people going away. This is a sliding scale, very much
   7     a sliding scale, but what I tried to emphasise there is
   8     that by having a visible constructive response to
   9     issues, it increased the likelihood of problems being
  10     brought to our attention.
  11   Q. Was the process one of your suggesting to someone that
  12     retraining was the appropriate course, or was it
  13     a question of them saying, "Well, I would like some
  14     retraining", or was it a mixture of the two?
  15   A. Oh, it was a mixture of the two. If people said "I wish
  16     to become competent in this and that", and they felt
  17     I had to give support to it, I suppose they would come
  18     and see me, but I suppose it was standard practice in
  19     a teaching hospital for people to go off for short or
  20     even extended periods to another centre to see the
  21     skills that that centre exhibited.
  22   Q. Would that come within the budget?
  23   A. It would be a matter of study leave, normally.
  24   Q. How would you, changing the topic, describe the degree
  25     to which you would appear to others to be a forceful

   1     character?
   2   A. I think I was made aware by people very close to me that
   3     I often appeared very fierce and very demanding,
   4     particularly when I was in fact relaxed. I learned to
   5     use that at times when it was necessary because there
   6     were times when, if somebody, for their own good, needs
   7     to recognise authority, it is much easier to do it by
   8     personality than sanction.
   9        I think everybody that knew me recognised that
  10     I was neither fierce nor any other of those adjectives
  11     you might use.
  12   Q. To what extent would you say you were a man who was firm
  13     in his own opinions?
  14   A. Not at all. Not at all. If there was an issue we would
  15     discuss it vigorously. I would often adopt
  16     a provocative, argumentative way in order to get people
  17     to put the facts as they saw them on the table. We
  18     would eventually reach an agreement and then I expected
  19     everybody, including me, to pursue that agreed path with
  20     all vigour. Perhaps I should not say it in public, but
  21     there do arise times when a wrong answer is much better
  22     than no answer and a wrong decision is much better than
  23     no decision. I believe that sometimes there is no right
  24     decision, it is just which decision is least harmful.
  25        What I would expect is that once we had agreed it,

   1     there would be no breaking of ranks, because that would
   2     make the people who were joining us in implementing it
   3     very insecure. There are times when they need clear
   4     leadership.
   5   Q. There are references, as you will have picked up from
   6     the transcript in what Marie Thorne had to say, to
   7     loyalty. She says in part, loyalty to the Chief
   8     Executive as being something which was of value within
   9     the Trust.
  10        To the extent that that was loyalty to decisions
  11     which had been made and to which you were party, do
  12     I take it that from your last answer you say, yes,
  13     a value was placed on that?
  14   A. Yes. I mean, you cannot demand loyalty; you have to
  15     earn it. My view is, you earn it by Trust.
  16   Q. At your statement, page 3, you have just dealt, on the
  17     previous page, with the funding of paediatric cardiac
  18     surgery. Then you go on to say this, at the end of the
  19     second line:
  20        "Indeed, throughout my time first as District
  21     General Manager and then as Chief Executive, I was
  22     constantly seeking to persuade all clinicians that
  23     issues of funding of services mattered."
  24   A. Yes.
  25   Q. You had been a clinician; you were now a manager?

   1   A. Yes.
   2   Q. Did you find it easy to persuade clinicians that funding
   3     mattered?
   4   A. No.
   5   Q. Did you find it on occasion frustrating?
   6   A. No. I had every sympathy with the views of people who
   7     believed that the Health Service provided everything
   8     that was necessary to everybody who could benefit
   9     without considerations of their ability to pay. I knew
  10     where that philosophy came from and when I suggested we
  11     should stay within budget, I had all sorts of views
  12     expressed. One challenged me for not using overspending
  13     as a management tool. It was not unusual for people to
  14     say I ought to stop the Trident programme and give them
  15     money and stop arguing. I understood their frustration,
  16     I understood their position, and I never met a clinician
  17     who did not think that his specialty was more important
  18     than any other.
  19   Q. By saying that the funding of services mattered, what
  20     are you saying? Are you saying that the funding is
  21     something which is critical, vital, must not exceed
  22     budget, to the extent that the services play second
  23     fiddle to the funding?
  24   A. I think you are offering me an argument that, if we had
  25     time, I would be able to defeat.

   1   Q. It is a deliberately provocative question, it is not
   2     an argument.
   3   A. I have heard it so many times as an argument.
   4   Q. I thought you might have done.
   5   A. Can I put it this way simply. I used to say to
   6     a clinician, if they were on the plains of some emerging
   7     nation just after a meteorological disaster and they had
   8     a box of penicillin and they knew there was no chance of
   9     any more penicillin coming through, who did they think
  10     should make the decision who got the penicillin, whether
  11     they should get a half dose or a full dose, and the
  12     answer is "A doctor of course". When you put them in
  13     the Health Service they demand there should be no bottom
  14     in the box and they should keep producing penicillin,
  15     and any suggestion that it should be financial they
  16     found offensive. If the limit was structural, they
  17     could look at that. We have had this argument round and
  18     round in all sorts of ways, but clinical freedom became
  19     a responsibility to patients, for each individual
  20     patient to do the very best in that patient's interests
  21     and what got dropped off at the end was "within the
  22     resources available."
  23   Q. Am I right in thinking the penicillin in a box is an
  24     example you have used on many occasions before in
  25     seeking to persuade clinicians, or seeking to persuade

   1     clinicians, of the importance of funding?
   2   A. Yes, I was trying to illustrate the sort of debates we
   3     used to have.
   4   Q. What effect, if any, do you think your seeking to
   5     persuade the clinicians that funding mattered had upon
   6     the service offered?
   7   A. They were often a less service than they would wish to
   8     provide. That is why, yesterday I think it was, I was
   9     quite passionate about the maintenance of the separation
  10     of purchaser from provider, so that an independent view
  11     was taken as to what care was needed in the community,
  12     what would be funded, and to try and persuade those in
  13     the provider unit to concentrate on trying to get that
  14     contract bigger, and trying to do the best possible they
  15     could within it.
  16   Q. With the constant persuasion from you that the funding
  17     mattered, was there any effect, do you think, upon the
  18     perception that the clinicians had of what was expected
  19     of them by you and by the Trust or by the Health
  20     Authority before that?
  21   A. I do not know about that. I think over a period of time
  22     they joined me in the real world.
  23   Q. So in short, what ultimately was your objective in
  24     stressing the financial?
  25   A. I think it was Margaret Maisey who used to keep saying,

   1     "It is our job to do the best we can with what we have"
   2     and I am not sure I can better that.
   3   Q. In the course of the evidence which we have had and
   4     received, we have been told in a statement by Rachel
   5     Ferris -- we need not get it up on the screen unless you
   6     want to have a look at it -- that she felt that having
   7     been appointed as a General Manager, she was given
   8     little guidance by you as to what was expected of her,
   9     and couples this with the suggestion that there was no
  10     support at all for General Managers.
  11        Has she got it right or not?
  12   A. No. I mean, please, what she is saying is wrong, but
  13     I really do not want to publicly criticise her.
  14   Q. She tells us that she felt she could not look to
  15     Margaret Maisey for support, and allies that, I think,
  16     with her perception of a culture of fear.
  17        Do you wish to comment on that or is your comment
  18     the same as that which you have just given?
  19   A. Well, I am sorry she feels like that now. One could say
  20     that we may have been guilty of promoting her before she
  21     was ready. We did that sometimes, because there were
  22     times when we wanted people to develop rapidly, and
  23     I have to say that there were times when, if you give
  24     somebody a post beyond them, they grow into it. As
  25     I read her paper, I was rather pleased that there was

   1     evidence that she had grown into the job.
   2        If you read her account carefully you will see
   3     that she was counselled and advised by her predecessor
   4     and that her job -- and she had been in the Trust a long
   5     time and had been to management development meetings,
   6     she knew that her job by that time was to support and
   7     make effective her Clinical Director. If she was
   8     somebody who had a culture of wanting everything neat
   9     and tidy with a policy and a protocol all written and
  10     her authority all defined, you can see that appointing
  11     her to a directorate that did not exist, which had to be
  12     developed and so on, may be for a time, quite
  13     unsettling.
  14        She succeeded for a time, she succeeded with the
  15     help of Margaret Maisey and I, but we could not have
  16     helped her by doing her job for her and defining it all;
  17     we would have encouraged her to stride out and solve the
  18     problems. I believe that the accounts suggest that she
  19     eventually did.
  20   Q. She will have to speak for herself, obviously, but the
  21     position appears open, at any rate, that she may have
  22     understood your encouraging her to make decisions for
  23     herself as a lack of support from you or direction from
  24     you.
  25   A. If her fundamental wish was that I should make the

   1     decision and that I should do her job, then I can
   2     understand if she was rather disappointed.
   3   Q. So far as the culture of fear or the difficulty of
   4     confiding in Margaret Maisey is concerned, that, again,
   5     the possibility may be open -- and you may wish to
   6     comment -- that that may be a reflection of the way in
   7     which your personality, as you have described it, may
   8     have been seen by others, even though it was not that
   9     which you knew yourself to be?
  10   A. I think you are going too far there. No, I do not
  11     accept that.
  12   Q. When you became aware that you might be perceived in the
  13     way that you have described some 5 or 6 minutes ago by
  14     others and in the way in which you said you used on
  15     occasions to make your point, did you take steps to
  16     reassure people that that was not the true you?
  17   A. Yes, of course I did. I was very close to the
  18     managers. I will not go into all of it, but, yes, we
  19     were a very close-knit, rather large bunch, and I am
  20     disappointed that she has chosen to say that. I suspect
  21     if I had retired a year later, she would have written
  22     something different.
  23   Q. There are a number of matters which you are entitled to
  24     comment on because they have been said about you by
  25     others. I am going to deal with a number of them to

   1     invite your comment, if you wish to comment.
   2   A. Thank you.
   3   Q. Because you must, of course, have that opportunity.
   4        It is said that it was unusual, in the way in
   5     which you managed matters, that the Director of
   6     Personnel did not have a role which extended to medical
   7     staffing.
   8   A. Can I ask you who said that?
   9   Q. Mr Ross.
  10   A. Well, I forgive him. The Personnel Medical Director was
  11     personally accountable to the Personnel Officer, and was
  12     all the time. We did go through a period a time ago
  13     where the Medical Personnel Officer had a personal
  14     relationship with a member of the Board of Governors,
  15     I mean a proper one and really saw herself as an
  16     independent function.
  17        The other half of it, as is characteristic of all
  18     consultant appointments, the work is done by the
  19     professional advisory machinery, who agree the job
  20     description, agree the necessity of the replacement and
  21     get the College's or whatever is necessary approval, and
  22     work very closely with the Medical Personnel Department
  23     to complete it. But there was no doubt that if anybody
  24     had drawn any management structure, they would have
  25     shown the Medical Personnel Officer for a long time as

   1     a district or Trust level officer accountable to the
   2     Director of Personnel.
   3        With my encouragement, we did try and I think we
   4     succeeded before I left, to delegate medical personnel
   5     issues to directorate level, but we still had
   6     a designated medical personnel expert who was in one of
   7     the directorates who advised the others about medical
   8     personnel issues.
   9   Q. It is said by Mrs Ferris that there was a lack of
  10     clarity on the roles and responsibilities of employees
  11     in cardiac services. So far as roles and
  12     responsibilities of employees in cardiac services are
  13     concerned, who would have responsibility for that?
  14   A. The Clinical Director. No doubt about it. But this,
  15     again, smacks of somebody who wants everything specified
  16     and defined and wants the job defined and the role
  17     defined and stabilised before it actually existed.
  18     Please, I do not want to make a big issue of it, but
  19     what this means is, in Charles Handy terms, we have
  20     a role model culture person put into an Athenian task
  21     orientated post, and it is well recognised by him and by
  22     me that that causes stress. It is not irretrievable,
  23     and it can be surmounted, but I have to say that you
  24     could almost put her account into Charles Handy's book
  25     as an example.

   1   Q. She complains that cardiology was too separate from
   2     cardiac surgery in November 1994. This would be at
   3     a stage after the directorate for cardiac services had
   4     begun. Would that be a fair criticism or not?
   5   A. I do not know whether it is a criticism. The purpose of
   6     creating the Directorate of Cardiac Services was to move
   7     everything together. If it had all been there, there
   8     would have been no point in creating the directorate.
   9     The initial task of the directorate was to resolve the
  10     problem of putting medical beds in or next to or
  11     whatever surgical beds, and of course, for Bristol, at
  12     least, that was new thinking.
  13   Q. She reports the point, the observation, that there were
  14     differential waiting times depending upon the level of
  15     the investment from the purchaser concerned?
  16   A. Yes.
  17   Q. First of all, if that happened, was that something that
  18     you personally would have known about?
  19   A. Yes, I did know about it, and it caused us considerable
  20     anxiety, because one of the problems is that you are
  21     a regional service, and you get different levels of
  22     contract from the different parts of your region, and
  23     the clinicians quite properly treat patients on the
  24     basis of urgency. If too many urgent patients arose in
  25     Somerset, then we would overdeliver Somerset's contract

   1     at the expense of, perhaps, Gloucester. I am not sure
   2     I can tell you how to resolve that problem. I do not
   3     think any of us would like to think because of the
   4     contractual arrangements a low priority patient from one
   5     part of the country should take precedence over another
   6     high priority patient from another. But it did present
   7     difficulties.
   8   Q. From what you say, it did happen?
   9   A. Absolutely. It was inevitable, if you think about it,
  10     because there was no possibility --
  11   Q. I think I understand the mechanism. She observes a lack
  12     of management information to analyse and form an
  13     overview of services which were provided.
  14        Is that a fair or unfair observation, would you
  15     say?
  16   A. In terms of what was happening in the hospital it is
  17     totally unfair because by that time we led the whole
  18     region in information technology and in terms of the
  19     workload, the nature of the workload, its relationship
  20     to contracts and all the rest of it.
  21        What I read into that and, please, I may be wrong
  22     because I have not talked to her since, is that she did
  23     not have information about community need, which of
  24     course was the role of the purchaser. It was nothing to
  25     do managerially, directly with the Directorate of

   1     Cardiac Services to have an independent assessment of
   2     the epidemiology, the incidence and what was needed.
   3     They had to have an interest and they had to persuade
   4     the purchaser, but that was the purchaser's role where
   5     the epidemiologists resided.
   6   Q. To be fair to her, she does make the point that there
   7     was what she describes as "inadequate dialogue" between
   8     the directorates and purchasers to find out what they
   9     wanted. If that was so, would that be the directorate's
  10     responsibility?
  11   A. I think that is a value judgment on her part, because in
  12     fact there were intensive discussions between managers
  13     and the cardiac unit with other directorates, and I was
  14     aware of those discussions and of their outcome. I am
  15     not sure I ought to speculate, but we did have a lead
  16     manager system because it was not possible for every
  17     Director, independently, to go to anything up to 200, it
  18     might have been 400, different purchasers. So the big
  19     purchasers, they directly negotiated. The small
  20     purchasers, a lead manager would go and negotiate the
  21     whole cross-section of contracts.
  22   Q. So it was not the position of her as General Manager in
  23     the Directorate of Cardiac Services negotiating directly
  24     with the purchaser, because --
  25   A. No, she would negotiate with the major purchasers in

   1     support -- I mean, really, I think the Clinical Director
   2     used to do it and we used to send, where necessary,
   3     district executive directors in support of them, we
   4     would send a team. But the leader of a contract
   5     negotiation would be the Clinical Director: very
   6     importantly, supported by the General Manager.
   7   Q. She comments on audit, and you may very well have dealt
   8     with these in what we have said earlier in respect of
   9     audit, and tell me if there is anything you would like
  10     to add to what you have already said, but she makes two
  11     comments. One is that audit was surgery led and the
  12     results were not published when purchasers wanted
  13     information about the appropriateness of treatment,
  14     outcomes and mortality rates as part of the contracting
  15     process, and secondly, she says that audits could have
  16     been more widely used to improve patient care and risk
  17     management.
  18   A. I think she was trying --
  19   Q. Have we adequately dealt with those or not?
  20   A. Yes. If I can say, it appears she wanted to run with
  21     audit before it could walk. Clearly her wishes and her
  22     ambitions there, it would be something that I would
  23     entirely support, but I think the timing is wholly
  24     wrong.
  25   Q. She says that there was rigid demarcation between staff

   1     groups, that is, there was no rotation of nurses between
   2     cardiac surgery and cardiology. What do you say about
   3     that?
   4   A. I am not at all surprised about that, because nurses
   5     specialise like doctors specialise and until we put the
   6     two units together, the cardiac nurses were on one side
   7     of the road, which was the main road, and the cardiac
   8     surgery was on the other side of the road, and I would
   9     think one lot of nurses would look upon themselves as
  10     medical nurses and the other would look upon themselves
  11     as surgical nurses.
  12   Q. What responsibility would the Director of Operations,
  13     herself being a nurse, have of that?
  14   A. I am not sure which bit you have. I was observing when
  15     the two services were separate, they were separate.
  16     I am not sure you --
  17   Q. I was talking about the demarcation which it is
  18     suggested was rigid.
  19   A. No, I do not think she created it. It exists, I am
  20     saying. Nurses specialise. Some do not like to, some
  21     like to be competent at everything and are very
  22     confident about it. Some nurses, many nurses, do the
  23     rounds and say, "This is what I am: I am a cardiac
  24     nurse/I am a cardiology nurse/I am a theatre sister",
  25     and some of them feel they wish to specialise in that

   1     and not move round, and I recognise that.
   2        I have to say, I can see no immediate benefit of
   3     persuading somebody who is competent and enthusiastic at
   4     nursing cardiology patients to say "From next week, we
   5     want you to nurse cardiac surgery patients". I do not
   6     understand the merit about it.
   7   Q. Was there a rolling penny, a rolling replacement
   8     programme, for capital equipment in cardiac surgery?
   9   A. Yes. I chaired the meeting which I notice that when my
  10     successor took place, he gave it to Roger Baird to do,
  11     but I chaired the meeting which allocated major medical
  12     equipment annually. That was not something that
  13     I specifically felt the Chief Executives should do, but
  14     when I was on the Medical Steering Committee, it was
  15     called the Executive Committee in those days, I was
  16     asked to do this and I chaired the meeting and when
  17     I ceased to be -- I think when I became Chairman of the
  18     Medical Committee I tried to give it up and everybody
  19     said "No, you are good at it" and I gave it up, and it
  20     was one of those jobs I could never get rid of, and
  21     I finished up as Chief Executive thinking "At long last"
  22     and they all said "You chair it".
  23   Q. So far as resources are concerned, plainly replacement
  24     has a resource implication. Can we look at UBHT
  25     111/236?

   1        Can we scroll down, please? Right down to the
   2     bottom. Remember, I took you to this. It talks about
   3     waiting hours. Can we turn overleaf, please? At the
   4     end there is a recognition of the limited budget?
   5   A. Yes.
   6   Q. And Mr Mott speaking there on behalf of the children and
   7     adolescents whose particular interests he had.
   8        Did you get many letters arguing for further
   9     resources for particular divisions or directorates?
  10   A. I cannot think I got more letters about anything else
  11     other than that. There was a whole pressure from very
  12     articulate, very informed consultants, all of whom
  13     thought their service uniquely was underfunded and
  14     demanded I should top-slice everybody else and give them
  15     money.
  16   Q. So how did you deal with it?
  17   A. Well, the Chairman, the first Chairman of the Health
  18     Authority asked me that, he asked me, "How can you
  19     tolerate it?" and I said, "If there is anybody in the
  20     hospital, in [what was then district], who does not want
  21     to increase the service they are providing, I would
  22     rather they went somewhere else". It was an enthusiasm
  23     that I welcomed, that I recognised, and I really would
  24     have been very disappointed if they did not have it. It
  25     was a matter of some challenge to channel these

   1     enthusiasms in the right direction, and to initiate
   2     ingenious mechanisms for achieving what we could, and
   3     I spent a great deal of my time pursuing the Health
   4     Service for additional sums of money.
   5   Q. You have told us in that, I think, first of all how you
   6     reacted to it, and on an individual basis, how you
   7     attempted to be creative to find resources, but if
   8     resources were not available, did you have a system of
   9     priorities?
  10   A. I did not. The Health Authority did. I helped them,
  11     but I would not like you to think that that is a task
  12     that an individual on their own could do it. Please, it
  13     would take too long to list all the initiatives we had
  14     to address this persisting conflict.
  15   Q. I do not want to take up too much time with this.
  16   A. Well, it took my time.
  17   Q. The answer is that the Trust Board developed priorities
  18     for resolving what one might call a conflict over
  19     finance?
  20   A. Yes. When we were at District, as I have tried to
  21     explain, we had a finite sum of money, which everybody,
  22     including me, agreed was woefully inadequate, and we had
  23     what people have described as an "infinite demand".
  24     I suppose, philosophically, it could not possibly be
  25     infinite but we never got anywhere near the end, so it

   1     was effectively infinite. And this I tried to say is
   2     a fundamental challenge to the health service. You do
   3     not resolve it by pretending it was not there or wishing
   4     it was not there, you have to address it. I believe one
   5     of the major steps which helped in addressing that issue
   6     was to separate the very difficult task of deciding what
   7     was necessary from the challenge of delivering what was
   8     decided, and I have to say that it is no surprise I went
   9     to the delivery end and did not take on the provider
  10     task.
  11        So, yes, that is the Health Service. Anybody who
  12     wants to work in the Health Service and not be
  13     perpetually beaten about the head for more resources
  14     really ought to go and work somewhere else.
  15   Q. You told us how part of your management style was
  16     encouraging managers to make decisions for themselves,
  17     rather than you telling them how to manage, which you
  18     could do, but it was more beneficial to encourage them.
  19        The suggestion is made that -- possibly, I do not
  20     know, in consequence of that approach -- you were not
  21     prepared to deal with problems: were you, or were you
  22     not?
  23   A. That would be wholly wrong. Wholly wrong. I actually
  24     not only dealt with problems, I spent a great deal of
  25     time trying to make sure problems did not arise.

   1     I encouraged people to tell me of issues before they
   2     were problems so we could resolve them. I used to say,
   3     "Please do not tell me when you have drowned, tell me
   4     when you fell in the river. Preferably, tell me when
   5     you are on the bank and think you might slip".
   6   Q. If it were the case that a manager came to you and you
   7     said, "Look, you ought to try this or try that --
   8   A. No, no, that is not the way of doing it.
   9   Q. Tell me how you do it.
  10   A. You indulge in what a lot of people now call
  11     "counselling". You do it by asking questions, by
  12     throwing in information, until the solution emerges.
  13     You make sure that the solution is suggested and owned
  14     by the Manager.
  15   Q. If it did not work, would you see that as a failure?
  16   A. The situation did not arise.
  17   Q. The suggestion is made by Mr Boardman that you "always
  18     knew best" and by Mrs Ferris that you "did not like to
  19     be challenged". It is suggested by Marie Thorne that
  20     you wanted people around you who had a similar approach
  21     to you.
  22   A. Yes, but I did not want people to agree --
  23   Q. All those comments tending to reflect a view of you?
  24   A. Well, the Marie Thorne one is quite the reverse. The
  25     "similar approach" I wanted was to have flexible,

   1     imaginative approaches and be prepared when we were
   2     thrashing out a solution to argue sometimes quite
   3     fiercely. It is a task model approach in which you have
   4     a group and you have to manage the group so that
   5     everybody's contribution is made and in the end, it was
   6     hoped that a consensus would be achieved and then there
   7     was no problem. If there was no consensus, then by the
   8     very definition of executive management, I would have to
   9     inform them of all the options that were going around,
  10     which one would be our policy.
  11        If that is mistaken for pretending to be always
  12     right, I am sorry. One of my phrases I used to use in
  13     radiology and in management is, "I offer infallibility
  14     to nobody".
  15   Q. In part of that last answer you were indicating that in
  16     response to Marie Thorne's point, you were looking for
  17     people who were similar in the sense that they were
  18     flexible, as you would wish to be?
  19   A. Yes.
  20   Q. You commented earlier, in respect of Mrs Ferris, that
  21     you saw her as someone who wanted a role model and
  22     therefore, by definition, I suppose, from your
  23     perception was not one of the flexible people you wished
  24     to have around you?
  25   A. That is pushing the observation too far. That suggests

   1     that somebody who is a model person stays that way and
   2     is a pure role model person with no flexibility to
   3     change, and that is not the case. I know for simplicity
   4     he talks about four different sorts of people, but those
   5     four different sorts of people are in everybody, but
   6     they are of different sizes. But they change size in
   7     different situations and at different times. So we
   8     developed managers. The one thing you cannot have in
   9     a health service, as I understand and know the Health
  10     Service today, you cannot have a stable, repetitive
  11     situation; certainly no year is like the one before or
  12     the one after. In my experience it is very rare that
  13     any week is like the one before or the one after.
  14   Q. Did you welcome people around you who took a very
  15     different view of things from you?
  16   A. There was no point in having everybody agreeing with me
  17     all the time. If everybody agreed with what I thought,
  18     I need not talk to them. I surrounded myself with
  19     people of different points of view, quite different
  20     aspirations, quite different backgrounds, because that
  21     is the only way you can increase the likelihood of
  22     reaching the proper decision. That is not a novel idea
  23     of mine. I mean, everybody recognises that. The one
  24     thing that is most dangerous in any manager, and
  25     certainly any senior manager, is ever to allow

   1     themselves to be surrounded by "yes-men". That is
   2     a road to disaster, a very short, steep road.
   3   Q. Two further points, I think. It was suggested to us by
   4     Mr Ross that he thought that devolution to the
   5     directorates had gone too far; that one of the
   6     consequences may be that warning signals within
   7     a directorate might not get heard outside those
   8     directorates.
   9        Is there force in that which he says?
  10   A. I do not know whether there is force for him in that
  11     which he says, but from my point of view they were not
  12     a long way away because I spent a great deal of time in
  13     the directorates. I was not, as some people wished to
  14     be, sitting in an office on the top floor,
  15     unapproachable; I was out and about. I actually went
  16     into directorates. I deliberately changed my pathway
  17     through the various parts of the Trust in order to have
  18     a look around. I had regular meetings with everybody in
  19     the directorate. So I have to say, to describe
  20     directorates as a long way away from me misunderstands
  21     what went on. But please, I can tell you what went on,
  22     what goes on now with Hugh Ross, with as much accuracy
  23     as he can tell you what went on when I was there.
  24   Q. Was it really a consequence of the devolution to
  25     directorates and the control that Clinical Directors had

   1     over those directorates that there was less planning
   2     conducted centrally, less central direction --
   3   A. No. Quite wrong.
   4   Q. Finally, picking up the points which have been raised by
   5     others, there were, were there, when you were Chief
   6     Executive, two Deputy Chief Executives?
   7   A. Yes.
   8   Q. That would be Mr Nix?
   9   A. That is right.
  10   Q. And the Medical Director?
  11   A. James Wisheart, yes.
  12   Q. When you were away, who took over?
  13   A. Graham Nix -- as far as I am aware, and clearly I was
  14     not there if I was away. But while I was away he would
  15     sit in my office and do my job, the totality of it.
  16   Q. How could he do a job which involved a medical side if
  17     his responsibility was essentially financial?
  18   A. By delegating it to the appropriate person. And to make
  19     sure there was no difficulty about that, I asked the
  20     Trust Board to recognise James Wisheart as the Deputy
  21     Chief Executive for medical matters. I think in the
  22     whole time he was there, and many times I was away, he
  23     was never called upon to act as the Deputy Chief
  24     Executive for medical matters; Graham Nix dealt with
  25     everything.

   1   Q. Is the consequence, when you were there, you were there
   2     as Chief Executive for financial matters and for medical
   3     matters?
   4   A. Yes, I mean, I was responsible for the budget. It was
   5     my budget, not the Treasurer's. He was accountable for
   6     the Treasury function, but it was my budget.
   7   Q. And you were Chief Executive for medical matters too?
   8   A. I was Chief Executive for everything. It was my patch.
   9   Q. Would it not follow if there were two Deputy Chief
  10     Executives, one for Finance and one for Medical, that
  11     neither one could properly do your job as a deputy?
  12   A. If that were the case, I would not have made that
  13     arrangement. There was no ambiguity and no difficulty,
  14     but what there was, was a reinforcement of the
  15     recognition that when Graham Nix was doing my job, he
  16     needed clearly an increased medical support -- might
  17     need it. To my knowledge, he never availed himself of
  18     it.
  19   Q. Dr Roylance, I have taken you through the main points
  20     which have been made in respect of you by others. It is
  21     likely that in the course of this Inquiry there will be
  22     other comments made about you, or for that matter, about
  23     others, which you would wish the opportunity to comment
  24     on.
  25        May I make it plain that you will have that

   1     opportunity, not only in writing, at any stage, because
   2     we remain open to hear from you until we finish our job
   3     here, both in terms of evidence and, if you wish,
   4     comment, but also that we expect to see you back to give
   5     evidence to us, to help us when we come to resolve the
   6     issues that led to your appearance before the General
   7     Medical Council.
   8        At that later stage, if there is anything which
   9     you feel should have been said on this occasion, you
  10     will, of course, have an opportunity to say it then,
  11     even though our primary focus may be somewhat different.
  12        I mention it to you, and forgive me for telling
  13     you what you already know, because of course we have
  14     a wider audience.
  15   A. Yes, I am aware of that.
  16   Q. That is the reason why I am not asking you, on this
  17     occasion, to deal at all with any part of the detail of
  18     those issues. What you have been asked about over the
  19     last day and three-quarters has been essentially the
  20     management structure, style and procedures.
  21        For your part, is there anything which you feel
  22     you would wish to add, perhaps to clarify that which you
  23     feel you may not have succeeded in getting across to us,
  24     or to volunteer because you have not been asked it?
  25   A. Yes, there is, and I promise I will not take very long,

   1     but I have some anxiety that we have been leaping about
   2     structurally, chronologically, and I generally hope it
   3     will be helpful if I just make six very brief bullet
   4     points. I am prepared to explain anything that I say
   5     that is not understood, and I am prepared to justify
   6     anything that is not initially accepted.
   7        I thought I would, if I may, say the following
   8     things:
   9        First of all, I have repeatedly said, and I think
  10     it is fundamental to this, that the National Health
  11     Service is characterised by an accelerating gap between
  12     what is possible and what is affordable. Unless that
  13     fundamental issue is accepted and understood, nothing
  14     else's makes a lot of sense.
  15        Over time, various initiatives to bridge that gap
  16     have been instituted. They include first of all
  17     increased funding, and if there were time, I would
  18     demonstrate that the more money that is put into the
  19     Health Service, the bigger is the shortfall between what
  20     is considered possible and what is affordable.
  21        So although we all welcome increased funding, it
  22     will not bridge the gap.
  23        Then there was "Let us manage the Health Service
  24     [the Griffiths report and so on] and make it more
  25     efficient, more effective and more business-like". As

   1     we have all seen, there is a tendency for that to divert
   2     money from health care into management. If you have
   3     what I call "professional managers" invited into the
   4     Health Service, it is not surprising that the amount of
   5     management is increased. In my judgment, in many
   6     Trusts, they are mostly managing management and not
   7     health care.
   8        Then there is the pious hope that evidence-based
   9     medicine would solve the problem and bridge the gap.
  10     That was fairly recent, five, six, seven years ago. In
  11     my view, all that does is sharpen the argument for more
  12     resources, because although there may be a slight delay,
  13     it will justify enormous expenditure on new
  14     developments.
  15        There is the view, the very proper view, that the
  16     gap might be substantially reduced by health promotion.
  17     The trouble is that it is very difficult to tell
  18     somebody with severe angina he cannot have his operation
  19     because we have spent the money encouraging proper
  20     diets, no smoking and proper exercise. In the same way,
  21     you cannot tell parents with a blue child that we have
  22     just diverted the money into research to try and stop
  23     blue children being born.
  24        In my personal belief, until you separate health
  25     promotion -- perhaps give it to local authorities as

   1     a responsibility -- and recognise the Health Service as
   2     a disease service, you will not make any progress
   3     there --
   4   THE CHAIRMAN: Dr Roylance, because it is very important
   5     that you should be able to put these on the record, may
   6     I urge you to go just a bit more slowly --
   7   A. Thank you, sir. I thought you were going to say, would
   8     I stop.
   9   THE CHAIRMAN: That is the last role I should play! The
  10     stenographer needs to be able to keep pace with you, and
  11     for that reason and because we want to read what you
  12     say, I would just urge you to go just a shade slower?
  13   A. I am most grateful to you, I was rushing, I hope you
  14     understand, for your time.
  15        Could I say that the last initiative -- this is
  16     part of the background of management -- was what I would
  17     describe as "concealment" of the shortfall. That is by
  18     the GP fund-holding system, where you give the GP the
  19     money and he does not send anyone to hospital until he
  20     can pay for it. That is the equivalent of the private
  21     system -- it is not private, but it is.
  22        So we live in an environment -- this is the third
  23     point -- of competing demands. It would be wrong, and
  24     I am sure the Panel will not do this, but I think the
  25     wider audience should recognise that it would be wholly

   1     wrong to focus solely on paediatric cardiac surgery.
   2        We have heard here that the adult cardiology
   3     service was angrily demanding that their funding should
   4     be increased very substantially. We have seen general
   5     paediatrics demanding that the position is quite
   6     untenable and their funding should be increased. We
   7     have not heard (but you will know) that the oncology
   8     service will say, "We cannot possibly have a waiting
   9     list; there are people with cancer needing treatment",
  10     and theirs was a very large six figure sum, if not
  11     a seven figure sum, that was needed --
  12   THE CHAIRMAN: Dr Roylance, you are doing it again!
  13   DR ROYLANCE: I beg your pardon. Thank you for telling me.
  14   THE CHAIRMAN: Please do not regard this as a criticism, it
  15     is just that we need to catch up with you sometimes.
  16   DR ROYLANCE: If there is a problem, I will go back to it.
  17     Do you want me to say anything again?
  18   THE CHAIRMAN: No, we can pick it up from the tape later.
  19     I am suggesting just a little more slowly, please.
  20   DR ROYLANCE: I do apologise, yes. I will not go through
  21     any more, but we have established that a Chief Executive
  22     in a teaching hospital Trust is constantly assailed with
  23     demands for more funds. These are not expressed in
  24     gentle terms of "All is well, but we would like some
  25     more"; there are aggressive demands that patients are

   1     dying, the service is unacceptable. This comes in all
   2     the time.
   3        You will have seen in the newspapers very recently
   4     somebody has done some work on waiting lists for cardiac
   5     bypass surgery and quantified that -- I think the figure
   6     was 10 people every week are dying on waiting lists to
   7     go into hospital and "Please could we have a few tens of
   8     millions of pounds".
   9        I really have to emphasise that everything I say
  10     about management is in that situation.
  11        The management culture we have been discussing,
  12     and all I would like to say is that when the NHS was
  13     introducing a "command and control" style of
  14     management, I would describe it as a failure orientated
  15     management with mechanisms to pick up failure the whole
  16     time. What my non-executive directors used to call the
  17     "real world" outside in industry and commerce was
  18     replacing that form of management by one of
  19     empowerment. I would say that one firm openly
  20     recognised that their workforce were responsible people
  21     holding important roles in the community outside work.
  22     Some were on parish councils, some were JPs, and they
  23     recognised that they did not want to squeeze as much
  24     money out of their firm for as little work as possible,
  25     and they trusted them. In so doing, they got more.

   1        My style has been caricatured many times, by me as
   2     well as other people, as one of aggressive trust. That
   3     means that the people concerned must recognise they are
   4     being trusted. I have to say, it is a very sound system
   5     that works; it has a good base in the management
   6     literature. Dare I say, it is also well based in
   7     theology.
   8        I will give you an example. I met two community
   9     nurse managers whilst we were doing it and asked them
  10     what it was like now that they were freed up from
  11     management controls and were able to concentrate their
  12     attention -- these were district nurses -- on improving
  13     the care which patients got in the community. They
  14     said, "It is absolutely marvellous, we can actually
  15     address and solve the problems in the community. We can
  16     free up a lot more resources". Then one of them turned
  17     round and said to me, "But we have never been so busy in
  18     our lives". That was because they were accountable to
  19     themselves. I deliberately sent no signals out that the
  20     name of the game was to convince me, or even deceive me,
  21     that they were working well. The name of the game was
  22     for them to satisfy themselves that they were working
  23     well.
  24        Please, I do not think that is a novel, a unique
  25     or an original form of management, but it is the

   1     management style I adopted and it was successful.
   2        I just have two more points. They really relate
   3     to consultants. I will not read it out, but in here
   4     there is a very apt description of what is called the
   5     existentialist culture of the consultant staff, or
   6     "senior experts". They are people who do not recognise
   7     themselves as being employed by anybody; they exercise
   8     independent judgment; they do not easily go into groups
   9     and they are virtually impossible to manage. There are
  10     no sanctions; you cannot fire them; they have secure
  11     terms and conditions of service, and in the Health
  12     Service I think still a consultant cannot be sacked
  13     without the prior approval of the Secretary of State for
  14     Health. I have heard it many times said, anybody who
  15     wishes to manage consultants should do their
  16     apprenticeship in the voluntary sector where none of the
  17     staff are paid and they can all please themselves.
  18     Unlike consultants in that area, I am told it is much
  19     easier to get rid of them without an industrial
  20     tribunal, but consultants are not manageable. Some
  21     people say -- and I have said this in other places -- it
  22     is like "herding cats".
  23        So one has to adopt a leadership style and one has
  24     to free up their abilities and recognise their culture.
  25     Any suggestion that the Health Service can be improved

   1     by attempting to reduce consultants to the role of
   2     subordinate officers who are controlled by somebody who
   3     has no idea of the work they are doing, is wholly
   4     unreasonable and not something I ever attempted.
   5        I would just like to finish off with another
   6     point. It is not conclusive this, but there are things
   7     that I think have not come across.
   8        In my last year as Chief Executive, the novel idea
   9     of clinical governance came in. It was a new idea and
  10     it followed the previous corporate governance which
  11     crudely could be said, "You must not put your hand in
  12     the till", but clinical governance was a very new
  13     concept that the managing authority, the Trust and the
  14     Chief Executives, should be responsible for the quality
  15     of clinical care.
  16        My understanding from a recent letter from the
  17     Chief Medical Officer and other information is that that
  18     is not yet introduced, but I have talked to people about
  19     it. What is quite clear is that the replacement of
  20     doctors, managing doctors, by the Trust and the Chief
  21     Executive managing doctors, is now being implemented by
  22     the Trust and the Chief Executive relying upon the
  23     Medical Director and the Regional Medical Officer to do
  24     the monitoring and report back to the Trust.
  25        So I think I would offer the suggestion that this

   1     is one of life's complete circles -- and there are
   2     many -- when we move from doctors managing doctors
   3     hopefully to a situation where doctors manage doctors.
   4        I genuinely hope that was helpful. I will say no
   5     more.
   6   MR LANGSTAFF: There is one matter I would simply ask you to
   7     clarify now, if you can, if possible, that is the
   8     page reference in Mr Handy's book where he talks about
   9     existentialists?
  10   A. I am sorry, I cannot give you it because he introduces
  11     first of all a description of the types, then what
  12     motivates them and then how to manage them, and so on,
  13     so it is recurrently through the book, but very easy to
  14     find.
  15   THE CHAIRMAN: We will find it. Mr Langstaff, looking at
  16     the time and aware of the fact that there are
  17     stenographers and others who have had a long day,
  18     including witnesses and us, I think you have come to
  19     some arrangement, have you not, behind you? Perhaps you
  20     can explain to me.
  21   MR LANGSTAFF: Sir, yes. Mr Francis has indicated that
  22     Dr Roylance is not only able but willing to come back
  23     tomorrow morning to be re-examined by him.
  24        Mr Lissack, who cannot be here tomorrow, would
  25     like to say something. I know there are time

   1     constraints upon at least one member of the Panel. It
   2     may be that you would feel, therefore, that the Panel's
   3     questions could wait until tomorrow morning as well.
   4   THE CHAIRMAN: I would be very happy to hear Mr Lissack
   5     now. I was going to ask your advice. Would that be
   6     acceptable to Mr Francis and others as well as to the
   7     witness if the Panel did have one or two questions, that
   8     they could put them tomorrow morning?
   9   MR LANGSTAFF (after conferring): Yes.
  10   THE CHAIRMAN: I am grateful. Mr Lissack, before calling
  11     you, may I say thank you to Dr Roylance? We will see
  12     you again tomorrow morning. Could you possibly bear
  13     with us for a couple of seconds while we hear
  14     Mr Lissack, and then I can adjourn for the day.
  15        Mr Lissack?
  16             ADDRESS BY MR LISSACK
  17   MR LISSACK: I will be brief. What I say, you will
  18     understand, is as much for consumption by those
  19     following from afar as for those here.
  20        Over the five days since receipt of this witness's
  21     statement, we and I am sure other parties, have been in
  22     close contact with Counsel to the Inquiry. That
  23     permitted us to provide, albeit late in the sense that
  24     it was not until overnight, last night/this morning,
  25     eleven areas that we invited my learned friend

   1     Mr Langstaff to deal with, with this witness.
   2        Of those eleven areas, five have not yet been
   3     approached, but we make no application to cross-examine
   4     at this stage. It does not seem to us to be
   5     appropriate. It seems those are matters deliberately,
   6     I understand, left until the next time this witness
   7     comes to give evidence to you, and it would not be right
   8     to try to take advantage of the procedures set out by
   9     you in the guidance you gave on 17th May to have two
  10     bites of the cherry.
  11        But -- and I say this again for those reading from
  12     afar in particular -- may I, on behalf of those
  13     I represent, make plain that we do regard this witness's
  14     action, or inaction as some might term it, as central to
  15     events at Bristol. We take the line that we do safe in
  16     the knowledge that he will be returning to give evidence
  17     in the course of Block 6, I anticipate, and
  18     understanding that the areas that my learned friend
  19     Mr Langstaff has not yet covered including those points
  20     we have made to him, may then be explored and if there
  21     should be anything left out, then we may have the right
  22     to apply to you in accordance with your rules.
  23        Also, we understand that any issues that, because
  24     of the shortness of time between receipt of statement
  25     and giving of evidence, touching upon matters more

   1     properly within Block 3, but of importance and not yet
   2     covered, that appear upon reflection to be material and
   3     of assistance to you to explore, may yet still be
   4     explored on that second visit.
   5   THE CHAIRMAN: Absolutely right, and I am grateful to you
   6     for all of those points. They are noted here and
   7     elsewhere, I hope.
   8   MR LISSACK: Thank you very much indeed.
   9   THE CHAIRMAN: May I just add that I know how helpful
  10     Counsel to the Inquiry has found the co-operation of all
  11     legal representatives over the last two days, and I here
  12     publicly thank them again. Mr Langstaff, you wanted to
  13     say something?
  14   MR LANGSTAFF: Sir, perhaps it is appropriate that, having
  15     said so much over the last few days, you should take the
  16     words out of my mouth!
  17   THE CHAIRMAN: I would not dream of doing that in the
  18     wildest of my dreams! Dr Roylance, I have thanked you.
  19     We shall see you tomorrow morning. Thank you all,
  20     ladies and gentlemen. We will adjourn until 9.30
  21     tomorrow morning.
  22   (15.45 pm)
  23     (Adjourned until 9.30 am on Wednesday, 9th June 1999)
  24
  25

   1                I N D E X
   2
   3     DR JOHN ROYLANCE (recalled):
   4       Examined by MR LANGSTAFF (continued) ........... 1
   5
   6     ADDRESS by MR LISSACK .............................. 171
   7
   8
   9
  10
  11
  

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